Routine Exposure Versus Non-Exposure of Recurrent Laryngeal Nerve during Thyroid Surgery: Our Experience of 300 Cases.

The technique of thyroidectomy has been in evolution for many years. It is a basic rule of surgery that an important structure of a human body must be recognized certainly during the surgical procedure in order to prevent its damage. The purpose of this study was to evaluate our routine identification and without identification of recurrent laryngeal nerve during thyroidectomy aiming to lessen the inadvertent injury of the recurrent laryngeal nerve. This retrospective clinical controlled study was performed in the Department of ENT and Head-Neck Surgery, BIRDEM General Hospital and the Department of General Surgery, BIRDEM General Hospital, Dhaka, Bangladesh from January 2014 to December 2018. Patients undergoing indirect laryngoscopy with normal vocal cords and those with carcinoma and re-do surgery having normal vocal cords were included in this study. Patients were excluded like containing hoarseness voice, abnormal movements of vocal cord. The total number of patients was 300 and these patients were randomly divided into two groups of 150 each using random number tables. In Group A the recurrent laryngeal nerves were identified by exposing the inferior thyroid artery and markedly seen in its entire course. Where as, in Group B, nerves were not identified during the operation. Immediate post operative direct laryngoscopy was performed by a surgeon with the help of an Anesthesiologist for the assessment of vocal cords. Patients with either persistent hoarseness of voice or not were followed up with indirect laryngoscopy or fiber optic laryngoscopy (FOL) at three and six months. In Group A, out of 150 patients, 6(4%) patients developed transient unilateral paralysis, resulting in slight hoarseness of voice postoperatively. The voice improved within 6 weeks. While 2(1.3%) patients developed permanent unilateral paralysis of recurrent laryngeal nerve. The voice and cord movement did not return to normal even after 6 months in one case while other one improved within the period of 6 months. In Group B, out of 150 patients, 14(9.3%) patients developed transient paralysis. Out of 14 transient paralysis 11 were unilateral and 3 were bilateral nerve paralysis. The voice was improved within 6 months in all of unilateral and bilateral transient paralyzed cases. While 6(4%) patients developed permanent paralysis of recurrent laryngeal nerve. Out of 6 permanent paralysis 2 cases were of bilateral recurrent laryngeal nerve paralysis required immediate tracheostomy. Rest 4 cases of unilateral permanent nerve paralysis, hoarseness of voice occurred but improved in 2 cases during the period varying from 2 to 6 months while in other 2 cases, it persisted even after 6 months. Frequency of recurrent laryngeal nerve palsies was significantly lower in Group A as compared to Group B. This difference remained statistically significant (p=0.046) between the two groups in terms of type of thyroid diseases, type of surgeries and number of surgeries. For essentially eliminating the risk of nerve injury during surgery, recurrent laryngeal nerve should be exposed and identified routinely in its entire course.

Long-term in situ moisture conservation in horti-pasture system improves biological health of degraded land.

In situ moisture conservation practices can conserve fertile topsoil and enhance available water in soil profile. We hypothesised that reclaiming degraded land ecologically through tree + pasture + in situ moisture conservation practices would significantly improve soil organic carbon (SOC) and health. Hence, the objectives were a) to identify changes in nutrient cycling enzymes and SOC status due to different in situ soil moisture conservation options in surface and subsurface soil layers, and b) to test the potentiality of soil enzymes to determine long-term nutrient availability. We conducted a long-term experiment involving aonla (Emblica officinalis) trees + pasture (Cenchrus ciliaris + Stylosanthes seabrana) + in situ soil moisture conservation measures viz. staggered contour trenches (T1), continuous contour trenches (T2), stone mulch (T3), vegetative barriers (T4), control (T5) and fallow land (T6) since 2007. Recommended dose of nitrogen (N), phosphorus (P) and potassium (K) were added to all treatments, except T6. SOC concentration increased by ~51 and 31% in T1 and T2, respectively, over T5 in surface (0-15 cm) soil. Culturable bacterial and fungal populations increased by ~20 and 95% in T1 over T5 in surface soil. Activities of all soil enzymes increased in T1 and T2 (ranging from 42 to 289%) over T5 and T6 in both surface and sub-surface (15-30 cm) layers. However, specific activity of phenol oxidase was ~25% lower for T1 than T6, suggesting more efficient SOC sequestration in T1. Moreover, geometric mean enzyme activity of T1 was ~65 and 33% higher than T5 and T3, respectively, in surface soil. Treated soil quality index (T-SQI) of T1 was ~184% higher than T5. Soil functional diversity was also ~1.24 and 1.22 times higher in T1 and T2 than T5, respectively. Peroxidase was the major C degrading enzyme in this ecosystem. Protease, urease and phosphatase significantly influenced N and P availability along with fruit and pasture yields. Importantly, ~96, 62 and 82% variability of SOC, N and P concentrations, respectively, could be attributed to their corresponding enzyme activities. Principal components analysis (PCA) revealed one-way operational role of soil enzymes. Thus, enzymes are potentially important for recycling nutrients from litters, root biomass of fruit trees and grasses to boost their availability in the long run. Adoption of horti-pasture system combined with moisture conservation practices and staggered contour trenches or continuous contour trenches ensured higher above ground biomass yield, SOC, nutrient availability and soil quality. Thus, long-term use of these practices could be recommended for reclamation and improving soil health and crop productivity of degraded lands of central India.

Evaluation of imprecision, bias and total error of clinical chemistry analysers.

Context Two Biosystems analysers are used in our laboratory, a fully automated A25 and a semi-automated BTS-350. Internal quality control is done for both but external quality control only for A25. As BTS-350 is used for backup, it is important that the results of both analysers are not just comparable but also within predefined limits of systematic, random and total error (TE). Aim To evaluate the imprecision, bias and TE of the two Biosystem analysers. Materials and Methods Biosystems level-1 quality control sera lot number 70A was run in duplicate for 32 days on both the analysers. Between day imprecision (measured by the coefficient of variation), bias and TE were calculated for ten analytes and were checked to see whether they are within the acceptable minimum limits, desirable limits and optimum limits of allowable error based on specifications on Westgard's website updated in 2014. Results On both the analysers, all the analytes except alkaline phosphatase were within the acceptable minimum limits of TE and most analytes were within the desirable limits of TE. Only TG on A25 was within the optimum limit of TE. Conclusion The two Biosystem analysers performed comparably with errors within acceptable limits for most analytes. BTS-350 was found to be a suitable and ready backup analyser for A25.

Acute invasive fungal rhinosinusitis: our experience in immunocompromised host.

Acute invasive fungal rhinosinusitis (AIFRS) is a potentially fatal infection that usually affects immunocompromised patients. Early diagnosis and treatment, including aggressive surgical debridement, antifungal medication and correction of underlying predisposing factors are essential for recovery. The records of 13 patients histopathologically diagnosed with invasive fungal rhinosinusitis were retrospectively reviewed. Demographic data, presenting symptoms and signs, underlying diseases, and outcomes of the patients are presented. The most common underlying disease was diabetes mellitus. Mucoraceae (n-8) and aspergillus (n-5) were the main fungi found in AIFRS. Mucosal biopsy confirmed fungal invasion to the nasal mucosa in all cases. Computed tomography and endoscopic findings showed a predominance of unilateral disease, with various stages of nasal involvement. All patients underwent surgical debridement and systemic antifungal therapy immediately after diagnosis. Four patients died due to AIFRS. A poor prognosis was detected to the extensiveness of AIFRS and to the underlying disease (patients with diabetes and haematological diseases had the worst outcomes), but not to fungus isolated. Invasive fungal rhinosinusitis is discussed in light of the current literature.

A KAP study on graduate nursing students of a tertiary health care teaching hospital in rural West Bengal, India.

Nursing personnel are the largest deliverer of health care worldwide, responsible for the constant care of in-patients. They are the most important link between doctors and patients. This study evaluated the knowledge, attitudes and practices of nursing students about different health care related aspects, which must have a profound impact on the quality service of any health care setup. Nursing students from a tertiary care teaching hospital from West Bengal, India were interviewed using a semi-structured pretested questionnaire. The subjects had sound knowledge regarding malaria, HIV disease transmission; possess positive attitude and good practices about medications. There was increased tendency of self-medication, which was alarming. The study showed improvement in knowledge of the nursing students during their nursing curriculum. It is clear from the present study that the efforts in spreading the knowledge about medicaments and disease have met with success to some extent. Furthermore tremendous effort has to be taken to convert the theoretical knowledge into 'safe practices'.

Analysis of post operative complications following total thyroidectomy.

This prospective study was carried out to find out the incidence and nature of post operative complications following total thyroidectomy in the management of carcinoma thyroid and multinodular goiter and to analyze the factors which are related with the development of complications. Study was done in the Department of ENT & Head-Neck Surgery, Surgery, Bangabandhu Sheikh Mujib Medical University and Department of ENT & Head-Neck Surgery, Dhaka Medical College Hospital, Dhaka, Bangladesh from April 2006 to September 2006. Fifty patients (50) were included prospectively for this work. The patients were between 12-63 years of age with a maximum incidence in 4th decade. Female was the predominant sex with a ratio of 4.55:1. Twenty eight patients were suffering from papillary carcinoma. Nine patients were suffering from follicular carcinoma, four patients from medullary carcinoma and nine patients from multinodular goiter. Out of 50 patients, 14(28%) developed complications. The complications were haematoma (4%), recurrent laryngeal nerve palsy (6%), hypoparathyroidism (16%) and wound infection (2%). All of them suffered from temporary complications except one patient, who suffered from persistent hypoparathyroidism. Recurrent laryngeal nerve paralysis in all three cases was unilateral. Complications were relatively more common in male. In carcinoma patients the rate of complications was more than twice than the multinodular goiter cases. Among the carcinoma cases, 7.31% cases developed recurrent laryngeal nerve paralysis and 19.51% cases developed hypoparathyroidism. From this study it is observed that a good number of patients still suffer from complications following total thyroidectomy.

Depression in the elderly in Vellore, South India: the use of a two-question screen.

BACKGROUND: Depression in the elderly is a common and disabling condition. The aim of the study was to evaluate the sensitivity and specificity of a two-question screen to identify depression and common mental disorders in the elderly. METHOD: Residents of a ward in the town of Vellore were identified by a door-to-door survey from which 204 subjects aged over 60 years were selected for the study by systematic random sampling. They were screened using the two-question screen. The Revised Clinical Interview Schedule (CIS-R) was employed to confirm the diagnosis. RESULTS: The prevalence of depression and common mental disorder, using the CIS-R standard, was found to be 31.5%. The two-question screen has a sensitivity of 93.8% and specificity of 48.2%. CONCLUSIONS: The high sensitivity of the two-question screen makes it a useful screening method which can be employed by health workers in the field.

Induction of angiogenesis after TMR: a comparison of holmium: YAG, CO2, and excimer lasers.

BACKGROUND: Transmyocardial laser revascularization (TMR) is an emerging treatment for end-stage coronary artery disease. A variety of lasers are currently available to perform the procedure, although their relative efficacy is unknown. The purpose of this study was to compare changes in myocardial blood flow and function 6 months after TMR with holmium:yttrium-aluminum-garnet (holmium:YAG), carbon dioxide (CO2), and xenon chloride excimer lasers in a model of chronic ischemia. METHODS: Miniswine underwent subtotal (90%) left circumflex coronary stenosis. Baseline positron emission tomography and dobutamine stress echocardiography were performed to document hibernating myocardium in the left circumflex coronary artery distribution. Animals were then randomized to sham redo-thoracotomy (n = 5) or TMR using a holmium:YAG (n = 5), CO2 (n = 5) or excimer (n = 5) laser. Six months postoperatively, the positron emission tomography and dobutamine stress echocardiography studies were repeated and the animals sacrificed. RESULTS: In animals undergoing TMR with holmium: YAG and CO2 lasers, a significant improvement in myocardial blood flow to the lased left circumflex regions was seen. No significant change in myocardial blood flow was seen in sham- or excimer-lased animals. There was a significant improvement in regional stress function of the lased segments 6 months postoperatively in animals undergoing holmium:YAG and CO2 laser TMR that was consistent with a reduction in ischemia. There was no change in wall motion in sham- or excimer-lased animals. Significantly greater neovascularization was observed in the holmium:YAG and CO2 lased regions than with either the sham procedure or excimer TMR. CONCLUSIONS: Transmyocardial laser revascularization with either holmium:YAG or CO2 laser improves myocardial blood flow and contractile reserve in lased regions 6 months postoperatively. These changes were not seen following excimer TMR or sham thoracotomy, suggesting that differences in laser energy or wavelength or both may be important in the induction of angiogenesis.

Right ventricular dysfunction after cardiac transplantation: primarily related to status of donor heart.

BACKGROUND: It is unclear whether right ventricular dysfunction after transplantation is due to donor brain death-related myocardial injury or recipient pulmonary hypertension. METHODS: A canine donor model of brain death and a monocrotaline pyrrole-induced chronic pulmonary hypertension recipient model were established, and used for 30 orthotopic bicaval cardiac transplantations divided into three groups: Controls (group A, normal donor/recipient), group B (brain-dead donors/normal recipient), and group C (normal donor/recipients with pulmonary hypertension). Right ventricular function was measured before transplant and brain death, 4 hours after brain death, and after transplant (1 hour off bypass) by load-independent means plotting stroke work versus end-diastolic volume during caval occlusion. Right ventricular total power and pulmonary vascular impedance were determined by Fourier analysis. RESULTS: In comparison to the control group right ventricular preload-recruitable stroke work and total power decreased significantly after brain death and transplant in group B (from 22.7 x 10(3) erg (+/-1.2) at baseline to 15.6 x 10(3) (+/-0.9) after brain death and to 11.3 x 10(3) (+/-0.9) after transplant). In group C there was a significant increase in pulmonary artery pressure, impedance, right ventricular preload-recruitable stroke work, total power after transplant. CONCLUSIONS: Normal donor hearts adapt acutely to the recipient's elevated pulmonary vascular resistance by increasing right ventricular power output and contractility. Brain death caused significant right ventricular dysfunction and power loss, which further deteriorated after graft preservation and transplantation. The effects of donor brain death on myocardial function contribute to right ventricular dysfunction after cardiac transplantation.

Valve replacement for appetite suppressant-induced valvular heart disease.

Valvular heart disease associated with the use of appetite-suppressant medication is a recently described clinical entity. Although the mechanism of valvular injury remains elusive pathologically, the valvular abnormalities resemble those observed in carcinoid syndrome. The incidence of clinically evident valvular heart disease is low with short-term (less than 3 months) exposure to appetite-suppressant drugs. Prolonged exposure to higher doses in addition to combination drug therapy confers an excess risk for valvular pathologic changes. We report the case of a patient with severe mitral regurgitation who had short-term exposure (3 weeks) to the combination of fenfluramine (20 mg) and phenteramine (15 mg).

Transmyocardial laser revascularization: experimental and clinical results.

BACKGROUND: Transmyocardial laser revascularization (TMR) is an emerging therapy for the treatment of coronary artery disease not amenable to percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass surgery (CABG). OBJECTIVE: To summarize the experimental and clinical experience to date with TMR. Specifically, the history of the technique, preclinical and clinical data, patient selection and perioperative management, as well as future applications of TMR are discussed. DATA SOURCES: All English language articles pertaining to TMR published through March 1999. MEDLINE was searched with the key words 'myocardial revascularization', 'lasers' and 'laser surgery', as well as the text terms 'transmyocardial laser revascularization', 'TMR' and 'TMLR'. Reference lists of articles obtained from MEDLINE were studied for additional references not discovered in computer searches. Pertinent abstracts published within the past two years were reviewed as well. STUDY SELECTION: Studies that produced original experimental or clinical data were selected. DATA SYNTHESIS: Experimental studies demonstrate that TMR channels become occluded in the early postoperative period. However, experimental data indicate that laser injury appears to promote neovascularization with secondary improvements in perfusion in treated regions. Human clinical studies confirm the efficacy of the procedure, with significant improvements in anginal class up to at least one year postoperatively, although documented improvements in myocardial perfusion have been less consistent. Perioperative morbidity and mortality appear to be increased in patients with unstable angina or reduced left ventricular function. CONCLUSIONS: With careful patient selection and peri- operative management, TMR is a safe and effective therapy for severe angina pectoris secondary to end-stage coronary artery disease. Additional studies are required to define the role of TMR in combination with PTCA, CABG and angiogenic growth factors, as well as the safety and efficacy of catheter-based TMR.

Inhibitory casting decreases a vibratory inhibition index of the H-reflex in the spastic upper limb.

OBJECTIVE: To test the hypothesis that application of an inhibitory cast to the spastic upper limb will decrease a vibratory inhibition index (VII) of the H-reflex in the spastic upper limb. DESIGN: Prospective, nonrandomized, open-label trial. SETTING: University tertiary care center. PARTICIPANTS: Eight adults with upper limb spasticity. INTERVENTION: Fiberglass cast application spanning the wrist to the upper arm. MAIN OUTCOME MEASURE: The amplitude of the H-reflex with and without continuous 60Hz vibration to the tendon of the flexor carpi radialis was measured, and the VII was calculated using the formula: [H-reflex amplitude (vibrated)/H-reflex amplitude (control)] x 100%. RESULTS: Mean VII decreased from baseline (70.7) on day 1 (67.6, p = .699), day 2 (55.9, p =.066), and day 3 (43.5, p = .033) of casting, and increased on day 4 (89.9, p = .146) after removal of the cast. CONCLUSION: Findings lend support to the idea that during application of an inhibitory cast motor neuron excitability is decreased in the spastic upper limb.

Right ventricular function in orthotopic total atrioventricular heart transplantation.

BACKGROUND: Total orthotopic heart transplantation was recently introduced into clinical practice as an alternative technique of orthotopic heart transplantation, adding bicaval and left and right pulmonary vein anastomoses to pulmonary artery and ascending aorta connection (total technique). The conventional technique (ventricular transplantation with atrioplasty) is compared with the total technique with particular emphasis on right ventricular performance. METHODS: Forty-eight mongrel dogs (23 to 31 kg) were used for 12 total and 12 standard orthotopic heart transplantations. Right ventricular (RV) function and atrial systole were analyzed with the use of micromanometry, sonomicrometry, and ultrasonic flow probes (preload-independent RV recruitable stroke work, RVPRSW). Fourier analysis was used to calculate RV power and pulmonary vascular impedance. RESULTS: There was no significant difference in cardiac ischemic and bypass times between the two groups. After transplantation, sinus rhythm was preserved after all total transplantations and after only one standard transplantation; no significant hemodynamic differences were observed. RVPRSW in the total group was conserved after transplantation; however, RVPRSW decreased by 39% (+/-8, p < .05) in the standard group. There was also a significant decrease in the rate of RV filling in the standard group after transplantation, suggesting decreased right atrial function. Pulmonary vascular impedance and RV power output were not significantly different after transplantation between the two groups. CONCLUSIONS: Total atrioventricular transplantation is a feasible alternative and conserves normal sinus rhythm. Ischemic and bypass times were not significantly different when the superior vena cava anastomosis is performed last after the release of the aortic cross-clamp. The insignificant decrease in the rate of RV filling with the use of the total technique suggests conserved RV diastolic function after transplantation with less decreased RV function in the total group.

An adult canine model of chronic pulmonary hypertension for cardiopulmonary transplantation.

BACKGROUND: This study establishes a chemically-induced canine model of chronic pulmonary hypertension (CPH) using monocrotaline pyrrole (MCTP) and then characterizes this model in terms of hemodynamic, morphologic, and cardiac functional changes. METHODS: Thirty-three adult mongrel dogs (22 to 25 kg) were used. All animals underwent pulmonary artery catheterization to measure central venous pressure, mean right ventricular pressure (mRVP), mean pulmonary artery pressure (mPAP), and pulmonary capillary wedge pressure before and 6 weeks after a right atrial injection of either 60 mg/kg monocrotaline (group A, n = 8), 5 mg/kg MCTP (group B, n = 4), 3 mg/kg MCTP (group C, n = 13) or placebo (control, n = 8). Six weeks after injection, hearts in control and group C dogs were instrumented with flow probes, dimension transducers, and micromanometers to measure dynamic ventricular pressures and volumes. RESULTS: No significant differences in baseline hemodynamic indexes were observed between groups. All animals in group B and five in group C died after MCTP injection as a result of pulmonary edema. No significant increase in any hemodynamic parameters occurred in group A or in control dogs 6 weeks after injection. In group C, significant increases in central venous pressure, mRVP, and mPAP were observed 6 weeks after injection. Significant increases in right ventricular (RV) function and the weight ratio of the RV to left ventricle were observed in group C when compared with controls. CONCLUSIONS: A chemically-induced canine model of CPH has been created. Significant increases in mRVP, mPAP, and pulmonary capillary wedge pressure were observed 6 weeks after MCTP injection. RV function adapts to the increased afterload in the short term without evidence of failure. A stable model of pulmonary hypertension is provided as a potential means to evaluate posttransplantation RV dysfunction in the setting of CPH.

Brain death further promotes ischemic reperfusion injury of the rabbit myocardium.

BACKGROUND: Little is known about preload-dependent cardiac function after brain death (BD) and subsequent graft preservation. METHODS: A validated model of BD in rabbits was developed and myocardial performance was studied after BD induction and 1 hour of subsequent global hypothermic ischemia using a validated rabbit model and an isolated work-performing heart preparation. RESULTS: Significant decreases in stroke work, left ventricular contractility, and left ventricular relaxation were observed 2 hours after BD. After global hypothermic ischemia, significant decreases in stroke work, left ventricular contractility, and left ventricular relaxation were observed in the BD group compared with controls. Cardiac output and coronary flow were also significantly decreased in BD hearts compared with controls. Creatine kinase release was increased by 32.5% in BD hearts compared with controls. CONCLUSIONS: In a rabbit model, BD combined with global hypothermic ischemia causes a significant decrease in left ventricular function compared with global hypothermic ischemia. This dysfunction may be attributed to a significant decrease in coronary flows in BD hearts.

Squalene metabolism in two species of Lagenidium.

Squalene metabolism of the sterol auxotroph Lagenidium giganteum was studied and compared with that of the positive control Lagenidium callinectes. Application of experimentally derived precautions ensured both the stability and the purity of squalene during incubations. Under these conditions mycelia of L. giganteum converted squalene to squalene oxide and to a sterol-like compound. Cell-free and microsomal preparations also converted squalene to the oxide, which was identified by thin layer chromatography with five different solvent systems, by co-chromatography with authentic oxide, and by conversion to the glycol. Supporting evidence for the production of squalene oxide was obtained by gas-liquid chromatography, high performance liquid chromatography, and autoradiography. The squalene oxide produced was identified by mass spectrometry.