Successful Multi-vessel Percutaneous Coronary Intervention for Recent Myocardial Infarction in a Patient with Dextrocardia and Situs Inversus.

Dextrocardia with situs inversus is a state which is characterized by abnormal positioning of the heart and other internal organs. It is a rare congenital anomaly and the exact cause is not known. More than 60 recognized genes are significant for the proper positioning and patterning of the organs in the body. However, a specific genetic cause of dextrocardia with situs inversus has not been identified and inheritance prototypes have not been established in the majority cases. There are partial available case reports of successful percutaneous coronary intervention (PCI) in these patients who have atherosclerotic coronary artery disease, especially when presenting with myocardial infarction. PCI is technically difficult because of dextrocardia. We hereby describe a 51-year-old male, who had a recent inferior wall myocardial infarction and underwent successful coronary angiography and PCI at a tertiary level hospital in Dhaka, Bangladesh.

Pancreatic cysts: Diagnostic accuracy and risk of inappropriate resections.

BACKGROUND: Pancreatic cystic neoplasms (PCN) frequently undergo surgery, given malignant potential. Pancreatic cyst surgery is associated with significant rates of morbidity and mortality. It is crucial to accurately characterize these lesions pre-operatively to avoid unnecessary surgery in patients with benign pancreatic cysts. AIM: We aimed to assess the correlation between pre-operative (pre-op) diagnosis based on imaging and clinical presentation, and post-operative (post-op) diagnosis based on histopathology in patients undergone pancreatic cyst surgery. METHODS: From January 2000 to January 2012, we randomly selected 2000 patients with ICD-9 code 211.6 and 577.2. Amongst these we identified 281 patients undergone pancreas surgery. Patients with no pre-op imaging or non-cyst indication for surgery were excluded (n = 107). Imaging details, demographics, pre-operative physician diagnosis and histopathologic details of pancreatic cysts were recorded in 174 patients. RESULTS: There was a discrepancy between the pre- and post-operative pancreatic cyst diagnosis in 54 (31%) patients. There was no difference in the proportion of various imaging studies (CT, EUS or MRI) between patients with a correct and patients with an incorrect pre-op diagnosis. The pre-op diagnosis was confirmed at pathology in 87.5% of the presumed SCNs, in 80% of the presumed pseudocysts, in 73.3% of the presumed BD-IPMNs, in 66.7% of the presumed MD/mixed-IPMNs and in 53.6% of the presumed MCNs. The accuracy of the pre-operative diagnosis of presumed MCN was significantly lower compared to the non-MCN cysts (53.6% vs. 75%; p = 0.037). Fourteen percent of resections were performed for asymptomatic benign cysts, preoperatively suspected to be potentially pre-malignant cysts. CONCLUSION: In nearly 1 out of 3 patients undergone pancreas cyst surgery, there is a discrepancy between pre- and post-op diagnosis. Pre-op diagnosis of presumed MCN is more likely to be incorrect, compared to the other cysts.

Conventional Brain MRI in Carbon Monoxide Poisoning.

Carbon monoxide poisoning is a common fatal condition which can have acute or chronic presentation with varying severity. It commonly involves globus pallidus and putamen but can involve other parts of brain. Conventional MRI using T1 weighted,T2 weighted and FLAIR sequences are helpful in determining the extent of damage to the brain. However, appropriate clinical and laboratory findings should supplement findings on imaging.

Renal drug dosing recommendations: evaluation of product information for brands of the same drug.

OBJECTIVES: To review the product information (PI) for various brands of the same generic drugs and investigate the extent to which information is currently available on dosing in renal impairment and the concordance between the dosing recommendations for the same generic drug. METHOD: The Monthly Index of Medical Specialities (MIMS) was examined for 28 generic drugs recommended to be used with caution in renal impairment. For each generic drug all available brands listed as having solid oral dosage form were recorded. For each identified brand, the current PI was consulted and data referring to renal impairment was collated. The dissimilarity between these PI regarding the renal dosage recommendation was determined. RESULTS: There was generally a lack of detailed information in the PI on the use of drugs in patients with renal impairment. The majority of PI documents (88 of 155 PI; 57%) provided quantitative dosage recommendations, but this was often not detailed enough to help users to make an informed decision. For 37 PI documents (24%), an altered dosage regimen was proposed without a quantifiable measure of renal function reported in the dose recommendation. The renal function severity category terms used and the associated quantitative values were also not consistent. It was observed that the recommendations varied among different brands of hydromorphone, morphine, oxycodone, tramadol, metformin and topiramate. CONCLUSION: The reporting of renal function quantification methods, and associated dosage recommendations, in PI requires standardisation to ensure optimal drug dosing. Regularly updating of PI is also necessary.

Dose adjustment guidelines for medications in patients with renal impairment: how consistent are drug information sources?

BACKGROUND: It is known that patients with renal disease are often administered inappropriate dosages of drugs. A lack of quantitative data in the available drug information sources and inconsistency in dosing information may augment the problem of dosing error. AIMS: To determine the concordance among five drug information sources regarding the dosing recommendations provided for drugs considered problematic in patients with renal impairment and to determine the consistency among the sources regarding the definition of renal impairment and categorisation of chronic kidney disease. METHODS: Five standard drug information sources were reviewed for 61 drugs recommended to be used with caution in renal impairment. Information on recommendations for dosage adjustment in renal impairment was extracted and analysed. Further, the definition and classification of renal impairment were recorded. The recommendation for each drug was coded into six different categories and the intersource reliability was calculated. RESULTS: Only slight agreement was observed among the sources (Fleiss Kappa: 0.3). Qualitative data were not well defined, and there was a lack of consistency in quantitative values. Some drugs marked as contraindicated in one source were not mentioned as such in others. Also, drugs considered as not requiring dosage adjustment in one source had explicit recommendations in other sources. The definition and classification of renal impairment differed among the five information sources. CONCLUSIONS: There should be an evidence-based approach to drug dosage adjustment in order to bring uniformity to the recommendations. Regular updating of the content of the drug information sources is also important.

Adoption of technology, management practices, and production systems in US milk production.

The introduction of new technology, management practices, and alternative production systems has resulted in rapid structural change in the US dairy industry. This paper examines adoption rates and adopter characteristics for the following dairy technologies, practices, and systems: holding pen with an udder washer, milking units with automatic take-offs, genetic selection technologies, recombinant bovine somatotropin, membership in the Dairy Herd Improvement Association, computerized feed delivery systems, computerized milking systems, use of a nutritionist to design feed rations, grazing, milking cows 3 times daily, and milking parlors. Four of these were used on a greater percentage of farms in 2005 than in 2000, but increased farm sizes and the interaction of farm size with adoption suggest a greater percentage of milk being produced under each, with the exception of grazing. Except for grazing, technologies were generally complementary.

Fiber-optic bronchoscopy: seven-year experience at Nepal Medical College Teaching Hospital.

Fiber-optic bronchoscopy is a safe and useful diagnostic and therapeutic tool for the management of the pulmonary diseases. The purpose of this study was to find out the demographic profiles, indications, bronchoscopic findings, and diagnoses of the patients who underwent bronchoscopic examination. Retrospective analysis of 231 consecutive bronchoscopies done in Nepal Medical College Teaching Hospital over the period of seven years (January 2003 to January 2010) was done. The commonest indication was radiological opacity (90.2%), followed by diffuse pulmonary infiltrates (4.3%). Cough was the commonest presenting symptom seen in 89.8% of the patients. 79.7% of the patients were smokers and the history of smoking among the patients diagnosed to have lung cancer was 94%. The commonest bronchoscopic finding was endobronchial growth (47.8%). Histopathological examination revealed malignancy in 53.8% of the patients, of which small cell lung cancer was 22.8% and non small cell lung cancer 77.2%. Even when growth was not visualized on bronchoscopy, biopsies attempted from the segments with radiological abnormality established the diagnosis of malignancy in 10.16%, pulmonary tuberculosis in 5.1% and Sarcoidosis in 2.2% of the cases.

Enteric fever with severe pancytopenia in a four year girl.

Typhoid fever and paratyphoid fever (also known as enteric fever) are severe systemic illnesses caused by salmonella typhi and S. paratyphi respectively. Enteric fever is prevalent in developing countries including Nepal, where it still remains as a major health problem. There have been reports of pancytopenia with enteric fever which has been attributed to mechanisms like bone marrow suppression, infection associated hemophagocytic syndrome and disseminated intravascular coagulation. We report here a case of severe pancytopenia in enteric fever as a result of bone marrow suppression due to systemic infection.

Postoperative skeletal stability and accuracy of a new combined Le Fort I and horseshoe osteotomy for superior repositioning of the maxilla.

Postoperative skeletal stability and accuracy were evaluated in a combination of Le Fort I and horseshoe osteotomies for superior repositioning of maxilla in bi-maxillary surgeries in 19 consecutive patients. 9 underwent Le Fort I osteotomy alone (preoperative planned superior movement <3.5 mm). 10 underwent Le Fort I and horseshoe osteotomy (combination group) (preoperative planned superior movement >3.5 mm). The maxilla was osteotomized and fixed with 4 titanium Le Fort plates followed by bilateral sagittal split ramus osteotomy of the mandible, fixed with 2 semi-rigid titanium miniplates. Maxillomandibular fixation was performed for 1 week. Lateral cephalograms were obtained preoperatively, 1 week postoperatively, 3, 6, 12 months later. The changes in point A, point of maxillary tuberosity, and upper molar mesial cusp tip were examined. Discrepancy between the planned and measured superior movement of the maxilla in the Le Fort I and combination groups was 0.30 and 0.23 mm, respectively. The maxillae in both groups were repositioned close to their planned positions during surgery. 1 year later, both groups showed skeletal stability with no significant postoperative changes. When high superior repositioning of the maxilla is indicated, horseshoe osteotomy combined with Le Fort I is reliable and useful for accuracy and postoperative stability.

Maxillary reconstruction using a bipedicled osteocutaneous scapula flap.

When managing extensive maxillary defects it is difficult to provide a stable biomechanical frame for prostheses, and obturators are difficult to use. This study reviews cases involving angular branch artery pedicled scapular bone flaps (SBF) combined with or without latissimus dorsi musculocutaneous flap (LDMF). Between 2004 and 2007, four wide maxillary defects were repaired using the angular vascularized branch of the scapular bone. Tumor resection with immediate reconstruction using combined LDMF and angular artery pedicled SBF was used in 3 cases and angular artery pedicled SBF alone in 1 case. Follow up was 6 months to 2 years. Satisfactory results were obtained for facial contour, appearance, speech, deglutition and breathing. No donor site complications or restricted shoulder movements were detected. The only complication was a minor infection of one flap. This procedure is useful, functionally and aesthetically, for reconstruction of wide extensive maxillary defects as bone supplied by the angular branch has a wider arc of rotation in relation to skin flaps and has a longer pedicle length from the axillary artery, long enough to reach the maxilla. This procedure also benefits from the flexibility of the soft tissue pedicle, such as the latissimus dorsi, serratus anterior and fasciocutaneous flaps.

A novel modification of a bone repositioning device and a new technique for reestablishing facial contours after mandibular resection surgery.

A novel modification of a bone repositioning device previously published by the same authors is introduced. A flexible tube to define the intersegmental bony relationship is filled with light-cured resin. It solidifies following exposure to strong visible light for about 1 min. This technique can be used for bone positioning after mandibular resection surgery and during positioning of the proximal segment after sagittal split ramus osteotomy. The authors also propose a simple method for determining the contour of the reconstructed mandible to regain the original shape and form. The advantage of this technique is its simplicity and flexibility compared with other methods of bone positioning during mandibular segmental surgery.

Mandibular reconstruction with bone transport in a patient with osteogenesis imperfecta.

Osteogenesis imperfecta (OI) was originally considered a connective tissue disorder, primarily involving type 1 collagen. It is characterized by numerous skeletal and extraskeletal defects, including bone fragility, multiple fractures, blue sclerae, hearing deficits, skin and ligament laxity, and dentinogenesis imperfecta (DI). The authors describe a 24-year-old Japanese man with OI and DI who had an ossifying fibroma of the mandible. Segmental resection was performed, and the mandible was reconstructed by distraction osteogenesis with the transport segment technique. This is the first report to describe a patient with OI undergoing mandibular reconstruction with bone transport, to the authors' knowledge.

The BMP signaling and its Smads in mandibular distraction osteogenesis.

AIM: The aim of the present study was to clarify the mechanism of signal transduction of bone morphogenetic proteins (BMPs) through their specific down signaling molecules Smads inducing bone formation in response to mechanical stimulus during distraction osteogenesis (DO) in the rat mandible. MATERIALS AND METHODS: Osteotomy of the left mandible was performed in 45 rats. Thirty rats underwent mandibular distraction (protocol; 5 days latency, 8 days distraction, and 2 weeks consolidation) while 15 rats served as non-distracted (fracture healing) group. The expression of BMPs-2,-4 and Smads 1, 5, and 8 were evaluated in the new regenerate area using immunohistochemistry. RESULTS: Expressions of BMPs-2,-4 and Smads 1, 5, and 8 were moderate during latency, significantly increased during distraction and decreased towards consolidation period. CONCLUSIONS: The enhanced expression of BMPs and its Smads during distraction compared to the non-distracted group suggests the possible role of BMP signaling pathway in translation of mechanical forces into biological results during DO.

Effect of phenol on the aggregation characteristics of an ethylene oxide-propylene oxide triblock copolymer P65 in aqueous solution.

The effects of phenol on the micellization, micellar growth, and phase separation of a poly(ethylene oxide)-block-poly(propylene oxide)-block-poly(ethylene oxide) (PEO-PPO-PEO) amphiphilic copolymer (Pluronic P65: EO19 PO30 EO19) in aqueous solution have been studied by cloud point, viscosity, dynamic light scattering (DLS), differential scanning calorimetry (DSC), fluorescence spectroscopy, and small-angle neutron scattering (SANS). Various concentrations of P65 have been chosen to estimate the effect of phenol on different concentration regions of P65. Phenol interacts quite differently at low concentrations (0-2%) than at high concentrations (2-10%) of P65, as per the observation that phenol is more predominant at smaller concentrations of P65. A marked decrease in the cloud points of the P65 solutions is observed in presence of phenol. The critical micelle temperature (CMT) of P65 shows a synergistic effect of phenol on P65 aggregates. Micellar transitions, phase separation, and aggregation behaviours like micellization and micellar growth in the presence of phenol have been observed by combining viscometry, DLS, DSC, and CP. DLS shows that the effect of phenol is predominant at high temperatures. SANS shows a high increase in axial ratio and aggregation numbers in the presence of phenol at fixed concentrations of P65. Fluorescence data illustrate that addition of phenol makes micelles polar but at the same time its favours aggregation. Water-soluble phenol (present in low concentrations) forms aggregates with P65, which can be separated by cloud point extraction, making this study interesting for separation of phenol from the phenol-water system.

Intraoperative surgical clearance confirmation of tongue carcinomas using ultrasound.

OBJECTIVES: The existence of tumour cells on the surgical margin can be shown in frozen sections. However, there has been no method to obtain information about surgical clearance intraoperatively. We propose a simple method to confirm the surgical clearance of tongue carcinomas during surgery. METHODS: Just after the resection of a tumour in a conventional manner, the resected fresh specimen was immersed in a gelatine solution, maintaining its original shape and orientation, and refrigerated for solidification of the gelatine. Then ultrasound observation of the gelatine-embedded specimen was performed from the surface of the gelatine. RESULTS: Very fine images could be obtained easily and without any specialist skills. CONCLUSIONS: With this method, the operator can easily obtain information about surgical clearance during the operation.

Characterization and susceptibility patterns of clinically important Enterococcus species in eastern Nepal.

Life threatening infections caused by enterococcus species with multidrug resistance has emerged as a threat to medical care in the present era. This study was conducted to characterize enterococcus species isolated from different clinical samples and to detect the pattern of susceptibility to some of the commonly used antibiotics in B.P Koirala Institute of Health Sciences (BPKIHS), a tertiary care hospital in eastern Nepal. Clinical samples submitted to the microbiology unit of Central Laboratory Service (CLS) for culture and sensitivity during March 2002 - February 2003 was analyzed. Enterococcus species were identified by colony characteristics, gram staining and relevant biochemical tests. Antibiotic susceptibility test was done by the Kirby Bauer disc diffusion technique. Of 50 Enterococcus species isolated, E. faecalis was the predominant isolate (48.0%) followed by E. faecium (32.0%) and E. avium (20.0%). Eighty-eight percent of E. faecalis showed sensitivity to cephotaxime and 87.0% to vancomycin. Multiple drug resistance was observed most commonly in E. faecium. Seventeen percent of E. faecium were resistant to vancomycin and 63.0% to ciprofloxacin and 44.0% to ampicillin. On the contrary E. avium rarely showed resistance to the antimicrobials tested including vancomycin. Enterococcal infections are common nowadays specially in hospitalized patients. Inappropriate use of antibiotics in clinical practice and poultry should be discouraged to prevent the emergence of multidrug resistant species.

A simple method for bone positioning of mandibular segments.

A simple bone-positioning technique is reported, using a combination of bone plates and a flexible tube filled with acrylic polymer. The flexible tube is solidified by injection of acrylic monomer. This technique is applicable for bone positioning after mandibular resection as well as positioning of the proximal segment after sagittal split ramus osteotomy. This technique has the advantages of greater simplicity and flexibility compared to previously reported methods of bone positioning.

Morphological change of the micelle of poly(styrene)-b-poly(2-vinylpyridine)-b-poly(ethylene oxide) induced by binding of sodium dodecyl sulfate.

Morphological change of a micelle of poly(styrene)-b-poly(2-vinylpyridine)-b-poly(ethylene oxide) (PS-PVP-PEO) polymer was induced by binding sodium dodecyl sulfate (SDS) to the PVP block in acidic aqueous solutions. The change in the size of SDS/PS-PVP-PEO complexes was detected by dynamic light scattering measurements and atomic force microscopy, and the binding of SDS was confirmed by zeta-potential measurements. When the micelle was free from SDS in acidic aqueous solutions, the hydrodynamic diameter of the micelle was 216 nm, reflecting the extended conformation of the PVP block due to the repulsion between protonated pyridine units. As the cationic PVP block was electrically neutralized with anionic SDS, the diameter was gradually reduced concomitant with the decrease in zeta-potential and finally reached 175 nm when the PVP block was completely neutralized. The decrease in the diameter shows the morphological change of the PVP block from extended to shrunken forms. Further addition of SDS did not cause the changes of the diameter nor zeta-potential. This indicates that SDS was not bound to the PS-PVP-PEO polymer after the PVP block was fully neutralized and that the hydrophobic binding of SDS to the polymer was negligible due to the low concentration of SDS.