Morphometric analysis and roosting ecology of bat species Pteropus Medius in Mansehra, Khyber Pakhtunkhwa, Pakistan

Morphometric measurement and roosting ecology of Pteropus medius were aimed to find out in Mansehra district of KP, Pakistan. Total 3149 numbers of bats were found in eight biological spots visited; Baffa Doraha, Darband, Dadar, Jallu, Hazara University, Garhi Habibullah Chattar Plain and Jabori, in total 299 numbers of different species of trees including; Morus alba, Pinus raxburghi, Eucalyptus camaldulensis, Morus nigra, Grevillea robusta, Brousonetia papyrifera, Platanus orientalis, Ailanthus altissima, Hevea brasiliensis and Populus nigra. Morphometric features were measured and found vary according to sex of the bats. The average wing span, wing`s length from tip of wing to neck, from thumb to tip of wing and the body`s length from head and claws were recorded to be 102.98 cm, 49.07cm, 28.7 cm and 22.78 cm respectively in males while 93.67 cm, 44.83cm, 24.78cm and 22.78 cm respectively in female bats. Mean circumference of the body including wings and without wing were measured as 22.78 cm and 17.29 cm in males and that of female were 20.07 cm and 16.9 cm. Average length of thumb 3.64 cm, ear`s length 3.1 cm, snout 5.62cm, eye length were 1.07 cm for both sexes and length between the feet in extended position were16.3 cm. Generally different measurement of males bodies were found to be greater than female such as mean body surface area, mass, volume and pressure were found to be 2691.79 cm2, 855.7gm,1236.4 ml and 295.77 dyne/ c m 3 for male and 2576.46 cm2, 852.71gm,1207 ml and 290.2 dyne/ c m 3 respectively for female. While weight and density for both males and females bats were same with mean of 8.59 newton and 0.701 g/m3. Findings of current reports can add valued information in literature about bats, which can be used for species identification and conservation.

Molecular detection and prevalence of Rotavirus with acute gastroenteritis among the children of rural and urban areas

Rotavirus is the main infective agent of acute gastroenteritis (AGE) in children under the age of five years and causing significant morbidity as well as mortality throughout the world. The study was carried out to detect the prevalence rate, genotypes strain and risk factors of Rotavirus among the children of rural and urban areas of district Bannu Khyber Pakhtunkhwa Pakistan. A total of 180 stool samples were collected from children under the age of 5 years from two major hospitals of Bannu from January to December (2015). The samples were analyzed by Reverse-transcriptase Polymerase Chain Reaction (RT-PCR) for the detection of Rotavirus, positive samples were further processed for genotyping (G and P type) through specific PCR. Of the total, 41 (23%) samples were positive for Rotavirus. The most prevalent G genotypes found were: G3, G8, G9 (each 29%), followed by G10 (15%), and G11 (10%). Whereas the prevalent P genotypes were: P-8 (25%), P-4 and P-10 (each 20%), P-9 (15%), followed by P-6 and P-11 (each 10%). Moreover, Rotavirus infection was more prevalent in summer (23.73%) and winter (22.7%) than spring (20%) and autumn (21.4%). Rotavirus infection exhibited high frequency in June (14%), October (8%) and November (6%). It is concluded that Rotavirus is more prevalent in children and various genotypes (G and P) of Rotavirus are present in the study area. Lack of studies, awareness and rarer testing of Rotavirus are the principal reasons of virus prevalence in district Bannu, Pakistan.

Prevalence of intestinal parasitic diseases in school children of rural areas of district Lower Dir, Pakistan

Present study was conducted among school children to recognize the prevalence of IPIs in rural communities of district Dir Lower, Pakistan. A sum of 324 samples of stool were collected (210 boys and 114 girls). Used direct smear method and formol ether sedimentation concentration technique for processing the samples. The result shows that 82% (n=266) were found infected comprised 64.8% male and 35.1% females. Children of the age group 10 to 12 years were found extremely infected 94.2% while 4-6 year age group were having minimum ratio of infection 72%. Current study shows mono parasitism in 50.6% of the students while 22.2% were infected with 2 species and 7.40% were infected with three species of parasites. Seven species of intestinal parasites were reported include Ascaris lumbricoid in male (n=122) 58.0% and in female (n=65) 57.0% followed by Hook worm (n=88) 41.9% and (n=44) 38.5%; Tania saginata (n=44) 20.9% and (n=24) 21.0%; Entrobius vermicularis (n=32) 15.2% and (n=16) 14.0%; Trichuris trichura (n=25) 11.9% and (n=22) 19.2%; Hymenolepis nana (n=24) 11.4% and (n=18) 15.7% and Entameoba histolytica (n=16) 7.61% and (n=14) 12.2% in male and females respectively. The study indicates that most occurring intestinal parasite in the current study were Ascaris lumbricoides 58.0% (n=122) followed by hookworms 41.9% (n=88). Male students were more infected than females in the present study.

Aerosols, airflow, and airspace contamination during laparoscopy

Laparoscopic surgery has been undermined throughout the COVID-19 pandemic by concerns that it may generate an infectious risk to the operating team through aerosolization of peritoneal particles. There is anyway a need for increased awareness and understanding of the occupational hazard for surgical teams regarding unfiltered escape of pollutants generated by surgical smoke and other microbials. Here, the aerosol-generating nature of this access modality was confirmed through repeatable real-time methodology both qualitatively and quantitively to inform best practice and additional engineering solutions to optimize the operating room environment.

Habitat selection by Asiatic black bear (Ursus thibetanus) in Siran and Kaghan Valleys, Pakistan

Asiatic black bear is present in variety of habitats like broad-leaves and coniferous forests, extending form sea level to 4300m elevation and change their habitat for food purpose seasonally. The present study was conducted at Kaghan and Siran Valleys, District Mansehra, Khyber Pakhtunkhwa, Pakistan to assess habitat of black bear. Line transect method was used for observation of bear signs. Twelve meter circular radius plots were selected for the concern vegetation's i.e. (trees, shrubs and herbs) and three to six plots were placed in each transect. At the result of sign survey, thirteen different categories of bear signs were recorded and encounter rate was calculated for each sign. A total of 1858 signs were observed during field surveys. Total (81%) coniferous species were recoded among trees, with the highest appearance of Pinus wallichiana (34.22%) and Spruce spp (27.76%), similarly broad leaves trees (18.56%) were also recoded from habitat plots. Most of the signs were encountered in bushy areas, whereas high number of Viburnum Spp (60.29%) was present. It is indicated that black bear prefers blend of Coniferous Trees, Viburnum and Ferns Species; probably because these plants provide enough food, protection, and meticulous shelter because more than 80% of habitat composed of these three species. Currently habitat destruction and increase in human population are the up-growing issues for wild animals (especially Asiatic black bear), which is highly sensitive to such problems. High levels of conservation efforts are recommended for the protection of black bear habitat and to avoid human interference in their territory.

Population distribution and habitat analysis of Rufous treepie (Dendrocitta vagabunda) in Abbottabad, Pakistan

The Rufous treepie (Dendrocitta vagabunda) belongs to family corvidae, order Passeriformes which includes about 100 species. The current study was conducted to gather information about the Population distribution and habitat analysis of D. vagabunda at District Abbottabad, Pakistan. The data were collected on monthly basis both morning and evening times (2018-2019). "The ''Point count Method" was used for population estimation and ''Quadrates Method" for habitat analysis of study area. The result shows an average month-wise population density of D. vagabunda was maximum at Jhangra 0.14±0.039/ha, whereas minimum at Havelian 0.11±0.022/ha. There was no significant difference (p>0.05) among monthly population densities of D. vagabunda, however, a significant difference (p<0.05) was found between morning and evening times population of the specie. The present study revealed that importance value index (IVI) of plants species at Sherwan, Bakot, Havelian, Langra and Jhangra were 59.6±12.6, 50.1±6.9, 53.4±6.3, 66.8±10 and 60.1±7.7. Likewise, the frequency of shrubs at Sherwan, Bakot, Havelian, Langra and Jhangra were 33.3±4.2, 45±9.4, 46.7±8.2, 55.6±22.2 and 37.5±8.5. Similarly, the frequency of herbs at Sherwan, Bakot, Havelian, Langra and Jhangra were 40.4±6.0, 37.5±5.6, 53.3±7.4, 48.5±5.2 and 46.9±7.4 respectively. Our results show the study area as suitable habitat for D. vagabunda.

Use of powered air-purifying respirators during surgical interventions

This clinical study confirms user acceptability of PAPR during surgery both at operating room team level as well as by groups of surgeons, anaesthesiologists and nursing level. While some care is needed in the use of this equipment, surgery can be performed safely with satisfactory user experience.

Therefore PAPR is useable for surgery but scope exists for improvement.

635 Can Virtual Clinics Streamline Urology Referrals from Primary to Secondary Care?

Introduction

The COVID-19 pandemic caused the UK to enter lockdown from 23^rd March to 8^th May 2020, necessitating Urology clinics to be conducted virtually. Our study aimed to assess whether new Urology referrals could be triaged and have an outcome arranged virtually before being seen by a specialist in clinic, thereby reducing referral to investigation wait-times.

Method

Retrospective data was collected from 23^rd March to 8^th May 2020 of new patient referrals consulted virtually in Urology outpatient clinics. Referrals were grouped into categories of presentation and outcome.

Results

642 new patients were consulted virtually during the study period. 181 (28.1%) had further imaging requested; of these, the presentations with the greatest proportion of patients with this outcome were those referred with imaging findings (50%), UTI/cystitis (43.1%) and scrotal symptoms (34.3%). 116 patients (18.1%) were added to the waiting list for procedures; 85 were for flexible cystoscopy, for which the commonest indications were UTI/cystitis (36; 55.4%) and haematuria (15; 55.5%).

Conclusions

Certain urological presentations can be triaged straight to investigation by when directly referred from Primary Care, thus reducing referral to investigation wait-time and increasing outpatient protocol efficiency.

Canaries in the mine

Gas leaks occur frequently at laparoscopy and create jet-streams equivalent in velocity to human speaking. Focus on surgical smoke underestimates the issue and means any such guidance is incomplete.

Airflow during clinical examinations with and without protective face masks

Close contact between the patient and physician markedly affects local airflow and their spared airspace, and this can be moderated by mask wearing. Understanding this is particularly relevant in the COVID-19 pandemic and for those new to clinical practice, in particular medical students.

Artificial intelligence indocyanine green (ICG) perfusion for colorectal cancer intra-operative tissue classification

A new concept in intraoperative decision support for tumour delineation is proposed showing that artificial intelligence provides categorising information and interpretation from the images captured during fluorescence-guided colorectal cancer operations. This is potentially applicable to all cancer subtypes and is pertinent to new fluorophore development.A new concept in intraoperative decision support for tumour delineation is proposed showing that artificial intelligence provides categorising information and interpretation from the images captured during fluorescence-guided colorectal cancer operations. This is potentially applicable to all cancer subtypes and is pertinent to new fluorophore development. A new concept in intraoperative decision support for tumour delineation is proposed showing that artificial intelligence provides categorising information and interpretation from the images captured during fluorescence-guided colorectal cancer operations. This is potentially applicable to all cancer subtypes and is pertinent to new fluorophore development.

Shows promise

Combined use of a videolaryngoscope and a flexible bronchoscope for awake tracheal intubation when front-of-neck airway is not an option

We report a case of successful tracheal intubation with the combined use of a videolaryngoscope and flexible bronchoscope in a patient with difficult airway when both techniques had individually failed. A 35-year-old man presented with airway obstruction due to massive neck swelling causing hypoxia, stridor and respiratory distress. He had a history of oral cancer which had been resected with bilateral neck dissection and free flap reconstruction 2 months previously. Due to extensive anterior neck swelling, we judged that front-of-neck airway would not be a suitable approach. After unsuccessful attempts at awake tracheal intubation with videolaryngoscopy and flexible bronchoscopy separately, we combined both techniques with a successful outcome. By using a combined technique to address the specific problems presented by this case, a life-threatening emergency was resolved. This case highlights why it is useful for anaesthetists to be familiar with multiple techniques to awake tracheal intubation, both individually and in combination.

Green recipes to quinoline: A review

The quinoline core possesses a vast number of biological activities such as anticancer, antimalarial, antimicrobial, antifungal, antitubercular and antileishmanial. The conventional classical synthetic methods require the use of expensive and harsh conditions such as high temperature. Currently the scientific communities are searching new methodology to eliminate the use of chemicals, solvents and catalysts, which are hazardous to human health as well as to environment. This review provides a concise overview of new dimensions of green chemistry approaches in designing quinoline scaffold that would encourage the researchers towards green chemistry as well as future application of these greener, non-toxic, environment friendly methods in designing quinoline scaffold.

Response of Proliferative Lupus Nephritis with Pulse Cyclophosphamide Therapy during Induction Period: A Single Centre Study in Bangladesh

This prospective study was conducted to assess the response of proliferative lupus nephritis with pulse cyclophosphamide therapy during induction period in the department of Nephrology of Dhaka Medical College, Dhaka, Bangladesh from December 2012 to November 2013. A total of 35 clinically diagnosed SLE patients of class III/IV lupus nephritis were included. But 3 patients were dropped out during follow-up, therefore finally 32 patients (class III = 4, class IV = 28) were studied. The patients were evaluated for response on the basis of proteinuria, serum creatinine & active sediment in urine after 6th cycle of cyclophosphamide and 62.5% patients achieved complete response, 25% patients achieved partial response & 12.5% patients achieved no response. The factors favored complete response was early clinical presentation (7 months duration), proteinuria ≤3gm/day& normal renal function during their initial presentation. And higher anti ds DNA titre was an independent predictor for partial response/no response.

Mercury in dental amalgam: Are our health care workers at risk?

Dental amalgam in fillings exposes workers to mercury. The exposure to mercury was investigated among 1871 dental health care workers. The aim of the study was to evaluate the risk of mercury exposure among dental compared to nondental health care workers and to determine other risk factors for mercury exposure. Respondents answered questionnaires to obtain demographic, personal, professional, and workplace information and were examined for their own amalgam fillings. Chronic mercury exposure was assessed through urinary mercury levels. In total, 1409 dental and 462 nondental health care workers participated in the study. Median urine mercury levels for dental and nondental health care workers were 2.75 μg/L (interquartile range [IQR] = 3.0175) and 2.66 μg/L (IQR = 3.04) respectively. For mercury exposure, there were no significant risk factor found among the workers involved within the dental care. The Mann-Whitney test showed that urine mercury levels were significantly different between respondents who eat seafood more than 5 times per week compared to those who eat it less frequently or not at all (p = 0.003). The urinary mercury levels indicated significant difference between dental workers in their practice using squeeze cloths (Mann-Whitney test, p = 0.03). Multiple logistic regression showed that only the usage of cosmetic products that might contain mercury was found to be significantly associated with the urinary mercury levels (odds ratio [OR] = 15.237; CI: 3.612-64.276). Therefore, mean urinary mercury levels of health care workers were low. Exposure to dental amalgam is not associated with high mercury exposure. However, usage of cosmetic products containing mercury and high seafood consumption may lead to the increase of exposure to mercury.

IMPLICATIONS

Exposure to the high levels of mercury from dental amalgam can lead to serious health effects among the dental health care workers. Nationwide chronic mercury exposure among dental personnel was assessed through urinary mercury levels. Findings suggest low urinary mercury levels of these health care workers. Exposure to dental amalgam is not associated with high mercury exposure. However, the usage of cosmetic products containing mercury and high seafood consumption may lead to the increase of exposure to mercury.

Parotid gland metastasis - an unusual presentation of adenocarcinoma of lung

Lung cancer is the most frequent malignant disease and the most common cause of cancer death in the world. Primary carcinoma of the lung was an uncommon cancer until the 1930s. Common cell types in bronchial carcinoma are squamous 35%, Adenocarcinoma 30%, Small-cell 20%, Large-cell 15%. We present a case of a bronchial neoplasm metastasis to the parotid gland. A 50 years old male patient presented with a 7×5cm painless parotid mass that was metastatic adenocarcinoma on histopathology. Then we thoroughly examined the patient and he was investigated accordingly. There was an abnormal shadow in the lung on chest x-ray, CT revealed a lung tumour on left side. Metastasis to the parotid gland from any distant primary site is quite unusual. We are going to present this case in the journal because of its rarity. Parotid gland metastasis from the lung is rare & if a careful examination is not performed primary focus may be overlooked, negatively affecting the lifetime survival rate & the prognosis of the patient.

Photocurrent response of MoS₂ field-effect transistor by deep ultraviolet light in atmospheric and N₂ gas environments

Molybdenum disulfide (MoS2), which is one of the representative transition metal dichalcogenides, can be made as an atomically thin layer while preserving its semiconducting characteristics. We fabricated single-, bi-, and multilayer MoS2 field-effect transistor (FET) by the mechanical exfoliation method and studied the effect of deep ultraviolet (DUV) light illumination. The thickness of the MoS2 layers was determined using an optical microscope and further confirmed by Raman spectroscopy and atomic force microscopy. The MoS2 FETs with different number of layers were assessed for DUV-sensitive performances in various environments. The photocurrent response to DUV light becomes larger with increasing numbers of MoS2 layers and is significantly enhanced in N2 gas environment compared with that in atmospheric environment.

Assessing glomerular filtration rate in healthy adult potential kidney donors in Bangladesh: a comparison of various prediction equations with measured glomerular filtration rate by diethylentriamine pentaacetic acid renogram

To ensure that potential kidney donors in Bangladesh have no renal impairment, it is extremely important to have accurate methods for evaluating the glomerular filtration rate (GFR). We evaluated the performance of serum creatinine based GFR in healthy adult potential kidney donors in Bangladesh to compare GFR determined by DTPA with that determined by various prediction equations. In this study GFR in 61 healthy adult potential kidney donors were measured with 99mTc-diethylenetriamine penta-acetic acid (DTPA) renogram. We also estimated GFR using a four variable equation modification of diet in renal disease (MDRD), Cockcroft-Gault creatinine clearance (CGCrCl), Cockcroft-Gault glomerular filtration rate (CG-GFR). The mean age of study population was 34.31 +/- 9.46 years and out of them 65.6% was male. In this study mean mGFR was 85.4 +/- 14.8. Correlation of estimated GFR calculated by CG-CrCl, CG-GFR and MDRD were done with measured GFR DTPA using quartile. Kappa values were also estimated which was found to be 0.104 for (p = 0.151), 0.336 for (p = 0.001) and 0.125 for (p = 0.091) respectively. This indicates there is no association between estimated GFR calculated by CG-CrCl, CG-GFR, MDRD with measured GFR DTPA. These results show poor performance of these equations in evaluation of renal function among healthy population and also raise question regarding validity of these equations for assessment of renal function in chronic kidney disease in our population.

Diagnostic accuracy of CT readings on coin lesions in the lung as compared with transthoracic CT-guided needle biopsy results

BACKGROUND

The aim of this study was to compare chest CT film reading results with histopathological results after CT-guided transthoracic needle biopsy of the lung. In addition, lung lesion morphology was evaluated and compared with the nature of the lesions.

PATIENTS AND METHODS

Pulmonary lesions of 133 patients who underwent chest CT were retrospectively grouped into benign, malignant or uncertain. All patients underwent CT-guided transthoracic biopsy. Results of CT diagnosis and histopathological evaluation were compared. In addition, CT features such as size, borders, shape and presence of necrosis were assessed and compared with histopathological results.

RESULTS

In 129 patients adequate specimens were obtained. Comparison of CT diagnosis with the histopathological results yielded the following results for chest CT: sensitivity 95%, specificity 43%, positive predictive value 83%, and negative predictive value 75%. Lesions with spiculated margins turned out to be associated with a significantly higher number of malignant lesions than lesions with smooth or blurred margins (p < 0.05). Lesions size, lesion shape as well as the presence of necrosis showed no significant relation to nature of the lesions (p > 0.05).

CONCLUSION

Radiological assessment of pulmonary lesions alone is not sufficient. the specificity of chest CT is not sufficient to make a definitive diagnosis, i. e., histological verification is still needed for further investigation in a large number of cases. Only lesions with spiculated margins showed a significantly higher number of malignant degenerations in histological evaluation.

Formulation and evaluation of controlled release matrices of ketoprofen and influence of different co-excipients on the release mechanism

The present work reports the study of different controlled release formulations of ketoprofen, which is a non-steroidal anti-inflammatory drug (NSAID) and like other NSAIDs requires large and frequent daily doses, resulting in severe side effects and non-compliance. To avoid these problems, controlled release matrices were developed using different grades of ethylcellulose polymer with a drug-polymer ratio of 10:3 by the direct compression method. The effect on drug release of partial replacement of lactose by different co-excipients, HPMC K100 M, starch and CMC, was also studied. The tablets were tested for their drug content, weight variation, friability, hardness, thickness and diameter, all these physical properties being within the USP range. The release profile of all formulations containing polymer and co-excipients was compared with a formulation developed without polymer and co-excipients. After a 24-hour release study, it was concluded that formulations containing different grades of ethylcellulose polymer showed prolonged release for 6-18 hours, but the formulation containing the polymer Ethocel standard FP 7 Premium without co-excipient showed controlled release for 24 hours. DSC and FT-IR studies were performed to investigate any incompatibility between drug, polymer and co-excipient but no interaction was found. Different kinetic models were used, such as first order equation, zero order equation, Higuachi equation, Hixon Crowel's equation and Korsmeyer-Peppas to study the release mechanism. The formulations containing co-excipients showed an enhanced release rate.

Bioequivalence study of two oral formulations of clarithromycin in human male subjects

To assess the bioequivalence of tablets formulations of Clarithromycin 500 mg each of test and reference products. A single post oral dose of each formulation was given to 14 male healthy volunteers. The study was conducted phase 1, open-label, randomized, complete two-way crossover designed with 7 days wash out period. The plasma concentration of Clarithromycin was quantified by validated microbiological assay method. The precision of the method was evaluated using calibrated 14-hydroxyClarithromycin concentration was detected semi quantitatively as equivalent of Clarithromycin/ml. The peak plasma concentrations of (3.63±0.80 ug/ml) and (3.31±0.35 ug/ml) was attained in about 1.42 hours and 1.49 hours for both test and reference Clarithromycin tablets respectively. The mean±SD values for total area under the curve (AUC) were 22.07±4.90 and 20.16±2.35 h.mg/L for both test and reference tablets respectively. This study indicated that the differences in all the bioequivalence parameters for test and reference Clarithromycin formulations are statistically non-significant; hence both formulations are considered bioequivalent.

Surgery for oesophageal cancer at Galway University Hospital 1993-2008

BACKGROUND

Surgical volume and outcome remain controversial in the management of oesophageal cancer.

AIMS

To assess the outcome of oesophagectomy for cancer at Galway University Hospital (GUH).

METHODS

Between 1994 and 2008, patients who underwent oesophagectomy were analysed.

RESULTS

During the study period, 126 oesophagectomies were performed for cancer. The average surgeon volume was 9 cases per year. The 30-day and overall in-hospital mortality rates were 6.3 and 7.9%, respectively. Restructuring of our critical care services has led to a reduction in 30-day mortality from 8.2 to 5.1%. The use of neoadjuvant chemoradiotherapy has increased from 17 to 35% during the study period. In patients who underwent resection, the 3 and 5-year overall survival rates were 45 and 29%, respectively.

CONCLUSIONS

Operative morbidity and mortality at GUH are comparable with worldwide outcomes. Improved resources and national restructuring of cancer services have significantly improved the quality of care and outcomes of patients.

Development and Validation of a RP-HPLC Method for Determination of Cyclosporine in Capsule

A simple, specific and accurate reverse phase high performance liquid chromatographic method was developed for the determination of cyclosporine in capsule dosage form. XTerra C18 column was used as stationary phase with mobile phase acetonitrile in combination with 0.1% trifluoro acetic acid buffer and pH is adjusted to 1.4. Method was developed in an isocratic run of 20% trifluoro acetic acid with 80% acetonitrile for 10 min, at flow rate of 1 ml/min. Effluents were monitored at 210 nm. Retention time of cyclosporine was 3.855 min. The method was validated for specificity, linearity, accuracy, precision, limit of quantification, limit of detection, robustness and solution stability. Limit of quantification and limit of detection of cyclosporine was found to be 100 ng/ml and 200 ng/ml. Recovery was found to be in the range of 98.08-101.55%. The proposed method was successfully applied for the quantitative determination of cyclosporine in a capsule dosage form.

Postoperative analgesia following caesarean deliveries in a rural health district of South Africa

The under-treatment of postoperative pain is prevalent worldwide. This cross-sectional study examined general practitioners' (GPs) knowledge and practices regarding postoperative analgesia in Caesarean deliveries. Postoperative analgesia was said to ensure that patients were pain-free (38.7%), achieved early mobilization (19.4%) and enabled early breast feeding (16%). Pethidine was the opioid of choice; normally prescribed eight hourly (69%) and was combined with non-steroidal anti-inflammatory drugs (NSAID) by 48.6% of doctors and used solely by 51.6%. The prescription of analgesics was mainly influenced by drug availability (45.2%) and potency (19.4%). Most doctors (93.5%) had never attended a pain management course or used pain scores. Doctors at level 1 hospitals were less likely to use pethidine in combination with NSAID (odds ratio: 0.11; confidence interval: 0.02-0.59) compared to those in the specialized hospital. The GPs recognized the importance of postoperative analgesia, but their practices made patients vulnerable to pain after caesarean section.

Isolated pancreatic metastases from a bronchogenic small cell carcinoma

We describe the case of a 60 year old female smoker who presented with a three month history of weight loss (14 Kg), generalized abdominal discomfort and malaise. Chest radiography demonstrated a mass projected inferior to the hilum of the right lung. Computed Tomography of thorax confirmed a lobulated lesion in the right infrahilar region and subsequent staging abdominal CT demonstrated a low density lesion in the neck of the pancreas. Percutaneous Ultrasound guided pancreatic biopsy was performed, histology of which demonstrated pancreatic tissue containing a highly necrotic small cell undifferentiated carcinoma consistent with metastatic small cell carcinoma of the bronchus.

[Comparison of analog and digital fluoroscopy devices regarding patient radiation exposure in enteroclysis]

PURPOSE

With the development and refinement of digital imaging, conventional fluoroscopic units are increasingly being replaced by state-of-the-art digital units for the practice of gastrointestinal imaging. The purpose of this study was to compare digital and conventional methods of gastrointestinal imaging by enteroclysis based on radiation exposure to the patient and fluoroscopy time.

MATERIALS AND METHODS

The medical records of 241 patients who underwent enteroclysis by the conventional technique in 1990 and 309 patients who underwent enteroclysis by digital technique between 2000 and 2004 were reviewed. The radiation exposure of the patient and the fluoroscopy time were evaluated.

RESULTS

The mean radiation exposure was significantly lower (p < or = 0.05) for patients examined by the digital technique (4945.07 cGy x cm (2)) than for patients examined by the conventional technique (7513.6 cGy x cm (2)). The fluoroscopy time was significantly lower with the conventional technique (mean fluoroscopy time 9 min 43 sec) than with the digital technique (17 min 10 sec).

CONCLUSION

We conclude that radiation exposure does not correlate directly with fluoroscopy time. Technical refinements of the digital technique such as Last Image Hold frames, which allow images to be stored with no increase in radiation dose and help to reduce digital fluorography exposures and pulsed fluoroscopy, result in significant dose reduction.

Survival and progression in high grade tumour subset of G2 and G3 pT1 bladder transitional cell carcinoma

AIMS

The newer 1998 WHO/ISUP grading system for bladder transitional cell carcinoma combined grade 3 (G3) and high grade tumour subset of grade 2 (G2) of the older 1973 WHO grading system into one homogenous high grade group. We evaluated for possible differences in survival and progression between these 2 grades in pT1 bladder tumours.

METHODS

From Jan 1(st) 1991-Dec 31(st) 2003, 105 (61 G2 and 44 G3) pT1 bladder tumours fulfilled the 1998 WHO/ISUP high grade criteria. Survival and progression of these tumours were assessed.

RESULTS

Of the 44 patients with G3 tumours, 20 are alive versus 22 of the 61 patients with high grade tumour subset of G2 (P=0.04). Of the 44 patients with G3 tumours, 13 progressed versus 12 of the 61 patients with high grade tumour subset of G2 (P=0.02). In multivariate analysis, G3 was a significant predictor of tumour progression (P=0.05) and marginally non-significant predictor of poor patient survival (P=0.056).

CONCLUSIONS

A notable difference in survival and progression between high grade tumour subset of G2 and G3 is observed.

Laserinduzierte interstitielle Thermotherapie (LITT) von Lebermetastasen unterschiedlicher Größe im Kleintiermodell

PURPOSE

To assess the effect of laser-induced thermotherapy (LITT) on liver metastases of various size from colon carcinoma in an animal model.

MATERIALS AND METHODS

Liver metastases were implanted in 20 Wistar Albino Glaxo (WAG) rats by subcapsular injection of cells from a colorectal strain (CC531) (day 0). The animals were divided into two groups with regard to the measured tumor size of 0.05 - 0.06 cm (3) (group A) and 0.10 - 0.12 cm (3) (group B). On day 14 after laparotomy, the tumors were exposed to 1064 nm Nd:YAG laser light at 2 watts for 5 minutes after intratumoral placement of the laser applicator set. The tumor volumes before (V1, at day 13) and after treatment (V2, at day 28) were determined by MRI and the mean tumor growth ratio (V2/V1) was calculated.

RESULTS

The mean tumor volumes V1 and V2 were 0.05 +/- 0.003 cm (3) and 0.23 +/- 0.016 cm (3) in group A, and 0.11 +/- 0.006 cm (3) and 0.68 +/- 0.037 cm (3) in group B. The mean tumor growth ratio (V2/V1) was 4.31 +/- 0.19 in group A and 6.11 +/- 0.14 in group B. The mean volume of the induced necrosis (0.15 +/- 0.01 cm (3)) was the same for both groups ( p > 0.05). Compared to group B, liver metastases of group A showed a significant slower tumor growth velocity (paired t-test, p < 0.0001).

CONCLUSION

The interventional treatment of large hepatic tumors with LITT leads to faster tumor growth compared to smaller lesions.

Transarterial chemoembolization alone and in combination with other therapies: a comparative study in an animal HCC model

The purpose of this study is to compare transarterial chemoembolization (TACE) alone and in combination with other therapies in an animal model. Subcapsular implantation of a solid Morris hepatoma 3924A in the liver was carried out in 50 male ACI rats (day 0). Tumor volume (V1) was measured by MRI (day 13). After laparotomy and retrograde placement of a catheter into the gastroduodenal artery (day 14), the following protocols of the interventional procedure were applied: TACE (mitomycin C + lipiodol) + immunotherapy (group A: TNFalpha + IL-2, group B: OK-432 + IL-2); TACE + antiangiogenesis therapy (group C: TNP-470, group D: endostatin); TACE alone in group E (control group). Tumor volume (V2) was assessed by MRI and the mean ratio of x (V2/V1) was calculated. Data were analyzed using Dunnett's t test (comparing therapeutic groups with the control group) and the Student-Newman-Keuls test (comparing significant therapeutic groups). Multivariate analysis showed a significant reduction in the tumor growth rate (P<0.05) in groups B (x=6.53) and C (x=4.01) compared to the mean ratio of the control group E (x=9.14). Significant results were observed in group C (P<0.05) in comparison with the other therapeutic groups. TACE combined with immunotherapy (OK-432) and antiangiogenesis therapy (TNP-470) retards tumor growth compared with TACE alone in an HCC animal model.

Totally endoscopic coronary artery bypass graft: initial experience with an additional instrument arm and an advanced camera system

BACKGROUND

Robotically enhanced telemanipulation for totally endoscopic coronary artery bypass does not provide adequate tactile feedback, traction, or countertraction. The exposition of coronary target sites is difficult, the visual field is limited, and the epicardial stabilization may be troublesome. A fourth robotic arm for endothoracic instrumentation has been added to the da Vinci surgical system to facilitate totally endoscopic operations. The stereoendoscope was upgraded with a wide-angle feature.

METHODS

The procedure was performed in five patients. Four of these patients had left internal thoracic artery (LITA) to left anterior descending artery (LAD) grafting on the beating heart and the fifth had sequential bypass grafting (LITA to diagonal branch and LAD) on an arrested heart. The additional effector arm of the da Vinci surgical system was brought into the operative field beneath the operating table and used as a second right arm. The wide-angle view was activated by either the console or the patient side surgeon.

RESULTS

The mean operative, port placement, and anastomotic times for a beating-heart totally endoscopic coronary artery bypass were 195 +/- 58, 25 +/- 10, and 18 +/- 5 min, respectively. All procedures were free of morbidity and mortality, with satisfactory angiographic control. The sequential arterial bypass grafting procedure was fully completed in totally endoscopic technique.

CONCLUSIONS

The additional instrumentation arm and wide-angle visualization are useful technical improvements of the da Vinci surgical system, solving the problem of traction, countertraction, and facilitated exposition of target sites as well as visualization of the surgical field. They provide potential for wider acceptance of totally endoscopic coronary artery bypass grafting in a larger surgical community.

First report on sequential totally endoscopic thymomectomy and adrenalectomy using computer-enhanced telemanipulation

BACKGROUND

Laparoscopic adrenalectomy is considered the standard method for removal of benign adrenal tumors, regardless of hormone activity. Minimally invasive surgery for thymomectomy aims at limited approaches, avoiding complete sternotomy or large thoracotomy.

METHODS

We report on a case in which totally endoscopic thymomectomy and adrenal gland resection were performed sequentially using a computer-enhanced telemanipulation system within 3 weeks.

RESULTS

Operating time was 4.5 h for totally endoscopic adrenalectomy and 1.5 h for totally endoscopic thymomectomy. The patient was transferred to the normal ward on the day of operation after either procedure and had an uneventful recovery. Pathology yielded no malignancy in both cases.

CONCLUSION

This report demonstrates the safety and feasibility of various totally endoscopic procedures performed sequentially.

Operative techniques in awake coronary artery bypass grafting

BACKGROUND

Off-pump coronary artery bypass grafting was implemented to reduce trauma of surgical coronary revascularization by avoiding extracorporeal circulation. High thoracic epidural anesthesia further reduces intraoperative stress and postoperative pain. In addition, this technique even allows awake coronary artery bypass grafting, avoiding the drawbacks of mechanical ventilation and general anesthesia in high-risk patients.

METHODS

Thirty-four patients underwent awake coronary artery bypass grafting with left internal thoracic artery to left anterior descending coronary artery by partial lower ministernotomy (n = 20), H-graft technique (n = 2), or rib cage-lifting technique (n = 2). In 9 cases we performed double bypass grafting, and in 1 case we performed triple-vessel coronary artery revascularization through complete median sternotomy. In addition to clinical outcomes, visual analog scale pain scores were recorded on days 1, 2, and 3 after surgery.

RESULTS

Thirty-one patients remained awake throughout the whole procedure. Three patients required secondary intubation because of incomplete analgesia (n = 1) or pneumothorax (n = 2). Procedure time was 90 +/- 31 minutes, and recovery room stay was 4.2 +/- 0.6 hours. There were no in-hospital deaths or serious postoperative complications. In 1 case a graft occlusion was documented on predischarge angiography. Early postoperative pain was low (visual analog scale score of 30 +/- 6).

CONCLUSION

These data demonstrate the feasibility and safety of various surgical coronary revascularization techniques without general anesthesia. Continuation of thoracic epidural analgesia provides good pain control and fast mobilization postoperatively. Surprisingly, the awake coronary artery bypass grafting procedure was well accepted by the patients.

Computer-enhanced telemanipulation enables a variety of totally endoscopic cardiac procedures

BACKGROUND

Since its introduction in the field of cardiac surgery in 1997, computer-enhanced telemanipulation has been used in a number of different specialized areas. In cardiac surgery, various procedures have been successfully completed in totally endoscopic fashion ever since. Between June 1999 and January 2002, 75 closed-chest cardiac procedures have been performed at our institution using the da Vinci telemanipulation system.

PATIENTS AND METHODS

In 42 patients, a single-vessel totally endoscopic coronary artery bypass was performed on the arrested heart (left internal thoracic artery (LITA) to left anterior descending artery (LAD), n = 36; right internal thoracic artery (RITA) to right coronary artery (RCA), n = 6). 12 patients had different types of multivessel revascularization using both internal thoracic arteries. 8 patients underwent LITA-to-LAD grafting on the beating heart. 10 patients underwent closure of an atrial septal defect (9 direct, 1 patch). 3 patients received an epicardial left ventricular pacemaker lead, 2 of which were reoperations.

RESULTS

Overall conversion rate to any kind of incision was 25 %. The last 26 LITA to LAD patients on the arrested heart had a conversion rate of 4 %. There were no mortalities, 3 patients required reexploration via a median sternotomy, and one patient suffered a hypoxemic brain damage. The first 22 TECAB patients demonstrated excellent graft patency in angiographic control upon discharge. None of the atrial septal defect (ASD) closures showed any residual shunt on the intraoperative transesophageal echocardiogram (TEE). Patients with end-stage heart failure had successful biventricular stimulation.

CONCLUSION

Our current experience confirms the feasibility of various totally endoscopic cardiac procedures with good clinical outcomes. After a steep learning curve, the conversion rate could be lowered to an acceptable figure. Some of these procedures at our institution became a reasonable treatment alternative in selected patients.

[Total arterial bypass operations with complete sternotomy in the awake patient]

BACKGROUND

In minimally invasive coronary artery bypass surgery beating heart procedures and operations via limited incisions became more popular and are routinely performed in many centers. An additional approach to minimize general trauma is avoidance of general anesthesia endotracheal intubation.

PATIENTS AND METHODS

Between March and June 2001, 14 spontaneously breathing patients underwent coronary artery bypass grafting on the beating heart without general anesthesia. Intra- and postoperative analgesia management was performed using continuous epidural infusion of local anesthetics at level Th2-Th3. Single (n = 8) as well as double (n = 5) and triple (n = 1) bypass grafting was performed with the off pump technique. Surgical access to the chest cavity was created via partial (n = 8) or complete sternotomy (n = 6).

RESULTS

Twelve patients remained awake throughout the procedure; 2 patients required secondary intubation due to incomplete sensory block and pneumothorax. Operating time was 94 +/- 18 minutes. Intermediate care monitoring time amounted to 4.8 +/- 0.6 hours. No surgery-related complications or myocardial infarction occurred. Postoperative angiography reviewed good graft function in all patients.

CONCLUSION

Our preliminary experience shows that complete surgical revascularization is safe and feasible without endotracheal intubation and general anesthesia. Thus, invasiveness in cardiac surgery is further reduced with less need for intensive care unit monitoring enabling faster mobilization and recovery.

Amyloidosis

Amyloidosis is not a single disease but a series of diseases in which there is extracellular deposition of a protein which, although it may be derived from different and unrelated sources, folds into a beta pleated sheet. There have recently been significant advances in elucidating the pathogenesis and in the treatment of this group of disorders. By identifying the source of precursor protein, treatment is aimed at eliminating or reducing the extent of deposition and is tailored for each patient. Early diagnosis is required for the optimal effect of treatment on patient survival and quality of life. An increased awareness among physicians of the spectrum of the disease and tools to aid its diagnosis is of increasing importance.

Immunohistochemical localization of trichloroacylated protein adducts in tetrachloroethene-treated mice

Tetrachloroethene (PCE), a common industrial solvent and environmental contaminant, is primarily used in the dry-cleaning industry. The toxicity of PCE has been linked to vision disorders, renal and hepatic cancer, and autoimmune diseases. Although the mechanism of toxicity is not fully understood, PCE forms trichloroacylated protein adducts in tissues where toxicity is known to occur. These adducts may be responsible for toxicity by altering the function of cellular proteins. Using Western blot analysis, formation of trichloroacylated protein adducts has been reported. To determine the localization of the adducts in a specific zone of a tissue, immunohistochemical staining was used in the study. An antiserum to trichloroacylated proteins was raised in rabbits and its specificity was established by enzyme-linked immunosorbent assay (ELISA). Female MRL-lpr/lpr and MRL +/+ mice were treated with PCE using a single 5-mmol/kg dose over 24 h or on every fourth day for 6 wk (total 20 doses). Formation of trichloroacylated protein adducts was observed in the liver, and localized to the centrilobular zones. Intensity and circumference of the staining around the central vein were much greater in subchronically treated mice than in acutely treated mice. No immunochemical reactivity was observed in any of the other tissues examined. This study shows that hepatic trichloroacylated protein adducts are localized in a region of the liver where PCE-mediated toxicity is known to occur. Immunohistochemical localization of these adducts and its association with PCE-induced toxicity support the contention that adducts may contribute to toxicity.

Anti-malondialdehyde antibodies in MRL+/+ mice treated with trichloroethene and dichloroacetyl chloride: possible role of lipid peroxidation in autoimmunity

Trichloroethene (TCE) and one of its metabolites dichloroacetyl chloride (DCAC) are known to induce/accelerate autoimmune (AI) response in MRL+/+ mice as evident from anti-nuclear, anti-ssDNA, anti-cardiolipin, and DCAC-specific antibodies in the serum (Khan et al., Toxicol. Appl. Pharmacol. 134, 155-160, 1995). In the present study, we measured anti-malondialdehyde antibodies (AMDA) in the serum of TCE- or DCAC-treated mice in order to understand the contribution of lipid peroxidation to this AI response. Female MRL+/+ mice (5 weeks old) received ip injections of 10 mmol/kg TCE or 0.2 mmol/kg of DCAC in corn oil (100 microl) every 4(th) day for 6 weeks, while controls received an equal volume of vehicle only, and AMDA was measured in the sera of these animals by an ELISA established in our laboratory. While TCE treatment caused only marginal induction of AMDA, DCAC treatment elicited a significant AMDA response. Furthermore, a time-response study of DCAC (0.2 mmol/kg, every 4(th) day, for 2, 4, 6, or 8 weeks) showed an induction of AMDA (3/4) after 4 weeks of treatment, which was even greater at both 6 and 8 weeks of DCAC treatment (5/5). These findings were further substantiated by the presence of AMDA in systemic lupus erythematosus-prone MRL-lpr/lpr mice as early as 6 weeks of age. Presence of AMDA, as observed in this study, not only indicates increased lipid peroxidation (oxidative stress), but also suggests a putative role of oxidative stress in inflammatory autoimmune diseases.

Fatty acid anilides: in vivo formation and relevance to toxic oil syndrome

Toxic oil syndrome (TOS), a multisystemic epidemic outbreak in 1981 in Spain, was caused by the ingestion of a cooking oil mixture containing rapeseed oil denatured with aniline. The mechanisms and causative agents responsible for the TOS are still not known. Although primary lesions observed in TOS patients could not be reproduced experimentally, the levels of fatty acid anilides (FAAs) and aniline in TOS-related cooking oil were considered proximate markers of TOS. Aniline, available from free aniline and FAAs ingested with TOS-related cooking oil, and its reconjugation with endogenous fatty acids could be an early event leading to TOS. Therefore, the present study was undertaken to determine the formation of FAAs following an oral dose of 2 mmol/kg aniline hydrochloride (AH) via gavage in rats. Here, 16:0, 18:0, 18:1, 18:2, 18:3, and 20:4 FAAs were analyzed in the whole blood, brown fat, liver, and pancreas at 0 (control), 0.25, 0.5, 1, 3, 6, 12, 24, and 48 hours. Generally, 16:0 and 18:1 FAAs were detected in the whole blood, brown fat, and liver of AH-treated rats with highest mean levels at 0.25 or 0.5 hour, except 3 hours for the whole blood. Only 16:0 FAA was detectable in the pancreas of AH-treated animals. The 18:0 FAA was also detected frequently in the liver while other FAAs were either in trace amounts or not detectable in the tissues analyzed in the present study. Overall, highest formation of the 16:0 FAA was found in the liver followed by pancreas and of 18:1 FAA in the whole blood and brown fat. These results indicate a rapid formation and further metabolism and disposition of FAAs in rat model and support our previous findings that 18:1 and 16:0 fatty acids are better substrates for the conjugation with aniline. Surprisingly, a small or trace amount of a few FAAs also detected in the tissues of control rats indicates their endogenous biosynthesis and/or presence. Results of 18:1 fatty acid incubation and aniline in the presence of fatty acid ethyl ester synthase, purified to homogeneity from rat liver microsome, suggest that formation of FAAs is catalyzed by an enzyme involved in the conjugation of fatty acids with xenobiotic alcohols. Because the FAAs are known to exert a wide range of toxicity in experimental animals and primary cell cultures, in vivo formation of FAAs could be an early event leading to TOS.