Giant Hydatid Cyst of Lungs

Introduction: Hydatid disease in humans is caused by zoonotic parasites, after accidental ingestion of food contaminated by ova of Echinococcus granulosus. Giant hydatid cyst of the lung is most commonly seen in children, but it is rare in human adults. The lung is the second most common organ affected by hydatid diseases after the liver in humans. History and radiological findings are usually helpful in diagnosing hydatid cysts, but serology can add to the diagnosis. A small pulmonary cyst may be asymptomatic; however, giant or ruptured cysts may develop fatal complications. The surgical intervention followed by pharmacological therapy is the treatment of choice for giant hydatid cysts of the lungs. Case description: Here, we present a case of giant right-side hydatid cysts, presented with complaints of dyspnea, fever, and hemoptysis. The patient was successfully managed by right thoracotomy with an uneventful postoperative course. Conclusion: Giant hydatid lung cysts can present with any respiratory symptoms with fatal outcomes. Surgery followed by pharmacotherapy is the treatment of choice for giant pulmonary hydatid cysts.

Random blood glucose on admission as prognostic factor for assessment of severity of acute myocardial infarction

Background: Assessment of risk factors or prognostic markers is essential to determine the adverse outcome related to acute myocardial infarction (AMI). The aim of the present study was to examine the role of random blood glucose as prognostic marker for assessment of severity of AMI.Methods: This prospective study was conducted on 79 patients with onset symptoms of AMI. All the patients both diabetics and non-diabetics underwent serum blood glucose estimation in the hospital. Primary endpoint of the study was all cause mortality till day 90 follow-up. The secondary end points were composite of death, reinfarction and heart failure till day 90.Mortality rate is higher in the diabetics as compared to nondiabetics.Results: The mean age group was 55.9 years. Males (86%) outnumbered females (14%). The mean BMI was 22.3±2.83. The mean random blood glucose in the study population was 138±92.9 mg/dl (7.7±5.15 mol). Of total 79 patients, 5 were diabetics, of them 2 (40%) died. Among 79 patients, 16 patients were died during 3 months following the qualifying event, 7 had heart failure and 4 had reinfarction.Conclusions: In patients with AMI, hyperglycemia should consider as one of the important prognostic marker to determine the adverse cardiovascular events.

A Prospective Study on Incidence of Peripheral Vascular Disease in Type 2 Diabetes Mellitus

Background: Diabetes levies a heavy toll on the vascular system, with both macrovascular and microvascular complications. PAD is one of the major microvascular complications of Type 2 DM [2]. PAD is highly prevalent in diabetes. It has a predilection for lower limbs. It has been assumed that the metabolic abnormality in the prediabetic phase predisposes to more distal and aggressive atherosclerosis. Methods: The duration of study was over a period of 6 month. Total 75 cases were included in this study with diabetic mellitus. This study was conducted in the Department of surgery in Krishna Mohan Medical College & Hospital, Mathura, U.P, India. Result: In our study 75 cases with diabetic mellitus were included. Out of 75 cases 64% male & 36% were female. Predominant age was >75 year followed by other age groups. In this present study, 15 cases of hypertensive & 2 cases of PVD out of hypertensive were found. Conclusion: This study suggested that incidence of PVD is about 10% in the present study. This has to be viewed seriously considering the huge diabetic population and due importance to be given for screening and prevention of PVD.

Comparison of hemodynamic responses to laryngoscopy and intubation with Truview PCDTM, McGrath® and Macintosh laryngoscope in patients undergoing coronary artery bypass grafting: A randomized prospective study.

Context: We hypothesized that reduced oropharyngolaryngeal stimulation with video laryngoscopes would attenuate hemodynamic response to laryngoscopy and intubation. Aim: Comparison of hemodynamic response to laryngoscopy and intubation with video laryngoscopes and Macintosh (MC) laryngoscope. Setting and Design: Superspecialty tertiary care public hospital; prospective, randomized control study. Methods: Sixty adult patients undergoing elective coronary artery bypass grafting (CABG) were randomly allocated to three groups of 20 each: MC, McGrath (MG), and Truview (TV). Hemodynamic parameters were serially recorded before and after intubation. Laryngoscopic grade, laryngoscopy, and tracheal intubation time, ST segment changes, and intra‑/post‑operative complications were also recorded and compared between groups. Statistical Analysis: SPSS version 17 was used, and appropriate tests applied. P < 0.05 was considered significant. Results: Heart rate and diastolic arterial pressure increased at 0 and 1 min of intubation in all the three groups (P < 0.05) while mean arterial pressure increased at 0 min in the MG and TV groups and at 1 min in all three groups (P < 0.05). A significant increase in systolic arterial pressure was only observed in TV group at 1 min (P < 0.05). These hemodynamic parameters returned to baseline by 3 min of intubation in all the groups. The intergroup comparisons of all hemodynamic parameters were not significant at any time of observation. Highest intubation difficulty score was observed with MC (2.16 ± 1.86) as compared with MG (0.55 ± 0.88) and TV (0.42 ± 0.83) groups (P = 0.003 and P = 0.001, respectively). However, duration of laryngoscopy and intubation was significantly less in MC (36.68 ± 16.15 s) as compared with MG (75.25 ± 30.94 s) and TV (60.47 ± 27.45 s) groups (P = 0.000 and 0.003, respectively). Conclusions: Video laryngoscopes did not demonstrate any advantage in terms of hemodynamic response in patients with normal airway undergoing CABG.

Where does the pulmonary artery catheter float: Transesophageal echocardiography evaluation.

Background: Pulmonary artery (PA) catheter provides a variety of cardiac and hemodynamic parameters. In majority of the patients, the catheter tends to float in the right pulmonary artery (RPA) than the left pulmonary artery (LPA). We evaluated the location of PA catheter with the help of transesophageal echocardiography (TEE) to know the incidence of its localization. Three views were utilized for this purpose; midesophageal ascending aorta (AA) short‑axis view, modified mid esophageal aortic valve long‑axis view, and modified bicaval view. Methods: We enrolled 135 patients undergoing elective cardiac surgery where both the PA catheter and TEE were to be used; for this prospective observational study. PA catheter was visualized by TEE in the above mentioned views and the degree of clarity of visualization by three views was also noted. Position of the PA catheter was further confirmed by a postoperative chest radiograph. Results: One patient was excluded from the data analysis. PA catheter was visualized in RPA in 129 patients (96%) and in LPA in 4 patients (3%). In 1 patient, the catheter was visualized in main PA in the chest radiograph. The midesophageal AA short‑axis, modified aortic valve long‑axis, and modified bicaval view provided good visualization in 51.45%, 57.4%, and 62.3% patients respectively. Taken together, PA catheter visualization was good in 128 (95.5%) patients. Conclusion: We conclude that the PA catheter has a high probability of entering the RPA as compared to LPA (96% vs. 3%) and TEE provides good visualization of the catheter in RPA.

Acute and sub-acute toxicity studies of Passiflora nepalensis in rats

This study was designed to elucidate the toxicity of widely used plant Passiflora nepalensis Walp. (Passifloraceae) in rats. We have taken methanolic extract isolated from whole plant of Passiflora nepalensis and studied their toxic effects. Acute, sub-acute toxicities and LD50 values were determined in experimental rats. The external appearance of the dead animals, the appearance of the viscera, heart, lungs, stomach, intestine, liver, kidney, spleen and brain were carefully noted and any apparent and significant features or differences from the normal were recorded after acute treatment with methanolic extract of whole plant of Passiflora nepalensis (MPN). Following the sub-acute administration of MPN for fourteen days, the vital organ such as liver, kidney and heart were carefully evaluated by histopathological and biochemical studies and any apparent and significant changes or differences from the normal were recorded. Pathologically, neither gross abnormalities nor histopathological changes were observed. Oral administration of MPN at the doses of 40, 80, 160 and 320 mg/kg body wt for fourteen consecutive days to male and female rats did not induce any short term toxicity. Collectively, these data demonstrate that the methanolic extract of Passiflora nepalensis have a high margin of safety.

Cardioprotective effect of Bombax ceiba flowers against acute adriamycin-induced myocardial infarction in rats

The present study was designed to evaluate the cardioprotective potential of aqueous flower extract of Bombax ceiba L., Malvaceae (BC), on the basis of biochemical and histopathological parameters in Adriamycin (Adr) induced myocardial infarction in rats and to compare with vitamin E, a known cardioprotective antioxidant. Male Wister rats were used as in vivo model for the study. BC was administered orally to Wister rats at different doses (150 mg/kg, 300 mg/kg and 450 mg/kg, b.w.) for six days/week for four weeks. Thereafter, all the groups except saline were administered Adr (20 mg/kg, i.p.). There was a significant decrease in myocardial superoxide dismutase, catalase and reduced glutathione in animals treated with Adr. Concurrently marked increase in extent of lipid peroxidation was reported. Co-treatment of BC/vitamin E and Adr resulted in an increase in the cardiac antioxidant enzymes and reduction in lipid peroxidation as compared to Adr-treated animals. Adr showed significant decrease (p<0.001) in the level of cardiac marker enzymes [Lactate dehydrogenase (LDH) and Serum glutamic oxaloacetic transaminase (SGOT)] in heart homogenate with corresponding increase in their level in serum. In BC/vitamin E treated groups significant increase (p<0.001) of LDH in heart homogenate and decrease of SGOT and LDH in serum were observed. Microscopic studies in Adr-treated animals revealed mitochondrial swelling, leukocyte infiltration, lipid inclusions and myofibrillar loss whereas the pre-treatment with BC/vitamin E led to a lesser degree of Adr-induced histological alterations. These findings suggest that aqueous flower extract of BC has protective effect against Adr-induced cardiotoxicity and may have potential as a cardioprotective agent.

Anesthetic management for emergency cesarean section and aortic valve replacement in a parturient with severe bicuspid aortic valve stenosis and congestive heart failure.

Asymptomatic women with mild aortic stenosis (AS) and normal left ventricular functions can successfully carry pregnancy to term and have vaginal deliveries. However, severe AS (valve area <1.0cm 2 ) can result in rapid clinical deterioration and maternal and fetal mortality. So, these patients require treatment of AS before conception or during pregnancy preferably in the second trimester. In suitable patients percutaneous balloon aortic valvutomy appears to carry lower risk. It can also be used as a palliative procedure allowing deferral of aortic valve replacement until after delivery. The present patient had severe critical AS with congestive heart failure that was refractory to medical therapy and the fetus was viable (>28wks). So, combined lower segment cesarean section and aortic valve replacement were performed under opioid based general anesthesia technique to reduce the cardiac morbidity and mortality.

Anesthetic management of patient with myasthenia gravis and uncontrolled hyperthyroidism for thymectomy.

The relationship between myasthenia gravis (MG) and other autoimmune disorders like hyperthyroidism is well known. It may manifest earlier, concurrently orafter the appearance of MG. The effect of treatment of hyperthyroidism on the control of MG is variable. There may be resolution or conversely, deterioration of the symptoms also. We present a patient who was diagnosed to be hyperthyroid two and half years before the appearance of myasthenic symptoms. Pharmacotherapy for three months neither improved the myasthenic symptoms nor the thyroid function tests. Thymectomy resulted in control of MG as well as hyperthyroidism. In conclusion, effective control of hyperthyroidism in the presence of MG may be difficult. The authors opine that careful peri-operative management of thymectomy is possible in a hyperthyroid state.

Efficacy and safety of PDE-5 inhibitor tadalafil in pulmonary arterial hypertension.

BACKGROUND: Pulmonary arterial hypertension (PAH) is a life threatening disease for which phosphodiesterase-5 inhibitor sildenafil is recently approved. We aimed to evaluate the efficacy and safety of tadalafil, a long acting congener of sildenafil, in treatment of PAH related to previous left to right shunt lesions. METHODS: In this blinded, cross over study, 11 patients with severe PAH related to congenital left to right shunt lesions (Eisenmenger syndrome) were randomly assigned to tadalafil (20 mg daily) or placebo for 4 weeks period, separated by a wash out period of at least 2 weeks. They were symptomatic with a six minute walk distance (6MWD)>or=50 m. The change in 6MWD, echo-Doppler determined pulmonary artery systolic pressure (PASP), WHO Class and modified Borg Dyspnea Index (BDI) were assessed after each therapy. RESULTS: Eight patients who completed the study protocol were analyzed. Tadalafil was associated with a significant increase in 6MWD (mean 409.25 SD 40.25 m vs 319.37 SD 42.39 m, p<0.0001), reduction in PASP (88.75 SD 23.26 mmHg vs 109.5 SD 23.78 mmHg, p<0.0001), improvement in BDI (4.62 SD 2.56 vs 6.37 SD 2.61, p=0.021) and WHO Class (6 patients vs 2 patients), compared to placebo. Tadalafil was well tolerated with no significant untoward effects. CONCLUSIONS: Tadalafil, in patients with PAH related to previous congenital left to right shunt lesions, lead to a significant improvement in exercise capacity (6MWD), PASP and WHO Class with reduced perceived exertion and was well tolerated.

Preoperative autologous plateletpheresis in patients undergoing open heart surgery.

Blood conservation is an important aspect of care provided to the patients undergoing cardiac operations with cardiopulmonary bypass (CPB). It is even more important in patients with anticipated prolonged CPB, redo cardiac surgery, patients having negative blood group and in patients undergoing emergency cardiac surgery. In prolonged CPB the blood is subjected to more destruction of important coagulation factors, in redo surgery the separation of adhesions leads to increased bleeding and difficulty in achieving the haemostasis and in patients with negative blood group and emergency operations, the availability of sufficient blood can be a problem. Harvesting the autologous platelet rich plasma (PRP) can be a useful method of blood conservation in these patients. The above four categories of patients were prospectively studied, using either autologous whole blood donation or autologous platelet rich plasma (PRP) harvest in the immediate pre-bypass period. Forty two patients were included in the study and randomly divided into two equal groups of 21 each, control group (Group I) in which one unit of whole blood was withdrawn, and PRP group (Group II) where autologous plateletpheresis was utilised. After reversal of heparin, autologous whole blood was transfused in the control group and autologous PRP was transfused in the PRP group. The chest tube drainage and the requirement of homologous blood and blood products were recorded. Average PRP harvest was 643.33 +/- 133.51 mL in PRP group and the mean whole blood donation was 333.75 +/- 79.58 mL in the control group. Demographic, preoperative and intra operative data showed no statistically significant differences between the two groups. The PRP group patients drained 26.44% less (p<0.001) and required 38.5% less homologous blood and blood products (p<0.05), in the postoperative period. Haemoglobin levels on day zero (day of operation) and day three were statistically not different between the two groups. We conclude that autologous plateletpheresis is a better method of blood conservation in terms of better haemostasis, and less requirement of blood and blood products in the postoperative period as compared with the autologous whole blood donation. This technique can be especially useful in the above-mentioned categories of patients.

Anaesthetic Considerations for Noncoronary Surgery on a Perfused Beating Heart under Cardiopulmonary Bypass.

Myocardial revascularisation on a beating heart with or without cardiopulmonary bypass has significantly reduced the incidence of cardioplegic myocardial injury. With this advantage in view, noncoronary open heart surgery was performed on a beating heart under cardiopulmonary bypass. We discuss the anaesthetic management of such cases. Thirty-three patients aged 14-56 years underwent open heart surgery on a perfused beating heart. Eleven of them underwent open mitral valvotomy, eighteen underwent mitral valve replacement, repair of atrial septal defect was performed in 3 patients and one had removal of left atrial myxoma. Cardiopulmonary bypass was instituted with aortic and bicaval cannulation. At normothermia, aorta was cross-clamped and continuous coronary perfusion was maintained through an aortic root needle at a rate of 4-6 mL/Kg/minute facilitating a beating heart. Trans-oesophageal echocardiography was routinely deployed. Anaesthetic considerations were focused towards the maintenance of the beating state of the heart, that included, strict control of electrolyte balance, maintenance of adequate perfusion pressure and ST segment monitoring. All the patients could be weaned off cardiopulmonary bypass without defibrillation or significant inotropic support. There was no operative mortality. Open heart surgery on a beating heart for non-coronary cardiac conditions appears to be a good and reproducible option to protect the myocardium from deleterious effects of cardioplegic arrest.