C-ARM Guided Angiogram/Angioplasty for Selected Failed Arterio Venous Fistula. A Report of a Procedure at University Hospital of Nepal.

End Stage Renal Disease is a last stage of Chronic Kidney Disease which is characterized by Glomerular Filtration rate of less than 15 ml/min/1.73 m2 . Hemodialysis is the most commonly used modality for treatment of Chronic Kidney disease. Among the access for hemodialysis arteriovenous fistula is the most common modality. However most common problems of fistula are significant stenosis of more than 50% which is characterized by limb swelling, pigmentation, tortuous veins, and difficulty maintaining flow during dialysis from AV fistula. These can be managed either by minimal intervention or with surgical intervention. Very few hospitals in Nepal and other countries have an angiographic suite to perform minimal intervention include angiogram with angioplasty. So in this case we try to address the use of C-Arm to perform angiogram or fistulogram and even angioplasty for the management of significant stenosis or complications of arteriovenous fistula.

Squatting position for delivery.

The study was conducted on 200 normal pregnant women who were randomly classified into 2 groups of 100 cases each. The control group comprised mothers in supine position throughout labour and delivery (46 primigravidae and 54 multigravidae). The squatting group consisted of cases who were kept ambulatory during the 1st stage and were asked to squat on ordinary delivery cots during the 2nd stage of labour. Third stage of labour was conducted in supine position. The squatting group comprised 42 primigravidae and 58 multigravidae. There was a mean difference (shortening) of 3 hours in primigravidae and 2 hours in multigravidae in the duration of 1st stage of labour between the squatting and control groups. In the duration of 2nd stage of labour the mean differences in primigravidae and multigravidae of the squatting and control groups were 20 and 13.5 minutes respectively. In the squatting group there were 79 normal vaginal delivery, 16 forceps delivery and 5 caesarean sections whereas in the control group there were 80, 18 and 2 cases respectively. Although foetal complications were comparable in both the groups, the incidence of maternal injuries was observed in 14 cases in control group and 38 cases in squatting group. It was concluded that without proper birthing chairs which can give good perineal support, the usual supine position is preferable.

Sequential respiratory, psychologic, and immunologic studies in relation to methyl isocyanate exposure over two years with model development.

Of 113 methyl isocyanate (MIC)-exposed subjects studied initially at Bhopal, India, 79, 56, 68, and 87 were followed with clinical, lung function, radiographic, and immunologic tests at 3, 6, 12, 18, and 24 months. Though our cohort consisted of subjects at all ages showing a varied severity of initial illness, fewer females and young subjects were seen. Initially all had eye problems, but dominant symptoms were exertional dyspnea, cough, chest pain, sputum, and muscle weakness. A large number showed persistent depression mixed with anxiety, with disturbances of personality parameters. The early radiographic changes were lung edema, overinflation, enlarged heart, pleural scars, and consolidation. The persistent changes seen were interstitial deposits. Lung functions showed mainly restrictive changes with small airway obstruction; there was impairment of oxygen exchange. Oxygen exchange improved at 3-6 months, and spirometry improved at 12 months, only to decline later. The expiratory flow rates pertaining to large and medium airway function improved, but those for small airways remained low. There were changes of alveolitis in bronchoalveolar lavage fluid on fiber optic bronchoscopy, and in 11 cases positive MIC-specific antibodies to IgM, IgG, and IgE were demonstrated. On follow up, only 48% of the subjects were clinically stable, while 50% showed fluctuations. Thirty-two percent of the subjects had lung function fluctuations. Detailed sequential behavior over 2-4 years was predicted for dyspnea, forced vital capacity, maximum expiratory flow rate (0.25-0.75), peak expiratory flow rate, VO2, and depression score. A model for clinical behavior explained a total variance of 52.4% by using the factors of cough, PCO2 and X-ray zones in addition to above five parameters. The behavior of the railway colony group (1640 patients) revealed a similar pattern of illness. When this observed pattern of changes was transferred to the affected Bhopal city sections (with an equitable age-sex distribution), our model results were again validated. Thus the picture of MIC-induced disease seems similar despite the differences for age-sex and initial severity of illness in our cohort and in the population of Bhopal city as predicted by our model.

Why deliver in the supine position?

This study was conducted at the Lokmanya Tilak Municipal General Hospital, Bombay, India during the year 1990. The aim was to compare the routinely used supine position versus ambulation in the first stage and squatting position during the second stage of labour. Our study was comprised of 200 patients both primigravidas and multigravidas; 100 were kept in the supine position throughout labour and 100 were kept ambulatory in the first stage and adopted the squatting position during the second stage. The study showed a shortening of both stages of labour in the squatting group but the incidence of complications was less in the control group. It was concluded that without proper birthing chairs which can give excellent perineal support, the usual supine position is preferable in our setup.

Rupture uterus: changing trends in etiology and management.

Sixty-four cases of rupture uterus which occurred during the period 1980-89 were studied and compared with 70 cases in the preceding decade (1970-79). The changing trends in etiological factors and management of this condition have been demonstrated. While spontaneous rupture continued to account for about two-thirds of the cases (70.3%), the incidence of traumatic rupture uterus has become less than half, from 17.1 to 7.8%, and that of scar rupture has increased to more than double (from 11.4 to 23.4%). As regards management, there are improved results seen with conservative repair of the uterus. It was also seen that a subtotal hysterectomy was more commonly resorted to than total hysterectomy in the later decade. There was a decrease in the overall morbidity from 42.8 to 35.9% and also in the mortality rate from 24.3 to 18.7%.

Use of intra-amniotic urea as a second trimester abortifacient.

PIP: The use of intraamniotic instillation of hypertonic saline with/without oxytocin in midtrimester abortion can sometimes lead to a fatal complication in the form of intravascular coagulopathy. Intraamniotic urea is used for the same purpose and has a similar mode of action. It decreases the circulating progesterone level and increases prostaglandin release. It can also cause fetal death. One of its major advantages is the lack of significant complications with inadvertent intravenous infusion of urea. 70 cases of midtrimester pregnancies were terminated by injection of 200 ml of urea (40%) intraamniotically between the period 8/77 to 8/78. The patients ranged in age from 20 to 35 years. No relationship was found between the induction-abortion interval and gestation period. Success rate was 88.7%; there were 8 failures. Average induction-abortion interval was 30.7 hours, with maximum abortions occurring between 24-48 hours. There were no major complications. Urea is also used intravenously in sickle cell crisis and neurosurgical procedures.^ieng