The effect of haematocrit on transthoracic electrical impedance and on the calculation of cardiac output by an impedance cardiograph.

The Transthoracic electrical impedance (TEI) was measured using the Bomed NCCOM3 non-invasive cardiac output monitor in 27 patients with polycythemia rubra vera (PCRV) and in a control group of 27 patients with normal haematocrits. The mean haematocrit was 49.4% (SD 2.61) in the patients with PCRV and 42.1% (SD 2.95) in the control group, a difference that was significant (p less than 0.001). The mean TEI was also significantly higher in patients with PCRV than in the control group (p less than 0.05), the respective values being 31.25 (5.48) Ohms and 27.5 (3.31) Ohms. The mean values for cardiac output (CO) and cardiac index (CI) were similar in both groups.

Haemodynamic effects of increasing angle of head up tilt.

OBJECTIVE: To investigate the haemodynamic effects of varying the angle of head up tilt. METHODS: 20 healthy subjects (12 female, eight male; mean (SD) age 33.6 (8.4) years) underwent head up tilt for five minutes to each of four angles of tilt in random order, with a five minute rest period at the horizontal between each angle. Forearm blood flow was measured using intermittent occlusion mercury strain gauge plethysmography at two and five minutes. Subjects underwent continuous monitoring of heart rate, systolic blood pressure (SBP), and diastolic blood pressure (DBP) by Finapres and cardiac output and stroke volume by impedance cardiography. Each variable was measured at two and five minutes, averaged over the period of blood flow measurement. RESULTS: Every haemodynamic variable at each angle was significantly different from supine values. Head up tilt produced progressive increases in heart rate (11-21%), SBP (12-21%), and DBP (20-33%) with increasing tilt angle. However, although 45 degrees produced significantly less haemodynamic effect, there were no significant differences for angles between 60 degrees and 90 degrees. Cardiac output fell on head up tilt by 17-20% and stroke volume by 28-34%, but increasing tilt angle produced no significant additional reduction in cardiac output and stroke volume because of increases in heart rate and vasoconstriction. CONCLUSIONS: Angles < 60 degrees produce significantly less haemodynamic effects than steeper angles. Increasing tilt angle beyond 60 degrees produces no apparent additional effect on cardiac output or sympathetic tone. Increasing tilt angle beyond 60 degrees confers no additional orthostatic stress and may not affect the sensitivity and specificity of head up tilt testing as previously thought. Sixty degrees of tilt is a more practical angle for support of a syncopal patient and is recommended.

The value of CT scans for children with headaches.

We studied the value of CT scans for all children referred because of headache to one secondary and one tertiary pediatric centre during a 1 year period. Of 117 children who were seen by the Pediatric Neurology Service, at the I.W.K. Children's Hospital, 4 had CT scans and only 1 of these was abnormal. The consultant Pediatrician saw 40 children because of headache. CT scans were done on 3 of these patients and all were normal. None of the children who had a clinical assessment alone had unrecognized neurological disease during 20 months of follow-up. Therefore only 1 of 157 children had significant intracranial pathology. We conclude that CT scans have a limited role in the management of children with headache.

Metastatic germ cell tumor to the heart presenting with syncope.

Malignant nonseminomatous germ cell tumors (NSGCT) rarely metastasize to the heart. The first such case presenting with syncope is described. Eight previously described cases of NSGCT with intracaval metastasis to the heart are reviewed and the literature to date is discussed. Transesophageal echocardiography is the diagnostic study of choice and treatment consists primarily of platinum-based chemotherapy followed by surgical resection of residual deposits.

Chloroma of the cranium with dural involvement.

An unusual case of chloroma (granulocytic sarcoma) of the cranium with involvement of underlying dura and presenting as an intracranial space occupying lesion, with no systemic evidence of myeloid leukaemia, is reported. Operative removal was followed by local radiation. The patient is well and no systemic evidence of leukaemia has been manifested nearly 4 years after operation. The literature is reviewed.

The use of remifentanil during general anaesthesia for caesarean delivery in two patients with severe heart dysfunction.

We describe the management of two patients with severe heart dysfunction requiring caesarean section because of incipient left ventricular failure. One patient had a bicuspid valve and developed symptoms of severe aortic incompetence during pregnancy. The second patient had known hypertrophic obstructive cardiomyopathy and developed chest pain and symptoms of left ventricular failure at 32 weeks' gestation. In both cases the worsening cardiac disease prompted the decision for operative delivery. We decided to employ general anaesthesia and achieved cardiovascular stability using remifentanil as an adjunct.

Epidemiology of chronic suppurative otitis media and deafness in a rural area and developing an intervention strategy.

Of 613 children evaluated in a village in Haryana 94 (15.3%) were observed to have chronic suppurative otitis media (CSOM). Fifty eight (61.7%) children had hearing impairment. CSOM contributed to 71.6% of the hearing impaired (58/81). On analysis of association of CSOM with literacy and socio-economic status of mothers, and age, sex, and upper respiratory tract infections (URI) in children positive correlation was observed only with URIs (P < 0.001). Literacy and socio-economic status of the mothers did not correlate significantly with knowledge about treatment seeking, and ear cleaning practices, probably due to the narrow range of incomes and literacy levels. An intervention program consisting of play, demonstrations, health charts and slogans, and aural cleaning and antibiotic drops was introduced.

A Study of Hostility, Career Choice and Job Satisfaction Among Surgeons.

The present study has been carried out to study the hostility pattern of surgeons and compare it with other specialities. 100 teachers working in different specialities in Post Graduate Institute of Medical Sciences (PGIMS) Rohtak (Surgery and allied specialties 21, Medical and allied specialities 14, Non-clinical specialities 30) were given Hostility and Direction of Hostility Questionnaire (HDHQ) along with questions regarding their choice of career and Job satisfaction. Hostility pattern did not differ statistically among these groups. Surgeons showed strong aptitude for the field and were contended with their choice of speciality but their Job satisfaction was low. Possible explanations and implications of the study are discussed.

Remifentanil infusion in association with fentanyl-propofol anaesthesia in patients undergoing cardiac surgery: effects on morphine requirement and postoperative analgesia.

BACKGROUND: We have prospectively assessed the effects of remifentanil on morphine requirement in the first hour after emerging from general anaesthesia after elective coronary artery bypass surgery and in the first 12 h postoperatively, and pain and agitation scores in the first hour after emerging from general anaesthesia. METHODS: Twenty patients undergoing off-pump coronary artery bypass surgery, receiving standardized propofol-fentanyl-based anaesthesia, randomly received infusions of either remifentanil 0.1 microg kg(-1) min(-1) (Group R, n=10) or saline (Group S, n=10), each infused at 0.12 ml kg(-1) h(-1). Propofol and trial drug infusion were continued into the postoperative period until the patients were ready to be woken up. Postoperative analgesia was provided with morphine infusion commenced immediately after operation, and was additionally nurse controlled on the basis of a visual analogue scale (VAS) score (0-10). Agitation score was recorded using a VAS of 0-3. RESULTS: In the first hour after discontinuing propofol and trial infusion, morphine requirements were significantly higher in the remifentanil group (8.15 (sd 3.59) mg) compared with the saline group (3.29 (2.36) mg) (P<0.01). There was no difference in the total morphine given during the period after stopping propofol or in the total requirement in the first 12 h postoperatively. There was no significant difference in either pain scores or agitation scores between the two groups. CONCLUSION: Use of remifentanil is associated with increased opioid requirement in the first hour after it has been discontinued.

Elevated plasma CD105 and vitreous VEGF levels in diabetic retinopathy.

Diabetic retinopathy is the leading cause of blindness in the industrialized world. Hyperglycaemia induces retinal hypoxia that upregulates a range of vasoactive factors which may lead to macular oedema and/or angiogenesis and hence potentially sight threatening retinopathy. In this study, we have focused on the association of CD105 and vascular endothelial growth factor (VEGF) with the development and progression of diabetic retinopathy by means of quantifying their expression in the plasma and vitreous of diabetic patients. CD105 levels were quantified in the plasma of 38 type I diabetic patients at various stages of retinopathy and 15 non-diabetic controls. In an additional cohort of 11 patients with advanced proliferative retinopathy and 23 control subjects, CD105 and VEGF were measured in the vitreous. The values were expressed as median (range) and statistical analysis was carried out using the non-parametric Mann-Whitney U test. Plasma CD105 levels were significantly increased in diabetic patients [1.8 (1.1-2.4) ng/ml] compared with non-diabetic controls [0.7 (0.3-1.8) ng/ml] (p<0.01). Plasma CD105 levels were elevated in diabetic patients with all stages of retinopathy, the highest level was observed in background retinopathy [2.3 (2.1-2.5) ng/ml] followed by proliferative retinopathy [2.1 (0.9-2.8) ng/ml] and advanced proliferative retinopathy [1.4 (0.6-1.8) ng/ml]. Vitreous contents of CD105 did not differ between controls and patients with advanced proliferative retinopathy, but vitreous levels of VEGF were elevated by approximately 3-fold in patients with advanced proliferative retinopathy [7.2 (1.90-15.60) ng/ml] compared with the control subjects [1.80 (1.10-2.210)] (p<0.01). These observations indicate that plasma levels of CD105 and vitreous levels of VEGF are associated with diabetic retinopathy, suggesting that CD105 and the angiogenic factor VEGF may play a critical role in the development and progression of diabetic retinopathy. Further studies are required to determine whether circulating CD105 levels could serve as a surrogate marker for early stage retinopathy and for monitoring disease progression.

A cost-effective cane molasses medium for enhanced cell-bound phytase production by Pichia anomala.

AIM: Formulation of an inexpensive cane molasses medium for improved cell-bound phytase production by Pichia anomala. METHODS AND RESULTS: Cell-bound phytase production by Pichia anomala was compared in synthetic glucose-beef extract and cane molasses media. The yeast was cultivated in 250 ml flasks containing 50 ml of the medium, inoculated with a 12 h-old inoculum (3 x 10(6) CFU ml(-1)) and incubated at 25 degrees C for 24 h at 250 rev min(-1). Different cultural parameters were optimized in cane molasses medium in batch fermentation. The cell-bound phytase content increased significantly in cane molasses medium (176 U g(-1) dry biomass) when compared with the synthetic medium (100 U g(-1) dry biomass). In fed-batch fermentation, a marked increase in biomass (20 g l(-1)) and the phytase yield (3000 U l(-1)) were recorded in cane molasses medium. The cost of production in cane molasses medium was pound 0.006 per 1000 U, which is much lower when compared with that in synthetic medium (pound 0.25 per 1000 U). CONCLUSIONS: An overall 86.6% enhancement in phytase yield was attained in optimized cane molasses medium using fed-batch fermentation when compared with that in synthetic medium. Furthermore, the production in cane molasses medium is cost-effective. SIGNIFICANCE AND IMPACT OF THE STUDY: Phytase yield was improved in cane molasses when compared with the synthetic medium, and the cost of production was also significantly reduced. This enzyme can find application in the animal feed industry for improving the nutritional status of feed and combating environmental pollution.

A study of psychiatric comorbidity in alcohol dependence.

The diagnosis of comorbid psychiatric conditions have important clinical ramifications as the outcome is poorer with multiple disorders. Various studies have shown that alcohol abuse has severe adverse effects on the course of metal illness and vice versa. Only a little data on the subject are available from our country. We interviewed 30 patients suffering from alcohol dependence using SCID - I & SCID - II. Seventy six percent of the sample had axis - I comorbid diagnosis and 40% had an axis -II diagnoses. Depressive disorder and cluster B personality disorders were the most common comorbid diagnosis.

Klingsor syndrome: a case report.

A Case of genital self-mutilation under the effect of delusions and hallucinations is described. The Importance of liasion between surgical and psychiatric services is highlighted.

The effect of four different surgical prone positions on cardiovascular parameters in healthy volunteers.

Twenty healthy volunteers were placed in four different surgical prone positions: on pillows, on an evacuatable mattress, on pelvic props and in the knee-chest position. The normal supine position was used as a control for the measurement of cardiovascular parameters. Mean arterial pressure was measured by automated oscillotonometry. Transthoracic electrical bioimpedance was used to measure cardiac output and heart rate. Cardiac index and total vascular resistance index were derived from these data. No significant changes in heart rate or mean arterial pressure occurred when the volunteers were moved from the supine position to any of the four prone positions or when returned to the supine position again. Cardiac index decreased significantly on going from the supine to the knee-chest position (20%) and onto the props (17%) but not onto the evacuatable mattress (11%) or the pillows (3%).

Neurotrauma in Pakistan.

The incidence of head and spinal injury is on the rise in developing countries. The number of deaths and burden of disability may be reduced, if not completely stopped, through preventive measures after an epidemiological survey on trauma. The goal can be achieved to a significant extent through the use of guidelines from the countries that have achieved a reduction in the incidence of neurotrauma. To determine the incidence and outcome of neurotrauma in developing countries, a study was necessary using standardized assessment parameters for global interpretation. Such a study was conducted to determine the sociodemographic characteristics, morbidity, and mortality of patients with head and spinal injury admitted to various neurosurgical centers in Pakistan from July 1, 1995 to June 30, 1999. A total of 260,000 patients were admitted with head injury over a 4-year period. The majority of patients presented during second decade (i.e., 33.2%) followed by first and third decade. There were 195,000 (75%) males, and 65,000 (25%) females with a ratio of 3:1. Road traffic accident was the commonest cause of head trauma. Mild, moderate, and severe head injury was observed in 135,200 (52%), 78,000 (30%), and 46,800 (18%) patients, respectively. Conservative management was carried out in 176,800 (68%) patients. Surgery was required in 83,200 (32%), 50% of which had depressed skull fracture, simple or compound. Follow-up period varied from 2 months to 2 years with a mean of 11 months. Patient's outcome was assessed according to Glasgow Outcome Scale (GOS). Good outcome was observed in 174,200 (67%). The total mortality was 46,800 (18%). In this study, 2654 patients ranging in age from 5 to 70 years had spinal injuries. There were 1922 males (72%) and 732 (28%) females. British Medical Research Council Scale was used for assessment of motor power of patients with spinal trauma. Of these, 780 patients (29%) had complete spinal cord injury. Surgical intervention was performed in 1800 patients (68%) and the rest were managed conservatively.

Prevalence and pattern of alcohol and substance abuse in urban areas of rohtak city.

A sample of 4,691 subjects aged 14 years and above were interviewed on a schedule based on WHO Questionnaire to collect information about prevalence & pattern of alcohol and substance abuse The study revealed a prevalence rate of 19 78%. 42.41% of users were in the age group of 25-34 years while 44.1 % were literate (up to matric). 45.04% among labourers were alcohol users. In terms of age of onset, 94.83% respondents had their first drink between the ages of 15-25 years. Most common type of alcohol consumed was country liquor by 69.07%. Majority (63.44%) of alcohol users said that they usually drink with some companion, only in the evening and night. 50.03% had arguments with family or friends after taking alcohol while 13.57% alcohol abusers confessed that they had neglected their family and work due to alcohol. In family history of 23.16% alcohol users, father was abusing alcohol. 26.61% alcohol users cited to be sociable as reason for their drinking. 16.81% users were smokers also while 6.89% had the habit of taking Pan Masala/Zarda. 2.04% of alcohol users were taking soolfa also along with alcohol while the frequency of opium and cannabis abuse was 1.51 and 1.18% respectively.

An epidural scoring scale for arm movements (ESSAM) in patients receiving high thoracic epidural analgesia for coronary artery bypass grafting.

Thoracic epidural analgesia appears to improve the outcome of patients undergoing coronary artery bypass graft surgery. Cranial extension of nerve blockade involving the third, fourth and fifth cervical nerve roots can cause apnoea. However, progressive paraesthesia and weakness due to cephalad spread of thoracic epidural analgesia will affect the arms before the diaphragm. A scale was designed to test three active movements of the arms bilaterally: hand grip (T1/C8), wrist flexion (C8/7) and elbow flexion (C6/5). This epidural scoring scale for arm movements (ESSAM) consists of four grades (0-3) based on the number of absent movements, and suggests appropriate action. The reliability of this scale was tested in 40 patients undergoing coronary artery bypass surgery. Twelve of the 40 patients had their epidural infusion reduced on the basis of the scale. Of these 12 patients, eight had a worst ESSAM score of 1, three had a worst score of 2 and one had a worst score of 3. In each patient, motor power returned following the reduction in infusion rate, taking between 30 min and 3 h. This scale appears to be a simple and reliable method for the early detection of the cephalad spread of thoracic epidural analgesia.