Incidental Intraoperative Diagnosis of Term Conjoined Twins: A Case Series.

Conjoined twins (Siamese twins) represent the rarest form of twin pregnancy. Reported here are two rare cases of conjoined term twins presented to the department of Obstetrics and Gynaecology within 3 months. The first case, 32 years of gravida 6 parity 5 referred from periphery after full trial of labour following multi-organ dysfunction and term intrauterine dead twins. Intraoperatively it was dead conjoined thoraco-omphalopagus females. The patient died after 3 days following multiorgan dysfunction syndrome and disseminated intravascular coagulation. The second case, 22 years gravida 2 parity 1 also referred from periphery in second stage of labour with diagnosis of 39 weeks intrauterine dead twins with obstructed labour, delivered by caesarean with intraoperative conjoined dead females of thoracophagus type. Twins are high-risk pregnancy. This rare diagnosis with complications could have been prevented by regular antenatal checkups, ultrasonography performed by radiologists and early referral antenatally in labour along with multidisciplinary approach. Keywords: conjoined; monozygotic twinning; siamese twins; twins.

Primary Caesarean Section among Multiparous Pregnant Women Visiting a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Caesarean section is one of the most common obstetric operations performed. Primary caesarean section in multiparous women means the first caesarean section done in the multiparity who had previously delivered vaginally. This study aimed to find out the prevalence of primary caesarean section among multiparous pregnant women visiting a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among multiparous women in a tertiary care centre from 15 June 2020 to 14 June 2021. Ethical approval was obtained from the Institutional Review Committee (Registration number: F-NMC/420/075/076). Demographic data were collected using predesigned proforma in parous women who had a previous vaginal delivery. A convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 1158 multiparity, primary caesarean section was found in 155 (13.39%) (11.43-15.35, 95% Confidence Interval). Most women 62 (40%) belong to 21-25 years and the majority were second gravida 51 (32.90%). The emergency caesarean section was done in 149 (96.12%). Indications for primary caesarean section were fetal distress 63 (40.63%), non-progress of labour and breech 12 (7.74%). Post-operative complications were uneventful in 110 (70.96%) cases. Conclusions: The prevalence of primary caesarean section in multiparous women was found to be higher than the other studies done in similar settings. Keywords: caesarean section; multiparity; prevalence.

An epidemiological study on the prevalence of temporomandibular disorder and associated history and problems in Nepalese subjects.

BACKGROUND: Temporomandibular disorder (TMD) represents a subgroup of painful orofacial disorders involving pain in the temporomandibular joint (TMJ) region, fatigue of the cranio-cervico-facial muscles (especially masticatory muscles), limitation of mandible movement, and the presence of a clicking sound in the TMJ. TMD is associated with multiple factors and systemic diseases. This study aimed to assess the prevalence of TMD in Nepalese subjects for the first time. METHODS: A total of 500 medical and dental students (127 men and 373 women) participated in this study from May 2016 to September 2016. The Fonseca questionnaire was used as a tool to evaluate the prevalence of TMD, and Fonseca's Anamnestic Index (FAI) was used to classify the severity of TMD. RESULTS: The majority of the participants with TMD had a history of head trauma, psychological stress, and dental treatment or dental problems. The prevalence of TMD in Nepalese students was mild to moderate. CONCLUSIONS: The prevalence of TMD in Nepalese subjects was mild to moderate. The majority of the study subjects had eyesight problems, history of head trauma, psychological stress, and drinking alcohol and had received dental treatments.

New echocardiography-based classification of mitral valve pathology: relevance to surgical valve repair.

A new echocardiography-based classification of mitral valve pathology is proposed, the adoption of which may provide a uniform approach to the assessment of individual cases by the cardiologist, cardiac anesthesiologist, and surgeon. This type of approach may facilitate the planning and execution of valve repair techniques, with higher rates of success than are currently reported.

Tricuspid and pulmonary valve disease evaluation and management.

The clinical detection and quantification of tricuspid valve disease, although important, is not entirely accurate. Diagnostic evaluation is based on echocardiography, and color flow Doppler is useful for quantifying tricuspid regurgitation. Echocardiography provides information on heart chamber dimensions, right ventricular function, and the degree of pulmonary hypertension. In addition, tricuspid stenosis can be accurately assessed using mean and end-diastolic pressure gradient measurements. The treatment options for tricuspid stenosis include balloon valvuloplasty and surgical valve repair. Functional tricuspid regurgitation associated with left heart disease may require surgical attention during an operation to treat the left heart disease. Severe tricuspid regurgitation usually requires surgery to be performed in association with mitral valve surgery. Mild-to-moderate tricuspid regurgitation requires surgery when annular dilatation or severe pulmonary hypertension is present. The surgical options include tricuspid valve repair, with or without an annuloplasty ring. In patients with a primary anatomic deformity of the tricuspid valve, replacement of the valve with a bioprosthesis or mechanical valve may be considered. Intermediate and long-term results favor annuloplasty valve repair over valve replacement. Pulmonary valve disease is predominantly congenital, and generally takes the form of pulmonary stenosis. Pulmonary regurgitation often results from surgical or balloon valvuloplasty and is associated with deleterious long-term sequelae. The recent development of percutaneous valve replacement was a major advance.

Valvulopatía tricuspídea y pulmonar: evaluación y tratamiento / Tricuspid and pulmonary valve disease evaluation and management

La detección clínica y la cuantificación de la valvulopatía tricuspídea, a pesar de su importancia, no son del todo exactas. La ecocardiografía es la base de la evaluación diagnóstica y el Doppler-color es útil para la cuantificación de la insuficiencia tricuspídea. La ecocardiografía proporciona información relativa a los tamaños de las cámaras, la función ventricular derecha y el grado de hipertensión pulmonar. De igual modo, la estenosis tricuspídea puede evaluarse de forma exacta con el empleo de gradientes medios y telediastólicos. Las opciones de tratamiento para la estenosis tricuspídea incluyen la valvuloplastia con balón y la reparación quirúrgica de la válvula. La insuficiencia tricuspídea funcional asociada a una cardiopatía izquierda puede requerir atención quirúrgica durante la operación por una afección del corazón izquierdo. La insuficiencia grave requiere generalmente una actuación quirúrgica asociada a la cirugía de la válvula mitral. La insuficiencia tricuspídea leve o moderada requiere cirugía en caso de dilatación anular o hipertensión pulmonar grave. Las opciones quirúrgicas incluyen la reparación de la válvula tricúspide con o sin anuloplastia. En los pacientes con una deformidad anatómica primaria de la válvula tricúspide, puede considerarse una sustitución valvular con una bioprótesis o una válvula mecánica. Los resultados a medio y largo plazo son favorables a la reparación valvular con anuloplastia, en comparación con la sustitución valvular. La valvulopatía pulmonar es de etiología predominantemente congénita, por lo general en forma de estenosis pulmonar. La insuficiencia pulmonar con frecuencia se debe a una valvuloplastia quirúrgica o con balón y tiene secuelas negativas a largo plazo. Los progresos recientes en la sustitución valvular percutánea son importantes (AU)

The clinical detection and quantification of tricuspid valve disease, although important, is not entirely accurate. Diagnostic evaluation is based on echocardiography, and color flow Doppler is useful for quantifying tricuspid regurgitation. Echocardiography provides information on heart chamber dimensions, right ventricular function, and the degree of pulmonary hypertension. In addition, tricuspid stenosis can be accurately assessed using mean and end-diastolic pressure gradient measurements. The treatment options for tricuspid stenosis include balloon valvuloplasty and surgical valve repair. Functional tricuspid regurgitation associated with left heart disease may require surgical attention during an operation to treat the left heart disease. Severe tricuspid regurgitation usually requires surgery to be performed in association with mitral valve surgery. Mild-to-moderate tricuspid regurgitation requires surgery when annular dilatation or severe pulmonary hypertension is present. The surgical options include tricuspid valve repair, with or without an annuloplasty ring. In patients with a primary anatomic deformity of the tricuspid valve, replacement of the valve with a bioprosthesis or mechanical valve may be considered. Intermediate and long-term results favor annuloplasty valve repair over valve replacement. Pulmonary valve disease is predominantly congenital, and generally takes the form of pulmonary stenosis. Pulmonary regurgitation often results from surgical or balloon valvuloplasty and is associated with deleterious long-term sequelae. The recent development of percutaneous valve replacement was a major advance (AU)

Current concepts in mitral valve prolapse--diagnosis and management.

Although mitral valve prolapse as a disease entity has been recognized for over 50 years, its precise definition has been elusive. Initial reports based the diagnosis on auscultatory findings (late systolic click - murmur), with left ventricular angiography as a confirmative test. Echocardiography, first the M-mode, and subsequently the two-dimensional, became the dominant diagnostic modality. However, the early reports did not distinguish between billowing valve and flail valve. The advent of surgical repair techniques provided a different perspective; the surgical definition of mitral valve prolapse is often different from that of cardiologists. Intraoperative echocardiography gained wide acceptance necessitating a common language to describe precise terminology of the leaflet anatomy and definition of valve prolapse. The present report proposes a terminology and definitions of valve prolapse with relevance to surgical mitral valve repair. The addition of real-time 3D transesophageal echocardiography now provides highly accurate localization of lesions and the multi segment assessment of valve pathology. The etiologic considerations and surgical repair techniques with the role of echo - surgery team in improved patient outcome are described.

Correlation of surfactant/polymer phase behavior with adsorption on target surfaces.

In this contribution, the phase behavior of a surfactant/polymer mixed system is related to the adsorption of a complex derived from the mixture onto a target surface. The phase map for the system sodium dodecyl sulfate (SDS, a model anionic surfactant)/pDMDAAC (poly(dimethyl diallyl ammonium chloride), a cationic polymer) shows behavior very typical of surfactant/oppositely charged polyelectrolyte mixtures. The predominant feature is a broad, two-phase region in the phase map which lies asymmetrically around the 1:1 stoichiometry of surfactant charge groups to polymer charge units. The overall controlling principle driving the phase separation is charge compensation. Excess of polymer yields an isotropic solution, as does a great excess of surfactant (termed resolubilization). The phase separating in the SDS/pDMDAAC system is characterized by a positive zeta-potential when the polymer is in excess and a negative zeta-potential when the surfactant is in excess. The surface charge properties of the precipitated phases are essentially identical to those of target particles (ground borosilicate glass) dispersed at the same approximate position in the phase map, suggesting that the surfactant/polymer complex at the precipitation boundary is the same as that adsorbing onto the pigment particle. This conclusion is confirmed by depletion studies which allow the polymer adsorption density to be determined. For polymer-rich systems, essentially all of the surfactant adsorbs along with the polymer via a high-affinity isotherm with a plateau coverage of about 0.8 mg polymer/m (2). Surfactant-rich systems adsorb with a similar affinity, despite the mismatch of the complex charge matching that of the particle surface. Once adsorbed, these complexes are not readily removed by rinsing, though complexes adsorbed from SDS-rich systems will lose excess surfactant upon extreme dilution. Over a wide range of surfactant-rich compositions, from 1:1 stoichiometry out toward the resolubilization zone, a chemical analysis reveals that the surfactant/polymer precipitate species consists of a 1:1 charge complex with the addition of about 0.25 mol of surfactant/mol of complex. Resolubilization of these sparingly soluble species is achieved simply by dilution to below their solubility limit.

Tricuspid valve disease.

The normal tricuspid valve anatomy and function have several dissimilarities to the corresponding mitral valve in the left heart, in part, based on lower pressures in the right heart chambers. The functional abnormalities resulting from tricuspid valve disease are classified as primary and secondary. Primary valve disease is any associated intrinsic valve pathology. The list of responsible conditions includes congenital, rheumatic, infective endocarditis, carcinoid heart disease, toxic effects of chemicals, tumors, blunt trauma, and myxomatous degeneration. The secondary tricuspid valve disease does not involve intrinsic anatomic abnormalities of the valve apparatus, aside from tricuspid annular dilation secondary to right ventricular dilation and dysfunction. The most common cause of tricuspid valve disease is secondary to left heart disease, either myocardial, valvular, or mixed. Although bedside diagnosis of advanced tricuspid valve disease is feasible, echocardiography provides valuable clues to the presence and severity of tricuspid valve stenosis and/or regurgitation with considerable accuracy. The tricuspid regurgitation signal using Doppler techniques is utilized for estimation of right ventricular systolic pressure, which, in the absence of right ventricular outflow obstruction, corresponds to pulmonary arterial systolic pressure. This is clinically useful since nearly 80 to 90% of patients exhibit some degree of tricuspid regurgitation. The treatment of tricuspid valve disease is guided by underlying etiology and pathology. Tricuspid valve repair is increasingly advocated for patients with advanced tricuspid regurgitation, especially when combined with surgery on the left heart pathology. Primary tricuspid valve disease is often treated by surgical approach specific to the underlying pathology.