The role of imaging in the diagnosis, staging, and management of the osteochondral lesions of the talus

Osteochondral lesions of the talus (OLT) represent an abnormality of the articular cartilage and sub-chondral bone. The abnormality is typically associated with trauma though the exact aetiology remains unknown. Multiple staging systems have been developed to classify the abnormality and management can vary from conservative treatment to different surgical options. Early diagnosis is essential for optimal outcome and all imaging modalities have a role to play in patient management. The aim of this article is to review the pathology, classification, multimodality imaging appearances of OLT, and how the imaging affects patient management.

Assessing the coronal plane deformity in Charcot Marie Tooth Cavovarus feet using automated 3D measurements

BACKGROUND

This study assesses the coronal-plane deformities in cavovarus feet secondary to Charcot-Marie-Tooth disease (CMT) using Weightbearing-CT (WBCT) and semi-automated 3D-segmentation software.

METHODS

WBCTs from 30 CMT-cavovarus feet were matched to 30 controls and analysed using semi-automatic 3D-segmentation (Bonelogic, DISIOR). The software used automated cross-section sampling with subsequent straight-line representation of weighted centre points to calculate 3D axes of bones in the hindfoot, midfoot and forefoot. Coronal relationships of these axes were analysed. Supination/pronation of the bones in relation to the ground and within each joint were measured and reported.

RESULTS

The most significant deformity in CMT-cavovarus feet occurred at the talonavicular joint (TNJ) with 23 degrees more supination than normal feet (6.4 ± 14.5 versus 29.4 ± 7.0 degrees, p < 0.001). This was countered by relative pronation at the naviculo-cuneiform joints (NCJ) of 7.0 degrees (-36.0 ± 6.6 versus -43.0 ± 5.3 degrees, p < 0.001). Combined hindfoot varus and TNJ supination resulted in an additive supination effect not compensated by NCJ pronation. The cuneiforms in CMT-cavovarus feet were therefore supinated by 19.8 degrees to the ground relative to normal feet (36.0 ± 12.1 versus 16.2 ± 6.8 degrees, p < 0.001). The forefoot-arch and 1st metatarsal-ground angles demonstrated similar supination to the cuneiforms suggesting no further significant rotation occurred distally.

CONCLUSION

Our results demonstrate coronal plane deformity occurs at multiple levels in CMT-cavovarus feet. Majority of the supination arises at the TNJ, and this is partially countered by pronation distally, mainly at the NCJ. An understanding of the location of coronal deformities may help when planning surgical correction.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

A Quality Improvement Project to Assess if Preoperative Trauma Patients Are Receiving Their Prescribed Medications Preoperatively

Introduction All preoperative trauma patients should receive their preoperative medications regardless of being nil per os (NPO). Anticoagulants, angiotensin-converting enzyme inhibitors (ACE-I), and angiotensin II receptor blockers (ARBs) should be omitted. This is according to both local and national guidelines. We noticed that some preoperative patients have not been receiving their morning medications prior to having their operations. This has led to pre and perioperative complications. The aim of this study, therefore, was to conduct a quality improvement project to assess if preoperative trauma patients are receiving their prescribed medications preoperatively when placed NPO. We then aimed to determine the adverse outcome associated with omission and to furthermore devise a robust system to prevent recurrence. Methods Data were collected from the relevant patients' drug charts on the day of the operation. These cases were available on the daily trauma list. We evaluated if there was any clear reason documented for not providing the medications. Following the first round, we implemented our action plan for posters to be taped to drug trolleys on the orthopedic wards and informed the nursing staff of the need to give preoperative medications. We deemed the following to be important medication classes: calcium channel blockers, neuromodulators, beta-blockers, anti-epileptics, digoxin, bronchodilators, anti-anginals, anti-epileptics, and benzodiazepines. This was re-audited after one month to assess compliance and monitor for improvement. Results Forty patients were included in the first round and 41 in the re-audit. In the first round, 16/41 (39%) patients received their medications correctly. In patients who did not receive their medications (n=25), 22 had important medication classes omitted. Post implementation of the posters, 25/41 (61%) patients received their medications correctly. In patients who did not receive their medications (n=16), 10 had important medication classes omitted. The main reason why medications were incorrectly not given was that patients were NPO. Conclusion This quality improvement audit shows that our interventions between audit cycles have made a significant improvement in patients receiving their medications and therefore this has a direct positive impact on patient safety and outcomes. We should continue to have a close rapport with the nursing staff to maintain standards of correct practice, and these audit findings should be escalated to the emergency theatre thereafter.

Cinnamic acid is beneficial to diabetic cardiomyopathy via its cardioprotective, anti-inflammatory, anti-dyslipidemia, and antidiabetic properties

Diabetes-related health issues are increasing day by day in public, and diabetic cardiomyopathy (DCM) is one serious issue among them. There is a lack of proper strategy to control and manage DCM. Here we are attempting a nutraceutical-based approach to protect the heart from DCM. The beneficial effect of cinnamic acid (CiA), was evaluated in an experimental model of diabetes. For this, diabetic model was created by feeding male Wistar rats with a high fat, high fructose diet for 6 months and a single dose of streptozotocin (25 mg/kg bwt). Metformin was used as the positive control. The diabetic rats showed insulin resistance, myocardial injury, and a significant increase of total cholesterol, triglycerides, and LDL. Development of DCM was evident from the increased cardiac mass index, LDH, CKMB, ANP, and CRP levels in the diabetic group. There was a significant increase in the levels of cardiac hypertrophy markers like TGF-β and β-MHC in the hearts of diabetic rats revealing DCM. Pro-inflammatory cytokines (TNF-α, IL-6) and lipid peroxides were significantly elevated in the serum of diabetic rats. Histopathology revealed inflammation and necrosis in the heart of diabetic rats confirming DCM. Oral administration of CiA (5 and 10 mg/kg bwt) prevented the development of DCM via its cardioprotective, anti-inflammatory, anti-dyslipidemia potential, and antidiabetic properties. Similarly, metformin (50 mg/kg bwt) has also shown protection against DCM. We conclude from this study that CiA is found to be beneficial against DCM and recommend more detailed preclinical and clinical studies to develop CiA-based nutraceutical against DCM.

2D Manual vs 3D Automated Assessment of Alignment in Normal and Charcot-Marie-Tooth Cavovarus Feet Using Weightbearing CT

BACKGROUND

The complex deformities in cavovarus feet may be difficult to assess and understand. Weightbearing computed tomography (WBCT) is increasingly used in evaluating complex deformities. However, the bone axes may be difficult to calculate in the setting of severe deformity. Computer-assisted 3D axis calculation is a novel approach that may allow for more accurate assessment of foot alignment or deformity. This study aimed to assess differences in measurements done manually on 2D slices of WBCT vs 3D computer models in normal and cavus feet.

METHODS

We retrospectively analyzed WBCT scans from 16 normal and 16 cavus feet in patients with Charcot-Marie-Tooth disease. Six measurements were assessed: talar-first metatarsal angle (axial plane), forefoot arch angle (coronal plane), and Meary angle, calcaneal pitch, and cuneiform and navicular to floor distances (sagittal plane). 2D measurements were performed manually and 3D measurements were performed using specialized software (Bonelogic, DISIOR). Bland-Altman plots and linear regression were used to analyze differences.

RESULTS

There were no significant biases in measured variables in normal feet. In the cavovarus group, automated assessment calculated increased sagittal plane deformity (fixed bias 7.31 degrees for Meary angle, 2.39 degrees for calcaneal pitch) and less axial plane deformity (fixed bias 10.61 degrees for axial talar-first metatarsal angle). The latter also demonstrated proportional bias indicating greater discrepancy with increasing adduction.

CONCLUSION

Measurements were comparable in normal feet suggesting automated techniques can reliably assess the alignment of bony axes. However, automated calculations show greater sagittal and less axial deformity in cavovarus feet than measured by manual techniques. This discrepancy may relate to rotational deformity seen in cavovarus feet, which may not be easily assessed manually. 3D automated measurements may therefore play a role in better assessing and classifying the cavovarus foot, which may ultimately inform treatment algorithms.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

A Rare Case of Large Hydatidiform Mole Mimicking a Term Pregnancy

Molar pregnancy is a type of abnormal pregnancy that usually presents with amenorrhea, vaginal bleeding and elevated serum ß-hCG levels. We report a rare case of complete hydatidiform mole occurring in a 46-year-old P2L2 lady who presented with a term size uterus and elevated serum ß-hCG level (> 15,00,000 per deciliter, anemia (hemoglobin: 8.1 g/dL), difficulty in breathing and minimal vaginal bleeding. During the course of her evaluation, she had profuse vaginal bleeding, she underwent suction and evacuation, but bleeding was not controlled despite measures to control it. She was given uterotonics and antifibrinolytic agents and uterine artery ligation. But was proceeded with emergency hysterectomy for uncontrolled hemorrhage. The content of suction and evacuation was vesicles with blood clots and histopathology was reported as complete hydatidiform mole. The patient received a total of 4 units of packed red blood cells. She was discharged from hospital on 5th postoperative day and was followed up serial serum ß-hCG level. Therefore, complete mole can present with enlarged uterus, vaginal bleeding and anemia. It is also important to note that intractable bleeding following suction and evacuation not being controlled with uterotonics and antifibrinolytic agents and uterine artery ligation may require hysterectomy to save the patient's life.

Ultrasonographic Evaluation of Inferior Vena Cava: Aorta Index with a Cut-off Value of 1.0 as a Predictor for Hypotension after Induction of General Anesthesia; An observational study

Background Hypotension after induction of general anesthesia (GA) is common due to pre-existing hypovolemia and has adverse effects on organ function. Out of several methods to predict post-induction hypotension, nowadays Inferior Vena Cava: Aorta (IVC: Ao) index has been studied with different cut-off values. However, limited studies have been performed in our part of the world. Objective To evaluate the efficacy of pre-induction Inferior Vena Cava: Aorta index with a cutoff value of 1.0 for predicting the occurrence of post-induction hypotension after general anesthesia in the Nepalese population. Method A total of 100 patients of ASA I and II, aged more than 18 years posted for elective surgeries under general anesthesia were enrolled in this cross-sectional, observational study. Ultrasonographic guided Inferior Vena Cava: Aorta index was calculated and based on a cut-off value of 1.0, two groups were formed. Seventy patients in group A with Inferior Vena Cava: Aorta index less than 1.0 and 30 patients in group B with Inferior Vena Cava: Aorta index more than 1.0 were enrolled. Vitals parameters were recorded every minute for five minutes after induction of general anesthesia. Incidence of hypotension was the primary outcome. Statistical analysis was done using student t-test, ANOVA test and Chi-square test. Result Inferior Vena Cava: Aorta index with cut-off value of 1.0 predicted post-induction hypotension with excellent efficacy. Total 65 patients developed post-induction hypotension, out of which 63 patients had Inferior Vena Cava: Aorta index less than 1.0. Conclusion We concluded that pre-induction Inferior Vena Cava: Aorta index with cut-off value of 1.0 have high diagnostic accuracy with high degree of sensitivity and specificity to predict hypotension after induction of general anesthesia.

Implant fracture of the TFNA femoral nail

BACKGROUND

The TFNA (Trochanteric Fixation Nail Advanced) Proximal Femoral Nailing System (DePuy Synthes) is frequently used for intramedullary fixation of proximal femoral fractures. The aim of this study was to evaluate all TFNA implant fractures at a UK trauma unit to ascertain any patient or surgical factors associated with implant failure.

METHODS

A retrospective study was carried out identifying all patients that sustained a TFNA implant fracture over a five-year period. Data was collected on demographic information, ASA, co-morbidities, mechanism of injury, fracture pattern according to the AO/OTA classification, procedure details and time to failure. Radiographs were assessed by two independent reviewers to identify tip-apex distance (TAD), calcar TAD, reduction quality and union status at time of implant failure.

RESULTS

Six cases were identified, all with implant breakage at the aperture for the proximal screw. All femoral fractures were intertrochanteric reverse obliquity type (OA/OTA 31A3). Two were traumatic fragility fractures and the remainder atraumatic. Mean time from index surgery to revision was 441 days (104-963). Mean TAD was 20.5 mm (15-24) and mean calcar TAD 24 mm (18-32). All six cases displayed radiographic non-union at the time of implant fracture.

CONCLUSION

Pathological fractures resulting in reverse obliquity type fracture patterns and subsequent non-union appear to be contributory factors to TFNA breakage at the proximal screw aperture. This may be further exacerbated by alterations to the nail design from previous generations. In these patients, close follow up with clinical and radiographic surveillance should be employed. Further biomechanical and clinical studies are required to compare this finding against other nail designs.

Knowledge on American Heart Association Guidelines Update for Cardiopulmonary Resuscitation among the Nurses Working at University Hospital, Kavre

Background Cardiopulmonary resuscitation is the foundational technique for the emergency treatment of cardiac arrest and the standardized training of it has been emphasized more than ever. Competence of the nurses in this lifesaving procedure is a critical factor in patient outcome from cardiac arrest and can largely prevent sudden death. Objective Many evidences suggest lack of knowledge on proper cardiopulmonary resuscitation among nurses so the aim of this study was to assess the knowledge on 2015 American Heart Association guidelines update for cardiopulmonary resuscitation among nurses working at University hospital and to identify the relationship between the level of knowledge and selected variables. Method Two hundred and sixty nurses working in Dhulikhel hospital participated in the study. A cross-sectional descriptive study was conducted using a predesigned questionnaire based on 2015 guidelines updates for cardiopulmonary resuscitation that incorporated total of 20 questions. Result Total 260 participated in the study and all were female. Only one third of the nurses had good knowledge regarding 2015 guidelines update for cardiopulmonary resuscitation. No significant results existed between the knowledge score and age of the nurses, duration of work experience. However, significant results existed between the knowledge score and qualification, designation of the nurses and previous training on cardiopulmonary resuscitation. Conclusion One third of the nurses had good knowledge regarding 2015 guidelines update for cardiopulmonary resuscitation in this study. Thus, knowledge and practical approach has to be updated with current guidelines in cardiopulmonary resuscitation in order to improve the safety and effectiveness of patient care.

Open Surgical Management of Abdominal Aortic Aneurysm at a Community Based University Hospital in Nepal

Aortic aneurysms are abnormal dilatation of aorta. The risk factors include male sex, age > 65, smoking, coronary artery disease and hypertension. Here we report a case of infra-renal abdominal aortic aneurysm (AAA) of diameter 6 cm. The patient sucessfully underwent aorto-biiliac bypass surgery using Dacron Y graft. During abdominal aortic aneurysm surgery anesthetic challenge is also of paramount importance and should be considered.

Improving Knowledge, Skill and Confidence of Novice Medical Doctors in Trauma Management with Principles of ABCDE

Background Trauma is one of the major public health concerns clamming about five million death annually worldwide. Experience and confidence of a doctor in the management of trauma patients have big impact on the overall outcome. Objective This study aims to evaluate the outcome of a trauma course in improving the knowledge, skill and confidence of novice doctors in managing trauma victims. Method A pre/post test analytical study was carried out among novice medical doctors from Kathmandu University School of Medical Science (KUSMS) who participated in a standard two and a half day trauma course, that utilizes the principles of ABCDE, as a part of their regular training. Pre-course knowledge and skill were compared with immediate post-course scores on the same guidelines. Objective structured and subjective written feedbacks from the participants were analyzed qualitatively to identify the perceptions of candidates. Result Sixty-eight males and twenty-nine females completed the course. The average pre-test scores in knowledge and skill were 8.3(33.2%) and 19.6(78.5%) respectively. Similarly the post-test scores were 16.04(64.2%) and 22.45 (89.5%) respectively, showing statistically significant improvements (P 0.000). The mean percentage improvement in knowledge was 48.8% and that in skill was 160.9%. The feedback analysis showed majority of the participants were satisfied with the course and they perceived improved "self-confident" in handling trauma cases. Conclusion All the novice doctors should participate in a standard trauma course hence their knowledge, skill and confidence in handling a trauma can be improved.

Study on Maternal and Immediate Fetal outcome of placenta previa

Aims:  This study aimed to analyze the demographic profile, maternal and fetal outcome of placenta previa.Methods:  This was a retrospective study done at Patan Academy of Health Sciences. The study population  comprised of all the patients that had caesarean section   for placenta previa  from April 2012 to October 2015. All patients diagnosed with placenta previa clinically, ultrasonograph or incidentally  during caesarean sections were recruited in this study.  The data were obtained from medical records and hospital database system. Individual charts were reviewed  and data on various  parameters were collected.Results:  In Patan hospital, there were total 126 placenta previa cases out of 21,552 deliveries during the two and half year period hence the incidence  was 0.58 %.  We were able to retrieve patient records of only 108 of 126 cases. The incidence of placenta previa was higher with increasing maternal age ≥30 years (41.67%), more common in multigravida (65.74%). We found that associated risks factors  included previous CS, multiparity and dilatation and curettage (40.74%).  Eleven patients required blood transfusion, seven of them had blood loss of 1000-1400 ml, one had blood loss of 2000 ml. Also, Caesarean hysterectomy were performed in two patients. In term of fetal outcomes, 37.04% were preterm birth and 29.63% of the babies had low birth weight.  There was one incident of congenital anomaly, one intrauterine fetal death and six neonatal deaths.Conclusions: Placenta previa is an obstetrics complication that is potentially life threatening to both the mother and the baby.

Ultrasound Guided Femoral Nerve Block to Provide Analgesia for Positioning Patients with Femur Fracture Before Subarachnoid Block: Comparison with Intravenous Fentanyl

Background Positioning patients with fractured femur for subarachnoid block is painful. Intravenous analgesics or peripheral nerve block like femoral nerve block or fascia iliaca compartment block are some of the available techniques to reduce pain. We compared the efficacy of femoral nerve block and intravenous fentanyl in providing effective analgesia before positioning for subarachnoid block. Objective This study was designed to compare between ultrasound guided femoral nerve block with lignocaine and intravenous fentanyl in providing effective analgesia before positioning patient with femur fracture in sitting position for subarachnoid block. Method Forty patients undergoing surgery for femur fracture were randomized to either femoral nerve block (FNB) or intravenous fentanyl (IVF) group. Group FNB (n=20) received 20 ml of 2% lignocaine around femoral nerve under ultrasound guidance. IVF group (n=20) received 2 mc/kg of fentanyl intravenously. Pain score on effected limb was assessed after five minutes. If VAS was ≤ 4, the patient was positioned in sitting for subarachnoid block. On failure to achieve this with the above treatment, intravenous fentanyl 0.5 mc/kg was administered and repeated as necessary before positioning. VAS during positioning was documented and compared between the two groups. Similarly, secondary outcomes of the intervention: quality of patient position, rescue analgesia and duration of the procedure were also compared. Data were subjected to Mann Whitney U-test and chi-square test. Level of significance was set at 0.05. Result FNB group had significantly less VAS scores (median) than IVF group :2 vs 3; p=0.037) during positioning for spinal anaesthesia. Procedure time (median) for spinal anaesthesia was also significantly less in FNB than in IVA group (10 vs 12 min; p=0.033) Conclusion Ultrasound guided femoral nerve block was more effective than intravenous fentanyl for reducing pain in patients with proximal femur fracture before spinal anaesthesia.

Comparison of Ultrasound Guided Transversus Abdominis Plane Block Versus Local Wound Infiltration for Post Operative Analgesia in Patients Undergoing Gynaecological Surgery Under General Anaesthesia

Background Transversus abdominis plane block has been recently developed as a part of multimodal post operative analgesic techniques. We compared the analgesic efficacy of this technique with local bupivacaine infiltration in patients undergoing gynaecological surgeries with pfannenstiel incision and lower midline incision under general anaesthesia.Objectives To evaluate the efficacy of ultrasound guided transversus abdominis plane block for postoperative analgesia.Methods Patients were randomly allocated to three groups: control group (n=15), transversus abdominis plane block group (n=15), who received bilateral transversus abdominis plane blockwith 0.25% bupivacaine, and local infiltration group (n=15), who received local wound infiltration with 0.25% bupivacaine at the end of surgery. All patients received intramuscular diclofenac 12 hourly and intravenous tramadol SOS in the postoperative period. Visual analogue scores for pain were assessed at 1,2,4,8,12 and 24 hours postoperatively and these were compared between the three groups. Average tramadol consumption in 24 hours were also compared among the three groups. Data were subjected to univariate ANOVA test and chi-square test. Level of significance was set at 0.05.Results Visual analogue scores were significantly less in transversus abdominis plane block group and effect lasted up to 12 hours at rest postoperatively and 8 hours during cough and movement.Conclusion Bilateral Transversus abdominis plane block was effective in reducing postoperative pain scores for 8 to 12 hours postoperatively. This block was also successful in reducing postoperative opioid requirement.Kathmandu University Medical Journal Vol.12(2) 2014: 93-96

Effect of preloading on hemodynamic of the patient undergoing surgery under spinal anaesthesia

BACKGROUND

Hypotension and bradycardia after conduction of spinal anaesthesia are common side effects because of sympathetic blockade. Efforts to prevent these complications have been attempted like preloading with crystalloids, colloids or use of vasopressors. The role of volume preloading to prevent hemodynamic changes associated with spinal anaesthesia has been recently questioned.

OBJECTIVE

The objective of the study was to investigate the effects of volume preload on changes of patient's hemodynamic.

MATERIALS AND METHODS

A Quasi- experimental design was used to conduct the study. Taking written informed consent, 40 patients of age group 18-45 years and ASA grade I and II undergoing surgery under spinal anaesthesia in operation theatre of Dhulikhel Hospital were selected as the sample of the study and allocated randomly to 2 groups. Group I did not receive volume preload and Group II received preload of 1000 ml of Ringer's lactate solution within 30 minutes immediately before giving the spinal anaesthesia. An observational checklist was used to collect demographic, intraoperative and post-operative records of systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR).

RESULTS

The findings revealed that the hemodynamic changes occurred in all patients. The decrease in SBP, MBP and DBP from baseline was statistically significant at all points of time (p = 0.000). The decrease in HR from baseline was not statistically significant at all points of time (p>0.05). The overall incidence of hypotension was 50%, among which 9 (45%) were from without preload group and 11 (55%) were from with preload group. The incidence of hypotension was similar in groups, sexes and surgical conditions (General Surgery, Gynae/Obs and Orthopaedics). There were no significant differences in hemodynamic changes among groups.

CONCLUSION

On the basis of findings, it is concluded that volume preloading had no effect on the incidence of hypotension and bradycardia after spinal anaesthesia.

Incidence and risk factor for ventilator-associated pneumonia in Kathmandu University Hospital

BACKGROUND

Ventilator associated pneumonia is a major cause of morbidity in the intensive care unit. Difficulties in identification of the risk factors, in diagnosing and in prevention, have intensified the problem.

OBJECTIVES

To measure the incidence of ventilator associated pneumonia in intensive care unit and to identify the risk factors associated.

METHODS

A prospective observational cohort study was done in which we evaluated 69 patients who were mechanically ventilated for more than 48 hours to find out the development of nosocomial pneumonia and presence or absence of risk factors. Data were subjected to univariate analysis using chi-square and t-test. Level of significance was set at 0.05.

RESULTS

Twenty two (31.88%) out of 69 patients developed ventilator associated pneumonia, majority of them between four days to 14 days. Reintubation, invasive lines, H2 blockers and low PaO2/FiO2 were identified as major risk factors in our study. Enteral feeding via nasogastric tube and use of steroids was not associated with development of ventilator associated pneumonia. The patients with ventilator associated pneumonia had significantly longer duration of mechanical ventilation (18.88+/-7.7 days vs 7.36+/-4.19 days) and stay (29+/-17.8 days vs 9.22+/-5.14 days). The morality was similar for both the groups with or without ventilator associated pneumonia.

CONCLUSION

The incidence of ventilator pneumonia is high. Patients requiring prolonged ventilation, re-intubation, more invasive lines and H2 blockers, are at high risk and need special attention towards prevention.

Management of shock in children in the emergency department

Early recognition of shock is the key to successful resuscitation in critically ill children. Often, shock results in or co-exists with myo-cardial dysfunction or acute lung injury. Recognition and appropriate management of these insults is crucial for successful outcomes. Resuscitation should be directed to restoration of tissue perfusion and normalization of cardiac and respiratory function. The underlying cause of shock should also be addressed urgently. The physiological response of individual children to shock resuscitation varies and is often variable and unpredictable. Therefore, repeated assessments with continuous, non-invasive monitoring are needed for taking appropriate decisions in the ED. Although global indices of tissue oxygen delivery such as the mixed venous oxygen saturation (SvO(2)) help in targeting therapies more accurately, it is often unavailable in emergency settings. Isotonic fluids form the cornerstone of treatment and the amount required for resuscitation is based on etiologies and therapeutic response. After resuscitation has been initiated, targeted history and clinical evaluation must be performed to ascertain the cause of shock. Management of co-morbidities such as asthma and seizures should be implemented simultaneously. Inotropes, respiratory support, antibiotics and steroids may also be needed during the management of shock. While the management of shock can be protocol based, the treatment needs to be individualized depending on the suspected etiology and therapeutic response.

Predicting difficulties during laparoscopic cholecystectomy by preoperative ultrasound

BACKGROUND

The aim of this study was to determine whether the preoperative USG finding can predict the risk of conversion or difficulty during the laparoscopic cholecystectomy.

MATERIALS AND METHODS

200 patients undergoing Laparoscopic cholecystectomy at Kathmandu Medical College Teaching Hospital were included. Sonographic parameters like size of gall bladder, wall thickness, distance between hepaticoduodenal ligament and Hartmann's pouch and the size of stone were taken into consideration and difficulties in terms of adhesions around gall bladder, anatomy of calot's triangle and difficulty in peeling off gall bladder from the bed and retrieval were analyzed.

RESULT

In 8 of 200 patients (4%), LC was converted to open procedure. In univariate analysis all the sonographic parameters we had included in this study were statically significant (p value <0.05).

CONCLUSION

Preoperative sonographic signs can predict the difficulty in laparoscopic cholecystectomy.

Potential role of dendritic cells for progression of atherosclerotic lesions

Atherosclerosis is a lipid related chronic inflammatory disease in which immune mechanisms play a pivotal part. Its lesion is filled with large numbers of immune cells. In 1995 dendritic cells (DCs) were identified in atherosclerotic plaques and thought to play an important part in atherogenesis. DCs express MHCI and ll, HLA-DR, CD1a, ICAM-1 and VCAM1 on their surfaces, and this explains their unique ability to activate naive T cells. The risk factors for atherosclerosis are the factors for DCs' activation and migration. Mature DCs are capable of presenting antigen to T cells, which play an important part in progression of disease. Statin and diltiazem have been shown to protect endothelial function by suppressing the function of DCs and play an important part in preventing atherosclerosis.

PHYSICIAN-PATIENT COMMUNICATION REGARDING PRESCRIBED MEDICATION IN AN AMBULATORY CARE SETTING IN KATHMANDU, NEPAL

Physician-patient interactions often lead to prescription of medicines. Safety andcompliance in the use of these medicines are largely dependent on proper verbal aswell as written communication between prescriber and patient. However, severalpublished reports suggest that such communication is often inadequate. The presentstudy indicated suboptimal doctor-patient communication at a tertiary care hospitalin Nepal. Fifty-two (21.7%) of the 240 patients/caregivers interviewed after out-patientconsultation claimed that doctors did not provide any information on prescribedmedicines. Nearly a quarter of the 188 patients/caregivers who did report havingreceived information could not recall what they had been told, and in more than halfof these cases the lack of recall was attributed to problems in communication. Frequentuse of the English language and Latin abbreviation in prescribed dosing schedulesindicated a need for improvement in written communication as well.Key Words: prescribing information; communication; physician-patient interaction; Nepal.

Acute respiratory failure and oxygen therapy

Acute Respiratory Failure (ARF) results in an inability to maintain gas exchange at a rate commensurate with the demands of the body and results in hypoxemia and/or hypercarbia, the mechanisms of which may be different. Hypoxemia commonly occurs due to Ventilation Perfusion (V/Q) mismatching, intrapulmonary shunt, diffusion defect or hypoventilation. Hypercarpnic respiratory failure may also be multifactorial but is usually due to inhibited central respiratory drive or inefficient respiratory muscle pump. Hypercapnia may occur in upper and lower airways obstruction, respiratory muscle fatigue and occasionally due to excess CO2 production (burns and excessive glucose administration). Issues in management centre around assessment of severity, determining the need for intervention, establishing diagnosis and etiology and institution of specific treatment. Diagnosis of respiratory failure may be made clinically and confirmed by blood gas analysis. Calculation of oxygenation indices will delineate extent of hypoxemia. When evaluating a child with respiratory failure, one should be aware that a child with prominent respiratory symptoms may have non-respiratory disease (i.e. metabolic acidosis, DKA) and conversely, advanced respiratory failure may be present in a child with no respiratory distress (central hypoventilation secondary to drugs, infection) careful assessment of history, complete physical examination and evaluation of lab parameters may clarify the diagnosis. Serial assessment of sensorium, respiratory symptoms, ABG and response to treatment will provide valuable clues to determine the need for intervention. Oxygen, like any drug, must be administered in a prescribed dose, only when indicated with the potential risks borne in mind. A variety of oxygen delivery devices are available; which ever device is used, the resulting FiO2 and devisable end points must be clearly determined. Hazards of oxygen therapy range from retinal damage in premature infants, damage to the alveolar capillary membrane with resultant hypoxemia) atelectasis and decreased mucociliary activity.

The incidence and management of post-tonsillectomy haemorrhage: a Singaporean experience

AIM OF STUDY

To audit the incidence and management of post-tonsillectomy haemorrhage in the Singaporean context.

METHODS

Three hundred and sixty-six consecutive tonsillectomies done over a 2-year period were retrospectively studied. Demographic details and indication for operation were evaluated in conjunction with the incidence and management of post-operative haemorrhage.

RESULTS

84.4% of the patients were adults while 58.7% were males. Chronic tonsillitis was the most common indication for operation (84.5%). The incidence of primary and secondary haemorrhage was 0.6% and 7.1% respectively. 3.8% of the patients had to return to the operation theatre to secure haemostasis. The use of post-operative antibiotics did not significantly affect the incidence of haemorrhage. There was no mortality from this complication. The haemorrhage rate was significantly higher among the adults (p = 0.048) and males (p = 0.019) in this study.

CONCLUSION

Our overall post-tonsillectomy haemorrhage rate was higher than that reported in most of the Western publications because adults rather than children predominated in our series. We report a low incidence of primary haemorrhage which is in keeping with the results of studies on electrodissection tonsillectomies. Our findings indicate that tonsillectomy is a safe procedure which can be performed on a day surgery basis if the patients are carefully selected.