Diagnostic Lacunae and Implications of an Automated Implantable Cardioverter Defibrillator Implantation in a Child with Type 3 Long QT (LQT3) Syndrome

A diagnosis of congenital long QT interval syndrome based on history and electrocardiogram was made in a child in the absence of readily available genetic testing. A genotype 3 (LQT3) was suspected after exclusion of other variants as the child was non?responsive to beta?blocker and sodium channel blocker medication. As the child continues to show episodic bradycardia, polymorphic ventricular ectopy, and T?wave alternans, a single?chamber automated implantable cardioverter?defibrillator implantation was done successfully. This report highlights how the diagnosis of LQT3 was arrived at as well as the anesthetic challenges in the management of patients with LQTS.

Safety and efficacy of ayush rasayana A and B in improving functionality of the elderly – A single-arm multicenter study

Background: As per Ayurvedic classics, Ras?yana is a term used for unique therapeutic measures intended to improve cognition, memory, physical strength and delay the degenerative processes. Ayush Rasayana A & B are developed from extracts of herbs pertaining rasayana property. Aims & Objectives: To assess the safety and effectiveness of ‘Ayush Rasayana A and B’ in improving physical endurance, quality of life and cognition of elderly. Materials and Methods: This is an open label, single arm, multi-centre study among 256 apparently healthy elderly between 60?75 years. Ayush Rasayan A was given for 6 days and Ayush Rayana B for 180 days. The effect of the trial drug was seen on functional capacity, quality of life and cognitive function and, safety of the intervention was assessed through haematological and biochemical tests, clinical examination and incidence of adverse events. Results: Significant improvement in 6 minute walk test and HMSE score was observed at 187th as compared to baseline (p<0.0001). Quality of life of the participants especially in domains of physical health, social relationship and environment also improved at the end of intervention period (p<0.0001). The haematological and bio-chemical parameters showed no significant changes as compared to baseline and no adverse events were observed during the study. Conclusion: Ayush Rasayana A and Ayush Rasayana B, both were well tolerated by all the participants. This ayurvedic intervention can be safely given to apparently healthy elderly to improve their functionality, quality of life and cognition. However, a randomized controlled trial is warranted to substantiate the efficacy of this drug.

Analysis of humpback whale sounds in shallow waters of the Southeastern Arabian Sea: An indication of breeding habitat.

The primary objective of this work was to present the acoustical identification of humpback whales, detected by using an autonomous ambient noise measurement system, deployed in the shallow waters of the Southeastern Arabian Sea (SEAS) during the period January to May 2011. Seven types of sounds were detected. These were characteristically upsweeps and downsweeps along with harmonics. Sounds produced repeatedly in a specific pattern were referred to as phrases (PQRS and ABC). Repeated phrases in a particular pattern were referred to as themes, and from the spectrographic analysis, two themes (I and II) were identified. The variation in the acoustic characteristics such as fundamental frequency, range, duration of the sound unit, and the structure of the phrases and themes are discussed. Sound units were recorded from mid-January to mid-March, with a peak in February, when the mean SST is ~28°C, and no presence was recorded after mid-March. The temporal and thematic structures strongly determine the functions of the humpback whale song form. Given the use of song in the SEAS, this area is possibly used as an active breeding habitat by humpback whales during the winter season.

Superbugs causing ventilator associated pneumonia in a tertiary care hospital and the return of pre‑antibiotic era.

The rise in super bugs causing Ventilator‑Associated Pneumonia (VAP) is a major cause of mortality and morbidity despite recent advances in management owing to the looming ‘antibiotic apocalypse’. The aetiology and susceptibility pattern of the VAP isolates varies with patient population, type of intensive care unit (ICU) and is an urgent diagnostic challenge. The present study carried out for a period of one year in a tertiary care hospital, enrolled patients on mechanical ventilation (MV) for ≥48 hrs. Endotracheal aspirates (ETA) from suspected VAP patients were processed by semi quantitative method. Staphylococus aureus, members of Enterobacteriaceae were more common in early onset VAP (EOVAP), while Nonfermenting Gram negative bacilli (NFGNB) were significantly associated with late onset VAP (LOVAP). Most of the isolates were multi drug resistant (MDR) super bugs. With limited treatment options left for this crisis situation like the pre‑antibiotic era; it is an alarm for rational antibiotic therapy usage and intensive education programs.

Hand hygiene in reducing transient flora on the hands of healthcare workers: An educational intervention.

Aim: Hand hygiene has now been recognised as one of the most effective intervention to control the transmission of infections in a hospital and education is an important tool to ensure its implementation. In order to convince the users and as a part of education, it is important to generate evidence on the role of hand hygiene in reducing the bacterial fl ora on their hands. The present study was undertaken in a tertiary care hospital to demonstrate the presence of bacterial fl ora on the hands of healthcare workers (HCW) in different categories, to teach them proper hand hygiene technique using alcohol-based hand rub and determine the outcome for reduction of bacteria. Materials and Methods: A total sample size of 60 subjects including resident doctors, medical students, nurses and hospital attendants were included in the study after obtaining informed consent. Each person was educated on the technique of hand hygiene with alcohol-based hand rub and hand impressions were cultured before and after hand hygiene. All the subjects were also given a questionnaire to assess their perception on hand hygiene. The WHO posters on proper hand hygiene were displayed in the appropriate areas of the hospital in addition, as an educational tool. Results: Majority (42 out of 60) of the HCWs had bacterial count up to 100 colonies or more on both hands before the application of hand rub while working in the hospital. After use of alcohol hand rub with a proper hand hygiene technique, it was found that the percentage reduction was 95-99% among doctors and nurses, 70% among hospital attendants and 50% among sanitary attendants. Staphylococcus aureus was present on the hands of eight persons of which three were methicillin-resistant Staphylococcus aureus. Conclusions: The study demonstrates that transient bacteria are present on the hands of HCWs but majority could be removed by proper hand hygiene, which needs continuous education to be effective. It also shows that active education by demonstrating the proper hand hygiene technique and direct observation of the practices, though demanding, are ideal to understand the attitudes and practices of HCWs and helps in planning implementation strategies

Sertoli-leydig cell tumor of the ovary in a young female: a case report and literature review

Sertoli-Leydig cell tumor [SLCT] of the ovary is an exceedingly unusual neoplasm that belongs to a group of sex-cordstromal tumors of ovary and accounts for <0.5% of all primary ovarian neoplasms. We present a case of primary ovarian SLCT in a 21-year-old female, who presented with a 6-month history of a pelvic pain, acne, hirsutism, and oligomenorrhea with elevated testosterone and dehydroepiandrosterone levels. Ultrasound and contrast computed tomography revealed well-defined hyper vascular heterogeneous solid lesion in left adnexa. Magnetic resonance imaging demonstrated ovarian origin of tumor, which turned out SLCT on histopathology. In this case, we discuss multimodality imaging findings of SLCT and its management aspects with review of literature

Vancomycin‑resistant Enterococcus faecium: Report of two cases.

Vancomycin‑resistant Enterococci (VRE), especially Enterococcus faecium has emerged as an important nososcomial pathogen and represents a serious threat to patients with impaired host defense. Early detection of patients colonised or infected with VRE is an essential component of any hospital program designed to prevent nosocomial transmission of this organism. The authors report two cases of VRE isolated from blood and surgical site pus of two neonates admitted in the same neonatal unit, highlighting that early detection, prompt and appropriate infection control measures were keys to successful containment of this dreaded pathogen.

Mixed pulmonary infection in an immunocompromised patient: A rare case report.

Patients who are immunocompromised are predisposed to a variety of common and uncommon pulmonary infections. We report a case of mixed pulmonary infection by drug resistant tuberculosis with a nocardiosis in a 49-year-old man who was a known case of chronic obstructive pulmonary disease, on prolonged corticosteroid use with diabetes mellitus. Chronic use of corticosteroids is a predisposing factor for opportunistic infections, such as nocardiosis or tuberculosis. Since such a mixed infection is rare, maybe a combined approach to therapy early in the course of disease would be effective in such cases.

Prevalence of anemia and micronutrient deficiency in elderly.

Background: Untreated geriatric anemia is important to diagnose early as it is associated with greater morbidity and mortality in comparison to the anemia in younger adults. Objectives: To determine the prevalence, patterns of anaemia, and to assess haemopoietic nutrient status of geriatric population attending a hospital. Material and methods: 2540 subjects aged 60 years and above, attending our geriatric clinic were screened for presence of anemia. 100 anemic subjects were randomly selected for further characterization. Tests carried out were, pattern of anemia, full blood count, serum ferritin and stool for occult blood. Vitamin B12, folate and other additional investigations were carried out in selected patients as per study protocol. Main outcome measure: Prevalence, pattern and underlying etiologies of anemia. Results: The prevalence of anemia was 71%. Normocytic blood picture was most common. Eleven cases had absolute iron deficiency. 5 and 2 cases had low vitamin B12 and folate levels respectively. Nine out of 11 (82%) patients with depleted iron stores had positive stool occult blood. Conclusions: Screening for anemia is important in all geriatric patients seeking medical care, irrespective of the presenting illness. Also a dedicated search for micronutrient deficiency and stool occult blood should be a routine component of the etiological work up of anemic elderly.

Sodium iodide symporter, estrogen receptor, and progesterone receptor expression in carcinoma breast - An immunohistochemical analysis.

Background: Sodium iodide symporter (NIS), a transporter of iodine is essential for thyroid hormone biosynthesis. It also plays a role in the radioiodine treatment of thyroid cancers. NIS mediated radioiodine transport to breast cancers is under active investigation due to its potential therapeutic utility. Cellular localization and quantification using immunohistochemistry may provide clues for its utility in management of carcinoma breast. Materials and Methods: Human NIS (hNIS) expression was therefore assessed by utilizing a rabbit polyclonal antibody raised against a cloned hNIS in different grades of infiltrating duct carcinoma of breast and its metastatic deposits namely in lymph nodes, bone marrow, and endometrium. Further, hNIS expression was compared with prognostic markers namely estrogen receptor (ER) and progesterone receptor (PR). Results: hNIS was positive in 90.6% cases (29/32) and Scarff-Bloom-Richardson grading was done in 25 cases and 23 cases were NIS positive. Among nongraded cases, 2/2 cases of carcinoma in-situ were positive and 4/5 were positive in cases having post therapy residual tumor status. The strong positivity for hNIS was seen irrespective of ER or PR status and of grade of breast carcinoma and correlated well with western blot analysis. In all the three metastatic sites, NIS was positive in the tumor. Conclusion: These findings indicate the utility of immnohistochemistry for NIS as a new potential prognostic marker and may provide guidance for possible radio iodine therapy in breast cancer patients.

Human sodium iodide symporter (hNIS) in fibroadenoma breast—A immunohistochemical study.

Human sodium iodide symporter (hNIS), responsible for the active transport of iodine is an integral plasma membrane glycoprotein present in the thyroid cells and extrathyroid tissues like breast and salivary glands. If its functional form is unequivocally shown in benign or malignant breast tissues, then it may serve as a basis for diagnosis and treatment using radioactive iodine. With an aim to analyze the hNIS expression in a distinct benign breast condition of fibroadenoma, biopsy proven fibroadenoma tissues, normal non-lactating breast tissue and biopsy proven infiltrating duct carcinoma tissues were examined for hNIS expression using immunohistochemistry. Out of 20 biopsy proven fibroadenoma tissues, 19 (95%) showed positivity for hNIS protein and only one was negative. Of these 10% were mildly positive, 50% cases were moderately positive and 35% showed intense positivity. None of the control tissue obtained from reduction mammoplasty specimens or normal breast tissues samples (5 cms away from the tumor) were positive. hNIS was also intensely positive  in 9 out of 10 (90%) infiltrating duct carcinoma tissues and moderately positive in one case. These preliminary results show that hNIS was present in high frequency as demonstrated by immunohistochemistry in fibroadenoma breast.

Accidental intestinal myiasis caused by genus Sarcophaga.

Myiasis of different organs has been reported off and on from various regions in the world. We report a human case of intestinal myiasis caused by larvae of Sarcophaga. A 25 - year - old male presented with symptom of passage of live worms in stool. Following diagnosis and treatment the patient improved completely with cessation of maggots in stool.

Diagnosis of endocarditis caused by Mycobacterium abscessus

We report a fatal case of native valve endocarditis due to Mycobacterium abscessus in a hemodialysis patient. The diagnosis was based on culture isolation of acid-fast bacilli from peripheral blood and a permanent catheter tip, and their identification as M abscessus by a reverse hybridization-based assay and direct DNA sequencing of the 16S-23S internal transcribed spacer region. Rapid diagnosis and combination therapy are essential to minimize mortality due to this pathogen. Although combination therapy was started with clarithromycin and tigecycline, the patient refused to take clarithromycin due to severe abdominal pain. The patient became afebrile after therapy with tigecycline alone although bacteremia persisted. He was discharged against medical advice and readmitted three months later for persistent fever. His blood cultures again yielded M abscessus and a transesophageal echocardiogram showed two mobile vegetations. The patient was noncompliant with therapy and died due to cardiac arrest and multiorgan failure. This report shows that M abscessus should also be considered in the differential diagnosis of infective endocarditis in hemodialysis patients

Relationship between plasma leptin and plasma insulin levels in type-2 diabetic patients before and after treatment with glibenclamide and glimepiride.

Type 2 diabetes affects 100 million people throughout the world. Among the various factors implicated in the causation of this disease, the role of leptin, an obesity gene product, is increasingly being investigated. This especially assumes importance in the light of knowledge that obesity confers a minimum of 3-10 fold higher risk of diabetes. This study was planned to investigate the relationship between leptin and insulin levels in type 2 diabetic patients before and after treatment with glibenclamide or glimepiride. 60 type 2 diabetic patients were recruited for the study and were divided into 2 groups-one receiving glimepiride and the other group receiving glibenclamide for duration of 10 weeks. This study demonstrated a highly positive correlation of plasma leptin levels with BMI, plasma insulin and insulin resistance. No gender specific differences were observed in leptin concentrations. The study, however, failed to demonstrate any possible relationship between glycemic control as assessed by blood sugars/ glycosylated hemoglobin (HbAlc) and plasma leptin. The administration of glibenclamide or glimepiride significantly lowered blood glucose levels coupled with a decrease in (HbAlc). Both the drugs increased insulin concentrations. Glibenclamide increased leptin levels but they remained unaltered with glimepiride. Glibenclamide and glimepiride were found to be equally effective in their glucose lowering action. However, the patients receiving glibenclamide experienced higher episode of hypoglycaemic spells than those receiving glimepiride.

Subclinical sickle cell crisis during cardiopulmonary bypass timely detection and early management

Sickle cell crisis can occur during cardiopulmonary bypass for cardiac surgical procedures in patients with sickle cell hemoglobin, which could lead to hemolysis. There is a dearth of such reports from the Arab world. We hereby present two cases from Oman with subclinical sickle cell crisis during cardiopulmonary bypass. The timely detection and early management resulted in good outcome. The good clinical practice for management of such patients is also discussed

Ventricular septal defects with pressure-overloaded right ventricle haemodynamic challenges

The right ventricular function is compromised in the presence of severe pulmonary hypertension and/or severe right ventricular outflow obstruction. Evolution in the medical and surgical management has improved the outcome in pressure overloaded right ventricle [RV]. This report describes two patients, aged 16 and 4 years. Echocardiogram and cardiac catheterisation revealed a large sub aortic ventricular septal defect [VSD] with elevated pulmonary artery pressures [PAP] in the first case, and pulmonary atresia, VSD, double outlet right ventricle, severely hypoplastic LPA, and a functioning Blalok Tausig shunt in the second case. The anaesthetic challenges of RV support are described, as well as the surgical technique in VSD repair, using valved patch closure to act as a pressure release valve to decompress the RV during hypertensive episodes. An innovative surgical technique for patients with over loaded RV, which were hitherto considered inoperable, is illustrated, emphasizing the role of anaesthetic management

The marginal seal of a flowable composite, an injectable resin modified glass ionomer and a compomer in primary molars--an in vitro study.

The present study was carried out to compare the marginal microleakage of some newer materials viz. a flowable composite, an injectable resin modified glass-ionomer and a compomer in Class I cavities of 30 non carious primary molars. After 0.5% basic fuchsin dye penetration and sectioning, the teeth were studied under stereomicroscope. The results obtained revealed that flowable composite showed significantly lower microleakage (p<0.05) as compared to injectable resin-modified glass ionomer and compomer. However, no significant difference was observed when injectable resin modified glass-ionomer cement was compared to compomer. This concludes that flowable composite materials adhere better to the primary teeth than resin modified glass ionomer and compomer.