Hepatic-pericardio-phrenic collateral (natural shunt) in a patient with Budd-Chiari syndrome

Hepatic venous outflow tract obstruction, Budd-Chiari syndrome (BCS), leads to portal hypertension and to the development of collaterals that bypass the obstruction. Described here is a BCS patient with an unusually large transdiaphragmatic collateral between the left hepatic and left innominate veins, which decompressed the oesophageal varices. This has not been reported earlier in the literature.     

ASSESSMENT OF VAGOTOMY BY POST-PRANDIAL ALKALINE TIDE

The effect of vagotomy on the post-prandial alkaline tide was assessed by measuring the fasting and postprandial urinary pH before and after vagotomy in 50 cases of chronic duodenal ulcer treated by posterior truncal vagotomy or gastrojejunostomy or pyloroplasty. Results showed that post-prandial urinary pH fell after vagotomy confirming the completeness of vagotomy. This test is safe, reliable, noninvasive and a simpler bedside procedure as compared to the conventional Hollander''s insulin test.KEY WORDS: Vagotomy, Alkaline tide     

ORIGINAL ARTICLE: Role of mean platelet volume as discriminating guide for bone marrow disease in patients with thrombocytopenia

Recently, platelet indices have been evaluated to determine their utility in knowing the mechanism of thrombocytopenia. This study was conducted to analyze the role of mean platelet volume (MPV) as a guide or an indicator for bone marrow disease in thrombocytopenic patients. All the patients with thrombocytopenia for various causes followed by bone marrow examination were divided into two groups, one group with and another without bone marrow disease, depending on pathophysiology. The MPV was statistically analyzed in both the groups to assess its role as guide for bone marrow disease in these patients. Mean MPV (average score of all individual mean values in patients) in the group with bone marrow disease was 7.3 fl, while in the group without bone marrow disease, it was 8.62 fl. Although the difference in MPV in the two groups of with (including megaloblastic anemia) and without bone marrow involvement was statistically significant (P value <0.001), its sensitivity and specificity scores as observed by receptor operating characteristic (ROC) curve at cut-off of <8.15 fl were not highly sufficient (67.7% sensitive and 65% specific). The study concluded that although MPV can be used as an initial hint for bone marrow disease in thrombocytopenic patients, it has limited sensitivity and specificity. The differentiation of megaloblastic anemia from other causes of pancytopenia involving the marrow requires bone marrow examination rather than using MPV as an indicator. Bone marrow examination remains the gold standard for discriminating hypoproductive type of thrombocytopenia from the hyperdestructive one. In addition, the role of other platelet indices should also be assessed further to know a better indicator for bone marrow involvement in thrombocytopenic patients.     

Massive Rectal Bleeding Due to Intestinal Tuberculosis

Two cases of massive rectal bleeding due to tuberculosis of the intestine are described and 24 reported cases of massive rectal bleeding in intestinal tuberculosis are reviewed. Tuberculosis of the intestine, though uncommon should be considered as a cause for rectal bleeding.     

Haemodynamic analysis of the effects of nicardipine and metoprolol alone and in combination in coronary artery disease

The circulatory consequences of concurrent slow-calcium channel(nicardipine) and cardioselective beta blockade (metoprolol)were evaluated in 20 patients with angiographically proven coronaryartery disease. The rest and exercise haemodynamic impact ofintravenous nicardipine (10mg) or metoprolol (10mg) alone wasdetermined by randomly allocating 10 patients to each drug;finally all patients were assessed on combination therapy. Theplasma levels of nicardipine (17 ±3 to 53 ±6 ngml-1) and metoprolol (36 ±5 to 97 ± 16 ng ml-1)achieved at the time of each study were in the established therapeuticrange.At rest nicardipine reduced systemic mean arterial pressureand systemic vascular resistance index; cardiac and stroke volumeindices increased without change in pulmonary artery occludedpressure. Metoprolol alone reduced systemic blood pressure,heart rate and cardiac index, and increased systemic vascularresistance index. Combination therapy reduced systemic arterialblood pressure and heart rate with relatively modest effectson cardiac index, systemic vascular resistance index and pulmonaryartery occluded pressure.During dynamic exercise nicardipinereduced systemic mean and diastolic arterial pressure and strokework index without change in other haemodynamic variables. Metoprololreduced exercise systemic arterial pressures, heart rate andcardiac index, and increased systemic vascular resistance indexand pulmonary artery occluded pressure. Combination therapyproduced changes similar to those at rest; at peak nicardipinepharmacodynamic activity, the cardiac depressant actions ofmetoprolol were largely offset by the induced reduction in leftventricular afterload.Thus these data suggest that nicardipineis safe to use concurrently with cardioselective beta-adrenoceptorblockade; moreover it may prove useful in offsetting some ofthe adverse haemodynamic effects of beta-blocking drugs in patientswith severe coronary artery disease.     

A BEFORE AND AFTER TRIAL OF THE EFFECTIVENESS OF NETWORK ANALYSIS IN HEALTH OPERATIONS MANAGEMENT

An intervention trial using “before-and-after” approach was undertaken to address the question whether network analysis as a health managerial tool of control can favourably affect the delays that occur in planning and executing the antimalaria operations of a Station Health Organization in a large military station. Exposure variable of interest was intervention with a network diagram, by which the potential causes of delay along the various activities were assessed and remedial measures were introduced during the second year. Sample size was calculated using conventional alpha and beta error levels. The study indicated that there was a definite beneficial outcome in that the operations could be started as well as completed in time during the intervention year. There was reduction in time requirement in 5 out of the 9 activities, the exact ‘p’ value being 0.08, by both parametric and non-parametric tests. The use of network analysis in health care management has been recommended.KEY WORDS: Health services research, Health care, Health plan implementation, Malaria, Network analysis, Operations research