Management of video?assisted thoracoscopic (VATs) bilateral cardiac sympathectomy in refractory ventricular storm: A case report

A 65?year?old male post?CABG surgery presented with history of ventricular storm refractory to antiarrhythmics and requiring multiple DC shocks. He got posted for VATs bilateral cardiac denervation for sympathetic remodulation. Patient was induced with high dose opioids and Etomidate and intubated with 37Fr left double lumen tube. A multidisciplinary approach was planned to tackle peri?operative cardiac event along with the placement of invasive monitors. Events that might lead to sympathetic overactivation because of laryngoscopy, pain, capnothorax, and surgical handling were kept in mind and avoided with optimum depth of anesthesia, analgesia, and pharmacological sympatholysis. There was no major cardiac event intraoperatively as well as in postoperative period.

Immunoglobulin M nephropathy nephropathy in adults and adolescents in India: A single-center study of natural history.

Background: Immunoglobulin M nephropathy (IgMN) is an idiopathic glomerulonephritis (GN) usually presenting clinically as steroid resistant/dependent nephrotic syndrome (NS) with pathology of mesangial proliferative GN or focal and segmental glomerulosclerosis with diffuse predominant mesangial IgM deposits. Not much information is available about its natural history. This is the first Indian study to our knowledge on IgMN in adults and adolescents. Materials and Methods: We evaluated renal biopsies performed at our center between January,'04 to September,'09. Biopsies of all adolescents and adults were evaluated for IgMN and we studied their age, gender distribution, blood pressure (BP), disease duration, steroid/immunosuppressive management and serial serum creatinine (SCr), urinary proteins, and BP values. Patients with other systemic diseases/infections and children were excluded. Results: IgMN constituted 4.3% of 2702 adult renal biopsies. No significant gender predilection was noted. Males presented at average age of 23.1 years, females at 30 years. Steroid-dependent NS was the commonest presentation noted in 75% followed by steroid-resistant NS. Hypertension was noted in 10% patients. Mesangial proliferative GN (MePGN) was commonest histopathological finding noted in 74.4%, followed by focal segmental glomerulosclerosis (FSGS) in 16.2%, and minimal change disease (MCD) in 9.4% biopsies. Sole IgM deposits were noted in 88.5%. All MCD, 35.6% MePGN reached remission, FSGS progressed to renal failure by 1 year. Hypertension, proteinuria, interstitial fibrosis, and FSGS were bad prognosticators. Conclusions: This is the first Indian study of IgMN in adults and adolescents carried out over a period of 5.8 years, which has shown that hypertension, proteinuria, and interstitial fibrosis at presentation have bad prognosis.

Accuflow an infusion rate monitor: an evaluation in pediatric patients.

OBJECTIVE: To evaluate the accuracy of ACCUFLOW an infusion rate monitor as compared to manual reading in pediatric surgical patients. METHODS: An observational study in 47 pediatric patients undergoing elective surgical procedures and needing an intravenous fluid with expected duration of infusion of at least one hour. The infusion rate was adjusted to the required flow rate with the help of the display on the ACCUFLOW. The flow rate as indicated by the ACCUFLOW display was checked every 15 minutes till the end of one hour. A simultaneous record of manual readings was also made. RESULTS: A total of 470 observations were made over the one hour observation period. The infusion rate as observed on the LCD display of the ACCUFLOW compared well with manual reading. A Bland Altman analysis showed the bias between the readings with the two methods to be very small and that there is no significant difference between the methods over the drop rate of 61-74 drops/min. In addition an alarm was heard in 9 cases. The alarm was mainly because of no flow or excess flow (3 cases each). Other causes for the alarm included slow flow, faulty i.v. lines showing fluctuations in flow rate and drip chamber not placed properly (1 patient each). CONCLUSION: ACCUFLOW is a low cost device that can be used to adjust and monitor the infusion flow rate. The alarm would alert the nursing staff when there is deviation from the preset rate of infusion. ACCUFLOW could thus be an attractive option for infusion rate monitoring in developing countries with limited healthcare resources and skewed patient nurse ratios. However applicability to infants and younger children and for longer infusions needs to be determined.

Vasoocclusion by sickled RBCs in 5 autopsy cases of sudden death.

Mortality in sickle cell disease is high at young age group. So it is necessary to find out the cause of death in young patients with sickle cell disease. We are presenting 5 cases of sudden death in young adults with undiagnosed sickle cell disease. The provocative factors for those terminal events were vasoocclusive crisis. In our patients crisis was secondary to fever (infection), conductive arrhythmia, cardiovascular collapse, post partum shock and hemorrhage. On microscopic examination of viscera, not a single patient showed signs of chronic organ damage, sequestration crisis or acute chest syndrome, which are the common causes of death in sickle cell disease.

Left shoulder region metastasis from hepatocellular carcinoma as an initial presentation--a case report.

Hepatocellular carcinoma metastasis as a soft tissue mass is rare; we came across a 65 years old female who presented with a left shoulder region mass. There was no previous history of any liver disease and liver function tests were normal. Histologically, it turned out to be a metastasis from hepatocellular carcinoma.