Diagnostic utility of ultrasonography and computerized tomography in gall bladder perforation: A case report.

Gall bladder (GB) perforation can be misdiagnosed as any other more common cause of acute abdomen. We present a case of a 72-year-female who had presented to the emergency department with an acute abdomen. The clinical presentation and the biochemical markers had pointed towards acute pancreatitis. However, the ultrasonographic examination of the abdomen and the pelvis suggested GB perforation which was confirmed by the multislice computerized tomography scan. Following this the patient underwent open cholecystectomy and was successfully managed. The invaluable contributions from the radiological modalities led to the successful management of the patient.

Ultrasound evaluation of normal orbital preseptal thickness.

INTRODUCTION: Orbital preseptal thickness is an important parameter not only in diagnosis of orbital cellulitis but also in recent classification and management of dark eye circle (DEC). OBJECTIVE: The aim of this study was to evaluate normal preseptal thickness and collect baseline data in normal skin in a given population with no orbital pathology. MATERIALS & METHOD: Ultrasound was performed on 42 patients (23 females and 19 males) with clinically normal eyes and orbits for evaluation of normal orbital preseptal thickness. The age ranged between 15 to 35 years with a mean age of 24.9 years. RESULTS: Our study concluded that normal preseptal thickness ranged from 2.1 mm to 5.5 mm. Mean preseptal thickness for both sides was 3.9 mm. CONCLUSION: Ultrasound can be used as quick, reliable and cost-effective modality for evaluation of orbital preseptal thickness.

Normal Width of Third Ventricle In Nepalese Population: Assessment By CT Scan.

INTRODUCTION: Cerebral ventricular enlargement occurs as a natural aging process but also has been associated with many neurological disorders. Whether this enlargement is primary or secondary to these pathological conditions remains controversial. Objective of the study was to tabulate and create normal references values for maximum width of third ventricle in Nepalese population according to age group and gender. METHODS: MTW was determined in two hundred (112 males and 88 females) and age ranging between 1- 93 years who had normal Computed tomography scan of the head .The data collected was analyzed with statistical program IBM SPSS version 20. RESULTS: Measurements of MTW in both males and females of the normal groups revealed no significant difference. No significant difference in MTW was noticed till the age of 49 years. Significant differences were noticed between 49 - 93 years of age. CONCLUSIONS: This study corroborated well with normal MTW values published in literatures from other parts of the world. However normal values specific to our local population becomes more relevant in interpreting CT scan of head in Nepal.

Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial.

PURPOSE: Cognitive impairment after critical illness is common and debilitating. We developed a cognitive therapy program for critically ill patients and assessed the feasibility and safety of administering combined cognitive and physical therapy early during a critical illness. METHODS: We randomized 87 medical and surgical ICU patients with respiratory failure and/or shock in a 1:1:2 manner to three groups: usual care, early once-daily physical therapy, or early once-daily physical therapy plus a novel, progressive, twice-daily cognitive therapy protocol. Cognitive therapy included orientation, memory, attention, and problem-solving exercises, and other activities. We assessed feasibility outcomes of the early cognitive plus physical therapy intervention. At 3 months, we also assessed cognitive, functional, and health-related quality of life outcomes. Data are presented as median (interquartile range) or frequency (%). RESULTS: Early cognitive therapy was a delivered to 41/43 (95%) of cognitive plus physical therapy patients on 100% (92-100%) of study days beginning 1.0 (1.0-1.0) day following enrollment. Physical therapy was received by 17/22 (77%) of usual care patients, by 21/22 (95%) of physical therapy only patients, and 42/43 (98%) of cognitive plus physical therapy patients on 17% (10-26%), 67% (46-87%), and 75% (59-88%) of study days, respectively. Cognitive, functional, and health-related quality of life outcomes did not differ between groups at 3-month follow-up. CONCLUSIONS: This pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy. Future work to determine optimal patient selection, intensity of treatment, and benefits of cognitive therapy in the critically ill is needed.

Long-term cognitive impairment after critical illness.

BACKGROUND: Survivors of critical illness often have a prolonged and disabling form of cognitive impairment that remains inadequately characterized. METHODS: We enrolled adults with respiratory failure or shock in the medical or surgical intensive care unit (ICU), evaluated them for in-hospital delirium, and assessed global cognition and executive function 3 and 12 months after discharge with the use of the Repeatable Battery for the Assessment of Neuropsychological Status (population age-adjusted mean [±SD] score, 100±15, with lower values indicating worse global cognition) and the Trail Making Test, Part B (population age-, sex-, and education-adjusted mean score, 50±10, with lower scores indicating worse executive function). Associations of the duration of delirium and the use of sedative or analgesic agents with the outcomes were assessed with the use of linear regression, with adjustment for potential confounders. RESULTS: Of the 821 patients enrolled, 6% had cognitive impairment at baseline, and delirium developed in 74% during the hospital stay. At 3 months, 40% of the patients had global cognition scores that were 1.5 SD below the population means (similar to scores for patients with moderate traumatic brain injury), and 26% had scores 2 SD below the population means (similar to scores for patients with mild Alzheimer's disease). Deficits occurred in both older and younger patients and persisted, with 34% and 24% of all patients with assessments at 12 months that were similar to scores for patients with moderate traumatic brain injury and scores for patients with mild Alzheimer's disease, respectively. A longer duration of delirium was independently associated with worse global cognition at 3 and 12 months (P=0.001 and P=0.04, respectively) and worse executive function at 3 and 12 months (P=0.004 and P=0.007, respectively). Use of sedative or analgesic medications was not consistently associated with cognitive impairment at 3 and 12 months. CONCLUSIONS: Patients in medical and surgical ICUs are at high risk for long-term cognitive impairment. A longer duration of delirium in the hospital was associated with worse global cognition and executive function scores at 3 and 12 months. (Funded by the National Institutes of Health and others; BRAIN-ICU ClinicalTrials.gov number, NCT00392795.).

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit

OBJECTIVE: To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002. METHODS: The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding. CONCLUSION: These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Sensitivity of particulate matter nitrate formation to precursor emissions in the California San Joaquin Valley.

The formation of secondary ammonium nitrate during the 1995 Integrated Monitoring Study (IMS95) in San Joaquin Valley, CA was investigated using a box model that simulates the atmospheric chemistry and gas/particle partition of inorganic compounds. The concentration of particulate matter (PM) nitrate was found to be sensitive to reductions in VOC emissions. Nitric acid, rather than ammonia, was the limiting reagent in the formation of PM nitrate. The formation of nitric acid was more sensitive to the availability of oxidants than that of NOx. Oxidant chemistry in wintertime conditions in the San Joaquin Valley was shown to be VOC-sensitive. In fact, a decrease in NOx emissions may have the counter-intuitive effect of increasing PM nitrate.

Ozone formation in California's San Joaquin Valley: a critical assessment of modeling and data needs.

Data from the 1990 San Joaquin Valley Air Quality Study/Atmospheric Utility Signatures, Predictions, and Experiments (SJVAQS/AUSPEX) field program in California's San Joaquin Valley (SJV) suggest that both urban and rural areas would have difficulty meeting an 8-hr average O3 standard of 80 ppb. A conceptual model of O3 formation and accumulation in the SJV is formulated based on the chemical, meteorological, and tracer data from SJVAQS/AUSPEX. Two major phenomena appear to lead to high O3 concentrations in the SJV: (1) transport of O3 and precursors from upwind areas (primarily the San Francisco Bay Area, but also the Sacramento Valley) into the SJV, affecting the northern part of the valley, and (2) emissions of precursors, mixing, transport (including long-range transport), and atmospheric reactions within the SJV responsible for regional and urban-scale (e.g., down-wind of Fresno and Bakersfield) distributions of O3. Using this conceptual model, we then conduct a critical evaluation of the meteorological model and air quality model. Areas of model improvements and data needed to understand and properly simulate O3 formation in the SJV are highlighted.

Guidance for the performance evaluation of three-dimensional air quality modeling systems for particulate matter and visibility.

Guidance for the performance evaluation of three-dimensional air quality modeling systems for particulate matter and visibility is presented. Four levels are considered: operational, diagnostic, mechanistic, and probabilistic evaluations. First, a comprehensive model evaluation should be conducted in at least two distinct geographical locations and for several meteorological episodes. Next, streamlined evaluations can be conducted for other similar applications if the comprehensive evaluation is deemed satisfactory. In all cases, the operational evaluation alone is insufficient, and some diagnostic evaluation must always be carried out. Recommendations are provided for designing field measurement programs that can provide the data needed for such model performance evaluations.