Ascending Aortic Aneurysm

16 Pages·2016·5.9 MB·English

Issue 19 Kartik - Poush 2073 (Oct. - Dec. 2016) For free circulation only
FFoorr ttwwoo ddeeccaaddeess TTIIMMEE PPhhaarrmmaacceeuuttiiccaallss hhaass ppeerrssiisstteennttllyy ssttrriivveedd ttoo pprroovviiddee
ssuussttaaiinnaabbllee ssoolluuttiioonn ttoo hheeaalltthh ccaarree cchhaalllleennggeess iinn NNeeppaall..
OOnn tthhiiss cceelleebbrraattiioonn ooff 2200tthh aannnniivveerrssaarryy,,
wwee tthhaannkk aallll oouurr wweellll wwiisshheerrss aanndd vvaalluueedd ccuussttoommeerrss
ffoorr ssuuppppoorrttiinngg uuss tthhrroouugghhoouutt oouurr jjoouurrnneeyy wwiitthhoouutt wwhhoomm,,
iitt wwoouulldd nnoott hhaavvee bbeeeenn ppoossssiibbllee ttoo mmaakkee tthhiiss gglloorriioouuss hhiissttoorryy..
""BBee aa ppaarrtt ooff oouurr cceelleebbrraattiioonn--
HHoonnoorriinngg oouurr ppaasstt,,
TTrreeaassuurriinngg oouurr pprreesseenntt && SShhaappiinngg oouurr ffuuttuurree""
Inspired by Excellence...
H.O.: Gaindakot-04, Nawalparasi, Ph.: 977-78-502004, Fax.: [phone], Email: [email protected]
Factory: Gaindakot-10, Nawalparasi, Ph.: 977-78-402004, Email: [email protected]
Marketing: Bakhundole-03, Lalitpur, Ph.: 01-5526905, Email: [email protected]
Website: www.timepharma.com, www.facebook.com/timepharma
Moments in TIME
TIME Pharma has made a remarkable presence in the Nepali
pharmaceutical market with a glorious history of 19 years. SSM Ujjwal Dev Pradhan Receiving Team Leader of
Achievers of FY 72/73
With an overwhelming rush of emotions I feel delighted to the Year 72/73 Award
pronounce that in upcoming Mangsir 2, 2073, we will be
celebrating our 20thanniversary.
"All great achievement requires TIME". The vision of our
Chairman and Managing Director to make our country self
sufficient in medicine lead to the initiation of TIME
Pharmaceuticals 19 years back, and a group of enthusiastic
entrepreneurs set on a journey to contribute towards the
health sector of the nation. Now, it feels great to stand at this
point, turning over the glorious pages of our organization and look back at what we have
achieved. It was a long and tough way to come but it was worth it, and I would like to
Phr. Ashesh Bhandary thank all our well wishers and valued customers for supporting us throughout our
Factory Operation Director journey without whom, it would not have been possible to make this glorious history.
Moreover, I would like to congratulate all the TIMEians for the 20th anniversary, whose
Phr. Prawan Dahal dedication and commitment towards delivering sustained and enhanced quality products
Sr. Technical Manager and services to our customers led to the consistent growth of the organization.
Marketing Team at Sun Temple,
Phr. Amrita Acharya Ifeel very delighted to share a brief prologue of our 2 decade old organization in this Bhuwaneshwor, Puri Marketing Team Enjoying at Puri Beach
Sr. Product Development Officer important issue of MEDITIME. Our 35000 Sq ft. ultra modern state of art manufacturing
plant is located in Gaindakot-10, Nawalparasi, 12 KM west from Narayangarh. The plant
Mrs. Mallika Gubhaju
has gone through various strategic and technological changes to adhere to various
Product Development Officer
standards in quality. All the production process is with compliance of WHO-GMP
Phr. Jenisha Karmacharya standard to achieve highest quality that satisfies the need of the customers. With the
Product Development Officer zeal of highly skilled and motivated human resources, we are moving ahead as a leading
pharmaceutical company in Nepal.
Phr. Aditi Wagle
Product Development Officer Our two decade journey was not a smooth one to walk through. It wouldn't have been
possible to reach zenith of success without continuous support of well wishers and
Phr. Anju Sharma dedicated team work besides many ups and downs in this 20 years journey. Nepalese
Product Development Officer pharma industry is contributing about 45% in total pharma business and remaining is
imported from other countries. In such a situation also, TIME Pharmaceuticals stand
tall as one of the leading pharmaceutical company in the nation manufacturing more
than 180 quality products.
Editorial 2
Health News Line 3 We have struggled through many natural calamities, political disturbances and other
In-Vitro Fertilization 4 challenges. Being a Nepalese company we stood together during every unpleasant
situation for self-sufficiency in pharmaceutical products to make healthy nation. Besides
Product Profile SiTA-M 5
the vision to providing quality medicine to every individual, we are also involved in
Ascending Aortic Aneurysm: conducting different CSR activities like health camp in earthquake epi-centric area,
Team Genesis Celebrating Participating in DEAN Conference
An active bomb in the thorax 6 environment awareness activities etc.
World Heart Day at Basantapur 2016
Anniversary Special 8 Lastly, I thank my editorial team for your continuous effort in publishing different issues
Company History 9 of MEDITIME, and now we present the 19th issue of MEDITIME at your service. Also,
Management of Acute Ischemic Stroke: Iwould like to thank all the medical fraternities and supporters who have been providing
their valuable article for the quarterly magazine from its initial issue.
Time is Brain 10
Self-management of PAD 11 Once again, HAPPY 20th ANNIVERSARY OF TIME PHARMACEUTICALS.
Scrub Typhus 12
;k{b+z ñ Ps cWoog 13
Brain Teaser 13
Winner & Article Contribution Pictures 14
Response Form 14
e-bulletin can also be viewed in www.facebook.com/timepharma
Moments in Time 15
All Right Reserved:
No part of this publication may be reproduced, in any retrievel system or transcribed in any form or
TIPMuEb lPishahremda &ce uOtiwcanlse (dP .b) yL:td. by any means - electronic, mechanical, photocopying, recording or otherwise - without written Participating in NESON Conference 2016 Participating in SODVELONCON 2016
Copyright@TIME Pharmaceuticals (P.) Ltd. permission of TIME Pharmaceuticals (P.) Ltd. Offenders are liable to legal consequences.
Liplow Sulfaz
2 Atorvastatin 5/10/20 mg Tablets Sulphasalazine 500 mg DR Tablets 15
Health News Line
Artificial blood vessels developed in the lab can grow within the recipient
In a groundbreaking new study led by University of Minnesota biomedical engineers, artificial blood vessels bioengineered
inthelabandimplantedinyounglambsarecapableof growthwithintherecipient.If confirmedinhumans,thesenewvessel
grafts would prevent the need for repeated surgeries in some children with congenital heart defects. One of the greatest
challengesinvesselbioengineeringisdesigningavesselthatwillgrowwithitsnewowner.Inthisstudy,UniversityofMinnesota
Departmentof BiomedicalEngineeringProfessorRobertTranquilloandhiscolleaguesgeneratedvessel-liketubesinthelab
fromapost-nataldonor'sskincellsandthenremovedthecellstominimizethechanceof rejection.Thisalsomeansthevessels
can be stored and implanted when they are needed, without the need for customized cell growth of the recipient. When
implantedinalamb,thetubewasthenrepopulatedbytherecipient'sowncellsallowingittogrow.
Todevelopthematerialforthisstudy,researcherscombinedsheepskincellsinagelatin-likematerial,calledfibrin,intheform
of a tube and then rhythmically pumped in nutrients necessary for cell growth using a bioreactor for up to five weeks. The
pumpingbioreactorprovidedbothnutrientsand"exercise"tostrengthenandstiffenthetube.Thebioreactor,developedwith
ZeeshanSyedain,aseniorresearchassociateinTranquillo'slab,wasakeycomponentof developingthebioartificialvessel
to be stronger than a native artery so it wouldn't burst in the patient. The researchers then used special detergents to wash
away all the sheep cells, leaving behind a cell-free matrix that does not cause immune reaction when implanted. When the
vessel graft replaced a part of the pulmonary artery in three lambs at five weeks of age, the implanted vessels were soon
populatedbythelambs'owncells,causingthevesseltobenditsshapeandgrowtogetherwiththerecipientuntiladulthood.
"What's important is that when the graft was implanted in the sheep, the cells repopulated the blood vessel tube matrix,"
Tranquillo said. "If the cells don't repopulate the graft, the vessel can't grow. This is the perfect marriage between tissue
engineeringandregenerativemedicinewhere tissueis growninthelabandthen,afterimplantingthedecellularizedtissue,
thenaturalprocessesoftherecipient'sbodymakesitalivingtissueagain."At50weeksofage,thesheep'sbloodvesselgraft
hadincreased56percentindiameterandtheamountofbloodthatcouldbepumpedthroughthevesselincreased216percent.
Thecollagenproteinalsohadincreased465percent,provingthatthevesselhadnotmerelystretchedbuthadactuallygrown.
No adverse effects such as clotting, vessel narrowing, or calcification were observed. Tranquillo said the next step is talking
withdoctorstodeterminethefeasibilityofrequestingapprovalfromtheFoodandDrugAdministration(FDA)forhumanclinical
trialswithinthenextfewyears.
Scrub typhus infection taking toll in Chitwan Memory Loss:
Not an Inevitable Part of Aging
More than 200 people have
US Scientists say memory loss is not an
beenfoundsufferingfromscrub
inevitablepartofageing.Thestudywas
typhus,abacterialdiseasethat
conductedonauniquegroupofadultsin
spreads from mice bite, in
their60sand70swithmindsassharpas
Chitwan district alone. District
people in their 20s. Researchers at
Public Health Office Chitwanís
Massachusetts General Hospital found
insectcontrolinspector,RamKC, Chiggermite Orientiatsutsugamushiunermicroscope Characteristicescharinapatient thattheseindividuals,calledìsuperagersî,
said the exact number of
performed just as well on memory tests
patients suffering from scrub
aspeopleathirdof theirage.
typhuswasknownaftertheresult
thatcameoutofbloodtestsconductedfromApril/Maytillmid-Septemberatthree Regionsinvolvedwithlearningandretaining
differenthospitalsinthedistrict. newinformationshowednosignoftypical
age-related shrinkage. Also, memory test
ìAtotalof 613patientsinquestiongottheirbloodtestedandamongthem,205
scorescorrelatedwithbrainsize.Thosewho
havesofarbeenfoundtohavecontractedthedisease,îhesaid.Aspertherecords
performedbestinthetestsalsohadgreater
at the office, as many as 188, nine and eight persons were diagnosed with the
thickness in the key brain regions the
diseaseovertheperiodoffourtofivemonthsatChitwanMedicalCollege,Narayani
researchers measured on MRI scans. The
CommunityHospitalandBharatpurHospitalrespectively.
studyauthorssaytheirwork,outlinedinthe
Thesearetheonlyhealthfacilitiesthatconductscreeningforthedisease.Thedisease Journal of Neuroscience, could ultimately
hassofarkilledtwopersons.Meanwhile,BharatpurHospitallatelyhasmadethe helpwithunderstandingtheprocessesthat
bloodtestforthediseasefreeofcost.Thefreeofcostlabtesthasbecomepossible leadtodementiaandiftherearewaysto
after the District Public Health Office provided the hospital with 200 kits. avoidthem.
Making babies without eggs may be possible, say scientists
Scientistssayearlyexperimentssuggestitmayonedaybepossibletomakebabies
withoutusingeggs.Theyhavesucceededincreatinghealthybabymicebytricking
spermintobelievingtheywerefertilizingnormaleggs.Thefindingscould,inthe
distantfuture,meanwomencanberemovedfromthebaby-makingprocess,say
theresearchers.
TheUniversityofBathscientistsstartedwithanunfertilizedeggintheirexperiments.
They used chemicals to trick it into becoming a pseudo-embryo. These "fake"
embryos share much in common with ordinary cells, such as skin cells, in the way
theydivideandcontroltheirDNA.Theresearchersreasonedthatifinjectingspermintomousepseudo-embryoscouldproduce
healthy babies, then it might one day be possible to achieve a similar result in humans using cells that are not from eggs.
Inthemouseexperiments,theoddsofachievingasuccessfulpregnancywereoneinfour.DrTonyPerry,oneoftheresearchers,
told the BBC News website: "This is the first time that anyone has been able to show that anything other than an egg can
combine with a sperm in this way to give rise to offspring. It overturns nearly 200 years of thinking. Those baby mice were
healthy,hadanormallifeexpectancyandhadhealthypupsof theirown.
AZT
Azithromycin250/500mgTablets/Suspension 3
IInn--VViittrroo FFeerrttiilliizzaattiioonn--SShhoorrtt HHiissttoorryy ttoo IIVVFF PPrroottooccoollss
In-vitro Fertilization (IVF) stands for GnRHanalogueinitiallyup-regulates
"Fertilizationinglass",i.e.fertilizationof theGnRHreceptorsinthepituitaryfor
maleandfemalegametesinglass.In1878, thefirst2-3days,increasingthesecretion
thefirstattemptsatIVFofmammalian of LH and FSH. After this time, the
eggs were made by the Viennese GnRH receptors in the pituitary are
Dr.SanuMaiyaShrestha
embryologistSchenk(Trounson,1999). downregulatedandthesecretionofLH
MD,DGO,M.Sc,FICS
In1891,HeapeWalterdemonstratedfor and FSH is reduced as long as the
Sr.Con.Gynecologist&
thefirsttimethatfertilizedeggsfroma analogue is given. Unlike GnRH
Obstetrician
rabbitcouldberetrievedandsubsequently agonists, the antagonists cause an
menstrual cycle Day 2 and the
transferredtoarecipient,whothengave immediateandreversiblesuppressionof
gonadotrophin injections for ovarian
birth to live off-spring (Heape, 1891). gonadotrophinsecretion.
stimulationarecommencedonDay3of
Thefirstsuccessfulin-vitrofertilization
UseofGnRHagonistenablesrecovery themenstrualcycle.BothFSHinjections
ofmammalianeggwithsubsequentbirth
ofalargernumberofoocytes,resulting andGnRHagonistsarediscontinuedon
wasreportedbyChangin1959(Chang,
inalargernumberofembryos,whichin the day of hCG trigger. The trigger
1959).Thefirstreportsofimplantation
turn,allowsbetterselectionofembryos injection is given when the leading
andpregnancyinhumanusingIVFwere
leadingtoanincreaseinthepregnancy follicle(s)is(cid:179)'2E18mmandthereareat
publishedduring1970sbySteptoeand
rate(Leonenetal.,2002). leasttwofollicleswithameandiameter
Edwards (Edwards and Steptoe, 1974;
of 16mm or greater. TVSOPU is
SteptoeandEdwards,1976).Sincethen, Themostcommonlyusedstimulation
performed35to38hoursafterthehCG
IVFhasbecomethemostrapidlyevolving protocolsinIVFare:
injection.
approachtoovercominghumaninfertility 1.IVFLongProtocol(IVFLP)
problem. 2.IVFShortProtocol(IVFSP) IVFAntagonistProtocol(IVFANT)
GnRH antagonists have recently been
IVFinvolvesfertilizationofthehuman 3.IVFAntagonistProtocol(IVFANT)
introduced in clinical practice for
ovum with spermatozoa outside the
IVFLongProtocol(IVFLP) pituitarydownregulationinIVFcycles.
woman's womb and transfer of the
In most centers, this has become the In this protocol, FSH injections for
resultingembryotoheruterus.Thereare
standardprotocol.GnRHagonistsare ovarianstimulationareadministeredfrom
manytreatmentmodalitiesinIVF.The
givenfor10to14daysorlonger("long Day1or2ofthemenstrualcycle.The
firstIVFbabywasbornasaresultofan
protocol")forpituitarydesensitization antagonistisusuallyadministeredfrom
oocytepickedupinanaturalmenstrual
before administering an exogeneous Day-6ofthegonadotrophininjections,
cycle (Steptoe and Edwards, 1978).
gonadotropin.GnRHagonisttreatment orfromthedaywhenatleastoneofthe
However,thesuccessrateofthistypeof
isusuallycommencedinthemid-luteal follicleshasreachedthesizeof14mm.
protocolisverylowcomparedtotheother
phaseofthemenstrualcycle.Insome Antagonist and gonadotrophin are
IVF protocols involving ovarian
centers,thelongprotocoliscombined continueduntilthedayofhCGtrigger.
stimulationwheremorethanonemature
with pre-treatment with Oral- Thetriggerinjectionisgivenwhenthe
follicleisobtained.TheMonashgroup
Contraceptive Pills (OCPs). In OCP leadingfollicle(s)is(cid:179)'2E18mmandthere
was then first to introduce ovarian
treatment,theGnRHagonistisusually are at least two follicles with mean
stimulation in IVF using clomiphene
commencedonthetwentiethdayofa diameterof16mmorgreater.TVSOPU
citrate and human menopausal
25dayOCPregime(Leonen,2002).It is performed 35 to 38 hours after the
gonadotrophin (hMG) combined,
isbelievedthatpretreatmentwithOCP hCGinjection.
yielding a large number of eggs and
reducestheriskofovariancystsinduced
improvingthepregnancyrate(Trounson Why"Creator'sIVFNepalPvt.Ltd."?
by the initial flare effect of GnRH
etal.,1981).Fromthenonwards,several The negative consequences of
agonists(Bijanetal.,1998).
otherregimensusingthesetwodrugswere childlessness are much stronger in
reported. After10to14daysofagonisttreatment, developing nations than in developed
pituitarydown-regulationisverifiedby nationsduetothelackofexpertiseand
Acommonproblemwiththeseproducts
determining the serum E2 technology.Unfortunately,theinfertility
isthatabout20%ofwomenwhoundergo
(E2<120pmol/L) or transvaginal problemindevelopingnationshasbeen
thistreatment,haveaprematureLHsurge
ultrasound(nofollicles>5or10mm). ignored as an international health
leadingtothecancellationoftreatment
Following pituitary down-regulation, problem.Theworldhasfocusedmoreon
(Loenenetal.,2003).Likewise,ovulation
FSH injections are commenced for thehighbirthrateandfamilyplanning
canalsooccuratinconvenienttimesof
ovarianstimulation.FSHinjectionsand strategiesinthedevelopingcountriesthan
day (Elder-Geva et al., 1999). These
GnRHagonistsarediscontinuedonthe on the problems of infertility.
problems have been overcome by the
day of the hCG trigger. The trigger Nevertheless,thehighbirthrateandthe
introduction of GnRH agonist and
injection is given when the leading infertilityratesarethetwosidesofthe
antagonisttreatmentsthatdesensitized
follicle(s)is(cid:179)'2E18mmandthereareat samecoininthedevelopingcountries.
the pituitary, thus preventing the
leasttwofollicleswithameandiameter Theprevalenceofinfertilityindeveloping
premature LH surge and allowing
of 16mm or greater. Transvaginal countriescanvaryfromlowtohigh.Sub-
schedulingoftheoocytepick-up(OPU).
sonography guided ovum pick-up SaharanAfrica,forexample,combines
GnRHwasfirstisolatedandcharacterized
(TVSOPU)isperformed35to38hours thehighestleveloffertilityintheworld
bySchallyandcolleaguesin1971(Schally
afterthehCGinjection. withthehighestprevalenceofinfertility
et al., 1971). Knobil was the first to
(Puttemensetal.,1995).However,there
demonstrate that GnRH when given IVFShortProtocol(IVFSP)
is a lack of epidemiological studies to
continuouslycausedadecreaseinLHand Thisprotocolissometimesnamedthe
confirm the incidence of infertility in
FSH secretion (Knobil, 1980). "flare" protocol. In this protocol, the
developingcountries.
Continuousadministrationofexogenous GnRH agonist is commenced from
Folvin
4 FolicAcid5mgTablets
Myselfbeingtheexperiencedpersonof job at Om IVF center, Om Hospital, establishedinMangsir,2072andlocated
feelingsub-fertilitypain,determinedto Nepal. at Satdobato-15, Lalitpur with an
gainexpertiseandacademicknowledge exclusiveprovisiontomanageinfertility
However, more than eight years of my
in Assisted Reproduction Technology couples.Thiscenterprovidesallfacilities
independentworkatIVFNepalPvt.Ltd.,
(ART),sothatIcouldprovideserviceto from simple Timed-Intercourse (TI)
Global Hospital gave me a vision and
suchcouplewithempathy. treatmenttocomplexIntra-Cytoplasmic
confidencethatsuchARTcenterrequires
Sperm Injection (ICSI) services with
Fortunately,Iwasgiventheopportunity muchprivacyandgoodconsiderationof
visiontoincreaseotherfacilitiesrelated
to gain wide theoretical and practical emotionalfactorsofcouplesalongwith
toART.
knowledgeinARTfromUniversityof competent staffs, as well as precise
NewSouthWales(UNSW),Australia equipments. Thus, the concept of Until now, we have conducted 54
during my Masters studies. After "Creator's IVF Nepal Pvt. Ltd." finally batches of IVF successfully under my
completion,Iwasfurtherabletosharpen emerged. leadership and outcomes of 50 IVF
myskillsinthisareaduringmythreeyears batchesareanalyzedandpresentedin
Creator's IVF Nepal Pvt. Ltd. was
thetablebelow.
BNatoc.h TCootamlpClyecteleds PreTgontaanlcyPrCeTlgionntiaacnlacly BPiorecTghonetaamnliccyal PrSeginngalnecyPreTgwnianncyPrTegrinpalentcy pQrueagdnraipnlceyt Bolivguhmted AMbiosrsteiodn AInbdourctieodn dseTilnoivgtaelelry deTtlwoivtianelry dteTrlioipvtlaeelrty Tobtaablmiesale fbeTamobtaiaelles OTHoStaSl* PrEecgtnoapniccy
1to50 573 259 214 45 144 52 13 1 21 27 7 109 37 8 106 11 9 4
45% 37% 8% 25% 9% 2% 0.2% 4% 5% 1% 19% 7% 1.4% 49% 51% 2% 0.7%
TotalDelivery=TotalSingleDelivery+TotalTwinDelivery+TotalTripletDelivery=109+37+8=154
TakeHomeBabyRate=27% TotalClinicalPregnancyRate=37% TotalPregnancyRate=45%
*OHSS:OvarianHyperstimulationSyndrome
Apologizesforthemistakeindataprintedin18thissue.Reprintedwithcorrection.
Product Profile
GENESIS
Fixcef
Cefixime100/200mgDT/DS 5
Ascending Aortic Aneurysm:
An active bomb in the thorax
Aortic aneurysm can be defined as a localized undue reason.Thoracicaorticaneurysmcan
dilation with 50% increase in size over the normal cause symptoms by compressing
diameter.Theìnormaldiameterîstrictlydependsonage, nearbystructure.Hoarsenessofvoice
sexandbodysize,aswellastheanatomicallocalization couldbeapresentingsymptomifit
DrKaushalKTiwari
of the affected aorta. For the physiologically smaller compressesrecurrentlaryngealnerve;
Asso.Professor&In-Charge
abdominalaorta,thetermaneurysmisusuallylimitedto stridor, dyspnea from tracheal, DepartmentofCardiothoracic
diametersexceeding30mm,while,onthecontrary,a bronchial or lung compression; andVascularSurgery
CMSTH,Bharatpur
thoracicaorticaneurysmshouldbeconventionallylarger dysphagia from esophageal
than40mm.AccordingtoElefteriadesJ,ascendingaortic compression;andplethoraandedema,fromsuperiorvena
aneurysmsaredividedintothreecategories,according cavacompression.Adullandvaguepaininneckandjaw
tothepatternoftheinvolvementoftheaorticroot.These maybeanindicationofaorticarchaneurysms,whileback,
are supracoronay aneurysm, annuloaortic ectasia interscapular, and/or left shoulder pain may occur with
(Marfanoid)andtubulardiffuseenlargementoftheaorta. descendingaorticaneurysms.Frequently,patientspresent
withsignandsymptomsofaorticinsufficiency,whichought
to be the main reason behind patient coming to clinical
attention.Ultimately,acutesyndromslikeaorticdissection
oraorticrupture,ifcouldmaketothehospital,mightpresent
withpotentiallylethaloutcomes.
Diagnosis
InstrumentalEvaluationofTheAscendingAorta
Forthediagnosisofaorticaneurysmseveraldiagnostictools
are available ranging from non-invasive examination like
SupracoronaryAneurysm AnnuloaorticEctasia TubularAneurysm
ChestX-ray,Echocardiography,Computedtomographyand
Typesofascendingaorticaneurysms
MRItoinvasiveexaminationlikeAngiography.Noninvasive
imagingisessentialforassessmentofaorticsizeandinsome
Aorticaneurysmsprobablyrepresentthemostlethaland cases functional parameters. It is important to know the
indolentenemyofthemedicalcommunity.Usually,they accuratesizeoftheaortabecausekeydecisionsregarding
silently and asymptomatically grow up until an acute management of the aortic aneurysm depend on size.
andoftencatastrophiccomplicationoccurs.Thethreats
ChestX-Ray
ofanon-operatedaorticaneurysmincludedissectionor
ChestX-rayoftenperformedasapartofgeneralexamination
ruptureoftheaorta,subsequentlyleadingtodeath.In
in patients with potential cardio-pulmonary disease. It
contrast, despite the armamentarium of modern
sporadicallydetectsabnormalitiesofaorticcontourorsize
perioperativeandpost-operativecardiacsurgicalcare,
thatrequiredefinitiveaorticimaging.
theriskofsurgeryincludesparaplegia,stroke,bleeding,
andmortalityrangingfrom3to9%afterelectivesurgery. Echocardiography
Conversely,incasesofacuteeventsmortalitycanbeas Echocardiographyisoneofthemostusedimagingmodality
high as 90%. In the United States, aortic aneurysms inthecardiology,whichhasahighsensibilityandspecificity
(thoracic and abdominal) constitute the 17th leading indiagnosingvarietyofcardiacpathologyincludingascending
causeofdeathinthegeneralpopulationandthe15th aortic aneurysm. Transthoracic echocardiography (TTE) is
forindividualsolderthan65years.Approximately15,000 morereadilyavailable,easytouse,transportableandcost
individuals die every year from this pathology in the effective.Noneedofcontrastandsedationmakeitasafirst
United States of America, which is more than death line diagnostic tool in clinical set up. However,
causedbyHIVinfection. transesophagealechocardiography(TEE)issuperiortoTTE
andmoreaccurateforassessmentofthethoracicaorta,but
Etiology
sometime requires sedation and has a small risk of
Risk factors for the development of thoracic aortic
complicationslikeesophagealperforation(lessthan0.03%).
aneurysmsincludehypertension,smoking,andchronic
In addition, with diagnosis of aortic dilatation,
obstructive pulmonary diseases. Ascending aortic
echocardiographymayrevealotherassociatedpathology
aneurysmsarealsorelatedwithbicuspidaorticvalve.
thatsuggeststheunderlyingetiologyoftheaorticdisease
Additionally, several genetic syndromes with a
(eg, bicuspid aortic valve). Nevertheless, for accurate
predispositionforascendingaorticaneurysmshavebeen
evaluationofascendingaorticaneurysmandtoconfirmthe
identified. Most common genetic diseases effecting
indicationforsurgery,therearesomerestrictions.TTEand
thoracic aorta are: Marfan Syndrome, Loeys-Dietz
TEEareuserdependent.TTEcanonlyvisualizetheproximal
Syndrome,Ehler-DanlosSyndrome,TurnerSyndrome,
partoftheascendingaorta,thusitcanmissananeurysmof
familial thoracic aortic aneurysm Syndrome, and still
themid-portionoftheascendingaorta.EvenTEEislimited
othersareidiopathic.
bytheinterposedtrachealaircolumnandcanbeìblindedî
SymptomsofAorticAneurysm totheupperportionoftheascendingaorta.Furthermore,
there is no universal agreement for exact place of aortic
Patients with a TAA are usually asymptomatic and
diametermeasurementandwhethertheaorticwallshould
diagnosedbychestX-raysorCT-scanrequestedforother
beincludedorexcludedintheaorticdiametermeasurement.
Lodip
6 Amlodipine2.5/5mgTablets
CTScan byfunctionalMRImayhaveutilityinthoracicaorticdisease
NewgenerationhelicalCTscanhassensitivityupto100% management.
andspecificitiesof98%to99%fordiagnosingabnormalities
Treatment
ofthethoracicaorta.IRADdatashowsthatinsomecenters,
Goldstandardfortreatmentoftheascendingaorticaneurysm
CThasbeenusedmorefrequentlythanEchoincaseof
isthesurgicaltreatment.However,conservativetreatment
aorticdissection.MajoradvantagesofCTscanare:very
could be advised at the initial stage with smaller aortic
wideavailability,abilitytoimageentireaorta,including
diameterandinpatientswithmorbidity,highriskfactorsfor
lumen,wallandperiaorticregion.Additionally,CTscanis
negative surgical outcome and who are not suitable for
moreorlessexactinthesizemeasurement,andithasa
surgical treatment due to other coexisting disease.
shorter examination time. Three dimensional
reconstructionsofCTimageshaveanimportantrolein In adult patients, conservative managements consist of
the planning of surgery. However, a CT scan with axial smokingcessation,lifestylemodification,astringentcontrol
imagescannotproperlyevaluatetheveryproximalportion ofhypertension,lipidprofileoptimization,andothermeasure
oftheascendingaorta.Inaddition,motionartifactcan toreduceriskofatheroscleroticprocess.
adverselyaffecttheresolutionofCTimagesoftheaorta,
Furthermore,severalothermedicaltreatmentoptionshave
althoughtechnologyisimproving,especiallywithECG
beenstudied.Inarandomizedcontrolstudyshowedthat
gatedtomographicangiography.Furthermore,riskofrenal
MarfanpatientstreateddailywithPropranololhasslowed
damagefromthecontrastmediausedduringCTscanis
aorticrootdilation(0.023vs0.084peryear).Inanotherrecent
arealobstacleinsomepatients.
randomized trial, angiotensin receptor blocker, losartan,
Angiography addedtobetablockerinagroupofpediatricpopulation
Theshapeoftheaortaisideallyseenangiographically. withMarfansyndromeshowsmoreeffectiveprotectionto
Images of the aortic contour are exceptional and slowtheprogressionofaorticrootdilatation. Additionally,
morphologyoftheaorticcanbeseenbeautifully.Thiscan amatrixmetalloproteinaseinhibitor,antibioticdoxycycline
facilitateaccuratesurgicalplanning.Additionally,itallow has shown promising effect in the slowing down of the
forevaluationandtreatmentofcoronaryarterydisease, growthrateoftheabdominalaorticaneurysm,butnostudy
aorticbranchdisease,aswellasassessmentofaorticvalve has reported effect of doxycycline on ascending aortic
and left ventricular function. However, diameter of the aneurysm.Tosummarizeit,noneofthestudieshasshown
ascending aorta from the angiographic images is not proven clinical benefit of these medical therapies in the
alwaysaccurateandsimpletocalculate.Itisnotavailable treatmentofascendingaorticaneurysm.
universallybecauseitrequiresthepresenceofexperienced
IndicationsForSurgery
physiciantoperform.Ithasdisadvantageofbeinginvasive
procedurethatistimeconsumingandrequirecontrast Ifmedicaltherapycanhaveapalliativeroleonlyinhigh-risk
mediumwithexposuretoradiation. cases,thoracicaorticaneurysmsurgerysignificantlyimproves
2-yearsurvivalfrom24%inun-operatedpatientsto70%in
MagneticResonanceImaging
patients undergoing aortic replacement surgery.
Magnetic resonance imaging (MRI) has been
recommended as the technique of first choice for the Surgical treatment is indicated in symptomatic and
detectionandfollow-upofbothaorticcomplicationsand asymptomaticpatientswithaorticdiametermorethan5.5
premorbidconditions,suchasintramuralhematoma,and cminotherwisenormalpatient,while4.0-5.0cminMarfan
aorticaneurysm.Itsotheradvantagesareabilitytoassess patientsandpatientswithgeneticallymediatedprocess.
branch artery involvement, diagnosing aortic valve Postoperative morbidity and mortality has significantly
pathology,andleftventriculardysfunction.MRIisinherently decreasedduetobetteranestheticmanagement,improved
amultiplanemodalitythatcanprovidehighqualityimages surgical techniques and progress in preoperative and
oftheaortaintransverse,axial,sagittal,andcoronalplane, postoperativecare.
aswellasinleftanteriorobliqueview.MRIhasshownhigh
Surgical treatment of the ascending aortic aneurysm
sensibility and specificity both for initial diagnosis and
compromises endovascular grafting and open surgical
progressionofaneurismaldisease.MRIoffersanon-invasive
procedure.Thedecisiontotreatananeurysmmustbemade
and accurate evaluation of TAA and it doesnít require
withsamerigorforendovasculartherapyasforopensurgical
nephro-toxiccontrastagentorionizingradiation,although
therapy.Thepresenceofasmallthoracicaneurysmisnota
ittakeslongertimetoacquireimagesandmightneed
validindicationforendovasculartherapyjustbecausestent
sedationinsomepatientsandisnotwidelyavailablein
therapyisavailable.Furthermore,stentdeploymentforthe
an emergency basis. It is also contraindicated in
ascendingaorticaneurysmisnotapprovedinmostofthe
claustrophobic patients, and patients with metallic
countries.
prosthesisandpacemakers.Useofcine-MRItechniques,
TTrruusstteedd lliinnee ooff ttrreeaattmmeenntt
combined to non-invasive haemodynamic data, offers
bothamorphologicalandfunctionalexaminationofthe
iinn IIsscchheemmiicc HHeeaarrtt
entireaorta,whichcanprovidewithinformationabout
diameter,geometry,bloodflowandaorticwallmechanical NationalBrand
properties.
FunctionalMRIExamination
Most of the study to evaluate ascending aorta using
functionalMRIhasbeendoneinMarfanpatientsorpatients
withbicuspidaorticvalve.However,itsroleinevaluating
biomechanicalpropertyoftheascendingaortainother
patientscouldbevaluableaswell.Informationsupplied GENESIS
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Rocin
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Management of Acute Ischemic Stroke:
Time is Brain
AcuteIschemicStroke(AIS)isaleading t Measurable neurologic deficit
causeofmorbidityandmortalityinadult
Exclusioncriteria
population. AIS care has undergone a
t Anyhemorrhageonneuroimaging Dr.GopalSedain
revolution since the approval of
(CTorMRI) AssistantProfessor
intravenous (IV) recombinant tissue
plasminogenactivator(rt-PA)foracute t Hypodensitygreaterthanonethird DepartmentofNeurosurgery
ischemicstrokebytheUSFoodandDrug cerebral hemisphere on CT IOM,TUTH
Administration(FDA)in1995.Asrt-PA t SystolicBloodPressure(SBP)greater m Follow-up CT or MRI scan at
has a time window of 4.5 hours, than185mmHgor approximately24hoursafterrt-PA,
numerousclinicaltrialsareongoingto before starting anticoagulation or
t Diastolic Blood Pressure (DBP)
expandtreatmentwindows,increasethe antiplateletagents
greaterthan110mmHg
numberofpatientseligiblefortherapy, m Delayantithromboticagentsfor24
and evaluate new and innovative t Serumglucoselessthan50mg/dL hoursafterrt-PA
therapies, particularly for t Plateletcountlessthan1lakh/mm3
neuroprotection. t Internationalnormalizedratio(INR) Earlydetectionofstroke
Pathophysiology greaterthan1.7 BñBalance:Asuddenlossofbalance
orcoordination,suchasnotbeingable
Inischemicstroke,decreasedorabsent t Elevated Partial Thromboplastin towalkastraightlineortouchafinger
circulatingbloodflowdeprivesneurons Time(PTT) tothenose.
of necessary metabolic substrates. t Any history of intracranial Eñ Eyes:Suddenvisionchanges,such
Becausethebraindoesnotstoreglucose, hemorrhage as or inoneeye.
ischemia is tolerated poorly. Cerebral t Arterial puncture at a F ñ Face Drooping : Droopiness or
blood flow usually is compromised noncompressiblesiteinpast7days numbnessononesideoftheface,such
becauseofocclusionofacerebralartery asanunevensmile.
t Major surgery in past 14 days
byaclot.Theamountofcollateralflow AñArmWeakness:inonearm,suchas
caninfluencethesizeoftheinfarctand t Gastrointestinal (GI) bleed or not being able to raise both arms.
ischemicpenumbra.Temperatureand hematuriainpast21days SñSpeechDifficulty:Slurredspeechor
glucosemetabolismalsohaveeffectson t Ischemic stroke, myocardial speech that is difficult to understand.
celldeathandtissueinjury.Animportant infarction,orseriousheadtrauma T ñ Time to Call : If any of the above
conceptinAISisthepenumbra.When inpast3months symptomsarepresent,it'simportantto
anarteryoccludes,neuronsareaffected callemergencyorgototheERrightaway,
Protocol
differently,dependingupontheamount evenifsymptomsseemtodisappear.Be
ofresidualbloodflow.Normalcerebral m Total dose of rt-PA: 0.9 mg/kg suretorecordthetimewhensymptoms
blood flow is greater than 50 mL/100 (maximumdose90mg) started.
mg/min.Oncebloodflowdecreasesto m Give10%asinitialIVbolus;Infuse
lessthan20mL/100mg/min,infarction remainderover1hour Technicalissues
occurs.Ifbloodflowdecreasestoless Stroke patients attend the emergency
m AdmitpatienttoanICUorstroke
than 10 mL/100 mg/min, irreversible henceemphasishastobetoeducatethe
unit for monitoring Neurologic
neuronal death occurs rapidly. Blood staffinemergencydepartmentregarding
assessments: every 15 minutes
flowbetween11and20mL/100mg/min earlydetectionofischemicstroke.The
during infusion, then every 30
is thought to represent the ischemic availability of alteplase (rt- PA) in the
minutesfornext6hours,thenevery
penumbra,anareawherethecellsare hospitalpharmacyisanotheressential
houruntil24hoursaftertreatment
functionallysilentbecauseofischemia, part. The cost of the treatment is
butarestillabletorecoverifbloodflow m BPmonitoring:every15minutesfor relativelyhigh.Alteplaseisavailablein
isrestored.Manyacutestroketherapies 2hours,thenevery30minutesfor 50mgvials(around75000NRs).A70kg
are targeted toward restoring flow or next6hours,theneveryhouruntil patientwouldrequire63mg(0.9x70)of
function to the ischemic penumbra. 24hoursaftertreatment the drug. The cost of 2 vials would be
m Administer antihypertensive around1.5lakhrupees.Consideringthe
Thrombolysis
medicationtomaintainsystolicBP longtermcostandsequelaeofischemic
The first method to restore cerebral less than or equal to 180 mm Hg stroke,itisworthconsideringtreatment
perfusionisclotlysis,withthegoalof anddiastolicBPlessthanorequal withthrombolysiswheneverappropriate.
re-establishingbloodflowtotheaffected to105mmHg rt-PAisavailableinNepalandweshould
tissue.Endogenoustissue-plasminogen m Delay placement of nasogastric useitinourpatientswheneverindicated
activator converts circulation tubes,indwellingbladdercatheters, to decrease the morbidity due to
plasminogen to plasmin, an enzyme orIApressurecatheters Ischemicstroke.
responsible for fibrin dissolution and
maintaining coagulation homeostasis.
Winner of MEDITIME 18th Issue:
Fibrinolysisisenhancedpowerfullyby
rt-PA.Patientwhoreceivedrt-PAwere
30%morelikelytohaveminimalorno Dr.KalyanSapkota Dr.RupakBhandari Dr.PukarThapa
disabilityat3months. InternalMedicine MDGP&ENT InternalMedicine
BharatpurHospital BPKISHDharan AlkaHospital
WhoshouldreceiveI/Vthrombolysis?
Dr.BholaShrestha Dr.TulikaDube Dr.PrakritiGyawali
Inclusioncriteria OrthopedicSurgeon ENTSpecialist Dermatologist
t Clinical signs and symptoms Pokhara FewaCityHospital HetaudaHospital
consistent with ischemic stroke
Dr.SagunPanta Dr.KrishnaBahadurThapa
t Patientlastseennormalwithin4.5 Psychiatry MDPhysician
hours TUTH,Kathmadu GMC,Pokhara
Hypernol
10 Propanolol10/20/40mgTablets