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   Table of Contents - Current issue
October-December 2022
Volume 15 | Issue 4
Page Nos. 171-234

Online since Thursday, December 22, 2022

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Neonatal screening for developmental dysplasia of the hip Ortolani and Barlow sign accuracy review p. 171
Ammar Mohammed Haidar Shehadeh, Mohamad Aikrch Al Haroun, Amer Kamel Sammak
Introduction: Developmental dysplasia of the hip (DDH) joint is a preventable cause of disability. If detected early, the result is expected to be a complete improvement. Ortolani and Barlow clinical test is performed early to detect DDH. However, the authors have different opinions regarding the accuracy of the Ortolani and Barlow sign and the need for an ultrasound scan (USS) as a screening tool for DDH. Methods: This review involves a comprehensive search on Medline through PubMed and OVID, then from Google Scholar and article references for any paper or clinical trial that studies the accuracy of Ortolani and Barlow sign against the gold standard USS. Results: Four studies have been included. Sensitivity lied between 7% and 28.3%, specificity between 94.5% and 99.8%, positive predictive value (PPV) 13.6%–85.7% and negative predictive value (NPV) 88.4%–97.7%. However, when the clinical examination was repeated more than twice and the USS at 6 months of age was considered the gold standard, sensitivity improved significantly to reach 84%, specificity 82%, PPV 14% and NPV 99%. The relative risk of DDH in patients with positive OB was between 6.11 and 7.4. Discussion: The OB could be considered a risk factor for DDH. It did not show enough sensitivity to be considered a valid screening test for DDH. Low sensitivity and PPV devalue OB for DDH screening. Alternatively, repeated clinical examination improves the test sensitivity and could be adopted in settings where universal USS is not possible due to lack of funds or experience.
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Autopsy trends in paediatric mortalities in a Nigerian tertiary hospital p. 176
Sebastian Anebuokhae Omenai, Uchenna Simon Ezenkwa, Harrison Ojevwe Egbo, Gabriel Olabiyi Ogun
Background: Sub-Saharan Africa has the highest childhood mortality worldwide. In this study, we reviewed post-mortem records retrospectively noting both the causes of death and autopsy trend in childhood documented at our hospital. Aim: This study was done to ascertain the mortality patterns in childhood as seen in post mortem examinations. Materials and Methods: Autopsy records of deceased who were 16 years or less performed from 2008 to 2017 in our hospital were accessed and reviewed. Written consents were duly obtained before all post-mortem examinations. The causes of death were defined using the International Classification of Diseases-11. Results: There were 89 cases representing 8.2% of 1092 autopsies performed within the review period. Most of the childhood mortalities were in the 1st year of life. The majority of cases in the 1st year of life were cases of early neonatal death (40%), followed by deaths from 29 days to 1 year (34.3%) and late neonatal death constituting 25.7% of cases. Infections resulted in deaths in 34.8% of cases, followed by malignancies at 12.4%, developmental anomalies at 10.1%, accidents at 6.7%, sickle cell disorder at 4.5%, and nephrotic syndrome at 4.5%. Pneumonia represented 48.4% of all infectious death, followed by bacteria sepsis of newborn at a distant 9.7%. Malignancies are the main cause of mortality in children above 10 years of age. It constitutes 36% of the cases in that age group. Mortalities from developmental anomalies were relatively more common in infants (17.1% of deaths). Conclusion: This study has shown varying causes of death in different age demographics among children in the population studied. Infection control and adequate treatment in addition to early diagnosis of malignancies are advocated.
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Smartphone use and perception towards the usefulness and practicality of its applications amongst Ghanaian anaesthetists Highly accessed article p. 180
Sanjeev Singh, Pavagada Shaifulla, Arti Singh, Isaac Owusu-Ansah
Background: In recent years, smartphone applications (apps) have generated an increasing interest worldwide. Anaesthesia, as a profession, has been one of the first to adopt new technologies. Aims and Objectives: This study aimed to assess the pattern of smartphone use in anaesthesia practice (duration, frequency and purpose of use), determine the perception of its use and identify factors influencing smartphone usage in anaesthesia practice and installation of anaesthesia-related apps amongst anaesthetists in Ghana. Materials and Methods: A cross-sectional survey of 284 randomly selected Ghanaian anaesthetists was conducted from January 2018 to August 2018, using a previously validated perception domain to measure the perception towards the usefulness and practicality of smartphones. To find the predictors of smartphone use and the installation of medical-related apps in anaesthetic practice, logistic regression models were used. Results: Two hundred and seventy-two anaesthetists responded with a response rate of 95.8%, and 75.9% installed anaesthesia-related apps, whereas 46.1% utilised them. The perception of anaesthetists towards the usefulness and practicality of smartphones in anaesthesia practice was 57.3 ± 18.6 and 61.2 ± 16.8, respectively; the overall percentage mean score was 59.3 ± 17.6, which was less than satisfactory. Only 17.4% of anaesthetists reported a positive level of perception towards smartphone use and practicality. Smartphone usage was 25.4% amongst anaesthetists with negative perceptions towards its usage. The mean total perception mean score was a significant predictor of both smartphone usage (β = 0.031, P < 0.001) and the installation of anaesthesia apps (β = 0.032, P < 0.001) after controlling for possible confounders. Conclusion: Smartphone utilisation in anaesthesia practice is low amongst Ghanaian anaesthetists. This could be ascribed to their less than satisfactory level of perception towards smartphone use in anaesthesia practice. On the other hand, their use and installation of apps in anaesthesia practice were predicted by the perceived usefulness and practicality of their use.
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The effect of BIS usage on anaesthetic agent consumption in high-risk patients for coronary artery bypass grafting off-pump surgery p. 187
Sanjeev Singh, Pavagada Shaifulla, Arti Singh, Isaac Okyere
Background: In patients undergoing coronary artery bypass grafting off-pump (CABG-OP) surgery with limited haemodynamic reserve, achieving the ideal anaesthesia depth is challenging. The risk of awareness during surgery increases with light anaesthesia, too deep anaesthesia can cause hypotension, delayed awakening, and increased morbidity and mortality. Aims and Objectives: In this study, we aimed to compare whether the use of the Bispectral Index (BIS) reduces the consumption of the anaesthetic drug and improves recovery time in CABG-OP surgery without awareness during surgery (ADS). Materials and Methods: This was a prospective, single-centre, randomised and double-blind comparative research performed on the American Society of Anaesthesiologists (PS) III patients booked for elective CABG-OP surgery under general anaesthesia. Patients received either propofol or isoflurane anaesthesia, and their consumption was calculated and compared. The conventional groups conventional propofol infusion group (CPG)-1 and conventional isoflurane group (CIG-3) received propofol and isoflurane, and haemodynamic parameters (±20% of initial values) were used to check the depth of anaesthesia. The groups BIS-guided propofol infusion group (BPG-2) and BIS-guided isoflurane group (BIG-4) received propofol and isoflurane, and BIS (value 50 ± 5) were used to check the depth of anaesthesia. In addition, haemodynamic parameters, awakening conditions, length of intubation, hospital stay and drug utilisation were recorded. To explicit ADS, patients were interviewed 24 h after extubation. Results: The quantity of propofol used was 178 ± 11 ml in CPG-1 and 117 ± 6 ml in BPG-2, with a 34.26% reduction with BIS. The isoflurane used was 39 ± 8 ml in CIG-3 and 25 ± 6 ml in BIG-4, with a 35.89% reduction in isoflurane requirement. This difference was statistically significantly low with BIS monitored anaesthesia compared to conventional anaesthesia. The length of intubation was 2.2 ± 1.27 and 2.3 ± 1.49 h in groups BPG-2 and BIG-4, respectively (P < 0.05). Conclusion: BIS monitoring aids CABG-OP surgeries by monitoring the depth of anaesthesia (BIS value 50 ± 5), preventing ADS (0%), reducing the anaesthetic agent requirement (propofol 34.26% and isoflurane 35.89%), reducing myocardial depression (mean arterial pressure maintained >74 mmHg) and aiding ultra-fast-track extubation (37% and 50% reduction in the duration of intubation in propofol and isoflurane with BIS).
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Partograph adherence and its barriers in a tertiary care hospital: A mixed-method study p. 195
Nirmalya Manna, Parthasarathi Bhattacharya, Ria Mukherjee, Adwitiya Das
Background: Partograph is a low cost, effective and mandatory tool for intrapartum monitoring. However, the partograph has been grossly underutilised. Aims and Objectives: The present study aims to find out the extent of the use of a partograph and the barriers to effectively using the same in a tertiary care facility. Materials and Methods: This cross-sectional study comprises quantitative and qualitative methods. The quantitative component consisted of a retrospective review of case sheets of patients undergoing uncomplicated vaginal delivery between 1 January 2020 and 15 February 2020. The percentage of cases where a partograph was initiated and completed was assessed. For the qualitative part, staff nurses on duty in the labour room during the study period and responsible for recording the partograph were invited to participate in a focused group discussion (FGD). Sister-in-charges, supposed to supervise the staff nurses were invited to participate an In-depth interview (IDI). Results: Out of 131 case sheets, a partograph was initiated in 64 (48.85%) cases and completed in 4 out of 64 partographs (6.25%). The 'Cervical dilatation' parameter was plotted in all 64 cases, while the 'amniotic fluid condition' was the least plotted parameter (12 [18.75%]). Data regarding the 'time of rupture of membranes' (15.63%) and 'condition at birth' (4.69%) were also neglected parameters. The FGD and IDI revealed 'shortage of staff and heavy workload', 'presentation in advanced labour', 'poor training and supervision', 'incomplete documentation of clinical information by doctors' and 'policy level lacunae' as the potential barriers to partograph adherence and completeness. Conclusion: Partograph adherence and completeness appeared inadequate in this tertiary care centre.
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Recovery from anaesthesia in post-COVID-19 mucormycosis debridement surgery: An observational study p. 201
Roopa Sachidananda, Dharmesh Arvind Ladhad, Vikas Joshi, Madhuri S Kurdi, Vikram Kemmannu Bhat, Athira Gopinathan Sarasamma
Background: Mucormycosis has emerged as the most common lethal post-COVID-19 infection. Since the onset of the COVID-19 pandemic, anaesthesiologists have faced the challenge of anaesthetising post-COVID mucormycosis patients, which requires extensive surgical debridement. Various perioperative factors can have an impact on the recovery from the neuromuscular blockade of these patients. Aims and Objectives: This study was undertaken to observe the recovery pattern from the neuromuscular blockade and the impact of various factors on extubation time. Materials and Methods: The retrospective study included all post-COVID-19 mucormycosis patients who underwent debridement surgery under general anaesthesia in a tertiary referral hospital. All the pre-anaesthetic evaluation charts, treatment charts and anaesthetic management charts were reviewed. The following outcome variables at recovery from anaesthesia were noted: duration of surgery, duration of anaesthesia and extubation time. Results: A total of 72 patients underwent post-COVID-19 debridement surgery in the study period, of which 26 patients were excluded from the study and 46 patients were included in the analysis. The median extubation time was 32 min and interquartile range was 7–37 min. Seventeen (37%) patients were extubated in <15 min and 29 (63%) patients were extubated after 15 min. The shortest extubation time was 2 min, whereas the longest was 1440 min. Conclusion: Extubation time was prolonged when post-COVID patients underwent debridement surgery for rhino-orbito-cerebral mucormycosis. Although pre-operative and intraoperative factors can impact recovery from neuromuscular blockade, our study did not demonstrate such findings. Delayed extubation time may be related to the COVID illness rather than pre-operative risk factors.
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Possible role of Andrographis paniculata for management of COVID-19: An observation on vimentin-related pathway p. 206
Pathum Sookaromdee, Viroj Wiwanitkit
Background: The use of traditional plants in the treatment of the medical problem is fascinating. Many studies on the benefits of traditional herbs on a variety of medical conditions, including respiratory disease, are now underway. Aims and Objectives: This study aim to asses the possible role of Andrographis paniculata, an Asian herb, for management of COVID-19. Materials and Methods: We employed network pharmacology to find a shared biological link between the pharmacological impact of Andrographis paniculata, a traditional Asian herb, and the pathophysiological process of COVID-19 in this short research. Results: The authors were able to find the common pathway through the vimentin node using interrelationship analysis. Conclusion: A. paniculata may be useful in the treatment of COVID-19.
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Health-related behaviours of urban school-going adolescents of a Metropolitan City of Eastern India p. 209
Adwitiya Das, Kuntal Bhattacharyya, Mariam Ansar, Saikat Bhattacharya
Background: Adolescence is the phase of attaining physical, mental and psychosocial maturity. Adolescents are susceptible to high-risk behaviours which affect both their physical and mental health. Aims and Objectives: This study aims to determine their sociodemographic profile, dietary preferences, physical activity, personal hygiene, substance abuse, interpersonal relationships, academic performance, etc., Materials and Methods: This cross-sectional study was undertaken amongst adolescents aged 16 to 19 years in two randomly selected schools. The youth Risk Behaviour Surveillance System questionnaire 2019 was used to find out different domains of adolescent behaviours. Their positive attributes fetched positive scores, whereas unhealthy attributes fetched negative scores. Bad scores (≤median) for each of the domains were computed, and logistic regression was done with sociodemographic and other variables. This was conducted in MS Excel and R 4.2.1. Results: Out of 145 adolescents interviewed, majorities (66.2%) were males, hailed from nuclear families (66.9%) and belonged to average financial status (53.8%). About 68.3% did not have any close friends. Dietary habits (71.0% had improper dietary habits) were worse amongst females (adjusted odd ratio [AOR] [95% confidence interval [CI] 1.58. 1.02–4.31) and amongst those coming from nuclear families (AOR [95% CI] 2.58 [1.57–7.47]). Health-related habit score was unsatisfactory at 28.9%. Substance abuse was noted in 16.6%; the presence of close friends (AOR [95% CI] 7.09 [3.24–26.71]) and either good (AOR [95% CI] 2.16 [1.22–53.39]) or poor (AOR [95% CI] 4.06 [1.54–57.73]) financial condition was the risk factors. Most (62.7%) had average school performance, and the majority wished to study in college. Poor school performance was associated with bad scores in health-related behaviour (AOR [95% CI] 7.43 [3.07–17.44]) and substance abuse (AOR [95% CI] 1.84 [1.02-12.35]). Conclusion: Regular assessment of various health-related risk factors must be done for the better physical and mental health of adolescents.
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Knowledge and attitude of resident doctors towards prehabilitation: An audit in a tertiary care centre p. 214
Ruchi Kumari, Anju Romina Bhalotra, Rahil Singh
Background: Major surgery is associated with a significant decline in the functional capacity of patients. Prehabilitation is the practice of enhancing a patient's functional capacity prior to surgery and thus improving postoperative outcomes. It is a multimodal approach, encompassing medical optimization, preoperative physical exercise, nutritional support, and stress/anxiety reduction. In this audit, we tried to find out how many resident doctors know about prehabilitation and, how they implement it in their patients in routine practice. Aims and Objectives: To study the knowledge amongst resident doctors regarding the role of prehabilitation in surgical patients; and to create awareness and implement quality practices for better post-operative outcomes. Materials and Methods: A questionnaire was prepared on Google docs with multiple choice questions and circulated electronically through emails with the participants. The submitted data were updated on Google docs and analyzed subsequently. Results: One hundred and ninety resident doctors participated in the audit. One hundred seventy residents (89.7%) were aware of holistic multimodal interventions. Three- fourths of residents (150 residents; 78.95%) accurately understood the rationale behind prehabilitation. Most of the residents (183 residents; 96.84%) were aware of preoperative medical optimization. A majority (188 residents; 98.95%) were familiar with the techniques of psychological support to patients. However, the knowledge with regard to the rationale behind prehabilitation and the category of patients requiring it, baseline functional capacity assessment, techniques for exercise intensity optimization, and questions pertaining to nutrition was unsatisfactory. Conclusion: Our audit focuses on the need to enhance the knowledge of resident doctors regarding the prehabilitation program to improve post-operative outcomes in patients.
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A huge mesenteric cyst: A case report and literature review p. 220
Maryam Makki, Rufaida Osman, Bassem Abou Hussein, Wessam Hazim Issa, Omar Al-Marzouqi
Rationale: Mesenteric cysts are rare and benign abdominal lesions, located in the mesentry of the bowel, and have different and non specific symptoms which make there diagnosis challenging. The treatment of choice for mesenteric cyst is surgery which can be either done laparoscopic or open depending on the size. Patient Concerns: Here we are presenting a case of a 19 year old gentleman with who presented complaining of abdominal pain and distension, the abdominal distension started 6 months prior to presentation that increased in size gradually. Diagnosis: Computed tomography was done and revealed huge mesenteric cyst 33 cm × 25 cm. Intervention: Exploratory laparotomy was done, and it showed a large solid/cystic mass in the abdomen arising from the root of mesentery; the lesion was pushing the surrounding organs; decompression of the cystic lesion was done and complete excision performed. Outcome: Post-operatively, the patient started on diet gradually; he improved clinically with no more pain and was discharged home on the fifth post operative day in a stable condition.
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Successful subarachnoid block following a dry tap in a geriatric patient p. 224
Chanise Monteiro Pereira Carvalho, Ashwell Savio Correia, Rohini V Bhat Pai
Rationale: Dry tap' is the absence of cerebrospinal fluid (CSF) despite lumbar puncture needle placement in the thecal sac. Patient Concern: it is a troublesome condition and poses significant challenges. Diagnosis: An experienced anaesthesiologist develops the ability to recognise the needle advancing through the ligaments culminating in a subtle 'pop' or 'give way' to ultimately reach the subarachnoid space, and the needle position is confirmed by a free flow of clear CSF. Intervention: subarachnoid block. Outcomes: successful subarachnoid block following a dry tap in a geriatric patient. Lessons: Spinal anaesthesia can be successful despite a dry tap in experienced hands and may be attempted before resorting to alternative techniques.
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Idiopathic proximal small bowel intussusception in an adult p. 227
Aabid Ashraf, Cheena Singh, Mohd Bilal
Rationale: Intussusception is fairly uncommon in adults accounting for 5% of all intussusception cases and is a cause in 1% of intestinal obstruction cases. The condition is usually associated with a pathological lead point. Idiopathic intussusception is comparatively rarer in adults. Patient Concerns: 24-year-old male with right lower abdominal pain and intermittent loose stools for fifteen days. Diagnosis: Proximal small bowel intussusception. Intervention: Resection of the involved segment with primary jejunojejunal anastomosis. Outcome: Uneventful postoperative course and full recovery. Lessons: Idiopathic intussusception, though rare in adults, should be suspected in all adults presenting with non-specific abdominal pain particularly in absence of distinct abdominal signs. Management is surgical and usually entails resection of the involved bowel.
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Multiple angina bullosa haemorrhagica like oropharyngeal lesions associated with severe acute respiratory syndrome coronavirus 2-induced immune thrombocytopenia: A rare case report p. 230
Mandeep Kaur, Virender Gombra, Apoorv Rana, Shamimul Hasan
Rationale: Angina bullosa hemorrhagica (ABH) or blood blisters have an acute onset and occur independently of other disturbances of the human body like vesiculo-bullous disorders, vascular disorders, systemic causes etc. ABH is sometimes painful in the oral cavity, most commonly affects the soft palate and less commonly affects the masticatory mucosa. Within a short period of time, these blood filled lesions burst spontaneously resulting in superficial erosions and healing without scarring within 1-2 weeks. ABH has a good prognosis and the only complication reported in the literature has been of airway obstruction. Patient Concerns: A 50 yr old female patient presented with the chief complaint of blood filled blisters and bleeding gums since one week. Diagnosis: Blood filled blisters were noted at multiple sites in the oral mucosa. Blood investigation revealed mild alteration in platelet count and endoscopy displayed involvement of the pharyngeal mucosa. A provisional diagnosis of ABH-like lesion as a covid -19 related delayed inflammatory reaction to LA was given. Interventions: Symptomatic management with topical agents was done. Outcomes: The lesions had completely healed by the seventh day and she remains symptom free eight months post episode. Lessons: The presented case is a very rare condition affecting the oral cavity and involvement of the pharyngeal mucosa additionally in a post COVID-19 patient is even more rare. A delayed inflammatory reaction to LA due to exposure to the SARS-COV-2 spike protein and dysregulation in immune function associated with immune thrombocytopenia (ITP) are postulated in this case of ABH-like lesions involving the oro-pharyngeal mucosa. It is very important to be clinically observant in recovered covid 19 patients too for atypical presentations.
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DUBAI triangle and Amin's Triangle, a new invention during TransOral Endoscopy Thyroidectomy Vestibular Approach (TOETVA) for critical view of safety for preservation of vital structures p. 233
Yasir Amin A.Latif, Aliya Ishaq, Mohd K Khalid, Esaaf H Ghazi, Rolf Hartung
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