Pregnancy associated breast cancer--the obstetrician's role.

Breast cancer is the most common cancer in many geographic areas, the most frequent cause of cancer deaths in women, and is also the cancer most likely to be seen during pregnancy and lactation. Delay in diagnosis appears to be the primary reason for the generally worse prognosis overall for all patients with breast cancer diagnosed during pregnancy and lactation. In this context, the patient's family physician or obstetrician who performs the routine antenatal examinations can play an important role by performing a vital breast examination which might bring to light and prompt timely investigation of otherwise asymptomatic breast masses.

Recording of double atrial potentials as a marker for isthmus block during ablation of atrial flutter.

Radiofrequency ablation is an established method for treatment of type I atrial flutter. The assessment of creation of complete bidirectional isthmus block following linear ablation of the isthmus is an integral part of ablation procedure. Conventionally, bidirectional isthmus block is tested by pacing on either side of ablation line and looking for reversal of activation sequence in the right atrium. We looked at the feasibility of recording double potentials, separated by an isoelectric interval along the ablation line as an alternative method to demonstrate bidirectional isthmus block. An attempt was made to record the double potentials following linear ablation of the cavotricuspid isthmus. Following ablation, bidirectional isthmus block was also tested by pacing from the coronary sinus os and the low-lateral right atrium. We could demonstrate double potentials in 9 of the 11 patients in whom we attempted to record them following linear ablation of flutter. The presence of bidirectional block by pacing from coronary sinus os and low lateral right atrium could be demonstrated in 10 (91%) patients. Thus, double atrial potentials, separated by an isoelectric interval can be demonstrated following ablation of atrial flutter. Double potentials, if demonstrable on coronary sinus os and low lateral right atrium pacing, could serve as an alternative marker of isthmus block.

Retroperitoneal cold abscess with tuberculosis of sacro-iliac joint and pubic bone: a case report of unusual presentation of osteo-articular tuberculosis.

Tuberculosis involving sacro-iliac joint and pubic bone presenting with massive retroperitoneal abscess is a rare entity. A 29-year-old female presented with history of discharging sinus in the sacrococcygeal region of 2 months duration. Plain x-ray revealed osteolytic lesion in right pubic bone and left sacro-iliac joint. Computed tomography scan revealed massive pus collection in the retroperitoneal region. Pus was drained extraperitoneally. Biopsy of the scraping of the abscess wall showed granulation tissue with foreign body type of giant cell. On follow-up the patient was doing well.

Epsilon aminocaproic acid in paediatric cardiac surgery to reduce postoperative blood loss.

We have studied the efficacy of epsilon aminocaproic acid in reducing postoperative blood loss in infants and children with congenital cyanotic cardiac anomalies undergoing corrective operative procedures. This prospective study was carried out on 170 infants and children randomly divided into two equal groups. Group A acted as the control group and received normal saline as placebo while group B patients received epsilon aminocaproic acid (100 mg/kg body wt) intravenously slowly soon after anaesthetic induction followed by 100 mg/kg in the cardiopulmonary bypass pump at the time of starting of cardiopulmonary bypass and 100 mg/kg after weaning from bypass over a period of 3 h. In group A the time for sternal closure after separation from bypass and administration of protamine was 75.18 +/- 5.5 min and in group B 50.7 +/- 5.2, (P < 0.001). Blood loss at 24 h in group A was 42.6 +/- 6.9 ml/kg/24 h and in group B 23.7 +/- 5.8 ml/kg/24 h, (P < 0.001). The need for packed red cells in group A was 21.8 +/- 7.1 ml/kg/24 h and in group B 10.7 +/- 7.8 ml/kg/24 h, (P < 0.001). The need for platelet concentrate in group A was 22.0 +/- 6.7 ml/kg/24 h and group B 6.2 +/- 3.2 ml/kg/24 h, (P < 0.001). Fibrin degradation products (split) in group A was 8.2 +/- 0.8 micrograms/ml, and group B 3.8 +/- 1.3 micrograms/ml, (P < 0.001). Reexploration rate was also considerably reduced in group B, 5 of 85 (6%) compared to group A, 13 of 85 (15%), (P < 0.001). It was found that epsilon aminocaproic acid is effective in reducing postoperative blood loss, packed red cells and plasma product requirements in paediatric patients undergoing corrective surgical procedures for congenital cyanotic heart diseases.

A comparison of esmolol and diltiazem for heart rate control during coronary revascularisation on beating heart.

This prospective study compared control of heart rate and haemodynamics during coronary artery revascularization without cardiopulmonary bypass using either esmolol or diltiazem. Sixty adult patients with one or two vessel coronary artery disease, were randomly divided into 2 groups. Group A (n=30) received a 50 microg/kg/ loading dose of esmolol followed by a 100 microg/kg/hr infusion, for control of heart rate during surgical anastomosis of the coronary vessel. Group-B (n=30) received 0.15 mg/kg of diltiazem as a loading dose followed by a 5 mg/hr infusion for heart rate control, during the anastomosis. It was seen that heart rate control was better in group A, 51.4 +/- 1.3 beats/min, (p <0.01) than in group B, 69.6 +/- 3.0 beats/min (p <0.05), as compared to baseline values of 80.6 +/- 12.1 beats/min in group A and 82.4 +/- 10.6 beats/min in group B respectively. Systemic vascular resistance and pulmonary artery wedge pressure were unchanged in group A but mean pulmonary artery pressure and pulmonary vascular resistance were significantly raised. Group B patients had decreased systemic vascular resistance, mean pulmonary artery pressure and pulmonary artery wedge pressure, and reduced right ventricular stroke work index at the time of distal coronary anastomosis. We concluded that although esmolol provided dramatically slower heart rates, during surgery, the resulting elevations in mean pulmonary artery pressure and pulmonary vascular resistance would require caution if used in patients with underlying right ventricular dysfunction from ischaemia or infarction. Diltiazem by virtue of its effects on systemic vascular resistance, cardiac output, and lowering of mean arterial pressure may be a better choice in hypertensive patients.

A comparison of esmolol & diltiazem for heart rate control during coronary revascularisation on beating heart.

This prospective study was done to compare the control of heart rate and haemodynamics during coronary artery revascularisation without cardiopulmonary bypass using either esmolol or diltiazem. Sixty adult patients with one or two vessel coronary artery disease, were randomly divided into 2 equal groups. Group A received a 500 micrograms/kg loading dose of esmolol followed by a 100 micrograms/kg/h infusion, for control of heart rate during surgical anastomosis of the coronary vessel. While Group B received 0.15 mg/kg diltiazem as a loading dose followed by a 5 mg/h infusion for heart rate control, during the anastomosis. It was seen that heart rate control was better in Group A, 51.4 (+/- 1.3) beats/min, than in Group B, 69.6 (+/- 3.9) beats/min but the decrease in heart rate was significant in both the groups at peak effect compared to respective predrug values. Group A patients had unchanged systemic resistance and pulmonary artery wedge pressure but mean pulmonary artery pressure and pulmonary vascular resistance were significantly raised. Group B patients had decreased systemic resistance, mean pulmonary artery pressure and pulmonary artery wedge pressure, and reduced right ventricular stroke work index. We concluded that although esmolol provided dramatically slower heart rates, during surgery, the resulting elevations in mean pulmonary artery pressure and pulmonary vascular resistance would require caution if used in patients with underlying right ventricular dysfunction from ischaemia or infarction. Diltiazem by virtue of its effects on systemic vascular resistance, cardiac output, and lowering of mean arterial pressure may be a better choice in hypertensive patients.

Peripheral giant cell granuloma--a case report.

Peripheral giant cell granuloma is a lesion arising mainly from the connective tissue of gingiva or periosteum of alveolar ridge. A case of peripheral giant cell granuloma involving a deciduous molar and the succedaneous tooth is reported. The lesion was large and interfered with occlusion. Surgical excision of the lesion along with the deciduous first molar was done. The underlying permanent first premolar was also involved, and had to be removed. The importance of an adequate salivary flow and maintenance of oral hygiene in the prevention of such lesions is stressed.

Radiofrequency catheter ablation of common atrial flutter--acute and follow-up results.

Atrial flutter with a structurally well-defined macro-reentrant circuit in the right atrium has recently become amenable to radiofrequency ablation with the recognition of isthmus as a narrow zone of slow conduction. This study describes 20 consecutive and symptomatic patients with atrial flutter (15 males, 5 females; mean age 38.5 +/- 10.2 years) who underwent radiofrequency ablation in our institute in the last 18 months. Fourteen patients had structurally normal hearts, while the remaining six patients had specific disorders (prior surgery for closure of atrial septal defect-2, idiopathic restrictive cardiomyopathy-1, primary sinus node dysfunction-2, tachycardiomyopathy-1). The endpoints of a complete isthmus block and conversion to sinus rhythm were achieved in 19 of the 20 patients. Total number of pulses needed to attain the endpoints was a mean of 4.2 (range 1-5), each pulse being delivered for 90 seconds. At a mean follow up of 9.4 +/- 3.2 months (range 6-12 months), recurrence of atrial flutter was seen in one patient, atrial fibrillation in two and sinus node reentrant tachycardia in one. These results are comparable to those reported in the literature. Achievement of a complete isthmus block appears to be an important endpoint in obtaining optimal results. The issues of alternative sites of ablation, long-term results and advantages of an 8 mm tip catheter need to be examined further. In conclusion, radiofrequency ablation appears to be the preferred mode of treatment for patients with atrial flutter with excellent short-term and mid-term results.

Annular pancreas in adults (2 case reports).

Two cases of annular pancreas in adults are being reported. In the first case, a middle aged lady presented with duodenal obstruction and gastric ulcer. Anterior H. S. V. with posterior truncal vagotomy and isoperistaltic duodeno-jejunostomy relieved her symptoms. In the second case, a young girl presented with duodenal obstruction, severe wasting and gross dehydration. She had an uneventful recovery following a duodeno-jejunostomy.

Vagal paraganglioma (2 case reports).

Paragangliomas are rare tumours of the head and neck and are a diagnostic challenge. Two cases of paragangliomas arising from the vagus are being reported. In the first case, an angiogram raised the possibility of intravagal tumour and exploration followed by biopsy confirmed the diagnosis. In the second case, it was a diagnostic surprise where exploration was done on a clinical suspicion of parotid swelling and on the table, the swelling was found to arise from the vagus nerve pushing the parotid gland laterally.