Direct in vivo assessment of microcirculatory dysfunction in severe falciparum malaria.

BACKGROUND: This study sought to describe and quantify microcirculatory changes in the mucosal surfaces of patients with severe malaria, by direct in vivo observation using orthogonal polarization spectral (OPS) imaging. METHODS: The microcirculation in the rectal mucosa of adult patients with severe malaria was assessed by use of OPS imaging, at admission and then daily. Comparison groups comprised patients with uncomplicated falciparum malaria, patients with bacterial sepsis, and healthy individuals. RESULTS: Erythrocyte velocities were measured directly in 43 adult patients with severe falciparum malaria, of whom 20 died. Microcirculatory blood flow was markedly disturbed, with heterogeneous obstruction that was proportional to severity of disease. Blocked capillaries were found in 29 patients (67%) and were associated with concurrent hyperdynamic blood flow (erythrocyte velocity, >750 mm/s) in adjacent vessels in 27 patients (93%). The proportion of blocked capillaries correlated with the base deficit in plasma and with the concentration of lactate. Abnormalities disappeared when the patients recovered. In healthy individuals and in patients with uncomplicated malaria or sepsis, no stagnant erythrocytes were detected, and, in patients with sepsis, hyperdynamic blood flow was prominent. CONCLUSION: Patients with severe falciparum malaria show extensive microvascular obstruction that is proportional to the severity of the disease. This finding underscores the prominent role that microvascular obstruction plays in the pathophysiology of severe malaria and illustrates the fundamental difference between the microvascular pathophysiology of malaria and that of bacterial sepsis.

The assessment of the gingival capillary density with orthogonal spectral polarization (OPS) imaging.

OBJECTIVE: In this study we evaluated the inter-observer agreement in the assessment of gingival capillary density using Orthogonal Polarization Spectral Imaging. METHODS: In this study gingival capillary density of 100 healthy subjects was determined by 2 independent observers. Agreement was quantified by calculation of the mean differences between the observers and the standard deviation of this difference and the limits of agreement. Reliability was quantified by means of the intraclass correlation coefficient (ICC). RESULTS: Fifty males and 50 females were included in the study. The mean age for males was 20+/-1.2 years and for females 20+/-1.4. OPS images showed remarkable good quality images of the gingival microcirculation. The interclass correlation between the 2 observers was 0.63 while the interclass correlation for the 6 measurements in observer 1 was 0.95 and 0.94 for observer 2. The mean capillary density for females in observer 1 was 83.69+/-16.4 and 83+/-16.0 in observer 2, versus 60.55+/-12.3 for observer 1 and 60.4+/-12.1 for males. The mean quantitative functional capillary density in male students was 60.48+/-10.7, compared to 83.45+/-13.5 in female students. CONCLUSIONS: OPS imaging enabled for the first time direct in vivo visualization and quantification of human functional gingival capillary density in healthy medical students. The inter-observer agreement was found to be good to fair on the quantification of gingival capillary density between the two independent observers. The intracorrelation coefficient (0.95) was excellent when assessing the reliability of one observer.

Effect of smoking on the gingival capillary density: assessment of gingival capillary density with orthogonal polarization spectral imaging.

OBJECTIVES: Microvascular changes because of smoking are frequently presumed in models because of the negative effect of smoking portrayed on the microcirculation. We hypothesized that cigarette smoke might lead to a decrease in gingival capillary density. MATERIALS AND METHODS: Capillary density was assessed with orthogonal polarization spectral (OPS) imaging, a technique using special optics by which a virtual light source is created at a depth of 1 mm within the mucosa. The light is absorbed by haemoglobin, resulting in an image of the capillaries in negative contrast. The gingival capillary density was measured in 20 healthy male dental students with a mean age of 25. Ten of the students were smokers and 10 were non-smokers. In each subject six images of the right maxillary pre-molar region were obtained, and the mean gingival capillary density was determined through the use of K&K software technology. RESULTS: The mean capillary density in smokers was 69.3 +/- 8.9 capillaries per visual field compared with a mean capillary density in non-smokers of 60.6 +/- 5.4 (p=0.33). CONCLUSION: No significant differences were found between the gingival capillary density of smokers and non-smokers.

Injection drug use and tricuspid valve endocarditis.

Tricuspid valve endocarditis is more common in injection drug users. Pulmonary valve and Eustachian valve endocarditis have been reported but are very rare. Earlier reports of endocarditis in injection drug users emphasized the dominance of right sided involvement. In a series of 105 patients 86 % were right sided and 14 % had left sided involvement. We report a case of isolated tricuspid valve endocarditis in an injection drug user affecting a structurally normal heart and review of the literature on this subject. Key Words: injection drug use, tricuspid valve endocarditis.

Study of serum lipid profile in type 2 diabetic patients attending KMCTH.

The study was aimed at identifying the association between two major risk factors for coronary artery disease (CAD), namely, type 2 diabetes and hyperlipidemia. Hyperlipidemia has a ocumented causative relation with CAD, but the major risk associated with diabetes may be due to the associated hyperlipidemia. Lipid profiles of 30 patients with type 2 diabetes were taken and a detailed clinical workup done, including estimation of the body mass index (BMI). The study revealed that dyslipidemia is very common in type 2 diabetics and the most common abnormality seen was increased serum triglyceride levels (73.3%). The next common abnormality was decreased serum high-density lipoprotein cholesterol (HDL-C) levels and increased serum low-density lipoprotein cholesterol (LDL-C) levels, both seen in 66.7% patients respectively. A high total serum cholesterol levels was seen in 46.7% patients. Forty percent of the patients examined were on the overweight side, 16.7% being overtly obese. Thus the study, despite having small number of patients, clearly shows the association between type 2 diabetes and hyperlipidemia, which may influence the mechanism by which type 2 diabetes is associated with increased CAD risk.

Correlation between serum-ascites albumin concentration gradient and endoscopic parameters of portal hypertension.

OBJECTIVE: We sought to determine the correlation between the level of serum-ascites albumin concentration gradient (SAAG) and the complications of portal hypertension (PHTN), manifested by the presence and grade of esophageal varices (EV). MATERIAL AND METHODS: Our study included 32 patients with ascites, demonstrated by ultrasonography, who had measurement of the SAAG. All had upper gastrointestinal endoscopy with assessment of the presence and size of EV. High SAAG was considered to be present when SAAG was >=1.1 g/dl and Low SAAG when it measured < 1.1 g/dl. RESULTS: We found that 25 of 32 (78.13%) patients had High SAAG and 7 of 32 (21.87%) had Low SAAG. Esophageal varices were present in 18 of 25 (72%) patients with High SAAG and in none of 7 (0%) patients with Low SAAG (p =<0.001). Among patients with High SAAG, EV were present in four of 8 patients (50%) with SAAG values of 1.10-1.49g/dl; in four of seven patients (57.1%) with SAAG values of 1.50-1.99g/dl; and in ten of ten (100%) with SAAG values of >=2.0g/dl (p = 0.037). The size of the esophageal varices had no association with the level of SAAG in patients with High SAAG (p = 0.426). CONCLUSIONS: In patients with ascites the presence of esophageal varices is associated only with patients with High SAAG. The presence of EV in patients with ascites and High SAAG is directly related to the degree of SAAG. The size of the EV in patients with ascites and High SAAG is not associated with the degree of SAAG.

Study of clinical profile and antibiotic sensitivity pattern in culture positive typhoid fever cases.

OBJECTIVES: The present study was designed to analyze the clinical profile and antibiotic sensitivity pattern in the cases of culture positive typhoid fever. METHOD: The study was conducted over a period of 1 year. Total of 46 culture positive cases of Typhoid fever were included in the study. The sensitivity pattern of isolates from blood culture was recorded. The modes of presentation, clinical course, lab investigation reports were also recorded. RESULTS: Out of 46 cases, 33 (71.7%) were males and 13 (28.3%) were females. Average age of presentation was 26.17 years. Fever was present in all patients. Resistance of S .typhi to amoxycillin, chloramphenicol and co-trimoxazole were significantly high. Ciprofloxacin showed resistance in 2 (4.3%) cases. Sensitivity to ceftriaxone was 100% in our study. CONCLUSION: Typhoid fever is one of the most common health problem in Nepal. Various drugs are being used in the treatment of typhoid fever, in the mean time resistance to many of them are emerging. An appropriate antibiotic has to be initiated only after culture sensitivity in typhoid fever.

Knowledge, attitude and practices among health care workers on needle-stick injuries.

OBJECTIVE: This study aimed to assess the knowledge, attitude and practices among health care workers on needle stick injuries. METHODS: A 15-item questionnaire was administered to seventy health care workers including nurses and paramedical staffs from different departments of Kathmandu Medical College and Teaching Hospital to measure knowledge, attitude and practices on needle stick injuries. RESULTS: Results showed that 4% and 61% of health care workers, respectively, were unaware of the fact that hepatitis B and hepatitis C can be transmitted by needle-stick injuries. 52 subjects (74%) had a history of needle-stick injuries and only 21% reported the injuries to the hospital authority. Only 23% were in the habit of using gloves for phlebotomy procedures all the time. 79% were of the impression that needle should be recapped after use. Only 66% were aware of Universal Precaution Guidelines. 16 subjects (23%) were negative for HBsAg, Anti-HCV and Anti-HIV and 54 subjects (77%) do not know about their immune status. 42 subjects (60%) had been vaccinated against hepatitis B, while 28 subjects (40%) were not vaccinated against hepatitis B. Only 6 subjects (14%) had been tested for Anti-HBs antibody after hepatitis B vaccination. CONCLUSION: The survey revealed that knowledge of health care workers about the risk associated with needle-stick injuries and use of preventive measures was inadequate. A standing order procedure (SOP) should be formulated regarding needle-stick injuries in all the health institutions. It should outline precautions to be taken when dealing with blood and body fluids. It should also contain reporting of all needle-stick injuries. Health care workers should be made aware of hazards, preventive measures and post-exposure prophylaxis to needle-stick injuries. A hospital-wide hepatitis immunization programme should also be started.

Clinical profile of typhoid patients.

OBJECTIVE: The present study was undertaken to determine the clinical profile of typhoid fever in hospitalised patients. DESIGN: Prospective cross-sectional study. SETTING: Kathmandu Medical College and Teaching Hospital. METHOD: Total of thirty patients above fifteen years of age who had clinical features strongly suggestive of typhoid fever and on blood culture found to be positive for Salmonella typhi were analysed for clinical features. RESULT: Among total of thirty cases, there were 17 (57%) males and 13 (43%) females. 86% of cases of typhoid fever clustered around 15-30 years of age. Predominant symptoms were fever (100%), headache (90%), abdominal Pain (37%) and constipation (33%). Common clinical signs were splenomegaly (37%), relative bradycardia (27%) and hepatomegaly (17%). None of the patients presented with complications. CONCLUSION: The clinical profile of typhoid fever in our study revealed not much difference from that of other studies on typhoid fever. Rose spots were not noticed and we did not find a single case of complication of typhoid fever. Probably early initiation of antibiotics prevented the complications.

Abnormal microcirculation in brain tumours during surgery.

Orthogonal Polarisation Spectral imaging is a new clinical technique that uses polarised light to visualise the microcirculation of organ surfaces. We have used this technique to compare the functional microcirculatory properties of three types of brain tumour with those of the normal cortex. Meningiomas were characterised by chaotic and dilated vessels with almost no erythrocyte movement and a dark background, glioblastoma by few vessels with low flow and a background close to that of the healthy cortex, and metastases by a very dark background, almost no flow, and a chaotic vascular pattern. This technique could provide useful information about microcirculatory morphology and kinetics for diagnostic use during neurosurgery.

Comparison of OPS imaging and conventional capillary microscopy to study the human microcirculation.

Orthogonal polarization spectral (OPS) imaging is a new clinical technique for observation of the microcirculation of organ surfaces. For validation purposes, we compared OPS images of the nailfold skin with those obtained from conventional capillary microscopy at rest and during venous occlusion in 10 male volunteers. These images were computer analyzed to provide red blood cell velocity and capillary diameters of the same nailfold capillaries at rest and during venous occlusion. Results showed that OPS images provided similar values for red blood cell velocity and capillary diameter as those obtained from capillary microscopy images. OPS imaging, however, provided significantly better image quality, as shown by comparison of image contrast between OPS imaging and capillary microscopy. This made image analysis better and easier to perform. It is anticipated, therefore, that OPS imaging will become a new and powerful technique in the study of the human microcirculation in vivo because it can be used on human internal organs.

Impaired vascular function in women with pre-eclampsia observed with orthogonal polarisation spectral imaging.

OBJECTIVE: To investigate in vivo the function of the microcirculation of the skin in pregnancy and pregnancy complicated with pre-eclampsia. DESIGN: Case-control study. SETTING: Academic Medical Centre. PARTICIPANTS: A group of 10 women with pre-eclampsia and a healthy control group of 10 pregnant women. METHODS: The microcirculation of the skin of the finger at rest and during venous occlusion was studied with laser Doppler fluxmetry and orthogonal polarisation spectral imaging. By inflating a cuff around the upper arm to a pressure of 50 mmHg, causing venous occlusion, the local sympathetic veno-arteriolar reflex was provoked. With laser Doppler fluxmetry the blood flow of the skin at a depth of 1-2mm was measured at rest and during venous occlusion. Orthogonal polarisation spectral imaging was used to assess red blood cell velocity at rest and during venous occlusion of the nutritive capillaries of the skin. RESULTS: Laser Doppler fluxmetry showed no significant difference between the normotensive group and the group with pre-eclampsia. Using orthogonal polarisation spectral imaging, venous occlusion produced a significantly greater decrease in red blood cell velocity in the control group than in the women with pre-eclampsia: (84% (81-88)(median and interquartile range) vs 58% (45-88), P = 0.0029). No differences in absolute red blood cell velocities were observed between groups either at rest or during venous occlusion. CONCLUSION: This study shows an impaired local veno-arteriolar reflex in pre-eclampsia at the nutritive, but not at the therrmoregulatory, level of the microcirculation of the skin.

Hypertension in Secretariate population of Bangladesh.

A total of 8,172 persons constituting 98.6% of the total Secretariate Population of Bangladesh were screened for elevated blood pressure. One thousand and ninety cases (13.3%) showed diastolic blood pressure of 90 mmHg or above. Those with diastolic blood pressure of 95 or above constituted 3.7% of the population. More than two-thirds of the latter group (71.6%) remained undetected indicating that vast majority of our hypertensive population remains undiagnosed and untreated. It is recommended that the misconception regarding symptomatic hypertenson should be removed by adequate emphasis on the preventive value of the control of hypertension on cardiovascular and cerebrovascular complication. A plea has also been made for a large-scale survey to determine the extent of the problem in Bangladesh.