Utility of opening rhythms in predicting time to return of spontaneous circulation in cardiac arrest victims in a resource constrained setting: a single centre prospective observational study

Background: Time to ROSC has been shown to be an important and independent predictor of mortality and adverse neurological outcome. In resource limited situations judicious deployment of resources is crucial. Prognostication of arrest victims may aid in better resource allocation. This study aimed to assess the time to Return of Spontaneous Circulation (ROSC) in cardiac arrest victims and its relationship with opening rhythms.Methods: Consecutive victims of cardiopulmonary arrest who presented to a single center were included in this study if they met the inclusion and exclusion criteria. Time at which opening rhythm was analyzed and time at which ROSC was achieved was noted. This was done for all cases and mean time to ROSC was calculated for each opening rhythm. All those patients who achieved ROSC were followed up till hospital discharge or death.  Primary outcome measured was achievement of ROSC and the secondary outcome was the survival to hospital discharge.Results: A sample size of 100 was calculated to yield a significance criterion of 0.05 and a power of 0.80 based on prior studies. Out of 100 patients studied. 58% had shockable rhythms and 42% had non-shockable rhythms.  Mean time to ROSC for shockable rhythm was 5.55±3.51 minutes, and for non-shockable rhythm is 17.29±4.18 minutes.  There was a statistically significant difference between opening rhythms in terms of survival to hospital discharge (p=0.0329).Conclusions: Cardiac arrests with shockable rhythms attained ROSC faster when compared to nonshockable rhythms. Shockable rhythms have a better survival to hospital discharge when compared to shockable rhythms. Opening rhythms may aid the clinician in better utility of resources in a resource constrained setting.

Management of stillbirths: an observational analysis at a rural tertiary care centre in Kerala, India

Background: Stillbirth is a distressing event, both for the expecting mother and the obstetrician. Several maternal, social and circumstantial factors influence its occurrence. These women with intrauterine fetal death need to be treated in a considerate manner. Our aim was to analyse different methods   of induction, management of labour and their outcomes in women with antepartum fetal demise.Methods: All women admitted to a tertiary care centre with intrauterine fetal death after 22 weeks during the study period of 24 months were recruited. Maternal sociodemographic characteristics and relevant investigations were studied. Induction of labour was achieved with mechanical and pharmacological methods.  Stillborn babies, placentae and umbilical cord were examined after delivery.Results: There were 175 women with IUFD   admitted during the study period. The stillbirth rate was 38.6 per1000 live births.148 women (84.57%) required induction of labour while16 women had spontaneous onset of labour. Among the 44 women with previous Cesarean section, 11 underwent elective Cesarean section. 19 women (57.6%) out of 33 cases of trial of labour after Cesarean had a successful vaginal delivery. There were 2 cases of rupture uterus and 10 women required ICU admissions. Intrauterine growth restriction was the leading cause of stillbirth (41.8%) followed by hypertensive disorders (27.7%).Conclusions: Present study has shown that vaginal birth can be achieved in most women with mechanical and pharmacological methods of induction within a reasonable period of time.

Factors associated with maternal near miss: A study from Kerala

Severe life-threatening situations leading to a 搉ear-miss� event may arise unexpectedly in pregnancy. Delay in seeking help, delayed access to care, and poor quality of emergency obstetric services can lead to undesirable outcomes. Women meeting the WHO 搉ear-miss� criteria were assessed using a cross-sectional study design. These women were interviewed to evaluate the circumstances leading to a near-miss event. Reasons for delays in getting proper care were studied using the �delays� model.� Thirty-two women met the criteria for 搉ear miss� during the 15-month study period, with a maternal near-miss incidence ratio of 9.27/1000 live births. One or more delays were identified in 21 (65.6%) near-miss cases. Delayed access to care was the most important factor for delay. A review of near-miss cases can be used to improve and optimize the existing obstetric services.

Fissures and Lobes of Lungs: A Morphological and Anatomical Study.

Background and Aims: The fissures of the lungs serve as boundaries for the lobes of the lungs. They also acts as barriers to avoid the spread of pathologies .The proposed aim of the study was to study the fissures and lobes of the lungs and their variations and to compare them with previous studies and to find their clinical implications. Methods: Thirty pairs of lungs were used for the study, obtained from formalin-fixed cadavers of south-indian origin. The lung specimens were observed for the patterns of lobes and fissures, variations were noted and specimenswere photographed. Results: Five right lungs showed absence of horizontal fissure. Out of thirty, twelve right sided lungs showed incomplete fissures.On the left side, seven specimens showed incomplete oblique fissure. In addition, two right-sided specimens and four left sided specimens showed presence accessory fissure. Conclusion: The results and their comparison with the previous works show that there is a wide range of difference in occurrence of major, minor and accessory fissures between and among different populations. Knowledge of such variations is mandatory for surgeons in pre-operative planning for performing pulmonary lobectomies and for radiologists for interpreting X-rays and CT scans.

Study on Branching Pattern of Arch of Aorta in South Indian Population.

Background and aim:Arch of aorta is the continuation of ascending aorta lies in the superiormediastinum. The present study aims at finding the branching pattern of arch of aorta and correlate it with the embroyological and clinical significance. Materials andMethods: 30 formalin-fixed cadavers procured fromthe department of anatomy, Karpaga Vinayaga Institute ofMedical Sciences,Madhuranthagamwere dissected to study the branching pattern of arch of aorta. Results:Out of 30 cadavers 19 cadaversNormal branching pattern (Right brachiocephalic, Left common carotid and Left subclavian artery).10 cadavers showed the left common carotid arising in common with the brachiocephalic trunk. Only one showed the left vertebral artery arising directly from the aorta, the origin lying between left carotid and left subclavian arteries. Conclusion: Knowledge of normal anatomy and frequency in the variations in the branching pattern of the arch of aorta is of great importance in patients who have to undergo aortic instrumentation, four vessel angiography or supraaortic thoracic, head and neck surgery.

Use of rituximab in pemphigus patients with chronic viral hepatitis: Report of three cases.

Use of rituximab in patients with chronic viral hepatitis can worsen pre-existing hepatitis or reactivate occult infection. There are no reports of use of rituximab in pemphigus patients with co-existing viral hepatitis. Herein, we report three pemphigus patients with co-existing chronic viral hepatitis (hepatitis C (n = 2), hepatitis B (n = 1)), who were treated successfully with rituximab under close supervision and concurrent antiviral drug administration. There was no derangement of the liver function tests or increase in viral load in any of the patients. By incorporating good collaboration with a hepatologist and close follow-up, such patients can be managed successfully with biologic therapies when the conventional treatment modalities have failed.

Study of palmar patterns in diabetic patients.

Nowadays study of dermatoglyphics has a great importance in judicial and criminal researches. Similarly its study is related to some genetic diseases has an immense applications. Diabetes Mellitus is the silent killer of mankind and public health problem. Therefore investigators are looking for new methods for its early diagnosis and treatment. Dermatoglyphics is a growing discipline and its ease and ready applicability render it as a useful tool to the clinician. Dermatoglyphics may be effectively employed as a screening procedure in future and may help in the early detection of cases of diabetes mellitus. Methods: The present study is undertaken with an aim to evaluate the dermatoglyphic features in diabetic patients. The study consists of 150 diabetic patients and 150 normal healthy individuals as controls. They were 75 males and 75 females in each group. Dermatoglyphic prints were taken by “Ink method” described by Cummins and Midlo and further subjected to statistical analysis to find the variations in the dermatoglyphic features among diabetic patients and control groups. Results: Mean value of a-b ridge count is neither increased nor decreased in diabetic patients (P = 0.852). Mean value of atd angle is slightly decreased in diabetic patients (P = 0.2332). The frequency of t and t' are increased (P = 0.8462, P = 0.6681) and the frequency of t" is decreased (P = 0.757) in diabetic patients but they are not statistically significant. Conclusion: From the present study, it appears that there do exists a variation in the dermatoglyphic patterns in diabetic patients with an advantage of being simple and economical ‘ink’ method. As the specific features of dermatoglyphic patterns are present in diabetic patients, it can be used for mass screening program to segregate the predicted diabetic patients.

Bifurcation Levels of The Common Carotid Arteries: A Cadaveric Study in South Indian Population.

Background and aim: The present study aims at finding the bifurcation level of common carotid artery and correlate it with the level of upper border of thyroid cartilage. Materials and Methods: Forty cadavers were dissected to study the bifurcation level of common carotid artery. The symmetry between the sides were noted. Results: The level of bifurcation of the common carotid artery was at the level of upper border of thyroid cartilage in sixty-seven cases .Only nine cases showed the higher level with the range of 3.2 mm to 19.3 mm above the level of upper border of thyroid cartilage.4 cases showed the lower level of bifurcation in the range of 2 mm to 10 mm below the level of upper border of thyroid cartilage. In the present study, the bifurcation levels were symmetrical on both sides. Conclusion: The bifurcation level of common carotid artery coincides with the upper border of thyroid cartilage in the present study. The awareness in the variation of bifurcation level is necessary to avoid undue complications during the surgeries and procedures done in head and neck region.

Rubella seronegativity among health care workers in a tertiary care north Indian hospital: Implications for immunization policy.

Background: Rubella is traditionally considered a childhood disease but has the potential to cause outbreaks in hospital set ups. It is important to know the susceptibility status of health care workers (HCWs) as to frame guidelines for their immunization and thus prevent hospital outbreaks. Participants: The rubella susceptibility status of 313 HCWs working in the institute was assessed. This study was initiated after we reported an outbreak due to rubella among HCWs of our institute. Materials and Methods: The serum samples were tested to determine Rubella IgG titres by enzyme linked immunosorbent assay (ELISA). Results: Overall, 48 (15.3%) subjects were found to be negative, thereby indicating their susceptibility to infection. Out of them, 29 (60.5%) were in contact with pregnant women during the course of their employment. There is a risk of nosocomial transmission of rubella from affected HCWs to their contacts especially pregnant women as many of the rubella infections are asymptomatic. Conclusion: Hence, we stress the need for vaccinating the HCWs at the start of their employment to contain the spread of infection and also to reduce the risk of outbreaks in work place.

Treatment of chronic hepatitis C in end stage renal disease: experience at a tertiary care centre.

Introduction: Treatment of patients with chronic hepatitis C (CHC) is difficult in the setting of end stage renal disease (ESRD). The present study aimed to analyze the treatment outcome in patients with CHC and ESRD, being evaluated for kidney transplantation. Methods: Data of 65 patients of ESRD with CHC (males: 53, mean age: 39.2±14.4 years) was analysed retrospectively. Patients were treated with either pegylated or conventional interferon (IFN) without ribavirin. Treatment response was assessed for rapid virological response (RVR), early virological response (EVR), end of treatment response (ETR) and sustained virological response (SVR). Results: All patients were receiving hemodialysis (duration 1-60 months). Sixteen patients (25%) (genotype 1: 11, genotype 3: 4, genotype 2: 1) agreed for treatment (13 pegylated IFN and 3 conventional IFN). RVR was achieved in 7 patients (44%) and out of 11 patients (69%) who achieved EVR, ETR was achieved in 7 (44%) patients. Seven patients (44%) dropped out during treatment (2 because of side effects). SVR could be demonstrated in one of 7 patients who achieved ETR (6 patients were lost to follow up after ETR). Conclusions: In our experience, dropouts before, during and after treatment are a major problem in patients with CHC and ESRD. Of those who complete treatment, around half of them are able to achieve the end of treatment response.

Hepatic amyloidosis presenting as intrahepatic cholestasis and portal hypertension: case series and review of literature

Liver involvement in systemic amyloidosis is not uncommon; however, presentation with jaundice is rare. It is considered a preterminal sign. We present four cases of primary AL amyloidosis with severe intrahepatic cholestasis, two of whom presenting also with features of portal hypertension with oesophageal varices. Histopathology revealed diffuse hepatic amyloid deposits in the lobules, portal tracts and sinusoidal space. Review of literature reveals that hepatic amyloidosis presenting with cholestasis and portal hypertension is unusual and portends a poor prognosis

Minimal hepatic encephalopathy: time to recognise and treat.

Minimal hepatic encephalopathy represents a part of the spectrum of hepatic encephalopathy and is the mildest form. While patients with hepatic encephalopathy have impaired intellectual functioning, personality changes, altered levels of consciousness, and neuromuscular dysfunction, patients with minimal hepatic encephalopathy have no recognisable clinical symptoms of hepatic encephalopathy but have mild cognitive and psychomotor deficits. The prevalence of minimal hepatic encephalopathy has been reported to vary between 30% and 84% in patients with liver cirrhosis and is higher in patients with poor liver function. The diagnosis is usually made by neuropsychological and/or neurophysiological testing in cirrhotic patients who are otherwise normal on neurological examination. Minimal hepatic encephalopathy is a clinically significant disorder that impairs the health-related quality of life, predicts the development of overt encephalopathy and is probably associated with a poor prognosis. Thus screening all patients with cirrhosis for minimal hepatic encephalopathy using psychometric testing is recommended. Pharmacologic therapy is recommended for patients diagnosed with minimal hepatic encephalopathy. The pathogenesis of minimal hepatic encephalopathy is considered similar to that of overt hepatic encephalopathy and ammonia plays a key role. Thus ammonia lowering agents such as lactulose, L-ornithine and L-aspartate that have good safety profiles are recommended. Future studies will better define the role of probiotics, levocarnitine and sodium benzoate.

Minimal hepatic encephalopathy.

Minimal hepatic encephalopathy (MHE) is the mildest form of spectrum of hepatic encephalopathy (HE). Patients with MHE have no recognizable clinical symptoms of HE but have mild cognitive and psychomotor defi cits. The prevalence of MHE is high in patients with cirrhosis of liver and varies between 30% and 84%; it is higher in patients with poor liver function. The diagnostic criteria for MHE have not been standardized but rest on careful patient history and physical examination, normal mental status examination, demonstration of abnormalities in cognition and/or neurophysiological function, and exclusion of concomitant neurological disorders. MHE is associated with impaired health-related quality of life, predicts the development of overt HE and is associated with poor survival. Hence, screening all patients with cirrhosis for MHE using psychometric tests, and treatment of those patients diagnosed to have MHE has been recommended. Ammonia plays a key role in the pathogenesis of MHE, which is thought to be similar to that of overt HE. Thus, ammonia-lowering agents such as lactulose and probiotics have been tried. These agents have been shown to improve cognitive and psychometric defi cits, and have good safety profile. Future studies will better defi ne the role of other drugs, such as rifaximin, acetyl L-carnitine and L-ornithine L-aspartate.

Minimal hepatic encephalopathy: diagnosis by neuropsychological and neurophysiologic methods.

Minimal hepatic encephalopathy (mHE) consists of cognitive deficits found on neuropsychological and/or neurophysiologic methods in patients with liver disease, present most commonly in cirrhosis. Patients suffering from mHE may have psychomotor slowing and cognitive deficits affecting their ability to perform many activities of daily life, especially driving and other activities requiring subtle cognitive abilities. It has been now been shown that patients with mHE improve after treatment with agents like lactulose and other therapeutic interventions. Neuropsychological and neurophysiologic tests have been widely used and have shown the greatest promise for the detection of mHE. Commonly used psychometric tests include trailmaking tests (number and figure connection tests) and Wechsler Adult Intelligence Scale (WAIS) for verbal and performance skills. Among the various neuropsychological or psychometric tests, trailmaking tests and block design and digit symbol tests from WAIS-performance battery appear to be adequate for diagnosis of mHE. Standardized tests including NCT A and B, line tracing, serial dotting test and digits-symbol test (PSE syndrome test) validated in German patients need validation in other populations. Both exogenous evoked potentials and endogenous event-related potentials have been used extensively in diagnosing mHE. However, the event-related P300 wave is the most consistent wave and can be considered the electrophysiological counterpart of the psychometric tests as both involve active use of the cognitive faculties. Other new tests like the critical flicker frequency have shown some promise but further studies are required to substantiate initial results. In conclusion, a combination of at least two psychometric (trailmaking tests [NCT or FCT], block design and digit symbol test) and neurophysiological tests (P300 auditory evoked potential or electroencephalography with mean dominant frequency) appears to be optimal in detecting mHE.

Brunner's gland polyp with upper gastrointestinal bleeding managed by endoscopic polypectomy: a report of two cases.

We report 2 rare cases of Brunner's gland adenoma presenting with upper gastrointestinal bleeding. They were removed by endoscopic polypectomy. In skilled hands, this method is safe and effective.