Allergic contact dermatitis by ophthalmological medications in Brazil: experience of a dermatology department.

SUMMARY: Topical treatments in ophthalmologic therapy are significant for the development of allergic contact dermatitis (ACD) in the periorbital region. Preservatives, antibiotics, glucocorticoids, and beta-blocker eye drops are defined as drugs with the highest sensitizing potential. The unavailability of patch test batteries containing substances of ophthalmological use makes it difficult for this diagnosis. In the present report, we describe six patients who developed ACD induced by different agents presenting in eye drops, confirmed with the cutaneous patch tests. The ACD diagnosis due to ophthalmic medications can be challenging, since many different agents can cause it, and the sensitivity of these cutaneous tests is low. Thus, early diagnosis is essential to avoid the complications of ACD on the skin and ocular disorders related to chronic periorbital eczema.

Standard vs. intensified management of heart failure to reduce healthcare costs: results of a multicentre, randomized controlled trial.

AIMS: To determine if an intensified form of heart failure management programme (INT-HF-MP) based on individual profiling is superior to standard management (SM) in reducing health care costs during 12-month follow-up (primary endpoint). METHODS AND RESULTS: A multicentre randomized trial involving 787 patients (full analysis set) discharged from four tertiary hospitals with chronic HF who were randomized to SM (n = 391) or INT-HF-MP (n = 396). Mean age was 74 ± 12 years, 65% had HF with a reduced ejection fraction (31.4 ± 8.9%) and 14% were remote-dwelling. Study groups were well matched. According to Green, Amber, Red Delineation of rIsk And Need in HF (GARDIAN-HF) profiling, regardless of location, patients in the INT-HF-MP received a combination of face-to-face (home visits) and structured telephone support (STS); only 9% (`low risk') were designated to receive the same level of management as the SM group. The median cost in 2017 Australian dollars (A$1 equivalent to ∼EUR €0.7) of applying INT-HF-MP was significantly greater than SM ($152 vs. $121 per patient per month; P < 0.001), However, at 12 months, there was no difference in total health care costs for the INT-HF-MP vs. SM group (median $1579, IQR $644 to $3717 vs. $1450, IQR $564 to $3615 per patient per month, respectively). This reflected minimal differences in all-cause mortality (17.7% vs. 18.4%; P = 0.848) and recurrent hospital stay (18.6 ± 26.5 vs. 16.6 ± 24.8 days; P = 0.199) between the INT-HF-MP and SM groups, respectively. CONCLUSION: During 12-months follow-up, an INT-HF-MP did not reduce healthcare costs or improve health outcomes relative to SM.

Establishing and managing a periodontal biobank for research: the sharing of experience.

Periodontal bio-repositories, which allow banking of clinically validated human data and biological samples, provide an opportunity to derive biomarkers for periodontal diagnosis, prognosis and therapeutic activities which are expected to improve patient management. This article presents the establishing of the Malaysian Periodontal Database and Biobank System (MPDBS) which was initiated in 2011 with the aim to facilitate periodontal research. Partnerships were established with collaborating centres. Policies on specimen access, authorship and acknowledgement policies were agreed upon by all participating centres before the initiation of the periodontal biobank. Ethical approval for the collection of samples and data were obtained from institutional ethics review boards. A broad-based approach for informed consent was used, which covered areas related to quality of life impacts, genetics and molecular aspects of periodontal disease. Sample collection and processing was performed using a standardized protocol. Biobanking resources such as equipment and freezers were shared with the Malaysian Oral Cancer Database and Tissue Bank System (MOCDTBS). In the development of the MPDBS, challenges that were previously faced by the MOCDTBS were considered. Future challenges in terms of ethical and legal issues will be faced when international collaborations necessitate the transportation of specimens across borders.

Nurses' perspectives on nurse-coordinated prevention programmes in secondary prevention of cardiovascular disease: a pilot survey.

BACKGROUND: Secondary prevention of coronary artery disease (CAD) is increasingly provided by nurse-coordinated prevention programs (NCPP). Little is known about nurses' perspectives on these programs. AIM: To investigate nurses' perspectives/experiences in NCPPs in acute coronary syndrome patients. METHODS: Thirteen nurses from NCPPs in 11 medical centers in the RESPONSE trial completed an online survey containing 45 items evaluating 3 outcome categories: (1) conducting NCPP visits; (2) effects of NCPP interventions on risk profiles and (3) process of care. RESULTS: Nurses felt confident in counseling/motivating patients to reduce CAD risk. Interventions targeting LDL, blood pressure and medication adherence were reported as successful, corresponding with significant improvements of these risk factors. Improving weight, smoking and physical activity was reported as less effective. Screening for anxiety/depression was suggested as an improvement. CONCLUSIONS: Nurses acknowledge the importance and effectiveness of NCPPs, and correctly identify which components of the program are the most successful. Our study provides a basis for implementation and quality improvement for NCCPs.

Long-term tolerance and efficacy of adjunctive exenatide therapy on glycaemic control and bodyweight in type 2 diabetes: a retrospective study from a specialist diabetes outpatient clinic.

BACKGROUND: Weight gain and hypoglycaemia are common adverse effects associated with anti-diabetic treatments. AIM: Our aim was to evaluate the long-term effects of adjunctive exenatide therapy on weight loss and glycaemic control in patients with type 2 diabetes. METHODS: A review of medical records in a specialist diabetes clinic over 5 years identified 446 patients who were prescribed exenatide therapy. We examined change in glycosylated haemoglobin (HbA1c), weight, albumin-creatinine ratio and hypoglycaemic medication during 24 months follow up. RESULTS: Subjects were aged 59 ± 10 years (49% women) and received exenatide in combination with oral agents and insulin (47%). During an average of 17 ± 14 months follow up, 51% (more women than men; odds ratio 1.69, 95% confidence interval 1.14­2.49) remained on treatment. Lack of efficacy (33%) and/or gastrointestinal (27%) side-effects were the main reasons for treatment cessation. At 24 months, there was a reduction in HbA1c of 0.7 ± 1.2% and weight loss of 4.3 ± 5.2 kg. Change in HbA1c was similar regardless of concurrent insulin therapy, yet insulin was associated with greater weight reduction (4.8 ± 5.3 vs 3.8 ± 5.1 kg, P = 0.016). Independent predictors of HbA1c response were higher baseline HbA1c, longer duration of diabetes and use of insulin or sulfonylureas at study end. Predictors of weight response were baseline use of insulin or thiazolidinediones, increased age, female sex and sulfonylurea or thiazolidinediones at study end. Longer exenatide treatment duration was favourable for reducing HbA1c and weight. CONCLUSIONS: Exenatide is effective in reducing HbA1c and weight, regardless of concurrent insulin, and in a specialist diabetes outpatient clinic, is recommended for use in clinical practice.

Atypical focal cortical dysplasia in a patient with Cowden syndrome.

A macrocephalic girl presented with generalised epilepsy due to focal cortical dysplasia. She later developed multiple hamartomatous lesions and was diagnosed to have Cowden syndrome. The diagnosis was confirmed by identification of a novel frameshift mutation in the PTEN gene of the patient.

Antibiotic-resistant Propionibacterium acnes among acne patients in a regional skin centre in Hong Kong.

BACKGROUND: There has been no study on antibiotic-resistant Propionibacterium acnes in Hong Kong. OBJECTIVE: We investigated the prevalence and pattern of antibiotic-resistant P. acnes and to identify any associated factors for harbouring the resistant strains. METHODS: Culture and sensitivity testing of P. acnes to commonly used antibiotics were performed. Resistance to tetracycline was defined at a minimal inhibitory concentration (MIC) of 2 µg/mL or more; erythromycin at an MIC of 0.5 µg/mL or more; clindamycin at an MIC of 0.25 µg/mL or more according to EUCAST. For breakpoints of doxycycline and minocycline, those with an MIC of 1 µg/mL or more were defined as resistant strains. RESULTS: Among the 111 specimens collected from 111 patients, 86 strains of P. acnes were recovered, one from each specimen. Twenty-five specimens had no growth. Forty-seven (54.8%) strains were found to be resistant to one or more antibiotics. Forty-six (53.5%), 18 (20.9%), 14 (16.3%), 14(16.3%) and 14 (16.3%) strains were resistant to clindamycin (CL), erythromycin (EM), tetracycline (TET), doxycycline (DOX) and minocycline (MR) respectively. Ten strains (11.6%) had cross resistance between the MLS antibiotics (erythromycin or clindamycin), one strain (1.2%) had cross resistance among the cyclines and 14 strains (16.4%) had cross resistance between the MLS and cycline antibiotics. Binary logistic regression showed an association between MLS antibiotic resistance with an increased age whereas cycline resistance was associated with the duration of treatment. CONCLUSION: Antibiotic-resistant P. acnes is prevalent in Hong Kong. Dermatologists should be more vigilant in prescribing antibiotics for acne patients.

Scholarship in anesthesiology: the role of critical appraisal, literature review, quality improvement, journal club, and presentation skills.

If asked to describe the term "anesthesiologist scholar", one may receive a variety of definitions depending on the individual's area of practice, location in the world, and the generation in which they trained. In this article, we review the roles of five core elements that make an anesthesiologist a "scholar": skills in critical appraisal, literature review, quality improvement, journal club participation, and presentation delivery. Although this list of scholarly components is not comprehensive, review of each element's role in the everyday practice and training of physicians will offer insight into their evolution and may offer a glimpse into the future of anesthesiologist scholars. Overall, through the dissemination, recognition, and support of scholarship through these practices, we will continue to achieve meaningful outcomes for our patients and promote a culture of collaboration worldwide. We should ensure that these topic areas become a bedrock of medical education globally, and we must foster opportunities for those who have already completed training to develop and master these skills as a part of their clinical and academic practice.

Decadal stability in coral cover could mask hidden changes on reefs in the East Asian Seas.

Coral reefs in the Central Indo-Pacific region comprise some of the most diverse and yet threatened marine habitats. While reef monitoring has grown throughout the region in recent years, studies of coral reef benthic cover remain limited in spatial and temporal scales. Here, we analysed 24,365 reef surveys performed over 37 years at 1972 sites throughout East Asia by the Global Coral Reef Monitoring Network using Bayesian approaches. Our results show that overall coral cover at surveyed reefs has not declined as suggested in previous studies and compared to reef regions like the Caribbean. Concurrently, macroalgal cover has not increased, with no indications of phase shifts from coral to macroalgal dominance on reefs. Yet, models incorporating socio-economic and environmental variables reveal negative associations of coral cover with coastal urbanisation and sea surface temperature. The diversity of reef assemblages may have mitigated cover declines thus far, but climate change could threaten reef resilience. We recommend prioritisation of regionally coordinated, locally collaborative long-term studies for better contextualisation of monitoring data and analyses, which are essential for achieving reef conservation goals.

Copper(II)-selective chelation improves function and antioxidant defences in cardiovascular tissues of rats as a model of diabetes: comparisons between triethylenetetramine and three less copper-selective transition-metal-targeted treatments.

AIMS/HYPOTHESIS: Treatment with the Cu(II)-selective chelator triethylenetetramine (TETA) improves cardiovascular disease in human patients, and cardiac and vascular/renal disease in rats used as a model of diabetes. Here we tested two hypotheses: first, that TETA elicits greater improvement in organ function than less Cu-selective transition-metal-targeted treatments; second, that the therapeutic actions of TETA are consistent with mediation through suppression of oxidative stress. METHODS: Rats were made diabetic with streptozotocin (55 mg/kg, i. v.) and treated from 8 weeks after disease induction for the following 8 weeks with effective dosages of oral TETA, or one of three less Cu-selective transition-metal-targeted treatments: D-penicillamine, deferiprone or Zn acetate. Treatment effects were measured in ex vivo cardiac and aortic tissues, plasma and urine. RESULTS: Diabetes damaged both cardiac and renal/vascular function by impairing the ability of cardiac output to respond physiologically to rising afterload, and by significantly elevating the urinary albumin/creatinine ratio. Diabetes also lowered total antioxidant potential and heparan sulphate levels in cardiac and arterial tissues, and serum ferroxidase activity, whereas it elevated urinary heparan sulphate excretion. TETA treatment rectified or partially rectified all these defects, whereas the other three experimental treatments were ineffectual. By contrast, none of the four drug treatments lowered diabetes-mediated elevations of plasma glucose or lipid concentrations. CONCLUSIONS/INTERPRETATION: TETA may limit the cardiac and renal/vascular damage inflicted by diabetes through its actions to reinforce antioxidant defence mechanisms, probably acting through selective chelation of 'loosely-bound'/chelatable Cu(II). It may also improve heparan sulphate homeostasis and bolster antioxidant defence by increasing vascular extracellular superoxide dismutase activity. Urinary albumin/creatinine ratio might prove useful for monitoring TETA treatment.

Light limitation selects for depth generalists in urbanised reef coral communities.

Depth range is an important species trait for coral reef organisms, yet it remains to be quantified and analysed adequately among tropical coral species. Filling this knowledge gap is crucial as the depth limits of corals are related to important environmental factors such as light and temperature. Furthermore, the health and survivorship of corals may be threatened due to warming-induced sea-level rise, particularly for colonies living at the deeper limits of species depth ranges. Here we collected benthic and environmental data along the reef profile to characterise the depth ranges of coral species, and analysed species diversity and community structure in relation to possible depth-related biophysical parameters on the sediment-stressed reefs of Singapore. The results reveal clear environmental covariations with depth, expectedly with light availability showing the most marked decline as depth increases. Live coral cover, species richness and diversity are associated positively and significantly with light, which also structures coral communities along the reef profile more strongly than temperature or sediment levels. Relatedly, we detect species-specific depth distributions with two main strategies observed among coral species: shallow specialists and depth generalists. We suggest that corals in Singapore are unlikely to be impacted by light limitation specifically as sea level rises due to the wider depth range of the deeper species. Our data will inform conservation efforts especially in the selection of sites and depths for coral transplantation.

Comparison of oesophagogastroduodenoscopy findings and diagnostic value in neurologically impaired children and 'normal' children.

OBJECTIVES: To review the oesophagogastroduodenoscopy findings in children with severe neurological impairment and 'normal' children, over a 7-year period from 2000 to 2007. DESIGN: Retrospective study. SETTING: Paediatric Unit of Caritas Medical Centre, Hong Kong. MAIN OUTCOME MEASURES: The frequencies of Helicobacter pylori status, peptic ulceration, and oesophagitis were compared. The diagnostic value of oesophagogastroduodenoscopy in these two groups of children was also examined. PATIENTS: Patient data were retrieved from the Hospital Authority Clinical Management system, excluding those under surgical care. The children were divided into two groups: 'normal' and neurologically impaired. Their demographic data, indications for oesophagogastroduodenoscopy, endoscopy diagnoses, and Helicobacter pylori status were compared, as was the diagnostic value of oesophagogastroduodenoscopy. RESULTS: From 2000 to 2007, 223 oesophagogastroduodenoscopies were performed in 176 patients aged 3 to 22 years; 134 were performed in 'normal' children (median age, 14; range, 3-22 years) and 89 in neurologically impaired children (median age, 12; range, 3-20 years). The three most common indications in 'normal' children were: epigastric pain (60%), gastro-intestinal bleeding (13%), and vomiting (7%). In neurologically impaired children, they were gastro-intestinal bleeding (51%), assessment for percutaneous endoscopic gastrostomy (27%), and follow-up for previous lesions (9%). Among 'normal' children, 14 had duodenal ulcers (associated with Helicobacter pylori in 13), but no patients had gastric ulcers or oesophagitis. Among neurologically impaired children, one had a Helicobacter pylori-negative duodenal ulcer, and four had gastric ulcers (three were Helicobacter pylori-positive). Twenty-four neurologically impaired children had oesophagitis. Neurologically impaired children had significantly more oesophagitis and gastric ulcers (P<0.001 and P=0.004, respectively) but less duodenal ulcers (P=0.024). In 111 children who had gastric biopsies, the Helicobacter pylori infection rate was 35% (31% in 'normal' children and 43% in the neurologically impaired). The diagnostic value was 37% in 'normal' children and 81% in the neurologically impaired (P<0.001). The overall diagnostic value of oesophagogastroduodenoscopy was 50%. CONCLUSION: The clinical presentation and endoscopic findings in 'normal' and neurologically impaired children were discrepant. Oesophagogastroduodenoscopy appeared to confer greater diagnostic value in neurologically impaired than 'normal' children. Diagnostic values in our unit were comparable to reports from western studies.

[Robotic head and neck surgery at the Chinese University of Hong Kong].

Introduction:Robotic surgery in the head and neck region has been used to approach many different areas within the head and neck region. Here we describe our experiences of its application at The Chinese University of Hong Kong.Methods:This is a retrospective review of all cases operated by the two authors since Jan 2015 at the Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong.Results:Twenty-four cases were performed with the da Vinci S or da Vinci Xi systems. Twenty-one cases were performed with the novel flexible robotic da Vinci SP system. There were no serious adverse events requiring a return to the operating room. Early results from the da Vinci SP have been previously published in seven patients that demonstrated the ability to reach the nasopharynx, oropharynx, hypopharynx, larynx and also retropharyngeal lymph nodes. There were no conversions to alternative surgical approaches. There were no serious adverse events or adverse events related to the use of this system.Discussion:In conclusion, through our experiences at The Chinese University of Hong Kong we have found the da Vinci robotic systems to be useful and safe in performing TORS and addressing pathologies in the neck through the retroauricular approach.

Intraocular currents, Bernoulli's principle and non-drainage scleral buckling for rhegmatogenous retinal detachment.

For many years, it is not fully understood how non-drainage scleral buckling surgery brings about spontaneous reattachment of the detached retina when retinal breaks remain open at the end of surgery. Various explanations have been put forward, but none more interesting than the effect of fluid currents associated with eye movements. One such explanation involved the physics of the Bernoulli's principle. Daniel Bernoulli was an eighteenth century Swiss mathematician and he described an equation based on the conservation of energy. The sum of pressure energy, potential energy and kinetic energy remains constant. Bernoulli's equation usually applies to closed system such as the flow of fluid through pipes. When fluid flows through a constriction, the speed of fluid increases, the kinetic energy increases. If there was no change in elevation (potential energy), then the increase in kinetic energy must be accompanied by a decrease in pressure energy. In ophthalmic surgery, the Bernoulli's effect is the basis for venturi pumps that drive vitrectomy and phacoemulsification machines. This essay expounds on how Bernoulli's effect might be relevant to scleral buckling for retinal detachment repair. In the era when vitrectomy is increasing the primary surgical operation for retinal detachment, the pervasive advice is to emphasise the importance of patient adopting head posture and remaining still postoperatively. The exception is non-drainage scleral buckling surgery. Early postoperative mobilisation may be vital to achieve reattachment.

Laws of physics help explain capillary non-perfusion in diabetic retinopathy.

The purpose is to use laws of physics to elucidate the mechanisms behind capillary non-perfusion in diabetic retinopathy. In diabetic retinopathy, loss of pericytes weakens capillary walls and the vessel dilates. A dilated capillary has reduced resistance to flow, therefore increased flow in that vessel and decreased in adjoining capillaries. A preferential shunt vessel is thus formed from the dilated capillary and the adjacent capillaries become non-perfused. We apply the laws of Laplace and Hagen-Poiseuille to better understand the phenomena that lead to capillary non-perfusion. These laws of physics can give a foundation for physical or mathematical models to further elucidate this field of study. The law of Laplace predicts that a weaker vessel wall will dilate, assuming constant transmural pressure. The Hagen-Poiseuille equation for flow and the Ostwald-de Waele relationship for viscosity predict that a dilated vessel will receive a higher portion of the fluid flow than the adjoining capillaries. Viscosity will decrease in the dilated vessel, furthering the imbalance and resulting in a patch of non-perfused capillaries next to the dilated 'preferential' shunt vessel. Physical principles support or inspire novel hypotheses to explain poorly understood phenomena in ophthalmology. This thesis of pericyte death and capillary remodelling, which was first proposed by Cogan and Kuwabara, already agrees with histological and angiographical observations in diabetic retinopathy. We have shown that it is also supported by classical laws of physics.

Small particle size lipid emulsions, satiety and energy intake in lean men.

Lipid emulsions have been proposed to suppress hunger and food intake. Whilst there is no consensus on optimal structural properties or mechanism of action, small particle size (small-PS) stable emulsions may have greatest efficacy. Fabuless®, a commercial lipid emulsion reported in some studies to decrease energy intake (EI), is a small-PS, 'hard' fat emulsion comprising highly saturated palm oil base (PS, 82nm). To determine whether small-PS dairy lipid emulsions can enhance satiety, firstly, we investigated 2 'soft' fat dairy emulsions generated using dairy and soy emulsifying agents (PS, 114nm and 121nm) and a non-emulsified dairy control. Secondly, we investigated a small-PS palmolein based 'hard' fat emulsion (fractionated palm oil, PS, 104nm) and non-emulsified control. This was a 6 arm, randomized, cross-over study in 18 lean men, with test lipids delivered in a breakfast meal: (i) Fabuless® emulsion (FEM); (ii) dairy emulsion with dairy emulsifier (DEDE); (iii) dairy emulsion with soy lecithin emulsifier (DESE); (iv) dairy control (DCON); (v) palmolein emulsion with dairy emulsifier (PEDE); (vi) palmolein control (PCON). Participants rated postprandial appetite sensations using visual analogue scales (VAS), and ad libitum energy intake (EI) was measured at a lunch meal 3.5h later. Dairy lipid emulsions did not significantly alter satiety ratings or change EI relative to dairy control (DEDE, 4035kJ; DESE, 3904kJ; DCON, 3985kJ; P>0.05) nor did palm oil based emulsion relative to non-emulsified control (PEDE, 3902 kJ; PCON, 3973kJ; P>0.05). There was no evidence that small-PS dairy lipid emulsions or commercial Fabuless altered short-term appetite or food intake in lean adults.

Effect of high-fat meals and fatty acid saturation on postprandial levels of the hormones ghrelin and leptin in healthy men.

OBJECTIVE: Ghrelin and leptin play a role in control of food intake and adiposity but mechanisms regulating these hormones in man are poorly defined and evidence that dietary fats may have adverse effects is inconclusive. We investigated whether high-fat meals, which differed in saturated fatty acid (SFA) content acutely modified these hormones. DESIGN: Randomised, double-blind, crossover trial. A high-fat (HF) test meal (59 +/- 4 g fat; 71% of energy as fat) was given for breakfast on two occasions. Meals comprised either high (approximately 70:30) or low (approximately 55:45) saturated:unsaturated fatty acid (SFA:USFA) ratio. Fasting and postprandial measurements of serum total ghrelin (RIA), leptin (enzyme-linked immunosorbent assay (ELISA)) and insulin (RIA) were made over 6 h. Postprandial measurements were also made at 10 and 24 h following a fat-exclusion lunch, snack and dinner. SUBJECTS: A total of 18 lean, healthy men. RESULTS: There was no significant effect of the fatty meal (time, P > 0.05), nor a differential effect of SFA:USFA ratio (treatment*time, P > 0.05) on ghrelin over 6h. Leptin decreased in response to both HF treatments (time, P < 0.001) but increased SFA content did not further inhibit hormone secretion (treatment*time, P > 0.05). There was no significant correlation between ghrelin or leptin and circulating insulin (P>0.05). CONCLUSION: We conclude that HF diets may adversely effect serum leptin, although the circadian decrease may account in part for this response. Increasing dietary SFAs had no deleterious effects on leptin or total ghrelin.

Exploratory analysis of the bacteriological status of post-irradiation wounds and its relationship to healing.

AIMS: To investigate the bacteriological status of post-irradiation wounds and its relationship to wound healing in patients with nasopharyngeal cancer. MATERIALS AND METHODS: One hundred and forty-six nasopharyngeal cancer patients with post-irradiation wounds on one or both sides of the neck were studied prospectively. Swabs were taken from the wounds at the initial study visit for bacteriological examination. A further swab for culture was taken when possible signs of infection developed. Wound healing was assessed on alternate days with respect to wound condition, the presence of clinical infection and healing time. RESULTS: The results showed that most of the post-irradiation wounds were colonised with bacteria. This was not associated with clinical signs of infection in any instance. There was no association between wound healing time and the presence of organisms, the identity of organisms, the number of species of organisms, or the use of antibiotics. CONCLUSIONS: The presence of bacteria in post-irradiation wounds, in the absence of clinical signs of wound infection, is not a barrier to wound healing. Oncology practitioners should recognise the unique features of radiation-induced wounds and skin reactions with confidence and provide appropriate treatment as needed.

Technique of anaesthesia in pulmonary hypertension and thrombophilia in early pregnancy.

Pulmonary hypertension in pregnancy is a rare condition but is associated with a high mortality. We report the case of a 29 year old female in early pregnancy with Protein C and S deficiency with recurrent deep venous thrombosis and pulmonary embolism and subsequent secondary pulmonary hypertension. The patient was counselled and consented for termination of pregnancy with tubal sterilization. She was administered continuous spinal anaesthesia with invasive monitoring. The successful anaesthetic management of this condition is described.