Management of difficult intubation in a patient with ankylosing spondylitis--a case report

We describe a case of difficult intubation in a patient suffering from ankylosing spondylitis undergoing total hip replacement surgery. The anesthetic management of 42 year old patient with difficult airway is discussed. Failure of epidural anesthesia procedure necessitated general anesthesia. The problems of performing awake fibreoptic intubation and other alternative techniques to secure the airway are described. Cervical spine involvement in ankylosing spondylitis is of great concern for the anesthetist. Longstanding progressive course of this disease leads to fibrosis, ossification and ankylosis of entire spine and sacroiliac joints. Cervical spine mobility is decreased and in severe cases total fixity occurs in a flexed position. Patient may also have atlanto-occipital and temporo-mandibular joint involvement as well. Cricoarytenoid cartilages involvement may result in upper airway compromise. Furthermore cervical spine vertebrae are prone to fractures, especially on hyperextension and may lead to spinal cord transection and quadriplegia. In this case report we describe the airway management of such patient with fixed rigidity of cervical spine and thoracolumbar kyphosis.

Phospholipid diversity: Correlation with membrane–membrane fusion events

The transport of various metabolically important substances along the endocytic and secretory pathways involves budding as well as fusion of vesicles with various intracellular compartments and plasma membrane. The membrane-membrane fusion events between various sub-compartments of the cell are believed to be mainly mediated by so-called "fusion proteins". This study shows that beside the proteins, lipid components of membrane may play an equally important role in fusion and budding processes. Inside out (ISO) as well as right side out (RSO) erythrocyte vesicles were evaluated for their fusogenic potential using conventional membrane fusion assay methods. Both fluorescence dequenching as well as content mixing assays revealed fusogenic potential of the erythrocyte vesicles. Among two types of vesicles, ISO were found to be more fusogenic as compared to the RSO vesicles. Interestingly, ISO retained nearly half of their fusogenic properties after removal of the proteins, suggesting the remarkable role of lipids in the fusion process. In another set of experiments, fusogenic properties of the liposomes (subtilosome), prepared from phospholipids isolated from Bacillus subtilis (a lower microbe) were compared with those of erythrocyte vesicles. We have also demonstrated that various types of vesicles upon interaction with macrophages deliver encapsulated materials to the cytosol of the cells. Membrane-membrane fusion was also followed by the study, in which a protein synthesis inhibitor ricin A (that does not cross plasma membrane), when encapsulated in the erythrocyte vesicles or subtilosomes was demonstrated to gain access to the cytosol.

A ribonuclease protection assay for the direct detection and quantitation of hepatitis C virus RNA

A ribonuclease protection assay (RPA) was developed for the direct detection and quantitation of HCV RNA in infected patients' sera or plasma using HCV [(32)P]RNA from the conserved 5'-untranslated region (5'-UTR) as a probe. We were able to directly detect the presence of HCV RNA by RPA in several infected patients' samples. The viremic status of HCV infected patients with indeterminate recombinant immunoblot assay (RIBA II) was also determined by this assay. Polymerase chain reaction (PCR) was also performed on all these samples and were found to be positive with a concordance of 100% between the results of PCR and RPA. The RPA was able to detect approximately 1 pg of HCV RNA. A limited sequence heterogeneity among HCV isolates was also observed by this assay, suggesting that this may be a faster method of detecting heterogeneous HCV sequences in patients' samples. This simple and specific method could be used to quantitate HCV RNA in order to better determine viremia and follow the course of HCV infection especially when RIBA II results are indeterminate.

Comparison of rigid vs flexible sigmoidoscopy in detection of significant anorectal lesions

OBJECTIVE

Sigmoidoscopy is an essential tool in colorectal clinics in the detection of anorectal lesions including rectosigmoid adenomas and carcinomas. However, rigid sigmoidoscope (RS) is still more widely used than flexible sigmoidoscope (FS) as the primary investigation, despite the fact that the latter is more comfortable to the patient and has greater diagnostic yield. Hence we wanted to compare the two modalities in terms of diagnostic use for picking up significant anorectal lesions.

METHODS

A retrospective review of all patients referred to the colorectal clinic who had undergone both rigid and flexible sigmoidoscopy for investigation of colorectal symptoms in 2001 was done. Findings recorded during rigid and flexible sigmoidoscopy including depth of insertion, site of lesion and complications were analysed.

RESULTS

152 patients underwent both rigid and flexible sigmoidoscopy as part of investigation of colorectal symptoms. Of the 115 (75.6%) declared normal by RS, 39 (33.9%) had significant lesions including 7 polyps and 4 malignant lesions within 20 cm of the anal verge during FS. Of the 31 patients (20.4%) in whom RS was not helpful due to faecal loading, 15 (48.4%) had significant lesions including 4 malignancies and 1 polyp --all within 20 cm of the anal verge during FS. Only 2 polyps and 1 malignant lesion were picked up by both flexible and rigid sigmoidoscopy. There were no complications in both procedures.

CONCLUSION

Since flexible sigmoidoscopy is superior to rigid sigmoidoscopy in terms of patient comfort, diagnostic value and ease of doing procedures like biopsy and polypectomy; it can be used as a front line investigation to exclude colorectal pathology in out patient clinics. The utility of rigid sigmoidoscope is in question and in view of obvious shortcomings, may be replaced by flexible sigmoidoscopy, though obvious resource constraints need to be considered.

Intraocular surgery for optic nerve disorders

This article discusses two current indications for intraocular surgery for optic nerve conditions. The first topic is macular detachment in association with congenital optic disc pit, and includes a review of the theories of pathogenesis and management options including our own experience of treatment with vitrectomy and gas tamponade. In addition, the histopathological findings of a new case of optic disc pit with serous macular detachment are presented, adding to the rare examples previously reported. The second subject is a radial optic neurotomy, a recently advocated treatment for central retinal vein occlusion, which, despite its controversial nature, is gaining in popularity.

Assessment of strontium and calcium levels in Pakistani diet

To cope with nuclear emergency effectively due to ingestion of fission fragment (90)Sr, adequacy of nutritionally and radiologically important elements strontium and calcium was studied in typical Pakistani diet and baseline analytical data were generated. Concentrations of strontium and calcium were measured by using inductively coupled plasma-atomic emission spectroscopy (ICP-AES) and atomic absorption spectrometry (AAS) techniques. Daily dietary intake of strontium and calcium varied from 0.9 to 5.7 mg and 217 to 713 mg with the geometric mean value x geometric standard deviation of 2.6 x 1.7 and 487.1 x 1.4 mg d(-1), respectively. The average Sr concentration in the Pakistani diet was 1.4 times higher while Ca concentration was 0.4 times lower than the recommended values of the International Commission on Radiological Protection (ICRP). The calculated Sr/Ca ratio 5.3E-03 was also higher than the ICRP value. The study depicts that the strontium concentration in the Pakistani diet is adequate, while the calcium concentration is inadequate according to international standards and needs improvement.

An observational study investigating the health provision for children with epilepsy within secondary schools in the East Midlands, UK

BACKGROUND

Epilepsy is a common medical condition affecting many children in mainstream education. The practice of local secondary schools and the health service with regard to pupils with epilepsy was examined. The extent to which these children had activities at schools restricted and the schools' perception of the health service with regard to epilepsy was explored.

METHOD

A structured interview was conducted with selected staff members from mainstream secondary schools in East Midlands region, UK.

RESULTS

Fourteen out of 17 schools participated. Fifty-seven children were identified from a total pupil population of 14 534. Seven schools used the DOH/DfEE (The Department of Health/Department for Education and Employment) 'Supporting Pupils with Medical Needs' publication as a resource. No schools created individual health care plans for children with epilepsy. Six out of seven schools reported appropriate provision for children during swimming activities. The commonest restriction was related to computer use. Nine schools stated a need for more training for staff members with regard to seizure management.

CONCLUSIONS

Schools rely heavily on obtaining medical information from non-medical sources. Individual health care plans for children with epilepsy are not commonly undertaken. Few children had any restriction or special provision placed upon them because of their epilepsy except in the area of computer use. Further action is needed to consider how the system for providing for such children can be improved so that each child's individual health needs can be satisfactorily met.

Do private doctors follow national guidelines for managing pulmonary tuberculosis in Pakistan?

As private medical practitioners play a major role of in providing care to pulmonary tuberculosis [TB] patients, a survey was made of knowledge and practice in 2 cities in Pakistan. Only 1 of the 245 physicians was aware that cough > 3 weeks alone is the main symptom suggesting pulmonary TB. The majority diagnosed [80%] and treated [83%] cases themselves without referral. Less than 1% relied on sputum microscopy alone for diagnosis. None of the practitioners were following National TB Control guidelines for prescribing drugs and none ensured compliance with anti-TB treatment under supervision of a doctor/health worker. Only 3% kept records of pulmonary TB patients. None of the physicians assessed the effectiveness of treatment with sputum microscopy alone; the majority [76%] used only clinical assessment

Do private doctors follow national guidelines for managing pulmonary tuberculosis in Pakistan?

As private medical practitioners play a major role of in providing care to pulmonary tuberculosis (TB) patients, a survey was made of knowledge and practice in 2 cities in Pakistan. Only 1 of the 245 physicians was aware that cough > 3 weeks alone is the main symptom suggesting pulmonary TB. The majority diagnosed (80%) and treated (83%) cases themselves without referral. Less than 1% relied on sputum microscopy alone for diagnosis. None of the practitioners were following National TB Control guidelines for prescribing drugs and none ensured compliance with anti-TB treatment under supervision of a doctor/health worker. Only 3% kept records of pulmonary TB patients. None of the physicians assessed the effectiveness of treatment with sputum microscopy alone; the majority (76%) used only clinical assessment.

Thorium concentration in Pakistani diet

To evaluate radiation doses due to ingestion of thorium activity by members of the public, baseline analytical data on thorium concentration in a typical Pakistani diet was generated. Food samples were collected from major districts/ cities of the country using the market basket method, and typical daily diets were prepared. Thorium concentration was determined by instrumental neutron activation analysis. It was found to vary from 1.6 ng g(-1) to 12 ng g(-1). The median value was 4.6 ng g(-1). This leads to median daily thorium intake of 2.7 microg d(-1). The geometric mean was 2.6 microg d(-1), which was 13% less than the ICRP value. Based on these measurements the average intake of 232Th activity was 10 mBq d(-1), and the average annual and committed effective doses for adults were estimated to be 8.8 x 10(-7) Sv y(-1) and 4.4 x 10(-5) Sv, respectively.

Nutritional and radiological impact of dietary potassium on the Pakistani population

The nutritional status of dietary potassium and the radiological impact of its isotope (40)K were estimated for the Pakistani population. Potassium concentration was determined in dietary samples by atomic absorption spectrometry. An average potassium concentration was 4.54+/-0.89 mg/g, which leads to potassium dietary intake of 2.69+/-0.54 g/day and the radiological hazard due to (40)K activity was 79.94 Bq/day. The annual and lifetime effective doses calculated for the reference Pakistani man weighing 64 kg due to measured activity of (40)K were found to be 1.65 x 10(-4) Sv y(-1) and 8.27 x 10(-3) Sv, respectively. Measured data showed that the potassium concentration in the Pakistani diet is adequate and safe according to international standards.

Sephadex and sephadex ion-exchange filtration improves the quality and freezability of low-grade buffalo semen ejaculates

The effect of sephadex and sephadex ion-exchange filtration on the improvement in quality and freezability of low-grade buffalo semen ejaculates was assessed. Two types of filtration columns were used: one containing only sephadex G-10 (FS) and the other sephadex G-10 along with ion-exchangers (diethyl amino ethane-52 (DEAE-52) cellulose and carboxy methyl-52 (CM-52) cellulose; FS+IE). Unfiltered samples served as controls. Semen ejaculates extended in Tris-citric acid (1:4) (n=16; initial motility 40-50%) were filtered at the rate of 1.5 ml/min under negative pressure at room temperature (28-30 degrees C). The mean recovery rate (%) of motile spermatozoa in the FS (85.9+/-1.51) and FS+IE (77.10+/-2.28) filtrates did not differ significantly. Percentages of sperm motility, normal acrosomes, and intact plasma membranes were highest (P<0.05) in FS+IE, intermediate (P<0.05) in FS and lowest (P<0.05) in controls at the three stages of cryopreservation (postfiltration final dilution, after equilibration, and after freezing). Mean sperm abnormalities were lowest (P<0.05) in the filtrates of FS+IE, moderate (P<0.05) in FS and highest in controls at all stages of freezing. Compared to dilution and equilibration, freezing greatly reduced (P<0.05) the overall percent motility, normal acrosomes and intact plasma membranes. The spermatozoa eluted through FS+IE columns proved more resistant (P<0.05) in bearing dilution, equilibration, freezing and thawing stresses than the spermatozoa from FS and control samples. It is concluded that filtration systems containing an FS+IE column can effectively enhance the quality and freezability of extended, low quality buffalo semen.

Caesium concentration in the Pakistani diet

Daily dietary intakes of radioactive and non-radioactive caesium for the Pakistani population were measured. Food samples were collected on market basket method and were analysed using Instrumental Neutron Activation Analysis technique. The radioactive caesium ((137)Cs) in these samples was below the detectable limit, i.e. 1 mBq g(-1). The geometric mean of the mass fraction of stable caesium was 9.56 x 1.53 ng g(-1). The estimated daily dietary intake of caesium was 5.65 x 1.53 microg d(-1) or 0.088 microg kg(-1) of body weight of the reference Pakistani man weighing 64 kg. These values are 38.2% smaller than the recommended ICRP values for a 70 kg standard man. However, caesium concentration in the Pakistani diet is comparable with other reported values in the literature.