Evaluation of thyromental height as a predictor of difficult laryngoscopy and difficult intubation: a cross-sectional observational study

Abstract Background and objectives Several anthropometric measurements have been suggested to identify a potentially difficult airway. We studied thyromental height (TMH) as a predictor of difficult laryngoscopy and difficult intubation. We also compared TMH, ratio of height to thyromental distance (RHTMD), and thyromental distance (TMD) as predictors of difficult airway. Methods This cross-sectional observational study was conducted in 300 adult surgical patients requiring tracheal intubation. Preoperatively airway characteristics were assessed. Standard anesthesia was administered. Degree of difficulty with mask ventilation, laryngoscopic view, duration of laryngoscopy, and difficulty in tracheal intubation (intubation difficulty scale score) were noted. Multivariate logistics regression analysis was performed to identify independent predictors for difficult laryngoscopy. Results Laryngoscopy was difficult in 46 of 300 (15.3%) patients; all 46 patients had Cormack-Lehane grade 3 view. Duration of laryngoscopy was 27 ± 11 s in patients with difficult laryngoscopy and 12.7 ± 3.9 s in easy laryngoscopy; p= 0.001. Multivariate analysis identified that TMH, presence of short neck, and history of snoring were independently associated with difficult laryngoscopy. Incidence of difficult intubation was 17.0%. A shorter TMH was associated with higher IDS scores; r = -0.16, p= 0.001. TMH and duration of laryngoscopy were found to be negatively correlated; a shorter TMH was associated with a longer duration of laryngoscopy; r = -0.13, p= 0.03. The cut-off threshold value for TMH in our study is 4.4 cm with a sensitivity of 66% and a specificity of 54%. Conclusion Thyromental height predicts difficult laryngoscopy and difficult intubation. TMD and RHTMD did not prove to be useful as predictors of difficult airway.

Myalgia during interferon therapy – does it warrant monitoring muscle enzymes.

Myositis during interferon therapy is a known but rare adverse event. However the clinician may overlook the symptom-complex of proximal muscle weakness and myalgia, seen in myositis, since myalgia is a commonly reported side effect of therapy. In this context then, is there a role for monitoring muscle enzymes to detect subclinical myositis in patients on interferon therapy? We prospectively monitored the creatine kinase (CK) and lactate dehydrogenase (LD) levels in all our patients who reported myalgia during treatment and noted that muscle enzymes remained within normal range throughout the duration of treatment. This excluded the possibility of subclinical myositis in myalgic patients and thus led us to conclude that routine monitoring of muscles enzymes is neither necessary nor beneficial.

Factors associated with attrition in patients with breast cancer: a retrospective study.

BACKGROUND: Attrition in follow up is a key limitation of longitudinal studies, especially in cancer patients in developing countries. We did a retrospective analysis of possible factors that resulted in attrition of patients with breast cancer during follow up. METHODS: This study is a comparison between patients who came for a follow up regularly to our clinic with those who did not but could be contacted on phone or by post. A computerized grouped database was constructed with the following parameters: age, religious community, other co-morbid conditions if present, distance from place of residence to our city, residence in city/ village, initial stage of the disease, type of treatment and disease relapse or death. RESULTS: Using binary logistic regression, disease relapse was found to be the most important cause of non-compliance. The odds ratio for irregularity or loss to follow up of patients with disease relapse was 2.53 (95% CI: 1.17-5.46; p = 0.02) for patients who were alive with disease relapse and 6.1 8 (95% CI: 3.47-11.02; p < 0.001) for patients who had died due to the disease compared with those who were alive and free of disease. The age and place of residence in a village were other significant factors. The odds of attrition due to age were 1.03 (95% CI: 1.01-1.05; p = 0.04) for each year of increase in age and that of residence in a village was 1.85 (95% CI: 1.02-3.36; p = 0.04). CONCLUSION: Age, disease relapse and residing in a village are important causes of attrition during follow up of patients with breast cancer in India.

New method of electrode placement for determination of cardiac output using impedance cardiography.

In thirty eight young healthy adult subjects, cardiac output was determined non-invasively by using two methods of electrode placement viz. vertical (uses silver braided wires in a band shape) and horizontal (conventional stick-on type surface ECG electrodes), using the technique of Impedance Cardiography. The recordings were taken in supine position on the same day in two separate sets with 30.0 min interval between two sets. In each set of recording, five successive recordings, each at an interval of five minutes were taken. The mean values of cardiac out put by two methods were compared. For the set I, the respective values (Mean +/- SD) of cardiac output by horizontal and vertical methods for the each of the five recordings were 4.87 +/- 0.77 and 5.03 +/- 0.64 for the first, 4.87 +/- 0.71 and 4.91 +/- 0.66 for the second, 4.99 +/- 0.67 and 5.00 +/- 0.70 for the third, 4.78 +/- 0.69 and 4.98 +/- 0.61 for the fourth, 4.84 +/- 0.69 and 4.98 +/- 0.62 for the fifth recording in supine position. The respective P values for these pairs for between the group comparisons were 0.33, 0.50, 0.96, 0.17, and 0.36. In addition, to see the repeatability for each method, within the group comparison was done, the P values were 0.71 and 0.91 for the horizontal and vertical methods, respectively. The mean value of cardiac output did not differ significantly between two methods for recordings of set II in supine position. The cardiac output measurement by placing four spot electrodes horizontally, gave consistent result on repeated measurements and their values showed concordance with the cardiac output values obtained by conventional four band electrodes tied around the chest.

Comparison of straight sternotomy and interlocking sternotomy in open heart surgery.

BACKGROUND AND OBJECTIVES: Stable sternal approximation is an important factor to avoid respiratory complications after open heart surgery. The present study is designed to compare interlocking sternotomy and straight sternotomy in terms of sternal stability, pain and respiratory function. METHODS: Sixty patients scheduled for open heart surgery underwent a standard midline sternotomy (n=30) or an interlocking sternotomy (n=30). The features assessed were pain on visual analogue scale during rest and during cough, peak expiratory flow rate and sternal instability. Evaluation was performed on the first, fourth post-operative days, on discharge and one month and three month follow up. RESULTS: Analysis of the peak expiratory flow rates, visual analogue ratings of pain intensity at rest and on coughing were carried out for each group only for those patients who completed the study. Postoperatively, in all patients there was significant reduction in peak expiratory flow rates. In the straight sternotomy group resting pain intensity was higher on discharge (2.6+/- 2 vs 1.6 +/- 2.3, P= 0.005). In the interlocking sternotomy group pain on coughing was significantly less than straight sternotomy group (median 0.5 vs 2.8, P=0.005) at 1 month follow up and at 3 months (median 0 vs 1.6, P=0.003). INTERPRETATION AND CONCLUSION: Interlocking sternotomy can be performed with good functional results and offers a less painful alternative to straight sternotomy.

Vitamin E-based therapy is effective in ameliorating transaminasemia in nonalcoholic fatty liver disease.

BACKGROUND: Comparative trials of ursodeoxycholic acid (UDCA), vitamin E and weight management programs among patients with nonalcoholic fatty liver disease (NAFLD) are lacking. AIM: To find an effective single agent or combination of agents for management of NAFLD. METHODS: In this retrospective study, consecutive patient with histologically confirmed NAFLD with raised ALT were included. The patients received either weight management (exercise and therapeutic lifestyle changes [TLC] diet with a target to reduce body weight 10% in 6 months) (group I) ; weight management + UDCA (300 mg BID) (group II); or weight management + UDCA + vitamin E (400 mg OD) (group III). Outcome measure was normalization of ALT. RESULTS: 42 patients (18, 12 and 12 in groups I, II and III, respectively) were included between 1996 and 2004. All patients in group III normalized their ALT levels, which was significantly higher than numbers in group I (8/18) and group II (5/12); (p=0.003). Post treatment ALT was significantly lower in group III (28.6 [9.3]) as compared to group I (59.3 [32.2]) and group II (49.0[31.8]); (p=0.01). Type of therapy received was the only factor predictive of ALT normalization. CONCLUSION: Combination regimen containing vitamin E appears to be effective in normalizing ALT among NAFLD patients.

Assessment of risk factors in laryngeal cancer in India: a case-control study.

Cancer of the larynx is fourteenth most common cancer in the world. Limited data are available from India on associations with risk factors and hence the present hospital based matched case-control study was conducted. Three hundred and five laryngeal cancer patients and an equal number of healthy controls matched for their age within 2 years, sex and place of residence constituted the study population. A pre-tested, semi-structured questionnaire was administered to each individual to elicit information on their socio-demographic profile, food habits and risk factors and dietary consumption patterns. Univariate logistic regression analysis and multivariate forward stepwise conditional logistic analysis were performed. In the univariate analysis a lower consumption of roots and tubers green leaf vegetable other vegetables and fruits, and higher consumption of milk, eggs, meat, tea, alcohol , smoking, consumption of betel leaf with tobacco as well as a preference for spicy and fried foods emerged as significant positive variables. After adjusting for education, years of use of alcohol, smoking, chewing of betel leaf with tobacco in the model, low green leafy vegetables and preference for spicy foods were found to be positively related to the risk of laryngeal cancer. There was a significant difference in the dietary consumption patterns of laryngeal cancer patients and controls, indicating a role for nutritional factors in the etiology of laryngeal cancer in the Indian population.

Prevalence of multiple micronutrient deficiencies amongst pregnant women in a rural area of Haryana.

Deficiencies of micronutrients (zinc, iron, folic acid and iodine) during pregnancy are known causes of Low Birth Weight (LBW). Studies have documented status of one or two micronutrients amongst pregnant women (PW). However, no attempt has been made to concurrently assess the prevalence of multiple micronutrient deficiencies and the factors associated with them amongst PW. OBJECTIVE: The present study was undertaken to assess the prevalence of multiple micronutrient deficiencies amongst PW in a rural area. METHODS: A community based cross sectional survey was conducted in six villages of a rural area of district Faridabad in Haryana state, India during November 2000 and October 2001. All PW aged 18 years or more, with pregnancy duration of more than 28 weeks were enrolled. Data were collected on socio-economic status and other demographic parameters. Serum zinc, copper and magnesium levels were estimated by utilizing the Atomic absorption spectrophotometry (AAS); serum ferritin and folate was estimated by Enzyme Linked Immuno Sorbent Assay (ELISA) method and the Radio-Immuno Assay (RIA) method, respectively and serum thyroid stimulating hormone (TSH) level was estimated by the Abbot AxSYM System. Serum zinc, copper, magnesium, ferritin, and folate levels less than 70.0 microg/dl, 80.0 microg/dl, 1.80 mg/dl, 15 ng/ml, and 3 ng/ml, respectively were considered as indicative of deficiency for respective micronutrients. The TSH levels of 4.670 and more indicated iodine deficiency status. Dietary intake of micronutrients was assessed utilizing 1-day 24-hour dietary recall methodology. Food consumption pattern was assessed utilizing the food frequency questionnaire methodology. RESULTS: Nearly 73.5, 2.7, 43.6, 73.4, 26.3, and 6.4 percent PW were deficient in zinc, copper, magnesium, iron, folic acid and iodine, respectively. The highest concurrent prevalence of two, three, four and five micronutrient deficiency was of zinc and iron (54.9%); zinc, magnesium and iron (25.6%); zinc, magnesium, iron and folic acid (9.3%) and zinc, magnesium, iron, folic acid and iodine (0.8%), respectively. No pregnant woman was found to have concomitant deficiencies of all the six micronutrients. Dietary intake data revealed an inadequate nutrient intake. Over 19% PW were consuming less than 50% of the recommended calories. Similarly, 99, 86.2, 75.4, 23.6, 3.9 percent of the PW were consuming less than 50% of the recommended folic acid, zinc, iron, copper, and magnesium. The consumption of food groups rich in micronutrients (pulses, vegetables, fruits, nuts and oil seeds, animal foods) was infrequent. Univariate and Multivariate logistic regression analysis revealed that low dietary intake of nutrients, low frequency of consumption of food groups rich in micronutrients and increased reproductive cycles with short interpregnancy intervals were important factors leading to micronutrient deficiencies. CONCLUSION: There was a high prevalence of micronutrient deficiencies amongst the PW of the area, possibly due to the poor dietary intake of food and low frequency of consumption of food groups rich in micronutrients. The concurrent prevalence of two, three, four and five micronutrient deficiencies were common.

Status of serum ferritin and folate levels amongst young women in a rural community of Haryana, India.

A community based cross sectional study was conducted amongst young married non-pregnant women aged 18 years or more from six randomly selected villages in Ballabhgarh block, district Faridabad, Haryana state. Data was collected on socio-demographic profile and obstetric parameters utilizing a pre-tested semi-structured questionnaire. The non-pregnancy status of the women was confirmed by inquiring about the last menstrual period. Serum ferritin and folate levels were assessed utilizing the ELISA and the RIA method, respectively Serum ferritin and folate levels less than 15.0 and 3 ng/ml were considered as indicator of poor iron and folic acid stores, respectively. The dietary intake of iron, folic acid and calories was assessed utilizing the 24-hour dietary recall methodology. Almost 63.8 and 27.7 % of the women had poor serum ferritin and folate levels. The mean dietary intake of iron, folic acid and calories was 14.8+/-7.7 mg, 49.2+/-20.1 microg, and 1564+/-411 kcal, respectively. There was an inadequate intake of food as revealed by their calorie intake that was 83.4% of the recommended dietary allowances. Only 6.9 and 7.8 % of the women were consuming iron and folic acid more than 75.0 % of the recommeded dietary allowances (RDA) Women with dietary intake of calories less than 50.0 % of the RDA had a lower serum ferritin level compared to the women who had a higher calorie intake. It was also revealed that there was a decreasing trend in serum folate levels with poor socio-economic status. Young rural women had poor serum ferritin and folate levels in the community studied, possibly due to poor dietary intake of food and thereby iron and folic acid. Distribution of iron and folic acid tablets may be recommended to young women of reproductive age group.