Predicting factors of patient satisfaction after varicose vein surgery at a university hospital in Nepal

INTRODUCTION

Varicose veins are a common vascular problem with a high prevalence, yet they are often neglected. The main objective of this study was to explore the patient satisfaction after varicose vein surgery, along with its predicting factors. To our knowledge, no similar study has been conducted in Nepal to date.

METHODOLOGY

This retrospective cross-sectional study included patients who underwent varicose vein surgery at Dhulikhel Hospital from September 2019 to February 2020. The satisfaction level after the surgery was assessed using a 10-point Likert scale questionnaire during a telephone interview with their verbal consent. Descriptive statistics and linear regression were performed to identify the predicting factors of patient satisfaction.

RESULTS

Among a total of 84 patients interviewed, 53.6% were male. The mean age of the participants was 43.13 ± 13.62 years. The mean patient satisfaction score was 42 ± 5.5, with nursing service, discharge teaching and hospital service being the highest scoring items in terms of patient satisfaction. Linear regression revealed age ≤40 years as a predictor of higher patient satisfaction (β=0.258, p=0.015) while early stage of varicose veins (β=-0.233, p=0.026) and duration of post-operative follow-up (β=-0.25, p=0.021) were negative predictors of patient satisfaction. This means that patients with C2-C3 venous disease and longer duration of postoperative follow-up tended to have lower satisfaction scores.

CONCLUSION

The overall patient satisfaction following varicose vein surgery was very good, and the major predictors of better satisfaction were age ≤40 years, C4-C6 clinical classification of venous disease and the shorter duration of follow-up after surgery.

Hemoperitoneum among Pediatric Abdominal Trauma Patients Visiting in Emergency Department of a Tertiary Care Centre: A Descriptive Cross-sectional study

Introduction: Pediatric abdominal trauma presents a major challenge for first-line responders in the Emergency Department for assessment and management. The Focused assessment sonography for trauma is a readily available, easy-to-use, and affordable tool for detecting hemoperitoneum during the initial assessment of trauma in the Emergency Department for adult traumatic patients. The aim of this study was to find the prevalence of hemoperitoneum among pediatric abdominal trauma patients visiting the Emergency Department of tertiary care centre through Focused assessment with sonography for trauma examination technique. Methods: This was a descriptive cross-sectional study conducted in the Emergency Department of a tertiary care hospital from 7 April 2019 to 7 April 2020. Among 413 pediatric trauma patients, 93 children (1 to 17 years) admitted to the Emergency Department who underwent focused assessment with sonography for trauma examination were included in the study. Ethical approval was obtained from the Institutional Review Committee (Approval number: 111/19). Convenience sampling was used. Point estimate and 90% Confidence Interval were calculated. Results: Among 93 children receiving focused assessment with sonography for trauma imaging in the Emergency Department with a history of blunt abdominal trauma, the prevalence of hemoperitoneum was 18 (19.34%) (12.61-26.09, 90% Confidence Interval). Conclusions: The prevalence of hemoperitoneum was similar to other studies conducted in a similar setting.

Massive Hemoptysis and Pulmonary Thromboembolism in a Patient with Pulmonary Tuberculosis: A Therapeutic Conundrum Managed with Bronchial Artery Embolization

Hemoptysis is a crucial entity taking into account its morbidity and mortality. Pulmonary tuberculosis is the leading cause for massive hemoptysis in our part of the world, which if left untreated may be life threatening. We present a case of a 37-year-old male patient with pulmonary tuberculosis with concurrent pulmonary thromboembolism presenting with massive hemoptysis, which was successfully managed with Bronchial Artery Embolization. This case represents that this measure can be a viable therapeutic choice for a patient with a severe lifethreatening hemoptysis, particularly when other treatment options are unavailable or ineffective.

Comparison of Blood Pressure Readings on a Bare Arm, over a Sleeve Arm and over a Rolled-Up Sleeve Arm in Outpatient Department of Medicine in Dhulikhel Hospital, Kathmandu University Hospital

Background: It is universally recommended that blood pressure should be measured on bare arm for accurate reading. However, this is seldom done in busy clinical schedules. This study aims to see if clothing adjustments should be a concern while measuring blood pressure under suboptimal conditions. Materials and Methods: This was a cross sectional study conducted at medicine department of Kathmandu University Hospital, Dhulikhel Hospital among conveniently selected 100 patients. After getting informed consent, consecutive blood pressure measurements were done over rolled-up sleeve arm, sleeve arm and bare arm in seated position. Socio-demographic information were obtained through an interview using a semi-structured questionnaire. Data were entered in Microsoft Excel and analyzed using descriptive and inferential statistics in Statistical Software for Social Sciences version 20. Results: The median of differences between sleeved arm and bare arm was 0 for both systolic and diastolic blood pressure and the median value for differences between rolled up arm and bare arm was 2 units for both systolic and diastolic blood pressure. Although the differences looked statistically significant, the size of the differences was not clinically significant. Conclusion: Meticulous clothing adjustment has clinically insignificant differences in measurement of blood pressure if patient is wearing thin sleeves. Therefore, in suboptimal conditions, blood pressure can be measured on rolled-up sleeve arm and sleeve arm if patient is wearing thin sleeve clothes.

Peripheral Vascular Trauma among Vascular Surgery Cases Operated in a Tertiary Care Hospital: A Descriptive Cross-sectional Study

Introduction:

Peripheral vascular trauma can result in limb or life-threatening injuries. Early surgical intervention leads to a better outcome. Diagnosis is made clinically, by non-invasive and invasive imaging modalities. Our aim in this study is to find out the prevalence of peripheral vascular trauma among vascular surgery cases operated in a tertiary care centre of Nepal.

Methods:

This is a descriptive cross-sectional study of peripheral vascular injuries that underwent operative management in a tertiary care hospital of Nepal from January 2018 to May 2020. Ethical approval was taken from the Institutional Review Committee of Kathmandu University School of Medical Sciences (Registration Number 79/20). Convenience sampling technique was used. Data for the study was retrieved from operation records of the patients along with their treatment summaries and entered and analyzed in the Statistical Package for Social Sciences version 20.0. All cases with complete records were included. Conservatively managed cases and cases that underwent primary amputation were not included in the study. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.

Results:

Among 624 vascular surgery patients, 40 (6.41%) (4.48-8.33 at 95% Confidence Interval) patients had presented with peripheral vascular trauma during the study period. There were 26 (65%) cases where the upper limb was involved.

Conclusions:

The prevalence of vascular surgery for peripheral vascular trauma among vascular surgeries operated in our study was similar to other studies done in similar settings. Vascular injury needs urgent intervention and appropriate management will result in a high chance of limb salvage and survival.

Spleen in the thorax: A case report on traumatic diaphragmatic rupture

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Diaphragmatic rupture is a rare complication of abdominal trauma.

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Herniation of abdominal contents can occur following diaphragmatic rupture.

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Spleen was present in the thorax in a case following blunt abdominal trauma.

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Care should be taken when inserting a chest tube in suspected cases.

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Treatment is surgical via Laparotomy or Thoracotomy.

Introduction

Most of the cases of diaphragmatic rupture occur following abdominal trauma and herniation of abdominal organs into the thorax can occur.

Presentation of case

Twenty three years old male presented after a blunt abdominal trauma following a road traffic accident. Investigations revealed a left sided diaphragmatic rupture with herniation of spleen and stomach into the left hemithorax. Surgical repair of the defect was done and splenectomy had to be done due to extensive splenic laceration. Two third of the spleen was found in the left hemithorax.

Discussion

Diagnosis of diaphragmatic rupture can be missed in cases of polytrauma. High clinical suspicion with aids from imaging modalities help in the diagnosis. In suspicion of herniation of abdominal contents into the thorax, one should be careful in insertion of chest tube in view of damaging the herniated organs. Treatment is surgical repair and reduction of herniated contents.

Conclusion

Although a rare entity, diaphragmatic rupture can occur in cases of abdominal trauma. High clinical suspicion with imaging helps in the diagnosis.

Diagnostic performance of the extended focused assessment with sonography for trauma (EFAST) patients in a tertiary care hospital of Nepal

Background

Thoracoabdominal trauma presents a diagnostic challenge for the emergency physician. The introduction of bedside ultrasonography (USG) provides a screening tool to detect hemoperitoneum, hemothorax, pneumothorax and pericardial effusion in torso injuries.

Aim

To evaluate the accuracy of extended focused assessment with sonography for trauma (EFAST) for chest and abdominal injuries performed by first responders in a tertiary care hospital of Nepal.

Methods

This was a prospective study including all trauma patients who obtained either an Injury Severity Score ≥15 or direct trauma to the trunk in 1 year period in the emergency department (ED) of Dhulikhel Hospital-Kathmandu University Hospital. The results of the EFAST were then compared with contrast-enhanced CT (CECT), radiology ultrasound (USG)/chest X-ray, or intraoperative findings when the EFAST was positive. The negative EFAST cases were observed for a minimum of 4 hours in the ED. Descriptive statistics and sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated.

Results

Out of 267 cases, 261 patients underwent an EFAST examination. The sensitivity and specificity were 94.8% and 99.5%, respectively. The negative predictive value was 98.53% whereas the positive predictive value was 98.21%. The overall accuracy was 99.4%.

Conclusion

The results of this study suggest that EFAST examination performed by first-line healthcare providers is a useful method for assessment of thoracic and abdominal injuries. EFAST was found to have a high specificity (99.5%) and positive predictive value (98.21%) which indicates that it is an effective technique for detecting intra-abdominal or thoracic injuries. However, the effectiveness of EFAST is limited by its being operator dependent, and thereby human error. For negative EFAST cases, we recommend a monitoring period of at least 4 hours, serial fast scan, or further investigation through other methods such as a CECT.

Level of evidence

Level I

Case report of eventration of diaphragm due to an unknown febrile illness causing phrenic nerve palsy and other multiple nerve palsies

INTRODUCTION

Diaphragmatic eventration can be congenital or acquired. Diagnosis is delayed due to no symptoms or very mild ones and is generally done by imaging modalities. This condition is managed by plication of the affected part of diaphragm by various surgical approaches.

PRESENTATION OF CASE

A forty seven years lady presented with one year long history of abdominal pain, bloating and fullness after meals who was being treated in line of peptic acid disorder. She had developed bilateral foot drop after typhoid fever at seventeen years of age. Clinical examination and imaging with chest x-ray, chest ultrasound and computed tomography scan suggested eventration of left hemidiaphragm. Plication of eventration of left hemidiaphragm was done via mini thoracotomy of the left thorax. There were no postoperative complications and she was discharged on the sixth postoperative day.

DISCUSSION

Acquired eventration of diaphragm is commonly due to traumatic phrenic nerve palsy but rarely can be associated with a history of infection causing nerve palsies. Thoracic ultrasound is an emerging modality for diagnosis supporting X-rays and CT Scans. Plication of eventration with minimally invasive techniques has less number of hospital stay and less pain compared to open approaches.

CONCLUSION

Non-traumatic diaphragmatic eventration due to acquired phrenic nerve palsy following an unknown febrile illness is a rare case to be reported in Nepal. The aim of treatment is expansion of intra-thoracic space which is done by plication of the diaphragm.

Identification of immunohistochemical prognostic markers for survival after resection of pulmonary metastases from colorectal carcinoma

BACKGROUND

Although aggressive resection of pulmonary metastases prolongs the survival of patients with metastatic colorectal cancer, there is a need for predictive pathologic parameters to understand the key molecular events of metastatic progression. The aim of this study was to verify immunohistochemical markers in addition to established clinical parameters after surgery.

METHODS

From our subset of patients undergoing resection of pulmonary metastases from metastatic colorectal carcinoma, we analyzed 39 patients (23 men and 16 women) between 2003 and 2007. Only patients who met the criteria for a potentially curative operation were included. All patients were analyzed with regard to age and sex, primary tumor location, stage of the primary tumor, history of hepatic metastases, number of pulmonary metastases, pre-thoracotomy carcinoembryonic (CEA) serum antigen level, and the presence of thoracic lymph node metastasis. Furthermore, we immunohistochemically investigated the expression of vascular endothelial growth factor (VEGF)-D, FBJ murine osteosarcoma viral oncogene homolog B (FOS-B), and melanoma antigen (MAGE)-A in the surgical specimens of pulmonary metastatic lesions.

RESULTS

The overall 3-year survival was 50.6 %. A significantly longer survival was observed with multivariate analysis in patients with a pre-thoracotomy serum carcinoembryonic antigen level of no more than 4.2 ng/mL ( P = 0.001), and Dukes stage A or B primary tumor ( P = 0.001). A significantly longer recurrence-free survival was observed with multivariate analysis in patients without thoracic lymph node involvement compared to patients with pulmonary and/or mediastinal lymph node metastases ( P = 0.006). The stage of the primary tumor remained significant ( P = 0.029), and FOS-B expression in tumor cells showed a trend towards favorable recurrence-free survival after pulmonary metastasectomy ( P = 0.059). No statistically significant difference was found in the overall survival rate or recurrence-free survival rate of patients with expression of VEGF-D or MAGE-A antigen in pulmonary metastatic tumor cells.

CONCLUSIONS

Our results suggest that in addition to clinically prognostic factors, FOS-B expression has a debatable impact on patient survival. We conclude that the evaluation of molecular and clinical prognostic parameters at the time of pulmonary metastasectomy offers a greater understanding of the metastatic process and provides important information for patient selection.

3. Internationales Symposium: „Autologe Transfusion - Von der Euphorie zur Ratio: Praktisches Handeln aus wissenschaftlicher Sicht” (Teil III)Does Hemodilution Enhance Coagulability?

Recent publications reported enhanced coagulability in hemodilution determined by TEG. In contrast, earlier reports have shown prolongation of in-vivo bleeding time in anemia. In order to take a closer look at this discrepancy undiluted and diluted anticoagulated blood samples (20 % with saline solution, hydroxyl-ethyl starch 6 % (HES), autologous platelet poor plasma (PPP)) were investigated by TEG (n = 10), ball (n = 10), and hook coagulometer (n = 15) as well as tests simulating primary hemostasis ex vivo (Platelet Function Analyzer PFA-100, n = 10).

RESULTS

Dilution with plasma changed TEG parameters in a way, when started by recalcification of the blood sample, which is characteristic of enhanced coagulability (r decreased in all and k in 8 of 10 samples, maximal amplitude increased in 9 out of 10). With HES, changes in TEG parameters mainly indicated reduced coagulability (k increased in 7 out of 10, MA decreased in 10 out of 10). When the coagulation was additionally activated by PTT reagent (InTEG) the TEG parameters also mainly showed hypocoagulation with the three dilution solutions. Coagulation times with ball and hook coagulometers were significantly prolonged by dilution especially with saline (+ 25 % and + 17 %, p < 0.001). Dilution always significantly (often abnormally) prolonged closure time in PFA-100 (saline + 41 +/- 18 %, PPP + 37 +/- 20 %, HES + 69 +/- 24 %) demonstrating disturbance of primary hemostasis, particularly with HES.

CONCLUSIONS

From the results obtained it can be concluded that the changes in the classical TEG (without addition of PTT-reagent), suggesting an enhanced coagulability, may be caused methodically as they are also found with autologous PPP. On the other hand, a disturbance of the primary hemostasis in hemodilution has to be taken into account from the results seen with the PFA-100 and a number of published data.

Measurement of primary haemostasis using a pressure clamp technique

With the PFA-100 a sensitive and specific screening test for primary haemostasis has recently become available. An important part of the device is a capillary, providing a defined haemodynamic resistance for the perfusion of the aperture. A modified method to measure platelet function (VCP2) is presented in which the capillary essentially is replaced with an 'electronic capillary' by clamping the pressure/flow relationship.

RESULTS AND CONCLUSION

Closure time (CT) and blood volume (BV) as determined by PFA-100 and VCP2 correlated well within (r = 0.922 - 0.952) and between the two methods (r = 0.86). The test variability (CV) of CT could be significantly reduced in the VCP2 method (collagen/epi 3.9 vs. 5.9%, p<0.05; collagen/ADP 3.3 vs. 6.9%, p<0.001), thus considerably increasing test reliability and reducing test variance. In preliminary clinical studies the VCP2 system showed comparable sensitivity for vWD and slightly less sensitivity regarding ASA ingestion. The test spectrum of VCP2 could be extended to more thrombocytopenic samples (< or =20 000/microl) even in combination with low haematocrit levels (20%), thus perhaps permitting the determination of the bleeding risk in bone marrow hypoplasia. Additionally, the sensitivity and applicability can easily be adapted to the desired need only by software modifications.

Proteolysis of SNAP-25 isoforms by botulinum neurotoxin types A, C, and E: domains and amino acid residues controlling the formation of enzyme-substrate complexes and cleavage

Tetanus toxin and the seven serologically distinct botulinal neurotoxins (BoNT/A to BoNT/G) abrogate synaptic transmission at nerve endings through the action of their light chains (L chains), which proteolytically cleave VAMP (vesicle-associated membrane protein)/synaptobrevin, SNAP-25 (synaptosome-associated protein of 25 kDa), or syntaxin. BoNT/C was reported to proteolyze both syntaxin and SNAP-25. Here, we demonstrate that cleavage of SNAP-25 occurs between Arg198 and Ala199, depends on the presence of regions Asn93 to Glu145 and Ile156 to Met202, and requires about 1,000-fold higher L chain concentrations in comparison with BoNT/A and BoNT/E. Analyses of the BoNT/A and BoNT/E cleavage sites revealed that changes in the carboxyl-terminal residues, in contrast with changes in the amino-terminal residues, drastically impair proteolysis. A proteolytically inactive BoNT/A L chain mutant failed to bind to VAMP/synaptobrevin and syntaxin, but formed a stable complex (KD = 1.9 x 10(-7) M) with SNAP-25. The minimal essential domain of SNAP-25 required for cleavage by BoNT/A involves the segment Met146-Gln197, and binding was optimal only with full-length SNAP-25. Proteolysis by BoNT/E required the presence of the domain Ile156-Asp186. Murine SNAP-23 was cleaved by BoNT/E and, to a reduced extent, by BoNT/A, whereas human SNAP-23 was resistant to all clostridial L chains. Lys185Asp or Pro182Arg mutations of human SNAP-23 induced susceptibility toward BoNT/E or toward both BoNT/A and BoNT/E, respectively.

New NO-donors with antithrombotic and vasodilating activities, Part 17. Arylazoamidoximes and 3-arylazo-1,2,4-oxadiazol-5-ones

Seven arylazoamidoximes (3), six phenoxycarbonyl derivatives (4), and six 1,2,4-oxadiazol-5-ones (5) have been prepared and their structure and purity established by spectroscopy and elemental analysis. In the EI mass spectra ready elimination of NO from the title amidoximes was observed. A new addition reaction of 3a with hydrochloric acid to 4-chlorophenylhydro-azoamidoxime 7 is described. The compounds were tested for nitric oxide dependent biological properties, i.e. platelet aggregation, antithrombotic effects, and decrease in blood pressure. In arterioles of rats 5/19 compounds inhibited the formation of thrombi with a laser beam by > or = 20% 2 h after oral administration of 60 mg/kg. Among these are three amidoximes (3a, 3e, 3f), one phenoxycarbonyl derivative (4a), and one oxadiazolone (5a). With the 4-chlorophenylazoamidoxime 3c a long lasting (24 h) decrease of blood pressure in spontaneously hypertensive rats was observed. Microsomal fractions of rat liver oxidize arylazoamidoximes and generate nitric oxide (e.g. 3a and 3b). NO was measured by the oxyhemoglobin assay. The influence of SOD, pretreatment of the rats with dexamethasone, as well as kinetic parameters were determined. Type 3 compounds, therefore, are a new class of NO donors. Type 4 and 5 compounds function as their prodrugs.

Loss of in vitro cytotoxicity of cisplatin after storage as stock solution in cell culture medium at various temperatures

BACKGROUND

Cisplatin (cis-dichlorodiammineplatinum [II]) is one of the most potent and widely used cytotoxic drugs in cancer therapy. However, in vitro cytotoxicity assays often yield diverging results. Therefore, it is believed by many investigators that cisplatin is not effective in vitro. The authors investigated whether the experimental conditions used could be responsible for the diverging results.

METHODS

In vitro cytotoxicity assays were performed using the original cisplatin solution as distributed by the manufacturer or a 5-fold dilution of this in cell culture medium after storage for 2 weeks or 1 month at various temperatures (room temperature, 4 degrees C, and -20 degrees C).

RESULTS

The original solution of cisplatin retained the full cytotoxic potency for at least 1 month under all storage conditions tested. The highest loss of cytotoxicity resulted from storage of cisplatin in cell culture medium in which a >7-fold increase in the concentration that inhibits 50% occurred after 2 weeks' storage at room temperature. Solutions stored in culture medium at -20 degrees C retained full cytotoxic potency.

CONCLUSIONS

Cisplatin is a potent cytotoxic drug in vitro when stored under appropriate conditions. These findings are of relevance for in vitro studies with cisplatin.

New NO-donors with antithrombotic and vasodilating activities, Part 16. 3-Amino-1,2,4-oxadiazol-5-ones as prodrugs for hydroxyguanidines

Nineteen 4-substituted 1,2,4-oxadiazol-5-ones (6a-s) were prepared as prodrugs for lipophilic hydroxyguanidines which should be metabolized in vivo to nitric oxide. This hypothesis was tested indirectly by measuring the antithrombotic properties of these compounds 2 h after oral administration to rats (60 mg/kg). In mesenteric arterioles seven compounds moderately (> or = 10%) inhibited the formation of thrombi by a laser beam. Maximum effects were observed in 6c (4-pentyl) and 6f (4-benzyl). The lack of activity in the corresponding 2-pentyloxadiazolone 10c, where no formation of nitric oxide seems possible, indirectly suggests that the antithrombotic properties of the title compounds could be mediated by the in vivo formation of nitric oxide.