A study of Deep Neck Space Infections at Kathmandu University Dhulikhel Hospital.

Background Deep neck infections are severe infections in potential spaces and fascial planes of the neck. Despite antibiotic therapy, these infections continue to cause significant morbidity and mortality. Objective To determine the clinical features, predisposing factors, socio demographic factors and complications associated with deep neck infections. Method Prospective study conducted in the Department of Otorhinolaryngology, Kathmandu University Dhulikhel Hospital between March 2018 and June 2020. Seventy-five patients with deep neck infections were enrolled. Result Submandibular abscess was most frequently observed (41.3%), followed by submental abscess (25.3%), parotid abscess(9.3%), ludwig's angina (6.7%), posterior triangle of neck abscess (4%), retropharyngeal abscess (2.7%), parapharyngeal space abscess (2.7%), and multiple space infections (8%). Staphylococcus aureus was the most common organism (53.3%), followed by Beta hemolytic Streptococcus (12%) and methicillin-resistant Staphylococcus aureus (12%). A negative culture was seen in 22.7%. Sixty-eight percent of patients underwent incision and drainage. Incision and drainage with dental extraction was done in 26.7%, four percent underwent incision and drainage with debridement and dental extraction, whereas 1.3% underwent incision and drainage with tracheostomy. Eight percent patients required Intensive care unit admission. Seven patients had descending mediastinitis, four out of which developed sepsis. When age and duration of hospital stay were correlated by using Pearson correlation coefficient, a remarkable correlation was observed (p=.020). Noteworthy relationship was not observed between different locations of deep neck infections and duration of hospital stay (p=.202). Conclusion Early identification of deep neck infections is often challenging. Proper knowledge and extreme vigilance is necessary when dealing with these complex entities to avoid life-threatening complications.

Does the Preoperative Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio Associate with Clinic-pathological Characteristics in Papillary Carcinoma of Thyroid.

Background Thyroid cancer is associated with local and systemic inflammatory activities. Many systemic inflammatory markers including the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) had shown credible and independent prognostic biomarkers in different malignant conditions. These markers are easy to reproduce, measure and inexpensive also. So, the preoperative evaluation of NLR and PLR is helpful in evaluating tumor growth and prognosis of papillary carcinoma of thyroid. Objective To evaluate the association of pre-operative NLR and PLR with clinic-pathological characteristic in papillary carcinoma of thyroid. Method This was a retrospective study performed in thirty one patients with the diagnosis of papillary carcinoma of thyroid. Preoperative NLR and PLR values were correlated with the clinical parameters like age, gender, lymph node metastasis, tumor size and pathological features (e.g., multifocality, bilaterality, extrathyroidal spread). Result There were thirty one patients, amongst which 13 were male and 18 were female. Similarly, the age distribution ranges from 27-68 years. The value of NLR was 2.37±1.09, and the value of PLR was 96.69±49.53.The increase in NLR was associated with increase in tumor size with statistically significant results. Similarly, increase in PLR was associated with increase in tumor size and multifocality with statistically significant results. Conclusion Increase NLR and PLR is associated with lymph node metastasis, extra thyroidal extension, multifocality of tumor and also bilaterality, so the risk can be stratified beforehand with measurement of NLR and PLR.

Clinical Profile and Diagnosis of Obstructive Sleep Apnea Syndrome using Overnight Polysomnography in a Tertiary Care Hospital.

Background Obstructive sleep apnea is a highly prevalent yet largely under-diagnosed disease that poses a significant burden on the healthcare system. Objective To determine the role of predictors for Obstructive sleep apnea syndrome and its severity in Nepalese population. Method Prospective and analytical study conducted in the Department of Otorhinolaryngology and Head and Neck surgery at Kathmandu University Hospital between March 2018 and June 2020. A total of 85 adult patients with Obstructive sleep apnea with an Epworth sleepiness score greater than 10 were included. Overnight polysomnography was done and scoring of sleep associated events were done according to the American Academy of Sleep Medicine criteria. Participants were classified as simple snoring and mild, moderate or severe Obstructive sleep apnea syndrome groups depending on the Apnea Hypopnea Index values. Relationship of Apnea hypopnea index was analyzed with age, neck circumference, body mass index and Epworth Sleepiness score. Result Simple snoring was seen in 18(21.17%) patients, 14(16.47%) had mild Obstructive sleep apnea, 13(15.29%) had moderate Obstructive sleep apnea, whereas the severe group consisted of 40(47.05%) patients. The minimum Epworth Sleepiness Score was 10 and the maximum was 25. The Apnea hypopnea index correlated positively with Body mass index (p=.010) and Epworth sleepiness score (p <.001). However, Apnea hypopnea index had no association with age (p=.437) and neck circumference (p=.118). Conclusion Health professionals need to be extremely vigilant while examining patients presenting with Obstructive Sleep Apnea. Polysomnography is the investigation of choice in the early identification of this treatable disease.

Digital Subtraction Angiography a Door Opener for Neurosurgical Residents who want to Perform Neurointerventional Procedures.

Digital subtraction angiography (DSA) has been a fluoroscopic golden investigative tool to know the vascular angiography of the brain and spinal cord. The technique in performing this procedure exposes residents in accessing the major vessels, branches of the arch of aorta, selective angiography and diagnosing different vascular anomalies of brain and spine. They are also exposed to the knowledge of different diagnostic catheters, its manipulation, use of dye and radiation exposure and safety. We would like to share our experience in training and disseminating the knowledge of digital subtraction angiography to the residents.

Universal Neonatal Hearing Screening: An Experience at Tertiary Care Hospital.

Background Hearing loss among neonates is one of the important health issue in pediatric population which may remain unnoticed until the child reaches a certain age. The importance of universal early screening, diagnosis and intervention in reducing the negative impact of congenital hearing loss has been described all over the world. Objective To observe the outcome of hearing screening by Automated Auditory Brainstem Response (AABR) in newborns delivered in Dhulikhel Hospital and neonates admitted in an intensive care unit (NICU) of Dhulikhel Hospital. Method A prospective study was done in neonates who were born at Dhulikhel Hospital, Kathmandu University Hospital from February 15th, 2017 to October 30th, 2019. AABR was used for their hearing assessment within 24 hours of birth and again at about 6 weeks of age in those neonates who failed the initial test. All the neonates admitted in NICU were studied regarding the risk factors based on Joint committee on Infant Hearing. Those who failed the test for the second time were referred for detailed audiological diagnostic work up. Result The screening rate was 92.6% of the total deliveries. A total of 5517 neonates comprising of 2800 males and 2717 females were screened from total deliveries of 5956 neonates in the study period. Among them, NICU (sick) babies were 422 (7.7%) and well babies were 5095 (92.3%). Out of them, 1675 failed the test in the first screening and 374 failed in the second screening. So, the total number of referred babies in second screening was 6.7% (374) out of 5517 screened. Amongst them, well babies were 6.59% (336), out of 5095 screened and sick babies were 9% (38) out of 422 screened. Low birth weight and prematurity were found to be the commonest risk factor present among them, followed by the use of ototoxic medications, hyperbilirubinemia and prolonged use of mechanical ventilation. Conclusion Automated Auditory Brainstem Response (AABR) is a very useful tool for hearing screening which should preferably be done in all the neonates where possible. It should be done within one month of life and those with confirmed hearing loss should receive early appropriate intervention for better hearing in future.

Deep Brain Stimulation in Parkinsons Disease in Nepal.

Background Parkinsons disease is a central nervous system degenerative disorder affecting motor system and characterized by progressive tremor, rigidity, gait abnormalities. Surgical treatment of Parkinsons disease is based on the changes in the basal gangliothalamocortical circuits which is altered in Parkinsons disease. Currently pallidotomy and Deep Brain Stimulation are available modes of surgical treatment of Parkinsons disease. Objective To know efficacy of deep brain stimulation in Parkinsons Disease in Nepal. Method All patients of idiopathic Parkinsons disease who underwent Deep Brain Stimulation in Annapurna Neurological Institute and Allied sciences since 2014 were included. The standard functional coordinates for Subthalamic nucleus and Globus pallidus internus was used. We used Zamarano-Dujovny (ZD) Fisher Frame with its software. Patients' Unified Parkinsons disease rating score, Modified Hoehn and Yahr Staging and Schwab and England Activities of daily living Scale were evaluated preoperativelyv as well as postoperatively. Result Ten patients underwent Deep Brain Stimulation. The male is to female ratio was 2:1. The mean age was 55.4±8.9 years and duration of illness was 5.5±2 years. There was a significant improvement in the scores for the main motor manifestations of the disease between the preoperative off-dopa and postoperative off-dopa/on-stim conditions. There was a significant improvement in Schwab and England Activities of daily living scale scores in the off-dopa condition between the preoperative score and the postoperative M6 score. Conclusion Our result of Deep Brain Stimulation is quite promising. However, it is very expensive and requires frequent follow-up for neuromodulation.

Role of Endoscopic Modified Inlay Butterfly Cartilage Perichondrium Myringoplasty in Hearing Outcome and Graft Uptake.

Background The endoscopes have better optics and magnification with wide angle of view due to angled lenses. It provides the excellent resolution of image in surgeries having many difficult anatomic nooks and corners like; antero-inferior recess of external auditory canal, middle ear cavity and difficult areas to visualize under microspore like sinus tympani. Likewise, the use of cartilage has very low metabolic rate, provide support to prevent retraction and reacts minimally to inflammatory reaction, so it has advantageous role in closure of tympanic membrane perforations. Objective The main objective of our study is to see the graft uptake rate and hearing results after endoscopic cartilage myringoplasty with our own modification. Method This is a prospective, cohort study conducted among 37 patients who underwent endoscopic modified inlay butterfly cartilage perichondrium myringoplasty using tragal cartilage. The hearing was assessed by comparing pre with post-operative ABG (Air bone gap) and ABG closure in speech frequencies (500Hz, 1KHz, 2KHz, 4KHz). Result Among 42 patients, 37 (88.09%) had graft uptaken. Other five patients had residual perforation because of infection. The post-operative ABG was smaller than pre-operative ABG.(26.41±8.47dB and 36.57±12.13dB respectively). The mean ABG closure was 10.15±10.23dB. The ABG closure was ≤ 10dB in 28(75.6%) patients. Conclusion Endoscopic modified inlay butterfly cartilage perichondrium myringoplasty has advantages in terms of hearing results and graft uptake rate as it is comparable or even better than others. So, it is advisable to perform this technique without any difficulty.

Thyroid Isthmus Agenesis in a Patient with Papillary Carcinoma of Thyroid.

Thyroid gland is the largest of all endocrine glands. It is composed of two lobes. These two lobes are joined by an isthmus and this resemble the letter "H". A wide range of morphological variations and developmental anomalies of the thyroid gland like hypoplasia, ectopy, hemiagenesis, and agenesis have been reported in literature. Out of these, the incidence of agenesis of the thyroid isthmus is rare, and very few cases have been reported. In our report, 28 year old male patient was found with agenesis of thyroid isthmus with papillary carcinoma in the right lobe of thyroid. During the operation it was seen that the right and left thyroid lobes were independent from each other and isthmus was absent. We will present a case of thyroid isthmus agenesis and discuss the clinical importance and the incidence of this case.

Surface roughness and packaging tightness affect calcium lactate crystallization on Cheddar cheese.

Calcium lactate crystals that sometimes form on Cheddar cheese surfaces are a significant expense to manufacturers. Researchers have identified several postmanufacture conditions such as storage temperature and packaging tightness that contribute to crystal formation. Anecdotal reports suggest that physical characteristics at the cheese surface, such as roughness, cracks, and irregularities, may also affect crystallization. The aim of this study was to evaluate the combined effects of surface roughness and packaging tightness on crystal formation in smoked Cheddar cheese. Four 20-mm-thick cross-section slices were cut perpendicular to the long axis of a retail block (~300g) of smoked Cheddar cheese using a wire cutting device. One cut surface of each slice was lightly etched with a cheese grater to create a rough, grooved surface; the opposite cut surface was left undisturbed (smooth). The 4 slices were vacuum packaged at 1, 10, 50, and 90kPa (very tight, moderately tight, loose, very loose, respectively) and stored at 1°C. Digital images were taken at 1, 4, and 8 wk following the first appearance of crystals. The area occupied by crystals and number of discrete crystal regions (DCR) were quantified by image analysis. The experiment was conducted in triplicate. Effects of storage time, packaging tightness, surface roughness, and their interactions were evaluated by repeated-measures ANOVA. Surface roughness, packaging tightness, storage time, and their 2-way interactions significantly affected crystal area and DCR number. Extremely heavy crystallization occurred on both rough and smooth surfaces when slices were packaged loosely or very loosely and on rough surfaces with moderately tight packaging. In contrast, the combination of rough surface plus very tight packaging resulted in dramatic decreases in crystal area and DCR number. The combination of smooth surface plus very tight packaging virtually eliminated crystal formation, presumably by eliminating available sites for nucleation. Cut-and-wrap operations may significantly influence the crystallization behavior of Cheddar cheeses that are saturated with respect to calcium lactate and thus predisposed to form crystals.

Effect of storage temperature on crystal formation rate and growth rate of calcium lactate crystals on smoked Cheddar cheeses.

Previous studies have shown that storage temperature influences the formation of calcium lactate crystals on vacuum-packaged Cheddar cheese surfaces. However, the mechanisms by which crystallization is modulated by storage temperature are not completely understood. The objectives of this study were to evaluate the effect of storage temperature on smoked Cheddar cheese surfaces for (1) the number of discrete visible crystals formed per unit of cheese surface area; (2) growth rate and shape of discrete crystals (as measured by area and circularity); (3) percentage of total cheese surface area occupied by crystals. Three vacuum-packaged, random weight (∼300 g) retail samples of naturally smoked Cheddar cheese, produced from the same vat of cheese, were obtained from a retail source. The samples were cut parallel to the longitudinal axis at a depth of 10mm from the 2 surfaces to give six 10-mm-thick slabs, 4 of which were randomly assigned to 4 different storage temperature treatments: 1, 5, 10°C, and weekly cycling between 1 and 10°C. Samples were stored for 30 wk. Following the onset of visible surface crystals, digital photographs of surfaces were taken every other week and evaluated by image analysis for number of discrete crystal regions and total surface area occupied by crystals. Specific discrete crystals were chosen and evaluated biweekly for radius, area, and circularity. The entire experiment was conducted in triplicate. The effects of cheese surface, storage temperature, and storage time on crystal number and total crystal area were evaluated by ANOVA, according to a repeated-measures design. The number of discrete crystal regions increased significantly during storage but at different rates for different temperature treatments. Total crystal area also increased significantly during storage, at rates that varied with temperature treatment. Storage temperature did not appear to have a major effect on the growth rates and shapes of the individual crystals that were chosen for analysis. The data indicated that the effect of storage temperature was complex, likely involving solubility changes, the formation of d(-) and l(+) lactic acid, and the occurrence of syneresis, which in turn affected the number of crystal formation sites and total crystal area on the cheese surface.

Therapeutic significance of insoles in patients with knee osteoarthritis.

OBJECTIVE: The effects of insoles on managing knee osteoarthritis (KOA) symptoms remain controversial. This systematic review provides insights into the therapeutic effects and outcomes of insole use in older adults with KOA. MATERIALS AND METHODS: The PubMed database was reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). The articles' titles, abstracts, and eligibility per the inclusion criteria were screened for relevance. Duplicated articles were removed, and full-text articles were retrieved for further assessment, in accordance with the eligibility criteria. The included articles have been analyzed for general information, participants, and relevant findings, such as painful symptoms, loading rate, and external knee adduction moment (EKAM). RESULTS: The initial search identified 335 articles. Nine studies, including seven randomized controlled trials, one cross-sectional study, and one cohort study, were included for review per the eligibility criteria. There were 639 KOA patients, of which the majority were female, diagnosed with Kellgren-Lawrence grades 2-3, with a mean age of 54.5 years. The lateral wedge insole helped reducing EKAM and loading rates in patients with KOA. We detetced no significant reduction in pain following the use of lateral wedge insoles. However, lateral wedge insoles combined with customized arch support showed significant improvements in pain and physical function in KOA patients. CONCLUSIONS: Lateral wedge insoles with arch support significantly improved pain and physical function in patients with KOA. Other insoles did not provide significant positive outcomes regarding pain reduction or joint deterioration in KOA patients.

Abnormal foot pressure in older adults with knee osteoarthritis: a systematic review.

OBJECTIVE: Knee osteoarthritis (KOA) is a progressive disease affecting the biomechanics of the knee and other parts of the lower extremities, such as the ankle and foot. Little is known about the pathophysiology of plantar pressure in patients with KOA, which could lead to foot disability. This review aimed to provide more in-depth information regarding the pathophysiology of plantar pressure patterns and their related parameters in older adults with KOA. MATERIALS AND METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed database was searched with the keywords "foot pressure and knee osteoarthritis" and "center of pressure and knee osteoarthritis". The eligible articles were evaluated based on five characteristics: KOA stages, sample size, country, study tool, and findings. The primary outcomes were plantar pressure and center of pressure (COP) in each area. Other outcomes were also evaluated, such as knee flexion angle, knee abductor moment, and clinical scores. RESULTS: Nine full-text articles were eligible for review, including 495 participants (256 patients with KOA and 239 healthy individuals). The mean age of patients with KOA was 60.2-77 years. Patients with KOA had a higher tendency for pronounced plantar pressure on the medial forefoot, mid-foot, or the foot's central area. The COP patterns were shorter and more lateralized in patients with KOA, reflecting the functional ability, pain, and well-being of patients with KOA. CONCLUSIONS: Abnormalities in plantar pressure and COP were observed in older adults with KOA. This information could be a basis for designing biomedical devices, orthoses, and other realignment osteotomies of the lower extremities that could relieve symptoms at the knee or foot, or reduce KOA progression.

Efficacy of intravenous perioperative parecoxib administration in the surgical fixation of unstable ankle fracture: a prospective, double-blinded, randomized, placebo-controlled trial.

OBJECTIVE: Little is known about the efficacy of perioperative intravenous (IV) non-opioid medication administration in patients undergoing orthopedic surgery. The objective of this study was to determine the efficacy of perioperative parecoxib in patients with unstable ankle fractures who were scheduled to undergo surgery. PATIENTS AND METHODS: In this double-blinded, prospective, randomized controlled trial, 40 patients who underwent open reduction and internal fixation for unstable ankle fractures were randomly allocated to the parecoxib group (parecoxib 40 mg IV 30 min before surgery and then 40 mg IV every 12 h for the initial 48 h postoperatively [n=20]) or the placebo group (saline [n=20]). The efficacy of pain control was assessed according to the total morphine used. Pain intensity (at rest/ambulation) and pain relief (at rest/ambulation) were assessed using the verbal numerical rating score (VNRS) and verbal numerical rating percentage (VNRP), respectively. Subjective rating of medication was performed by each patient. All outcomes were recorded by trained personnel who were blinded to the patient group allocation. RESULTS: The mean patient age was 49.3±18.0 years. There were no significant differences between the two groups in terms of pain intensity, pain relief, patients' subjective ratings of the medication at both the preoperative and postoperative periods, total quantity of morphine used, side effects, and acute complications of surgery (p>0.05). The mean length of hospital stay tended to be shorter in the parecoxib group than in the placebo group (6 vs. 9.9 days; p=0.183). CONCLUSIONS: Although the perioperative administration of parecoxib did not provide significantly better postoperative pain control or reduce the opioid requirement relative to placebo, its use led to a shorter hospital stay.

Prevalence of methicillin-resistant Staphylococcus aureus in a tertiary hospital in Nepal.

SETTING: Patan Hospital, Lalitpur, Nepal. OBJECTIVES: To describe 1) the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and its antibiotic sensitivity pattern; 2) the demographic and clinical characteristics associated with MRSA infections; and 3) the treatment outcomes of in-patients with MRSA infection among patients with S. aureus infection between January 2018 and December 2020. DESIGN: This was a cross-sectional study using electronic and paper-based hospital records of patients with S. aureus infection. RESULTS: Of the 1,804 patients with S. aureus infection, 1,027 patients (57%, 95% CI 55-59) had MRSA. The MRSA were susceptible to vancomycin (100%), linezolid (96%), doxycycline (96%), chloramphenicol (86%) and cotrimoxazole (70%), and resistant to erythromycin (68%), clindamycin (56%), gentamycin (58%), ciprofloxacin (92%) and ofloxacin (91%). The prevalence of MRSA was higher in 2019, among out-patients, and in respiratory samples, and lower in blood samples. Of the 142 in-patients with MRSA, 93% had a successful clinical outcome (cured/improved). CONCLUSION: More than 50% of patients with S. aureus infection had MRSA that were resistant to commonly available antibiotics. This calls for strengthening surveil-lance and good infection control practices in this hospital.

LIEU: Hôpital de Patan, Lalitpur, Népal. OBJECTIFS: Décrire 1) la prévalence de Staphylococcus aureus résistant à la méticilline (MRSA) et son profil de sensibilité aux antibiotiques ; 2) les caractéristiques démographiques et cliniques associées aux infections à MRSA ; et 3) les résultats thérapeutiques des patients hospitalisés atteints d'infection à MRSA parmi ceux atteints d'infection à S. aureus de janvier 2018 à décembre 2020. MÉTHODE: Il s'agissait d'une étude transversale réalisée en utilisant les dossiers hospitaliers électroniques et papiers des patients atteints d'infection à S. aureus. RÉSULTATS: Sur les 1 804 patients atteints d'infection à S. aureus, 1 027 patients (57%, IC 95% 55-59) avaient un MRSA. Les MRSA étaient susceptibles à la vancomycine (100%), au linézolide (96%), à la doxycycline (96%), au chloramphénicol (86%) et au co-trimoxazole (70%), et résistants à l'érythromycine (68%), la clindamycine (56%), la gentamycine (58%), la ciprofloxacine (92%) et l'ofloxacine (91%). La prévalence des MRSA était plus élevée en 2019, parmi les patients ambulatoires, ainsi que dans les échantillons respiratoires. Elle était plus faible dans les échantillons sanguins. Sur les 142 patients hospitalisés avec MRSA, 93% ont connu un résultat clinique favorable (guérison/amélioration de l'état). CONCLUSION: Plus de 50% des patients atteints d'infection à S. aureus avaient un MRSA résistant aux antibiotiques habituellement disponibles. La surveillance et les pratiques de contrôle des infections doivent donc être renforcées dans cet hôpital.

Chemical changes that predispose smoked Cheddar cheese to calcium lactate crystallization.

We have observed a high incidence of calcium lactate surface crystals on naturally smoked Cheddar cheese in the retail marketplace. The objective of this study was to identify chemical changes that may occur during natural smoking that render Cheddar cheese more susceptible to calcium lactate crystal formation. Nine random-weight (approximately 300 g) retail-packaged samples of smoked Cheddar cheese were obtained from a commercial manufacturer immediately after the samples were smoked for about 6 h at 20 degrees C in a commercial smokehouse. Three similarly sized samples that originated from the same 19.1-kg block of cheese and that were not smoked were also obtained. Within 2 d after smoking, 3 smoked and 3 control (not smoked) samples were sectioned into 5 subsamples at different depths representing 0 to 2, 2 to 4, 4 to 6, 6 to 8, and 8 to 10 mm from the cheese surface. Six additional smoked cheese samples were similarly sectioned at 4 wk and again at 10 wk of storage at 5 degrees C. Sample sections were analyzed for moisture, L(+) and D(-) lactate, pH, and water-soluble calcium. The effects of treatment (smoked, control), depth from cheese surface, and their interactions were analyzed by ANOVA according to a repeated measures design with 2 within-subject variables. Smoked samples contained significantly lower moisture and lower pH, and higher total lactate-in-moisture (TLIM) and water-soluble calcium-in-moisture (WSCIM) than control cheeses. Smoked samples also contained significant gradients of moisture, pH, TLIM, and WSCIM, with lower moisture and pH, and higher TLIM and WSCIM, occurring at the cheese surface. Gradients of moisture were still present in smoked samples at 4 and 10 wk of storage. In contrast, the pH, TLIM, and WSCIM equilibrated and showed no gradients at 4 and 10 wk. The results indicate that calcium and lactate in the serum phase of the cheese were elevated because of smoking, especially at the cheese surface immediately after smoking treatment, which presumably predisposes the smoked cheeses to increased susceptibility to calcium lactate surface crystallization.

Characterization of calcium lactate crystals on cheddar cheese by image analysis.

Previous research demonstrated that crystal coverage on the surface of Cheddar cheese can be quantitatively and nondestructively measured using image analysis of digital photographs of the cheese surface. The objective of the present study was to extend image analysis methodology to quantify and characterize additional features of visible crystals on cheese surfaces as they grow over time. A random weight (approximately 300 g) retail sample of naturally smoked Cheddar cheese exhibiting white surface crystals was obtained from a commercial source. The total area occupied by crystals and total number of discrete crystal regions on one of the surfaces (approximately 55 x 120 mm) was measured at 3-wk intervals for 30 wk using image analysis. In addition, 5 small (approximately 0.3 mm radius) individual crystals on that surface were chosen for observation over the 30-wk period. The crystals were evaluated for area, radius, and shape factor (circularity) every third week using image analysis. The total area occupied by crystals increased in a linear manner (R(2) = 0.95) from about 0.44 to 7.42% of the total cheese surface area over the 30-wk period. The total number of discrete crystal regions also increased but in a nonlinear manner that was best described by a quadratic relationship. Measurement of discrete crystal regions underestimated the true number of crystals present at the cheese surface due to merging of adjacent crystals as they grew and merged into a single crystal region over time. Throughout this period, the shapes of the 5 individual crystals closely approximated perfect circles, except when adjacent crystals merged to form a single irregular crystal region, and the area occupied by each of the 5 crystals increased in a near-linear manner (R(2) = 0.95). Image analysis approaches may be used to evaluate crystal formation and growth rates and morphology on cheese.

Compositional factors associated with calcium lactate crystallization in smoked Cheddar cheese.

Previous researchers have observed that surface crystals of calcium lactate sometimes develop on some Cheddar cheese samples but not on other samples produced from the same vat of milk. The causes of within-vat variation in crystallization behavior have not been identified. This study compared the compositions of naturally smoked Cheddar cheese samples that contained surface crystals with those of samples originating from the same vat that were crystal-free. Six pairs of retail samples (crystallized and noncrystallized) produced at the same cheese plant on different days were obtained from a commercial source. Cheese samples were 5 to 6 mo old at the time of collection. They were then stored for an additional 5 to 13 mo at 4 degrees C to ensure that the noncrystallized samples remained crystal-free. Then, the crystalline material was removed and collected from the surfaces of crystallized samples, weighed, and analyzed for total lactic acid, L(+) and D(-) lactic acid, Ca, P, NaCl, moisture, and crude protein. Crystallized and noncrystallized samples were then sectioned into 3 concentric subsamples (0 to 5 mm, 6 to 10 mm, and greater than 10 mm depth from the surface) and analyzed for moisture, NaCl, titratable acidity, L(+) and D(-) lactic acid, pH, and total and water-soluble calcium. The data were analyzed by ANOVA according to a repeated measures design with 2 within-subjects variables. The crystalline material contained 52.1% lactate, 8.1% Ca, 0.17% P, 28.5% water, and 8.9% crude protein on average. Both crystallized and noncrystallized cheese samples contained significant gradients of decreasing moisture from center to surface. Compared with noncrystallized samples, crystallized samples possessed significantly higher moisture, titratable acidity, L(+) lactate, and water soluble calcium, and significantly lower pH and NaCl content. The data suggest that formation of calcium lactate crystals may have been influenced by within-vat variation in salting efficacy in the following manner. Lower salt uptake by some of the cheese curd during salting may have created pockets of higher moisture and thus higher lactose within the final cheese. When cut into retail-sized chunks, the lower salt, higher moisture samples contained more lactic acid and thus lower cheese pH, which shifted calcium from the insoluble to the soluble state. Lactate and soluble calcium contents in these samples became further elevated at the cheese surface because of dehydration during smoking, possibly triggering the formation of calcium lactate crystals.

Development and application of image analysis to quantify calcium lactate crystals on the surface of smoked Cheddar cheese.

Calcium lactate crystals that form white specks or haze on the surface of cheese constitute a significant quality problem for producers of Cheddar cheese. Subjective methods to evaluate crystal coverage of cheese surfaces have been reported previously, but objective methods are currently lacking. The objectives of this work were to develop and evaluate an objective method to measure the area occupied by calcium lactate crystals on surfaces of naturally smoked Cheddar cheese samples using digital photography and image analysis. Coefficients of variation ranged from 1.29 to 4.68% for 5 replicate analyses of 3 different cheese surfaces that ranged from approximately 2 to 49% of total surface area occupied by crystals. Thus, results showed a high degree of repeatability for the 3 cheese surfaces, which ranged from very slight and geometrically simple to very heavy and geometrically complex crystal coverage. The method underestimated total area occupied by crystals on the 3 surfaces by 0.24 to 4.83% unless the fainter crystal regions that went undetected during initial thresholding were manually segmented and quantified. The wet weight of crystal substance collected per unit of surface area from 20 different cheese samples increased exponentially as the percentage of total surface area occupied by crystals increased. These data were consistent with subjective observations that crystal regions appeared to grow vertically as well as horizontally as they expanded to occupy greater surface area. Image analysis was well suited for evaluating changes in crystal coverage during cheese aging because measurements were made nondestructively and with minimal disruption to the cheese. The area occupied by crystals on 6 different surfaces from 3 different cheese samples increased linearly (R2 = 0.94 to 0.99) during storage at 4 degrees C for up to 33 wk. However, the rates of increase differed significantly among the 3 cheese samples. Image analysis may serve as a useful tool to quantitatively evaluate the effects of factors such as cheese composition, packaging conditions and storage temperature on rate of crystal growth and time of crystal appearance during storage.

Lignocaine and Esmolol on Stress Response to Laryngoscopy and Intubation.

INTRODUCTION: Laryngoscopy and tracheal intubation causes significant sympathetic response resulting in hypertension and tachycardia. In individuals with systemic hypertension, coronary artery disease, cerebrovascular disease and intracranial aneurysm, the effect of this transient sympathetic response can evoke life threatening conditions like pulmonary oedema, cardiac failure and cerebrovascular haemorrhage. METHODS: Patients were randomly divided into two groups, 30 in each group. Group I received 50 mg of esmolol and group II received lignocaine 2 mg/kg. Haemodynamic parameters like pulse, systolic blood pressure, diastolic blood pressure and mean arterial pressure were measured before induction of anaesthesia, immediately after intubation then at intervals of one minute, three minutes, five minutes, seven minutes and 10 minutes. RESULTS: There was no significant difference in demographic or base line vital signs between two groups (Table 1). The mean systolic blood pressure (SBP) increased on laryngoscopy and tracheal intubation by 15 mmHg in the group I whereas in group II it was 17.4 mmHg. There was a significant rise in diastolic blood pressure (DBP) in both the groups, but the rise was lesser in group II than in group I. CONCLUSION: Both esmolol and lignocaine were not effective in attenuating hemodynamic stress response to laryngoscopy and tracheal intubation; however esmolol was superior to lignocaine in blunting the stress response.

Retrospective study on early outcome of acute burn injuries treated at Nepal Cleft and Burn Centre of Public Health Concern Trust-Nepal.

BACKGROUND: Nepal Cleft & Burn Center, Kirtipur Hospital, Kathmandu has been providing the acute burn care since 2013 with 10 ICU beds, 32 general beds and two operating rooms. This study analyses the demographics of and early outcome in the acute burn patients. METHODS: This is a descriptive retrospective study of the clinical data of acute burn patients admitted from January 1 to December 31, 2014. RESULTS: There were 78 patients from 3 months to 88 years of age with a median age of 29 years. Forty six (58.9%) were females and 32 (41.1%) were males. Most of the injuries (n=57; 73%) occurred inside the house. Flame burn was the commonest mode of injury (n= 48, 61.6%). Only eleven (14.1%) patients arrived on the same day of the injury. The time elapsed was from 1 to 67 days with a median of 5 days. Only two (2.5%) patients had poured water for more than 20 minutes. Range of total body surface area (TBSA) involved was 1% to 70% with a median of 12%. Range of hospital stay was 1 to 105 days with a median of 17 days. Sixty (76.9%) patients underwent 102 surgical operations. Twenty six (33.3%) patients needed blood transfusion. A total of 15 (19.2%) patients died. None survived a burn injury of more than 40% TBSA. CONCLUSIONS: Treatment of acute burn is very challenging with high mortality rate. A lot of effort is needed to change the present standard of care. Awareness programs on First Aid treatment of burn injuries together with the preventive programs focused on high risk population such as females and children in a large scale needs to be organized as soon as possible.