Multidetector CT Evaluation in Arterial Stenting

Background

Multidetector CT (MDCT) represents breakthrough in CT technology, significantly improving CT Angiography applications.

Methods

Twenty one patients with aortoiliac & branch aneurysms or stenosis were evaluated by Digital Subtraction Angiography (DSA) and Multidetector CT (MDCT) before and after endovascular repair.

Results

There were eight cases of aortic & branch aneurysms and 13 with stenosis. Four cases had aortic aneurysms, while one case had left subclavian artery aneurysm, thoracic aneurysm, femoral and popliteal artery pseudoaneurysms. Of the 13 cases with stenotic lesions, iliac stenosis was seen in eight patients. The others included carotid, vertebral, aortic, renal and aortic bifurcation stenotic. MDCT offered accurate information on shape and size of aneurysm, shape and patency of graft, the presence or absence of perigraft thrombosis or endoleaks, while in stenotic lesions it provided useful information on shape of graft, its location, its patency and the presence and quantity of distal flow.

Conclusion

MDCT was found to be a potentially useful modality during initial evaluation and follow up of patient undergoing endovascular repair.Key Words: Multidetector Computed Tomography, Endovascular stents, Arterial disease     

A Systematic Review of the Performance Characteristics of Clinical Event Monitor Signals Used to Detect Adverse Drug Events in the Hospital Setting

Objective

We conducted a systematic review of pharmacy and laboratory signals used by clinical event monitor systems to detect adverse drug events (ADEs) in adult hospitals.

Design and Measurements

We searched the MEDLINE, CINHAL, and EMBASE databases for the years 1985–2006, and found 12 studies describing 36 unique ADE signals (10 medication levels, 19 laboratory values, and 7 antidotes). We were able to calculate positive predictive values (PPVs) and 95% confidence intervals (CIs) for 15 signals.

Results

We found that PPVs ranged from 0.03 (95% CI, 0.03–0.03) for hypokalemia, to 0.50 (95% CI, 0.39–0.61) for supratherapeutic quinidine level. In general, antidotes (range = 0.09–0.11) had the lowest PPVs, followed by laboratory values (range = 0.03–0.27) and medication levels (range = 0.03–0.50).

Conclusion

Data from this study should help clinical information system and computerized decision support producers develop or improve existing clinical event monitor systems to detect ADEs in their own hospitals by prioritizing those signals with the highest PPVs.     

Hip Fractures: The St Ann's Bay Regional Hospital Experience

Objectives:

To study the outcome of hip fractures in a cohort of patients from two different time periods (2002–2003 and 2006–2008).

Methods:

Patients treated for hip fractures at the St Ann''s Bay Regional Hospital, which provides orthopaedic care for the parishes of St Ann, St Mary and Portland, were retrospectively analysed between 2002–2003 and 2006–2008.

Results:

A significant increase in the recorded incidence of hip fractures, from 19 in the 2002–2003 time period to 101 in the 2006–2008 time period was noted. There was a drastic fall in the in-hospital mortality rate (43% in the 2002–2003 time period compared to 4.5% in the 2006–2008 time period). In the 2006–2008 period, 82.9% of patients were ambulant at discharge compared to 36% from the 2002–2003 time period.

Conclusion:

Early surgical fixation is necessary to allow rapid mobilization in these patients for whom the consequences of bed rest would otherwise be devastating.     

The Value of Patient Self-report for Disease Surveillance

Objective

To determine the accuracy of self-reported information from patients and families for use in a disease surveillance system.

Design

Patients and their parents presenting to the emergency department (ED) waiting room of an urban, tertiary care children’s hospital were asked to use a Self-Report Tool, which consisted of a questionnaire asking questions related to the subjects’ current illness.

Measurements

The sensitivity and specificity of three data sources for assigning patients to disease categories was measured: the ED chief complaint, physician diagnostic coding, and the completed Self-Report Tool. The gold standard metric for comparison was a medical record abstraction.

Results

A total of 936 subjects were enrolled. Compared to ED chief complaints, the Self-Report Tool was more than twice as sensitive in identifying respiratory illnesses (Rate ratio [RR]: 2.10, 95% confidence interval [CI] 1.81–2.44), and dermatological problems (RR: 2.23, 95% CI 1.56–3.17), as well as significantly more sensitive in detecting fever (RR: 1.90, 95% CI 1.67–2.17), gastrointestinal problems (RR: 1.10, 95% CI 1.00–1.20), and injuries (RR: 1.16, 95% CI 1.08–1.24). Sensitivities were also significantly higher when the Self-Report Tool performance was compared to diagnostic codes, with a sensitivity rate ratio of 4.42 (95% CI 3.45–5.68) for fever, 1.70 (95% CI 1.49–1.93) for respiratory problems, 1.15 (95% CI 1.04–1.27) for gastrointestinal problems, 2.02 (95% CI 1.42–2.87) for dermatologic problems, and 1.06 (95% CI 1.01–1.11) for injuries.

Conclusions

Disease category assignment based on patient-reported information was significantly more sensitive in correctly identifying a disease category than data currently used by national and regional disease surveillance systems.     

Using a Surgeon-modified Iliac Branch Device to Preserve the Internal Iliac Artery during Endovascular Aneurysm Repair: Single-center Experiences and Early Results

Background:

To evaluate the feasibility of a new surgeon-modified iliac branch device (IBD) technique to maintain pelvic perfusion in the management of common iliac artery (CIA) aneurysm during endovascular aneurysm repair (EVAR).

Methods:

From January 2011 to December 2013, a new surgeon-modified IBD technique was performed in department of vascular surgery of Peking Union Medical College Hospital in five patients treated for CIA aneurysm with or without abdominal aortic aneurysm. A stent-graft limb was initially deployed in vitro, anastomosed with vascular graft, creating a modified IBD reloaded into a larger sheath, with or without a guidewire preloaded into the side branch. The reloaded IBD was then placed in the iliac artery, with a covered stent bridging internal iliac artery and the branch. Finally, a bifurcated stent-graft was deployed, and a limb device was used to connect the main body and IBD.

Results:

Technical successes were obtained in all patients. The mean follow-up length was 24 months (range: 6–38 months). All grafts remained patent without any sign of endoleaks. There were no aneurysm ruptures, deaths, or other complications related to pelvic flow.

Conclusions:

Using the surgeon-modified IBD to preserve pelvic flow is a feasible endovascular technique and an appealing solution for personalized treatment of CIA aneurysm during EVAR.     

Traumatic bilateral carotid artery dissection following severe blunt trauma: a case report on the difficulties in diagnosis and therapy of an often overlooked life-threatening injury

Background

Traumatic carotid artery dissections are very rare, often overlooked and life-threatening injuries. Diagnosis and treatment are difficult especially in multiple injured patients.

Case presentation

We report on a 28-year-old female major trauma patient (injury severity score, ISS 50) who was involved in a motor vehicle accident. She was primarily transferred to a level II trauma center. After initial assessment and operative management, an anisocoria was diagnosed on the intensive care unit. Subsequent CT angiography and extracranial duplex sonography revealed a bilateral internal carotid artery dissection. The patient was transferred to our level I trauma center where conservative treatment with high-dose heparin therapy was started at day two after trauma. Outcome after 6 months was very good.

Conclusion

Besides presenting the case and outcome of this patient, the article discusses the diagnostic and therapeutic management of this extremely rare and often overlooked dangerous injury. To avoid overlooking carotid artery dissections, CT angiography of the neck region should be generously included into the initial multislice CT whole-body scan, when the injury results from an according trauma. For the best outcome, sites of hemorrhage should be abolished quickly and the anticoagulative therapy should be initiated as soon as possible. Interdisciplinary treatment of trauma surgeons and neurologists is crucial.     

Study of Drug Resistant Pulmonary Tuberculosis

Background

Drug resistance has emerged as a major problem in management of pulmonary tuberculosis (PT) with increase in its incidence.

Methods

Sixty patients who presented to a tertiary referral chest centre with drug resistant PT were included in the study out of 835 clinically diagnosed cases of PT treated between January 2000 and May 2002. They were studied to see the incidence, pattern of drug resistance and response to treatment.

Results

7.2% of the clinically diagnosed cases of PT had drug resistance and 14.8% of the 403 strains of mycobacterium tuberculosis (MTB) tested were resistant to one or more antitubercular drugs (ATD). 40 cases (66.7%) had initial resistance and acquired resistance was seen in 20(33.3%) out of the 60 cases of drug resistant PT. Single drug resistance was observed in 21 cases (35%), two drug resistance in 19 (31.7%) and 20(33.3%) cases showed resistance to three or more drugs. Individual drug resistance breakup was: INH(H) – 36(8.9%), Rifampicin (R)-38(9.4%), Ethambutol (E) – 14(3.5%), Streptomycin (S) – 34(8.4%), Pyrazinamide (Z) – 2(0.5%), Ciprofloxacin (C) – 2(0.5%), Ethionamide (N) – 2(0.5%), Cycloserine – 1(0.3%) and Kanamycin – 1(0.3%). 98.3% showed sputum conversion after starting reserve drugs. Average period of sputum conversion was 10 weeks. 3.3% were HIV positive.

Conclusion

Incidence of drug resistance was not as high as reported by some other workers and majority of the cases showed satisfactory outcome.Key Words: Drug resistant pulmonary tuberculosis     

Incidence of healthcare associated infection in the surgical ICU of a tertiary care hospital

Background

Healthcare associated infections (HAI) have taken on a new dimension with outbreaks of increasingly resistant organisms becoming common. Protocol-based infection control practices in the intensive care unit (ICU) are extremely important. Moreover, baseline information of the incidence of HAI helps in planning-specific interventions at infection control.

Methods

This hospital-based observational study was carried out from Dec 2009 to May 2010 in the 10-bedded surgical intensive care unit of a tertiary care hospital. CDC HAI definitions were used to diagnose HAI.

Results

A total of 293 patients were admitted in the ICU. 204 of these were included in the study. 36 of these patients developed HAI with a frequency of 17.6%. The incidence rate (IR) of catheter-related blood stream infections (CRBSI) was 16/1000 Central Venous Catheter (CVC) days [95% C.I. 9–26]. Catheter-associated urinary tract infections (CAUTI) 9/1000 urinary catheter days [95% C.I. 4–18] and ventilator-associated pneumonias (VAP) 32/1000 ventilator days [95% confidence interval 22–45].

Conclusion

The HAI rates in our ICU are less than other hospitals in developing countries. The incidence of VAP is comparable to other studies. Institution of an independent formal infection control monitoring and surveillance team to monitor & undertake infection control practices is an inescapable need in service hospitals.     

Spiral CT Angiography: Applications in Neurovascular Imaging

Background

The advent of Spiral Computed Tomographic (CT) angiography has provided the patients a non-invasive, accurate and fast modality of imaging the vasculature.

Methods

Spiral CT angiography was performed in 30 patients to evaluate intracranial circulation using standard protocols of data acquisition. The images were processed and reconstructed in 3-dimension to delineate anatomy and pathology accurately.

Results

The study established that CT angiography is an accurate modality for evaluating the intracranial circulation in a variety of abnormalities. It is safe both in terms of being non-invasive and exposure to radiation. It has a distinct advantage over other non-invasive modalities of imaging like MRI in the evaluation of patients with metallic stents and clips.

Conclusion

CT angiography has tremendous potential in imaging the intracranial vasculature. It is unquestionably safer than catheter angiography as it avoids arterial puncture and intra-arterial catheter manipulation. It is fast and capable of producing excellent 3-dimensional images of the intracranial vasculature.Key Words: Neurovascular imaging, Spiral CT, CT Angiography     

Evaluation of interactive teaching for undergraduate medical students using a classroom interactive response system in India

Background

The classical didactic lecture has been the cornerstone of the theoretical undergraduate medical education. Their efficacy however reduces due to reduced interaction and short attention span of the students. It is hypothesized that the interactive response pad obviates some of these drawbacks. The aim of this study was to evaluate the effectiveness of an interactive response system by comparing it with conventional classroom teaching.

Methods

A prospective comparative longitudinal study was conducted on 192 students who were exposed to either conventional or interactive teaching over 20 classes. Pre-test, Post-test and retentions test (post 8–12 weeks) scores were collated and statistically analysed. An independent observer measured number of student interactions in each class.

Results

Pre-test scores from both groups were similar (p = 0.71). There was significant improvement in both post test scores when compared to pre-test scores in either method (p < 0.001). The interactive post-test score was better than conventional post test score (p < 0.001) by 8–10% (95% CI-difference of means – 8.2%–9.24%–10.3%). The interactive retention test score was better than conventional retention test score (p < 0.001) by 15–18% (95% CI-difference of means – 15.0%–16.64%–18.2%). There were 51 participative events in the interactive group vs 25 in the conventional group.

Conclusions

The Interactive Response Pad method was efficacious in teaching. Students taught with the interactive method were likely to score 8–10% higher (statistically significant) in the immediate post class time and 15–18% higher (statistically significant) after 8–12 weeks. The number of student–teacher interactions increases when using the interactive response pads.     

Outbreak investigation: Salmonella food poisoning

Background

An outbreak of food poisoning was reported from a Military establishment on 29 May 2011 when 43 cases of food poisoning reported sick in a span of few hours.

Methods

A retrospective-prospective study was conducted. Data regarding the onset of symptoms, presenting features and history of food items consumed was collected. A detailed inspection of the mess for hygiene and sanitary status, cooking and storage procedure, and rodent nuisance was also carried out.

Results

A total of 53 cases of food poisoning occurred between 29 and 31 May 2011. All cases had symptoms of diarrohea followed by fever (96.2%), headache (84.9%), abdominal pain (50.1%), nausea and vomiting (49.1%) and bodyache (39.6%) respectively. Based on the Attributable Risk (AR = 46.67%) and Relative Risk (RR = 4.5, 95% CI = 1.22–16.54) Potato-bitter gourd vegetable served during dinner on 28 May 2011 was incriminated as the food item responsible for outbreak.

Conclusion

Symptomatology, incubation period and presence of rodent nuisance suggested contamination of Potato–bitter gourd vegetable with non-typhoidal Salmonella spp.     

Laparoscopic Cardiomyotomy for Achalasia: A Single Unit study

Aims

Achalasia is a rare incurable neuromuscular disorder of the oesophagus. A number of treatment options are available. We reviewed our results of laparoscopic cardiomyotomy over a 30 month period.

Methods

18 patients with manometric features of achalasia underwent surgery between 2004 and 2006. Pre and postoperative weight and dysphagia scores were recorded (maximum score 45=normal, 0=complete dysphagia). Change in the Body Mass Index (BMI) was measured. Other symptoms (heartburn, epigastric pain, regurgitation, odynophagia and sleep disturbance) were scored on a 0–4 scale of increasing severity.

Results

At mean follow up of 16.2 months the mean dysphagia score was significantly improved from 7.5 to 33.9 (p<0.005). BMI was significantly increased from 22.3 to 25.8 kg/m² (p<0.05). Scores for heartburn, epigastric pain, regurgitation, odynophagia and sleep disturbance were also significantly improved. The average inpatient stay was 3.1 days and average operating time 111 minutes. One mucosal perforation occurred which was repaired intraoperatively. No patients required secondary operative intervention.

Conclusions

Laparoscopic cardiomyotomy is a safe, highly effective, minimally invasive treatment for achalasia.     

Electronic health records in small physician practices: availability,use, and perceived benefits

Objective

To examine variation in the adoption of electronic health record (EHR) functionalities and their use patterns, barriers to adoption, and perceived benefits by physician practice size.

Design

Mailed survey of a nationally representative random sample of practicing physicians identified from the Physician Masterfile of the American Medical Association.

Measurements

We measured, stratified by practice size: (1) availability of EHR functionalities, (2) functionality use, (3) barriers to the adoption and use of EHR, and (4) impact of the EHR on the practice and quality of patient care.

Results

With a response rate of 62%, we found that <2% of physicians in solo or two-physician (small) practices reported a fully functional EHR and 5% reported a basic EHR compared with 13% of physicians from 11+ group (largest group) practices with a fully functional system and 26% with a basic system. Between groups, a 21–46% difference in specific functionalities available was reported. Among adopters there were moderate to large differences in the use of the EHR systems. Financial barriers were more likely to be reported by smaller practices, along with concerns about future obsolescence. These differences were sizable (13–16%) and statistically significant (p<0.001). All adopters reported similar benefits.

Limitations

Although we have adjusted for response bias, influences may still exist.

Conclusion

Our study found that physicians in small practices have lower levels of EHR adoption and that these providers were less likely to use these systems. Ensuring that unique barriers are addressed will be critical to the widespread meaningful use of EHR systems among small practices.     

Incidence of high altitude pulmonary edema in low-landers during re-exposure to high altitude after a sojourn in the plains

Background

There is uncertainty whether acclimatized low-landers who return to high altitude after a sojourn at low altitude have a higher incidence of pulmonary edema than during the first exposure to high altitude.

Methods

This was a prospective cohort study consisting of men ascending to 3400 m by road (N = 1003) or by air (N = 4178). The study compared the incidence of high altitude pulmonary edema during first exposure vs the incidence during re-exposure in each of these cohorts.

Results

Pulmonary edema occurred in 13 of the 4178 entries by air (Incidence: 0.31%, 95% CI: 0.18%–0.53%). The incidence during first exposure was 0.18% (0.05%–0.66%) and 0.36% (0.2%–0.64%) during re-exposure (Fisher Exact Test for differences in the incidence (two-tailed) p = 0.534). The relative risk for the re-exposure cohort was 1.95 (95% CI, 0.43%–8.80%). Pulmonary edema occurred in 3 of the 1003 road entrants (Incidence: 0.30%, 95% CI: 0.08%–0.95%). All three cases occurred in the re-exposure cohort.

Conclusion

The large overlap of confidence intervals between incidence during first exposure and re-exposure; the nature of the confidence interval of the relative risk; and the result of the Fisher exact test, all suggest that this difference in incidence could have occurred purely by chance. We did not find evidence for a significantly higher incidence of HAPE during re-entry to HA after a sojourn in the plains.     

Comparison of PET/CT with conventional imaging modalities (USG,CECT) in evaluation of N0 neck in head and neck squamous cell carcinoma

Background

Evaluation of a clinically N0 neck is mandatory in cases of squamous cell carcinoma of head and neck region in order to determine the need to address the neck. The study was designed to compare the accuracy of PET/CT scan with that of USG and CECT Neck in assessing clinically N0 neck in cases of squamous cell carcinoma of upper aerodigestive tract.

Methods

Single center, prospective, study over a 2 year period. All Cases of squamous cell carcinoma of upper aerodigestive tract with no palpable neck lymphadenopathy and who were scheduled for surgery were evaluated with USG, CECT and 18F-FDG PET/CT, of the neck. Post operative histopathology was correlated with pre-operative nodal status. Statistical analysis was done using the chi square test.

Results

In the 49 patients enrolled, 51 neck sides underwent dissections. Sensitivity of USG, CECT and PET-CT was 4.76%, 23.80% and 71.43% respectively while the specificity was 93.33%, 93.33% and 96.67% respectively. The positive predictive value (PPV) calculated for USG, CECT and PET-CT was 33.33%, 71%, 93.5% respectively while the negative predictive value (NPV) 58.33%, 63.63% and 82.85% respectively.

Conclusions

In N0 neck in head and neck squamous cell carcinoma, though FDG-PET-CT is more accurate than either USG or CECT in staging of the neck, it is not accurate enough to alter the current treatment paradigm.     

Breast Feeding Practices among Families of Armed Forces Personnel in a Large Cantonment

Background

There seems to be a gap in the available literature and scientific knowledge about breast-feeding practices among families of armed forces personnel in our country, which needs to be studied.

Methods

A cross sectional epidemiological study design was undertaken on a randomly selected sample of 175 families of armed forces personnel staying in a large cantonment and having at least one child in the age group of 3–24 months.

Result

The study observed positive association between various breast feeding practices such as feeding colostrum, demand/scheduled feeding, exclusive breast feeding for 4–6 months, partial breast feeding for 6 – 18 months and various sociodemographic variables such as age, religion, socio-economic status of mother (military rank of husband), parity and place of residence of the mother (where childhood was spent).

Conclusion

Higher proportion of mothers feeding colostrum was observed because of better educational status of mothers and organized health education activities available to the families of armed forces personnel. Majority (89.14%) gave demand feed and only 10.86% gave scheduled feed. On the other hand a relatively smaller percentage (47.43% and 29.32%) followed the correct practice about duration of exclusive and partial breast-feeding respectively.Key Words: Colostrum, Demand/Scheduled feeding, Breast feeding     

Tuberculosis Drug Resistance and Outcomes among Tuberculosis Inpatients in Lilongwe,Malawi

Setting/Objective

We evaluated clinical characteristics, yield of solid vs. liquid culture, polymerase chain reaction (PCR)-based drug-resistance profiles, and clinical outcomes of tuberculosis (TB) inpatients in Lilongwe, Malawi.

Design

We enrolled adult patients admitted to the Bwaila TB Ward from Jan-Aug/2010. Evaluations included questionnaires, clinical exam, chest radiograph, HIV status, CD4 lymphocyte count, plasma HIVRNA and sputum analysis including Auramine-O stain, Lowenstein-Jensen (LJ) and Mycobacterial Growth Indicator Tube (MGIT) culture, and susceptibility testing using the HAIN GenoType® MTBDRplus.

Results

Eighty-eight patients were enrolled (88% re-treatment, 42% smear positive, 93% pulmonary TB, 74% HIV co-infected). At baseline, 44/88 (50%) MGIT and 28 (32%) LJ cultures were positive with a mean time to positivity of 12.1 (Range 1–42) and 21.5 (Range 7–58) days, respectively. Four percent (3/77) of retreatment patients or 8% of the 38 MGIT+ PCR-confirmed retreatment cases had multi-drug resistant tuberculosis (MDR TB). One MDR TB patient was smear negative and only one MDR patient was identified with LJ. Lower mean hemoglobin at admission was associated with mortality (10.5 vs. 7.5; p<0.01; CI 101 9.8–11.0).

Conclusions

The MDR TB burden among the retreatment population in Lilongwe, Malawi is similar to regional estimates by the WHO (7.7% 95% CI 0–18.1). MDR TB patients are not routinely identified with sputum smear or LJ, suggesting more efficient technology should be adopted.     

Antifungal activity of four honeys of different types from Algeria against pathogenic yeast: Candida albicans and Rhodotorula sp.

Objective

To evaluate the antifungal activity of four honeys of different types from Algeria against pathogenic yeast i.e. Candida albicans (C. albicans) and Rhodotorula sp.

Methods

Four Algeria honeys of different botanical origin were analyzed to test antifungal effect against C. albicans, and Rhodotorula sp. Different concentrations (undiluted, 10%, 30%, 50% and 70% w/v) of honey were studied in vitro for their antifugal activity using C. albicans and Rhodotorula sp. as fungal strains.

Results

The range of the diameter of zone of inhibition of various concentrations of tested honeys was (7–23 mm) for Rhodotorula sp., while C. albicans showed clearly resistance towards all concentrations used. The MICs of tested honey concentrations against C. albicans and Rhodotorula sp. were (70.09–93.48)% and (4.90–99.70)% v/v, respectively.

Conclusions

This study demonstrates that, in vitro, these natural products have clearly an antifungal activity against Rhodotorula sp. and C. albicans.     

Sonographic Biometry of Normal Kidney Dimensions among School-age Children in Nsukka,Southeast Nigeria

Background:

Some kidney diseases are usually associated with changes in kidney size.

Objective:

To determine sonographically the normal limits and percentile curves of the kidney dimensions according to age, gender and somatometric parameters among school-age children.

Methods:

A prospective cross-sectional research design and convenience sampling method were utilized. Participants included 947 normal subjects (496 boys and 451 girls) aged 6–17 years old. The sonographic examination was performed on a Shenzhen DP-1100 machine with 3.5 MHz convex transducer. Longitudinal and transverse dimensions of the kidneys were obtained in coronal plane with the subject in the supine or left lateral decubitus position.

Results:

The means of right and left kidney lengths in mm were 79.6 ± 8.1 and 81.6 ± 8.3, respectively while those of the right and left kidney widths in mm were 35.03 ± 3.6 and 35.09 ± 3.6, respectively. Dimensions of the kidneys were not statistically different in boys and girls (p > 0.05). There was a statistically significant difference between right and left kidney length (p < 0.05). Height correlated best with both kidney lengths. Thus the normal limits, prediction models and percentile curves of kidney lengths were established with respect to height.

Conclusion:

Sonographic determination of pathologic changes in the size of the kidney necessitates knowing the normal ranges of its length especially with respect to height in school-age children.