Indian Guidelines for Indications and Timing of Intervention for Common Congenital Heart Diseases: Revised and Updated Consensus Statement of the Working Group on Management of Congenital Heart Diseases. Abridged Secondary Publication

ustification: A number of guidelines are available for management of congenital heart diseases from infancy to adult life. However,these guidelines are for patients living in high income countries. Separate guidelines, applicable to Indian children, are required whenrecommending an intervention for congenital heart diseases, as often these patients present late in the course of the disease and mayhave co-existing morbidities and malnutrition. Process: Guidelines emerged following expert deliberations at the National ConsensusMeeting on Management of Congenital Heart Diseases in India, held on 10th and 11th of August 2018 at the All India Institute of MedicalSciences, New Delhi. The meeting was supported by Children’s HeartLink, a non-governmental organization based in Minnesota, USA.Objectives: To frame evidence based guidelines for (i) indications and optimal timing of intervention in common congenital heartdiseases; (ii) follow-up protocols for patients who have undergone cardiac surgery/catheter interventions for congenital heart diseases.Recommendations: Evidence based recommendations are provided for indications and timing of intervention in common congenitalheart diseases, including left-to-right shunts (atrial septal defect, ventricular septal defect, atrioventricular septal defect, patent ductusarteriosus and others), obstructive lesions (pulmonary stenosis, aortic stenosis and coarctation of aorta) and cyanotic congenital heartdiseases (tetralogy of Fallot, transposition of great arteries, univentricular hearts, total anomalous pulmonary venous connection, Ebsteinanomaly and others). In addition, protocols for follow-up of post surgical patients are also described, disease wise.

Early Outcomes of Neonatal Cardiac Surgery in India

Objective: To assess outcomes and factors influencing outcomes in neonates requiringcardiac surgery in India. Methods: This study reports on review of hospital data from atertiary care cardiac surgical institute from January-2009 to December-2015. Results: A totalof 200 neonates were included; of them, 5% of the cases were antenatally diagnosed andmost of them had unmonitored transport (111, 55.5%). The overall mortality rate was 13.5%,(n=27) and 178 (89%) underwent complete defect repair. There was a significant associationof mortality with shock, the number of inotropes, intra-operative procedure, residual lesion,aortic cross-clamp and deep hypothermic circulatory arrest time (all P<0.05). Logisticregression analysis showed ventilation duration, cardiac-bypass time, shock, and residualcardiac lesion as independent predictors of mortality. Conclusion: Cardiac defects werefound to have late detection and most transports were unmonitored. Complete surgical repairand shorter cardiac bypass time can potentially improve neonatal cardiac surgical outcomes

Financial audit of wastage of anticancer drugs: Pilot study from a tertiary care center in India

"PURPOSE: Drug wastage is a major concern in oncology where costs of antineoplastic drugs are exorbitant, and the disposal of toxic drugs increases the chances of occupational hazards to healthcare and sanitary workers and environmental pollution at the site of disposal. The principal objective of this study was to ascertain the extent of drug wastage and calculate its financial costs. MATERIALS AND METHODS: This was a prospective pilot study conducted to ascertain the quantity of drug wastage in a tertiary care hospital.This pilot study was conducted in day care and inpatient facilities in February 2016. The prescription of cytotoxic drugs, recommended dose, the quantity used, and remainder (waste) left were recorded from the nurses and pharmacy files of the hospital. Cost evaluation of the actual use and the waste was undertaken and an audit was conducted to understand in which anticancer drug the maximum wastage was generated. RESULTS: The results of this study indicated that 6.1% of the total amount of reconstituted drugs was wasted. The highest drug wastage was observed in trastuzumab (29.55%), followed by etoposide (20.4%), dacarbazine (17.14%), daunorubicin (16.67%), and carboplatin (11.29%). Cost analysis showed that the total cost of the drug issued during the study period was Rs. 1,294,975 and the cost of drug wastage amounted to Rs. 143,820 (11.1%). CONCLUSION: To the best of authors’ knowledge, this is the first study from India and the results indicate that the financial impact of anticancer drug wastage was substantial. Attempts should be directed at minimizing the wastage and cost savings without risking patients’ treatment regimen and administering effective dose schedule."

Chronic periodontitis prevalence and the inflammatory burden in a sample population from South India

Periodontal diseases are among the most prevalent oral diseases in the world. Apart from repercussions in the oral cavity, there is evidence that periodontitis contributes to systemic damage in chronic diseases such as cardiovascular disease, diabetes, and preterm low birth weight. Aims: The aims of this study were to estimate the prevalence of chronic periodontitis in a sample urban population (<18 years) in Tamil Nadu and to estimate the inflammatory burden posed by chronic periodontitis by calculating the periodontal inflammatory surface area. Settings and Design: This was a population-based study and cross-sectional design. Subjects and Methods: A total of 1000 individuals (<18 years) were selected and screened for their periodontal status, oral hygiene status (OHI), and the periodontal inflamed surface area (PISA) in an outreach center located in Chennai, India. Statistical Analysis Used: The proportion of individuals with different periodontal states (health, gingivitis, and periodontitis) was determined. A multivariate logistic regression analysis was performed to assess the influence of the individual risk factors such as habits (tobacco use), systemic conditions (diabetes), and oral hygiene maintenance on periodontitis prevalence in the sample population. Results: A high prevalence of periodontal disease was observed in the study population (42.3%). Among the urban participants, age, cigarette smoking, pan chewing, decayed, missing, and filled teeth scores, OHI scores, and PISA scores were found to be significantly associated with periodontitis (P < 0.05). Conclusions: Periodontitis prevalence appears to be high even in areas with adequate access to oral health care and an inflammatory burden risk exists in a definitive manner.

Palmar Dermatoglyphic Patterns in Bronchial Asthma between Afro-Trinidadian and Indo-Trinidadian: A Comparative Study.

Background: Dermatoglyphics, the ridged skin covering our palms and sole, are not only found on human beings. All primates have ridged skin, and it can also be found on the paws of certain mammals and on the tails of some monkey species. Palmar creases develop during the 2nd and 3rd month of intrauterine life and are not influenced by movement of hand in utero. They are of considerable clinical interest because they are affected by certain abnormalities of early development including genetic disorders. Aim: The present study is carried out to correlate the dermatoglyphic patterns in patients of bronchial asthma. Methods: Dermatoglyphic prints were obtained from both hands of 100 patients of bronchial asthma among Afro-Trinidadian and Indo-Trinidadian. Hundred normal healthy individuals, without family history of bronchial asthma, were selected as control group. The qualitative parameters like whorls, loops and arches were studied in the above mentioned study groups. Results: Presence of whorls loops and arches showed significant difference, p<0.01in III and IV digits in Afro-Trinidadian group and only in III digit in Indo-Trinidadian group when compared to the controls. The intergroup comparisons also showed significant changes in the percentage of all the finger print patterns in the II & III digit in Afro-Trinidadian bronchial asthma patient when compared with Indo-Trinidadian bronchial asthma patients. Conclusion: Presence of whorls, loops and arches on both the III digit can be used as one of the diagnostic criterion for patients with bronchial asthma.

Transabdominal and Transrectal Sonographic Variation of the Prostate Volume and Dimensions: In Evaluation of Benign Prostatic Hyperplasia.

Benign prostatic hyperplasia (BPH) is the non-malignant enlargement of the prostate. Estimation of Prostate volume and dimensions contribute significantly to the management of BPH. Correlations between the trans-abdominal and trans-rectal ultrasound methods in estimating prostate volume and dimensions were studied with variable results. Ninety-one consecutive patients of 50 years or older with were scanned by Trans abdominal and transrectal sonographs (TA&TRUS) at the same session after obtaining the consent. All the scans were performed on a single ultrasound machine. The volume and dimensions of the prostate obtained by both methods were compared and correlated using Pearson correlation coefficient. The data was analysed further in groups based on volumes and ethnicity. Twenty-four patients were also scanned by other consultant radiologist and the data was analysed to compare the interobserver variations. Results: The mean age of the patients was 66.03±10.41 years. The mean prostate volume for ninety one patients by TA & TRUS was 44.4±35.1 ml and 46.2±34.7 ml, respectively (r = 0.965, p<0.001). Among the total patients 42 were of East Indian (EI) origin, 45 were of Caribbean African (CA) origin and 4 were of mixed race. The mean prostate volume of EI race by TA & TRUS was 35.3±23.3 and 38.9±25.9 ml respectively(r = 0.950, p<0.001). The mean prostate volume of CA race by TA & TRUS was 50.8±39.4 and 51.0±38.5 ml, respectively (r = 0.967, p<0.001). The mean prostate volume of observer A and observer B by TA & TRUS was 43.5±28.8 and 45.8±25.9 ml (r = 0.953, P<0.001) and 46.6±39 and 46.9±27.4 ml (r = 0.877, p<0.001) respectively. Conclusion: Strong correlation between TA & TRUS estimation of prostate volume and dimensions for volumes up to 100ml found in our study offers TAUS as a cost effective, less invasive, quick and well tolerable alternative to TRUS. TRUS however may be a reasonable choice for accurate measurements in larger (>100 millilitres) prostates, this needs to be further investigated by a larger sample size.

Effect of dexmeditomidine on postoperative junctional ectopic tachycardia after complete surgical repair of tetralogy of Fallot: A prospective randomized controlled study.

Introduction: Incidence of junctional ectopic tachycardia (JET) after repair of tetralogy of Fallot (TOF) is 5.6–14%. Dexmeditomidine is a α-2 adrenoceptor agonist modulates the release of catecholamine, resulting in bradycardia and hypotension. These effects are being explored as a therapeutic option for the prevention of perioperative tachyarrhythmia. We undertook this study to examine possible preventive effects of dexmedetomidine on postoperative JET and its impact on the duration of ventilation time and length of Intensive Care Unit stay. Methods: After obtaining approval from the hospitals ethics committee and written informed consent from parents, this quasi-randomized trial was initiated. Of 94 patients, 47 patients received dexmedetomidine (dexmedetomidine group) and 47 patients did not receive the drug (control group). Results: Dexmedetomidine group had more number of complex variants like TOF with an absent pulmonary valve or pulmonary atresia (P = 0.041). Hematocrit on cardiopulmonary bypass (CPB), heart rate while coming off from CPB and inotrope score was significantly low in the dexmedetomidine group compared to control group. The incidence of JET was significantly low in dexmedetomidine group (P = 0.040) compared to control group. Conclusions: Dexmedetomidine may have a potential benefit of preventing perioperative JET.

Immunolocalization of Bcl-2 oncoprotein in amlodipine-induced gingival overgrowth.

Background: Drug-induced gingival overgrowth (DIGO) is one of the unwanted side effects of amlodipine therapy, but the pathogenesis still remains unclear. Apoptosis, which plays a ubiquitous role in tissue homeostasis, including gingiva, may be involved in the development of gingival enlargement. Aims and Objectives: (i) To study the distribution of Bcl-2 in healthy and overgrown gingival tissues. (ii) To compare and correlate the Bcl-2 expression in gingival samples from subjects on amlodipine therapy to the findings in healthy controls. Materials and Methods: A total of 25 subjects were recruited for the study - 15 hypertensive patients and 10 systemically healthy subjects. Both the groups were analyzed for Bcl-2 expression using immunohistochemistry. Results: Few of the control specimens showed weak positivity to Bcl-2 antibody, with the distribution limited to the basal cell layers alone, whereas 10 hyperplastic specimens expressed Bcl-2 and, unlike the control group, the distribution pattern was seen in both basal and suprabasal layers. Conclusion: The results indicate that the pathogenesis of amlodipine-induced gingival overgrowth might involve inhibition of apoptosis, especially with morphogenesis of hyperplastic gingival epithelia.

Immuno-localization of glucose transporter 4 in healthy human gingiva.

Background: The gingiva has been shown to be a target tissue for several hormones. Insulin induces uptake of glucose in the peripheral tissues by upregulating the Glucose transporter 4 expression. Little information is available on the expression of Glucose transporter 4 in human gingiva. Aim: In this regard, a pilot study was performed with the aim of determining the distribution pattern of Glucose transporter 4 in healthy human gingiva. Materials and Methods: Immuno-histochemistry was performed on 10 mounted sections of healthy human gingiva with the primary antibody Glucose Transporter 4 (GLUT 4). Appropriate positive and negative controls were used. Results: Glucose transporter 4 expression was observed in the basal and suprabasal layers of the gingival epithelium and fibroblasts of the gingival connective tissue. Conclusion: This may be the first study to demonstrate the expression of GLUT 4 in the healthy human gingiva. The results of this study raise the possibility that gingiva may serve as a target tissue for insulin action.

Evaluation of telomerase expression in chronic periodontitis.

Background : Human telomerase is a multi subunit ribonucleoprotein enzyme concerned with telomeric lengthening and homeostasis in man. This enzyme has been found to be elevated in inflammatory conditions like rheumatoid arthritis and silica injury lung. Since chronic periodontitis is also an inflammatory condition where immune cells and cytokines mediate tissue destruction, we set out to evaluate telomerase in gingival tissue samples from healthy subjects and chronic periodontitis patients by reverse transcriptase polymerase chain reaction. Materials and Methods : Gingival biopsies were obtained from eight healthy subjects and eight chronic periodontitis patients. Reverse transcriptase polymerase chain reaction (RTPCR) was carried out to evaluate telomerase gene expression in the samples. Results : None of the healthy gingival tissue samples expressed the telomerase gene while all the chronic periodontitis samples expressed it. The severe chronic periodontitis samples expressed the gene more intensely than the moderate chronic periodontitis samples. Conclusion : Various mechanisms have been explained to account for telomerase elevation in chronic periodontitis .This study helps us understand the role of telomerase in the pathogenesis of periodontal disease. It could be concluded that telomerase could be used as a marker to assess the severity of inflammation in chronic periodontitis.

Immunolocalization of CD 34 positive progenitor cells in healthy human gingiva - a pilot study.

Background & objectives: The gingiva is a tissue with a high turnover rate of both epithelial and connective tissue cells. In an attempt to identify the possible source of cells which maintain the tissue turnover, we used CD 34, a well established marker of peripheral blood stem cell in healthy human gingiva to determine the origin of progenitor cells in healthy gingiva. Methods: Healthy human gingival samples (n=15) were collected from patients undergoing orthodontic extraction. Immunohistochemistry was done on 5 micron paraffi n fi xed section using the primary antibody CD34 and a universal secondary immunoperoxidase kit. The sections were examined for a golden brown stain indicative of a positive staining. Results: Of the 15 samples 12 demonstrated a positive staining for the endothelial cells. Of these 12 samples, 11 demonstrated positive staining for stromal and paravascular cells and 10 a positive staining for the basal epithelium layers. Interpretation & conclusions: The presence of CD 34 positive cells in gingiva in stromal, paravascular location, and basal layer of the gingival epithelium was demonstrated. We speculate that these could be fi broblastic progenitors originating from the peripheral blood stem cells and the positivity stained epithelial cells could be gingival epithelial stem cells.

Malnutrition in children with congenital heart disease (CHD) determinants and short term impact of corrective intervention.

OBJECTIVE: To identify determinants of malnutrition in children with congenital heart disease (CHD) and examine the short-term effects of corrective intervention. METHODS: Patients with CHD admitted for corrective intervention were evaluated for nutritional status before and 3 months after surgery. Detailed anthropometry was performed and z-scores calculated. Malnutrition was defined as weight, height and weight/height z-score <or= -2. Determinants of malnutrition were entered into a multivariate logistic regression analysis model. RESULTS: 476 consecutive patients undergoing corrective intervention were included. There were 16 deaths (3.4%; 13 in-hospital, 3 follow-up). The 3-month follow-up data of 358 (77.8%) of remaining 460 patients were analyzed. Predictors of malnutrition at presentation are as summarized: weight z-score <or= -2 (59%): congestive heart failure (CHF), age at correction, lower birth weight and fat intake, previous hospitalizations, >or= 2 children; height z-score <or= -2 (26.3%): small for gestation, lower maternal height and fat intake, genetic syndromes; and weight/height z-score <or= -2 (55.9%): CHF, age at correction, lower birthweight and maternal weight, previous hospitalizations, religion (Hindu) and level of education of father.Comparison of z-scores on 3-month follow-up showed a significant improvement from baseline, irrespective of the cardiac diagnosis. CONCLUSIONS: Malnutrition is common in children with CHD. Corrective intervention results in significant improvement in nutritional status on short-term follow-up.

Expression of insulin like growth factor binding protein-5 in drug induced human gingival overgrowth.

BACKGROUND & OBJECTIVE: Insulin like growth factor binding proteins (IGFBPs) control the distribution, function and activity of insulin like growth factors (IGFs) in various cells, tissues and body fluids, thereby modulating their metabolic and mitogenic effects. IGFBP-5, the most conserved IGFBP, can function through IGF or directly play a role in fibrosis. Cyclosporine A (CsA) widely used in organ transplant patients, often causes various side effects including gingival fibrotic overgrowth. This study was carried out to assess the mRNA expression of IGFBP-5 in healthy human gingival, chronic periodontitis and CsA induced gingival overgrowth tissues. METHODS: Total RNA was isolated from gingival tissues collected from eight patients with chronic periodontitis, eight patients with CsA induced gingival outgrowth and an equal number of healthy individuals, and subjected to reverse transcription (RT)-PCR for IGFBP-5 gene expression. RESULTS: CsA induced gingival overgrowth tissues expressed increased IGFBP-5 mRNA compared to control and chronic periodontitis. INTERPRETATION & CONCLUSION: Increased mRNA expression of IGFBP-5 in CsA induced gingival outgrowth tissues may be associated with increased collagen synthesis, thereby promoting fibrogenesis.