Beating heart versus conventional coronary bypass surgery : Our experience

Background: Off-pump Coronary Artery Bypass (OPCAB) has become the standard surgical treatment of Coronary Artery Disease in most centres in India. It is clear from the current evidence that, in certain patients, OPCAB offers advantages over conventional Coronary Artery Bypass Grafting (CABG). Experience of this procedure in the Armed Forces is highlighted.     

Psychological Correlates of Outcome after Coronary Artery Bypass Graft

Background

Psychological effects of Coronary Artery Bypass graft (CABG) have been of interest all over the world but there is a paucity of Indian work.

Methods

30 patients undergoing CABG at a service hospital were included. All patients filled a specially designed proforma. Mini Mental Status Examination, Hospital anxiety and depression scale, Coronary scale, Seattle angina questionnaire and Euro-QOL 5D were performed before and seven days after CABG.

Results

43.3% had significant anxiety and 30% had significant depression before CABG. Following CABG, 36.67% of the patients had significant anxiety while 40% had significant depression. On the Seattle angina questionnaire, physical limitation reduced from 71.6 ± 7.9 to 53.1 ± 14.6. There was significant improvement in treatment satisfaction from 37.8 ± 6.1 to 59.4 ± 4.2 following CABG. On th euro quality of life scale (EQ5D) health status improved from 38.17 ± 9.51 before CABG to 68.5 ± 5.28 after CABG.

Conclusion

There is a significant incidence of anxiety and depression in patients undergoing CABG, both before and after surgery.Key Words: CABG, anxiety, depression     

Platelet Functions in Cardiopulmonary Bypass Surgery

Background

Haemorrhage after Cardio Pulmonary Bypass (CPB) Surgery is a well recognised complication that leads to significant morbidity and mortality. The incidence varies between 5-25% depending upon the clinical situation. Several factors are implicated as causative but none have been precisely proved.

Methods

Our study was an attempt to evaluate the haemostatic defect with particular reference to platelet function abnormalities during cardio pulmonary bypass surgery, in order to reduce the morbidity and mortality associated with post CPB haemorrhage. Flow cytometric evaluation of different platelet glycoproteins like GPIb/IX, GPIIb/IIIa and GMP-140 was done.

Results

The marker expression showed deregulation during surgery which returned to base after bypass was terminated. In contrast, the cases with bleeding showed significant variation. P-Selectin (GMP 140) expression decreased progressively till 3^rd post-operative day showing lack of activation of platelets in cases of severe bleeding.

Conclusion

Longer duration of CPB initiates plasmin generation through heparin, which raises the PAI-1-tPA complex and thereby down regulating the functions of platelets. This suggests a link between duration of CPB, bleeding, platelet dysfunction and fibrinolysis. Hence serial estimations of the levels of GMP-140 and tPA can predict severe bleeding.Key Words: CardioPulmonary Bypass, Platelet dysfunction, flowcytometry, platelet glycoproteins, haemorrhage     

微创冠状动脉旁路移植术中的备体外循环

目的 探讨非体外循环下冠状动脉旁路移植(OPCAB)术中的备体外循环。方法 2000年1月至2004年9月，603例计划实施OPCAB手术患者，体外循环采用“干备”和“湿备”2种方法。结果 603例患者中采用“湿备”23例，“干备”580例。术前临时改为体外循环下手术者“湿备”3例，“干备”19例，术中改为体外循环下手术“干备”1例。23例体外循环下手术患者无死亡。结论 “备体外”是OPCAB手术不可缺少的一部分，选择合适的“备体外”方法，有助于提高OPCAB手术的安全性。     

全动脉化非体外循环冠状动脉搭桥术的临床应用

目的探讨全动脉化非体外循环冠状动脉旁路移植术(冠脉搭桥术)的手术技术、安全性和近中期手术效果。方法 2004年3月～2012年4月接受全动脉化非体外循环冠脉搭桥术(包括微创冠脉搭桥)患者35例,人均搭桥2.7支(1～4支)。其中常规开胸非体外循环冠脉搭桥30例,胸腔镜辅助下微创冠脉搭桥5例。同期行体外循环下全动脉化冠脉搭桥8例,同期行一根乳内动脉和静脉做常规非体外循环冠脉搭桥248例,比较不同手术方式的死亡率、并发症、桥血管数目和近中期疗效等。结果全动脉化非体外循环冠脉搭桥术后仅1例患者因胸骨感染死亡,34例症状明显改善顺利出院,随访效果均良好,无心绞痛发作,心功能明显改善。结论全动脉化非体外循环冠状动脉旁路移植术临床效果较好,并发症及死亡率较体外循环下搭桥少,总的风险更低,但因患者病变、病情及各种因素,本术仍不能完全取代冠状动旁路移植术。     

急诊冠状动脉搭桥术围术期手术效果分析

目的探讨急诊冠状动脉搭桥术的手术指征、并发症及围术期处理方法。方法回顾28例急诊CABG手术患者。入选病例均符合ACC/AHA有关冠心病手术指南中急诊冠状动脉搭桥术适应证。分析入选病例的围术期危险因素及死亡原因。结果本组所有病例有心肌梗死病史,大部分有高脂血症、高血压和糖尿病,以及合并左室肥厚,一半病例有左主干病变。围术期死亡3例,占10.7%;10例出现围术期并发症,占35.7%。围术期并发症包括二次开胸止血、心包填塞、恶性心律失常、急性肾衰竭和MOSF等。合并手术操作(瓣膜置换等),更长的体外循环转机时间和主动脉阻断时间是主要的死亡原因。结论急诊冠状动脉搭桥术是挽救生命、缓解症状和提高生活质量的有效手段。缩短体外循环转机时间和主动脉阻断时间可减少术后死亡和出血并发症。     

Use of buffy coat thick films in detecting malaria parasites in patients with negative conventional thick films

Objective

To determine the frequency of malaria parasite detection from the buffy coat blood films by using capillary tube in falciparum malaria patients with negative conventional thick films.

Methods

Thirty six uncomplicated falciparum malaria patients confirmed by conventional thick and thin films were included in the study. The patients were treated with artemisinin combination therapy at Hospital for Tropical Diseases, Bangkok, Thailand for 28 day. Fingerpricks for conventional blood films were conducted every 6 hours until negative parasitemia, then daily fingerpricks for parasite checks were conducted until the patients were discharged from hospital. Blood samples were also concurrently collected in 3 heparinized capillary tubes at the same time of fingerpricks for conventional blood films when the prior parasitemia was negative on thin films and parasitemia was lower than 50 parasites/200 white blood cells by thick film. The first negative conventional thick films were compared with buffy coat thick films for parasite identification.

Results

Out of 36 patients with thick films showing negative for asexual forms of parasites, buffy coat films could detect remaining 10 patients (27.8%) with asexual forms of Plasmodium falciparum.

Conclusions

The study shows that buffy coat thick films are useful and can detect malarial parasites in 27.8% of patients whose conventional thick films show negative parasitemia.     

Prevalence of unsuspected glucose intolerance in coronary artery disease (CAD) patients: Importance of HbA1c

Background

The mortality and morbidity rates are two to fourfold higher among Coronary Artery Disease (CAD) patients with type 2 diabetes mellitus (DM). American Diabetes Association (ADA) and World Health Organization (WHO) define different criteria for the diagnosis of glucose intolerance. This study compares the available diagnostic criteria for DM in Indian men and their importance in CAD patients.

Methods

This cross-sectional study was done on 794 male volunteers; 483 individuals from general population and 311 patients undergoing angiography for evaluation of CAD. Individuals with previous clinical history of diabetes mellitus were excluded.

Results

More than 90% of diabetics by ADA criteria could be diagnosed by Fasting plasma glucose (FPG) and HbA1c criteria while FPG and pg2h plasma glucose (WHO criteria) could detect only 74%. Impaired Fasting Glucose (IFG) or Impaired Glucose Tolerance (IGT) was present in 36.7% of individuals diagnosed to be diabetic based on HbA1c; more in CAD +ve group (53.8%) than in general population (23.6%). ROC analysis suggests >121 mg/dl of FPG or >6.2% of HbA1c as optimum cut-off for the diagnosis of DM. FPG and HbA1c criteria have higher Relative Risk for presence of coronary artery occlusion and HOMA-IR.

Conclusion

Inclusion of HbA1c in the criteria for diagnosis of DM (ADA criteria) can detect large number of cases with persistent hyperglycemia in the non-diagnostic range of DM (IFG or IGT) among general population and CAD patients. This has special relevance to epidemiological studies as the diagnosis of DM can be made on single fasting blood sample.     

Early Results of Coronary Endarterectomy Combined with Coronary Artery Bypass Grafting in Patients with Diffused Coronary Artery Disease

Background:

It is still a challenge for the cardiac surgeons to achieve adequate revascularization for diffused coronary artery disease (CAD). Coronary endarterectomy (CE) offers an alternative choice of coronary artery reconstruction and revascularization. In this study, short-term result of CE combined with coronary artery bypass graft (CABG) was discussed in the treatment for the diffused CAD.

Methods:

From January 2012 to April 2014, 221 cases of CABG were performed by the same surgeon in our unit. Among these cases, 38 cases of CE + CABG were performed, which was about 17.2% (38/221) of the cohort. All these patients were divided into two groups: CE + CABG group (Group A) and CABG alone group (Group B). All clinical data were compared between the two groups, and postoperative complications and in-hospital mortality were analyzed. The categorical and continuous variables were analyzed by Chi-square test and Student''s t-test respectively.

Results:

Diabetes mellitus, hypertension, hyperlipidemia, and peripheral vascular disease were more common in group A. In this cohort, a total of 50 vessels were endarterectomized. Among them, CE was performed on left anterior descending artery in 11 cases, on right coronary artery in 29 cases, on diagonal artery in 3 cases, on intermediate artery in 2 cases, on obtuse marginal artery in 5 cases. There was no hospital mortality in both groups. The intro-aortic balloon pump was required in 3 cases in Group A (3/38), which was more often than that in Group B (3/183). At the time of follow-up, coronary computed tomography angiogram showed all the grafts with CE were patent (50/50). There is no cardio-related mortality in both groups. All these patients were free from coronary re-intervention.

Conclusions:

Coronary endarterectomy + CABG can offer satisfactory result for patients with diffused CAD in a short-term after the operation.     

瞬时血流测量技术在不停跳冠状动脉旁路移植术中的应用

目的在不停跳冠状动脉旁路移植术(Off-pump Coronary Artery Bypass Grafting,OPCAB)中应用瞬时血流测量仪(Transit-time Flowmetery,TTFM)测量血管桥的血流量,根据平均血流量、搏动指数(Pulsatility Index,PI)和血流曲线图,判定血管桥的通畅性,及时对不通畅的血管桥进行修正,提高手术效果。方法2001年7月—2005年6月,对256例OPCABG病例的498支血管桥进行血流测量,分析平均血流量、PI和血流曲线图。结果共15例16支血管桥测量结果显示平均血流量偏低、PI过高、血流曲线图不正常三种情况中的一种或几种,检查发现:乳内动脉损伤3支,静脉桥扭曲或旋转7支,吻合口狭窄4支,血管桥张力过大2支,总的血管桥修正率为3%(16/498)。结论TTFM测量血管桥血流量,简便可靠,重复性强,可及时发现不通畅的血管桥并纠正,确保手术效果。     

Misoprostol as aid in First Trimester MTP

Background

Medical Termination of Pregnancy (MTP) is a commonly performed during the first trimester. Dilatation and Evacuation (D & E) mandates rapid dilatation of cervix with metal dilators, which requires anaesthesia and may be associated with trauma to the uterus, cervix and later cervical incompetence. The problem of rapid cervical dilatation is obviated with intravaginal misoprostol.

Methods

Intravaginal misoprostol tablet 200 microgram was inserted, a night prior to MTP to ripen the cervix. Cervix was dilated with metal dilators only in cases where cervix did not loosen up sufficiently. Products of conception were removed by suction.

Results

Out of 108 cases cervical dilatation was not required in 96 cases (88.9%).

Conclusion

Intravaginal misoprostol 200 microgram proved effective as a priming agent prior to MTP in the first trimester.Key Words: Misoprostol, MTP     

The use of chicken legs for teaching wound closure skills

Objective

Training models are required to impart surgical skills, like wound closure techniques, prior to practice in patients. In an ideal case, the tissue characteristics of the model are close to those of humans, easy to create and of low cost.

Methods

Here, we describe a model to train students in wound closure technique using conventional chicken legs obtained from the supermarket.

Results

The described model has good tissue characteristics, does not require any lavish preparation and is of minimal cost (0.62 Euro or 0.78 USD).

Conclusions

Chicken legs appear to be an appropriate tool for teaching wound closure techniques.     

Medical and Surgical Management of Keratomycosis

Background

Fungal keratitis is a diagnostic and therapeutic challenge to the ophthalmologist. If not treated energetically it results in marked ocular morbidity and permanent visual loss.

Methods

Twenty five patients of fungal keratitis were studied for their response to management and final visual outcome.

Result

Males outnumbered females. Medical treatment was successful in 72% cases, while 28% required surgical intervention. Keratoplasty was done in five patients out of which graft was clear in four after one year of follow up. Three of these underwent optical keratoplasty since therapeutic grafts became opaque.

Conclusion

Early recognition of the disease and institution of prompt therapy is the key to successful management in fungal keratitis. Occasionally surgical management is required to preserve anatomical integrity of the globe and to salvage useful vision.Key Words: Fungal keratitis, Keratomycosis, Keratoplasty     

A Study of Efficacy of Misoprostol in Missed Abortion

Background

Missed abortion is a common emergency where uterine evacuation is performed by surgical means.

Method

A total of 30 patients were included in this study to evaluate the efficacy of tablet misoprostol for uterine evacuation in cases of missed abortion. The gestational age ranged from 8-22 weeks. 21 out of 30 patients were primigravidae and the rest multigravidae. Tablet misoprostol (200mcg) was applied vaginally in the posterior fornix every eight hours to a maximum of five tablets. Success rate, complications and side effects were the main outcome measures.

Results

The procedure was successful in all cases. Two out of 30 cases required check curettage. Gastrointestinal side effects like vomiting and diarrhoea were seen in few cases.

Conclusion

The use of tablet misoprostol is effective for uterine evacuation in cases of missed abortion.Key Words: Misoprostol, Missed abortion     

非体外循环冠状动脉搭桥术的手术配合体会

目的 探讨非体外循环冠脉搭桥术(OPCAB)的手术配合方法.方法 对30例多支冠心病患者非体外循环冠状动脉搭桥术进行手术配合.结果 心理护理到位,手术物品准备齐全,手术过程顺利,患者生命体征平稳,手术成功率100％.结论 对OPCAB术进行术前、术中、术后整体护理可以有效提高手术配合质量,保证手术顺利进行.     

A prospective review of the labor analgesia programme in a teaching hospital

Background

The structured labor analgesia programme in our tertiary care hospital has been in place for the past few years. We undertook this study to analyze the programme and to draw conclusions to further improve the outcomes.

Methods

A prospective analysis of the data pertaining to 200 patients participating in an ongoing labor analgesia programme in a tertiary care hospital from Nov 2008 to Aug 2009 was performed.

Results

Mean visual analog score (VAS) before epidural block was 8.34 ± 0.79. Post procedure the average VAS score was 2.20 ± 0.79. One hundred and fifty six (78%) parturients delivered vaginally, 18 (9%) required instrumentation with vacuum including 1 forceps delivery in a multiparous parturient. In 17parturients (8.7%) fetal distress led to a decision to perform LSCS for delivery. Multiparous patients were significantly more satisfied as compared to nulliparous patients (p = 0.010).

Conclusion

The study demonstrated excellent pain relief and patient satisfaction with minimal complications. The safety and efficacy of epidural bupivacaine in concentrations less than 0.625% combined with 25 mcg of fentanyl demonstrated in our study should be considered are commendation for the widespread adoption of the procedure in tertiary care hospitals.     

Late-stage disease at presentation to an HIV clinic in eastern Tanzania: A retrospective cross-sectional study

Background

Late presentation and delayed treatment initiation is associated with poor outcomes in patients with HIV. Little is known about the stage at which HIV patients present at HIV clinics in Tanzania.

Aim

This study aimed at determining the proportion of HIV patients presenting with WHO clinical stages 3 and 4 disease, and the level of immunity at the time of enrollment at the care and treatment center.

Methods

A retrospective cross-sectional study was conducted among 366 HIV-infected adults attending HIV clinic at Mwananyamala Hospital in Dar es Salaam, Tanzania. Data were obtained from the care and treatment clinic database.

Results

Late stage disease at the time of presentation was found in 276 (75.4%) of the patients; out of whom 153 (41.8%) presented with CD4 count <200 cells/ul and 229 (62.6%) presented with WHO clinical stage 3 or 4 at the time of clinic enrollment. Strategies to improve early diagnosis and treatment initiation should be improved.     

Medical Abortion-An Alternative to Surgical Abortion

Background

Termination of early pregnancy has traditionally been done surgically, but agents are now available which can terminate pregnancy if taken orally, vaginally or parenterally. We have used a combination of mifepristone and misoprostol for termination of early pregnancy.

Material and Method

Fifty patients having amenorrhoea of upto 56 days with confirmed intrauterine pregnancy, were selected for medical termination of pregnancy. The patients were given tablet mifepristone (200mg) on day 1 and tablet misoprostol (400mcg) on day 3. On day 14, an ultrasound was done to confirm complete abortion.

Result

Majority 35 (70%) patients had amenorrhoea between 40 – 50 days. The duration of bleeding was less than 5 days in 12%, between 5 -10 days in 56%, 10 -13 days in 16% and greater than 14 days in 16%. In all patients with bleeding of more than 14 days ultrasonography confirmed intrauterine products & a suction evacuation was done. In this series there were no failures.

Conclusion

The combination of mifepristone and misoprostol is an effective method for termination of early pregnancy up to 56 days of amenorrhoea.Key Words: Medical abortion