Anaerobes in cardiac infections: A decade experience from the tertiary care center

Purpose: Anaerobic infections are common yet life-threatening. They are being recovered from all sites of the body, including the cardiovascular system. This study was aimed to determine the retrospective analysis on the isolation of anaerobes in cardiovascular samples received for a decade-long duration. It helps in knowing the frequency of isolation of anaerobic causes of cardiovascular infection. Methods: All cardiovascular samples from the department of Cardio-thoracic vascular surgery from January 2010 to December 2020 were studied. Results: Of 601 samples received, predominant samples were vegetations and valvular tissues of 258, followed by 98 samples of pericardial tissues, 92 samples of embolus, 90 samples of blood and post-operative collections, and 63 excised aneurysms and vascular grafts. Of the total, 15 samples grew anaerobes where Clostridium species were the predominant isolates. Clostridioides difficile was isolated in 2 samples. Conclusions: Anaerobes in cardiovascular samples are uncommon yet form a significant cause of morbidity and mortality. Most infections are from the contiguous spread, penetrating trauma, and hematogenous causing endocarditis or valvular infections. These conditions and samples form the seat of infectious focus and clinical suspicion towards the anaerobic cause of these conditions, especially in conventional routine culture-negative samples. Timely diagnosis of anaerobic infections plays a vital role in the good prognostic outcome of patients undergoing cardiothoracic and vascular surgery.

Synthesis, Spectral Characterization of Cu (Ii) and Ni (Ii) Complexes with Thiosemicarbazones and Semicarbazones Derived from Pyridine-2-Carboxaldehyde.

Ni (II) and Cu (II) complexes were synthesized with L1(Pyridine-2-carboxaldehydethiosemicarbazones) and L2 (Pyridine-2-carboxaldehydesemicarbazones). These complexes were characterized by elemental analysis, molar conductance measurements, magnetic susceptibility measurements, mass, IR, electronic and EPR spectral studies. The molar conductance measurements on the complexes in DMSO correspond to non electrolytes nature with L1. The molar conductance measurements with L2 lie in the range 210-226 Ω-1cm2mol-1 indicating the complexes were 1:2 electrolyte thus the complexes may be formulated as [M(L)2]X2 where M= Ni (II) and Cu (II) complexes. On the basis of spectral studies an octahedral geometry has been assigned for Ni (II) complexes. A tetragonal geometry suggested for Cu (II) complexes.

Tobacco Consumption Practices among the School Students.

Research question: What is the prevalence of tobacco consumption in school students of Anand Taluka in Gujarat. Settings: Urban and rural areas of Anand taluka of Gujarat. Study design: A cross-sectional study. Participants: School students of class 11th and 12th of selected schools. Methodology: Sample size taken for the study purpose was 1200 in accordance with the prevalence of tobacco consumption in Kheda district of Gujarat. The study was conducted with the help of pre-tested, self-administered questionnaire. Urban and rural areas were selected by simple random sampling and school students were selected by systematic random sampling. Results: The prevalence of current tobacco users was found to be 8.2%. Chewing is the most preferable form of tobacco use. Maximum number of users started tobacco use at the age of 11-15. The study showed a lack of knowledge in the students regarding the consequences of tobacco use. Friend’s and teacher’s smoking behaviour is significantly associated with student’s tobacco consumption.

An epidemiological study of health and nutritional status of under five children in semi-urban community of Gujarat.

In developing countries, children of 0-5 years of age form a large as well as "high risk" group. Malnutrition poses a grave risk to the health of these children. The main objectives of this study were to assess the health & nutritional status of children of 0-5 years of age group & to study the influence of various epidemiological factors on health & nutritional status of children on 0-5 years of age group. It is a community based cross sectional study done in randomly selected three wards of Petlad town, district Anand in Gujarat state. 300 children of age group 0-5 years selected by systematic sampling method. Mother of each child included in the study was subjected to personal interview in her own house followed by clinical examination & anthropometric measurements of the child. The three indices of nutritional status namely, weight for age, height for age, & weight for height were expressed in standard deviation units from the median for the international reference populations as per WHONCHS standards & were compared with WHONCHS growth reference data. The prevalence of under weight (wt. for age below 2SD) was 43.67%. 50.3% children were found stunted (ht. 1br age below -2 SID) with higher prevalence in 2nd and 5th year of life. Prevalence of wasting (wt. for ht. below 2SD) was comparatively low (23.2% with a peak in 3rd year of life). These nutritional parameters showed a significant association with parental education, socio-economic status, family size, environmental conditions (safe drink water, sanitary waste disposal & overcrowding), & episodes of common diseases.

Management of bio-medical waste: awareness and practices in a district of Gujarat.

With the objective of assessing the level of awareness about the various aspects of biomedical waste and disposal practices by the medical practitioners this study was conducted. It was a cross sectional study. 30 hospitals with more than 30 beds minimum were randomly selected from Sabarkantha district, Gujarat. The doctors and auxiliary staff of those 30 hospitals were the study population. While all the doctors knew about the existence of the law related to biomedical waste but details were not known. Doctors were aware of risk of HIV and Hepatitis B and C, whereas auxiliary staff (ward boys, ayabens, sweepers) had very poor knowledge about it. There was no effective waste segregation, collection, transportation and disposal system at any hospital in the district. There is an immediate and urgent need to train and educate all doctors and the staff to adopt an effective waste management practices.

Anterior urethral valves.

Posterior urethral valves (PUV) are the most frequent cause of obstructive uropathy in boys. Rarer causes of obstructive uropathy include bladder diverticulae, meatal stenosis and urethral or bladder stones. Anterior urethral valves are rare causes of urinary obstruction in boys and are ten times less frequent than PUV in the literature(1-6). This paper highlights our experience with 5 patients with anterior urethral valves.

Ten-year experience with the arterial switch operation.

BACKGROUND: Arterial level repair is considered the most appropriate procedure for transposition of the great arteries. This report describes our experience with the arterial switch operation over the past decade. METHODS AND RESULTS: From January 1991 to January 2001, a total of 299 patients underwent an arterial switch operation for transposition of the great arteries or double-outlet right ventricle. Group I (n=169, 56.5%) comprised patients with transposition of the great arteries in whom the ventricular septum was essentially intact. Group II patients (n=130, 43.5%) had transposition of the great arteries with an additional significant ventricular septal defect or had double-outlet right ventricle with a subpulmonic ventricular septal defect. Of the total, 245 (82%) were males and 54 (18%) were females. In group I, the ages ranged from 2 days to 18 years (median 19 days) and weight ranged from 1.7 to 68 kg (median 2.5 kg). In group II, the ages ranged from 4 days to 4 years (median 90 days) and weight ranged from 2.5 to 17 kg (median 4 kg). Fifteen percent of the patients (25/169) in group I and 30% of the patients (39/130) in group II had features of bacteriologic infection. Arterial switch operation was performed on standard lines. In group I, 141 patients (83.4%) had a primary arterial switch operation while 28 (16.6%) underwent a rapid two-stage repair. Twenty-three patients required concomitant relief of associated anatomic left ventricular outflow tract obstruction. Operative mortality was 8.8% (15/169) in group I and 33% (44/130) in group II with an overall mortality of 19% (59/299). The major causes of operative mortality included pulmonary arterial hypertensive crisis (n=21), sepsis and related complications (n=16), and left ventricular failure (n=8). Coexisting arch anomalies, longer cross-clamp time, late presentation, and preoperative bacteriologic infections were incremental risk factors. Follow-up ranged from 1 to 10 years and was 87% complete. On follow-up, 91% of the patients were asymptomatic and off all medications. There were 3 late deaths and 5 patients required reoperation. CONCLUSIONS: Excellent long-term results are obtained in operative survivors following the arterial switch operation. However. operative mortality remains a concern in our set-up.

Sleep disorders versus epilepsy: use of video EEG as a diagnostic tool.

Sleep disorders, especially parasomnias, are easily confused with the nocturnal epilepsies. Two cases are presented to show how misdiagnosis can occur, and video electroencephalogram can be used to resolve the issue so as to prescribe the specific treatment, avoid wrong treatment and unnecessary suffering.

Total anomalous pulmonary venous connection: surgical experience in Indians.

BACKGROUND: We report a retrospective analysis of the demographic. morphological and clinical profiles of patients along with results of operative repair for total anomalous pulmonary venous connection. METHODS AND RESULTS: In the last 15 years, 248 patients (168 boys, 80 girls) underwent repair for total anomalous pulmonary venous connection. Their ages ranged from I day to 24 years (median 8 months) and 145 of them were < or = 1 year of age. The patients' weight ranged from 2 to 52 kg (median 5 kg). About 70% of patients (n = 174) were less than the 50th percentile of predicted weight for age and sex. The anomalous connection was supracardiac in 134 (54%), cardiac in 80 (32.2%), infracardiac in 9 (3.6%) and mixed in 25 (10.1%) patients. Fifty (20.2%) patients had obstructed drainage and 76 patients (30.2%) had moderate or severe pulmonary arterial hypertension. Forty-five patients (18.1%) had to be operated upon on an emergency basis. All the patients were operated upon using moderately hypothermic cardiopulmonary bypass. In 114 patients, circulatory arrest was used. There were 45 (19.1%) in-hospital deaths. The major causes of early death were pulmonary arterial hypertensive crisis in 19 (7.7%) and low cardiac output syndrome in 17 (6.9%) patients. Age < or = 1 year (odds ratio 2.16; 95% confidence interval: 1.22-3.82, p=0.008), severe pulmonary arterial hypertension (odds ratio 5.86; 95% confidence interval: 2-17, p=0.001), and need for emergency surgery (odds ratio 3.65; 95% confidence interval: 1.59-8.38, p=0.002) were independent risk factors for early death. Follow-up ranged from 1 to 180 months (median 48 months). There were 4 lake deaths. Actuarial survival at 12 years was 92.6% +/- 2.8%. CONCLUSIONS: In Indian circumstances, mortality continues to be high in infants with total anomalous pulmonary venous connection. Severe pulmonary arterial hypertension appears to be the most important predictor of operative mortality. Severe malnutrition, delayed diagnosis and late referrals possibly contribute to the high mortality.

Surgical experience with dissecting and nondissecting aneurysms of the ascending aorta.

BACKGROUND: Patients who underwent replacement of the ascending aorta with a prosthetic graft for treatment of ascending aortic aneurysm and dissection between January 1992 and December 2000 were studied. METHODS AND RESULTS: Bentall's operation, using a composite aortic valve and prosthetic graft. was performed in 82 patients (70 males). Indications for the procedure included ascending aortic aneurysm (n=54 including 16 patients with Marfan's syndrome): DeBakey Type I or II aortic dissection (n=26 including 10 patients with Marfan's syndrome) and ascending aortic aneurysm with severe aortic stenosis (bicuspid aortic valve disease) (n=2). Bentall's procedure with the inclusion technique was performed in 72 patients and a Cabrol fistula created in 63 patients. In 10 other patients, coronary button transfer was done without a Cabrol fistula. There were 6 early deaths (7.3%) and 8 patients required re-exploration for excessive bleeding. Eighteen patients showed low cardiac output while the wound of 8 became infected. Postoperative arrhythmia and renal failure was seen in 26 and 6 patients, respectively. Four patients had pericardial effusion. Follow-up ranged from 1 month to 8 years. There were 8 late deaths, the causes of which include congestive heart failure (n=3). cerebral hemorrhage (n=3) and sudden cardiac death (n=2). Two patients reported back with dissection of the descending thoracic aorta and await surgery. CONCLUSIONS: Bentall's operation is a safe procedure with an acceptable mortality and morbidity.

Omentopexy for limb salvage in Buerger's disease: indications, technique and results.

Buerger's disease is a limb-threatening condition occurring in the young and productive age group and its management has always been a challenging problem. A large number of medical and surgical options have been suggested, but the quest for an ideal solution to this problem continues. Omentopexy for Buerger's disease is an attractive option, which is rapidly gaining popularity. We discuss the historical aspects, technical considerations and results of omental transfer for this limb-threatening condition. In doing so, the relevant literature on the subject has been extensively reviewed. In all published series, there has been marked improvement in intermittent claudication and rest pain. Ischaemic ulcers have healed and the progression of gangrene has stopped. If carried out with the complete understanding of the anatomy of the omental vascular arcade, the results of omentopexy are gratifying, thus avoiding amputation and conserving the limb.

Does inhaled nitric oxide improve survival in operated congenital disease with severe pulmonary hypertension?

BACKGROUND: The present study aimed to assess the impact of inhaled nitric oxide on survival following correction of congenital heart defects with residual pulmonary arterial hypertension. METHODS AND RESULTS: Inhaled nitric oxide was utilized for the management of residual pulmonary hypertension in 24 children following surgical correction of their underlying heart defects. Their ages ranged from 15 days to 14 months (median 5 months). Pulmonary artery hypertension was diagnosed either by direct pulmonary artery pressure monitoring or by echocardiography. Inhaled nitric oxide was used electively in 22 patients when the ratio of the mean pulmonary arterial pressure and mean systemic arterial pressure exceeded 0.5. In the remaining 2 patients, nitric oxide was used only to manage a pulmonary hypertensive crisis. Inhaled nitric oxide was also used a second time in 2 patients who developed delayed pulmonary hypertensive crisis. Twenty-two patients showed an initial response to therapy and the pulmonary artery pressures dropped significantly. Of the patients on direct pulmonary artery pressure monitoring, a pulmonary artery to systemic artery pressure ratio below 0.3 on prolonged therapy was associated with a survival ratio of 4/6 (including 1 neurological death and one reoperation); that between 0.3 and 0.5 with a survival ratio of 3/4. Three out of four patients with sustained echocardiographic and clinical response also survived and were discharged from the hospital. All the patients who showed a lack of response to (n=2), tolerance to (n=1), or dependence on (n=6) the use of inhaled nitric oxide died. In addition, all 5 patients who had a pulmonary hypertensive crisis died, 3 in spite of successful resuscitation with nitric oxide. Thus, excluding one neurological death and one re-operation, only 9 (41%) out of 22 patients survived. CONCLUSIONS: Though inhaled nitric oxide is effective in lowering pulmonary pressure, it does not appear to improve the survival rate following repair of congenital heart disease in those with associated severe pulmonary hypertension. A randomized trial between the use and non-use of inhaled nitric oxide is warranted to determine its exact role in influencing survival in patients with residual pulmonary hypertension following surgical repair.

Cardiac arrhythmias in surgically repaired total anomalous pulmonary venous connection: a follow-up study.

Twenty-five patients with diagnosis of total anomalous pulmonary venous connection, who had undergone corrective surgery, were studied at variable time period after surgery with 24-hour ambulatory electrocardiographic monitoring (Holter) and echocardiography. The aim of this study was to record arrhythmias, if any, and to correlate occurrence of arrhythmia with adequacy of repair and other related variables. All the patients were clinically asymptomatic. Twenty-four hours ambulatory electrocardiographic monitoring of these patients showed the presence of significant arrhythmias in 21 of the 25 patients. These included supraventricular ectopics in 19 patients, ventricular ectopics in 8, atrioventricular block in 2, right bundle branch block and atrial fibrillation 1 each and atrial tachycardia in 2 patients. There was no correlation between development of arrhythmia and age at repair, type of connection, operative approach and adequacy of repair. The study indicates that cardiac arrhythmias can occur in otherwise asymptomatic patients after correction for total anomalous pulmonary venous connection. Thus, these patients require long-term follow-up, even if they are asymptomatic.

Iatrogenic esophageal perforation during devascularization procedure managed with Thal wrap.

We describe the successful use of 270 degrees Thal's partial fundal wrap to close an iatrogenic esophageal perforation in a patient who underwent devascularization and splenectomy after failure of sclerotherapy for bleeding esophageal varices.

Post-infarction ischaemic mitral regurgitation: what determines the outcome.

Ischaemic mitral regurgitation is an important determinant of survival in patients with coronary artery disease. A retrospective analysis was performed to evaluate the overall outcome and its determinants in patients with ischaemic mitral regurgitation. Over a period of 10 years, 72 patients underwent operations for mitral regurgitation of ischaemic origin. Age ranged from 37 to 68 years (mean 54.6 +/- 10.4 years), and 62 (86.1%) were male. Thirteen (18%) patients had acute and 59 (82%) had chronic ischaemic mitral regurgitation. Twenty-one patients were in New York Heart Association class II, 32 in class III and 19 in class IV. Moderate to severe left ventricular dysfunction was present in 42 patients. Valve prolapse was present in 35 (48.6%) patients and restricted leaflet motion secondary to myocardial dysfunction was present in 37 (51.4%) patients. All the patients were operated using standard cardiopulmonary bypass technique. Mitral valve was replaced in 33 patients and repaired in 39. Repair included a combination of techniques: chordal transposition (n = 2), chordal shortening (n = 18), leaflet resection (n = 2), posterior collar annuloplasty (n = 35) and annuloplasty with flexible Duran's ring (n = 3). Operative mortality was 18.1 percent (13/72). Low cardiac output was the cause of death in the majority (n = 10). Acute presentation and presence of restricted leaflet motion were the significant predictors of early mortality. Follow-up ranged from 3 to 84 months (mean 41.6 +/- 10.2 months). Late mortality was 46.2 percent. Actuarial survival in operative survivors at five years was 44.4 +/- 8.8 percent. To conclude, ischaemic mitral regurgitation carries a poor early and late outcome, with left ventricular dysfunction and presence of restricted leaflet motion being important contributors to it. In addition, acute presentation also reflects greater early mortality.

Clinical profile of AIDS: a study at a referral hospital.

The present study describes the clinical and epidemiological features of 74 patients with human immunodeficiency virus (HIV) infection who presented to a referral hospital. Sixty two patients (83.7%) were diagnosed to have acquired immune deficiency syndrome (AIDS). Mean age of the patients was 34.9 +/- 12 years and male to female ratio was 3:1. Majority of patients (80%) were from lower socio-economic class. Multiple unprotected heterosexual contact with commercial sex workers in metropolitan cities of India, mainly Mumbai, was major risk factor in 82.1% male patients while most of the females (66.6%) had acquired infection from HIV positive husbands. Blood transfusion was the risk factor in 9(12.1%) patients. Sixty eight patients were infected with HIV 1, one with HIV 2, and five patients with both HIV 1 and HIV 2. Fever and weight loss were the commonest presenting symptoms. Tuberculosis, oropharyngeal candidiasis, and interstitial pneumonitis were present in 54.8%, 40.3% and 20.9% patients, respectively. Fourteen patients (22.5%) had generalised lymphadenopathy. Herpes zoster, cryptococcal meningitis, and peripheral neuropathy were infrequent. Response to standard antifungal and antitubercular treatment was satisfactory. Kaposi's sarcoma, lymphoma, and CNS toxoplasmosis were not found. The clinical manifestations of AIDS patients are strikingly different from that in the Western countries. It, thus, necessitates setting up of different guidelines for the clinical diagnosis and management of AIDS in India.

Normothermic cardiopulmonary bypass & post-operative blood loss.

Normothermic cardiopulmonary bypass (CPB) has been shown to have less disruptive effects on coagulation factors and platelet function. Ninety patients undergoing valvular heart surgery were randomly divided into two groups of 45 patients each to undergo normothermic (35 degrees C-37 degrees C) or hypothermic (28 degrees C) bypass. We found normothermic bypass to significantly reduce bypass time and requirements of fluid and blood post-operatively. However, there was no reduction in post-operative blood loss, re-exploration rate or blood product requirements by use of normothermic cardiopulmonary bypass.

Surgery for aortic valve endocarditis.

From March 1994 to March 1997, 36 patients with aortic valve endocarditis were managed surgically. Of these, 30 patients had native valve endocarditis and six had prosthetic valve endocarditis. In patients with native valve endocarditis, surgical procedures included aortic valve repair (n=6), homograft aortic valve replacement (n=9), Ross procedure (n=5) and prosthetic aortic valve replacement (n=10). There were three early and two late deaths in this group. In patients with prosthetic valve endocarditis, aortic valve replacement with a homograft was performed in all. Active infection and prosthetic valve endocarditis were the most important predictors of early mortality. The availability of a homograft valve provides an alternative to prosthetic valve replacement in patients with aortic valve endocarditis.