Pancycle Aortic Incompetence and Double Alternans in Pediatric Heart Failure

A 12?year?old boy presented with bicuspid aortic valve, severe aortic regurgitation, and dilated dysfunctional left ventricle in heart failure. He underwent aortic valve replacement with a 23 mm TTK Chitra heart valve prosthesis (tilting disk). He was gradually weaned off milrinone and noradrenaline in the intensive care. Echocardiography showed severe left ventricular dysfunction with an ejection fraction of 24%. The radial pulse was regular and of normal volume but exactly half that of the heart rate. Evaluation of the rhythm and echocardiography revealed an interesting hemodynamic phenomenon with double alternans.

Rectus muscle pseudo-adherence syndrome

Purpose: To describe a clinical entity called “rectus muscle pseudo?adherence syndrome” following buckling surgery. Methods: A retrospective data review was undertaken to analyze the clinical profile of strabismus patients who had developed it following buckling surgery. Between 2017 and 2021, a total of 14 patients were identified. The demography, surgical details, and intraoperative challenges were reviewed. Results: The average age of the 14 patients was 21.71 ± 5.23 years. The mean pre?op deviation was 42.35 ± 14.35 prism diopters (PD) of exotropia, and the mean post?op deviation was 8.25 ± 4.88 PD of residual exotropia at 26.16 ± 19.53 months follow?up. Intraoperatively, in the absence of a buckle, the thinned?out rectus adhered to the underlying sclera with much denser adhesions along its margins. When there was a buckle, the rectus muscle adhered to the outer surface of the buckle again, but less densely, with marginal union into the surrounding tenons. In both scenarios, due to the absence of protective muscle coverings, the rectus muscles were naturally adsorbed onto the immediately available surface in the presence of active healing by the tenons. Conclusion: While correcting ocular deviations following buckling surgery, a false sense of an absent, slipped, or thinned?out rectus muscle is very much possible. This is due to active healing of the muscle with the surrounding sclera or the buckle in a single layer of tenons. This is the rectus muscle pseudo?adherence syndrome, where the culprit is the healing process and not the muscle

Clinical Outcomes of Del Nido Cardioplegia and St Thomas Blood Cardioplegia in Neonatal congenital Heart Surgery

Objectives:Cardioplegia is essential for adequate myocardial protection. There continues to remain ambiguity regarding the ideal cardioplegia for adequate myocardial protection in congenital heart surgery. This study compares clinical outcomes using St Thomas II solution and Del Nido cardioplegia in neonates undergoing cardiac surgery. Methods: All neonates (<30 days) from 2011 to 2017 who underwent surgery requiring cardioplegic arrest were analyzed retrospectively. We divided the cohort into two groups depending on cardioplegia received, as group A (Blood cardioplegia with St Thomas II solution, n = 56) and group B (Del Nido cardioplegia, n = 48). Various demographic, intraoperative, early postoperative, and discharge variables were analyzed. Results: Two groups were similar in age, gender, pre?operative diagnosis, and risk category. Cardiopulmonary bypass (CPB) time (P = 0.002), aortic cross?clamp (ACC) time (P = 0.018), and the number of doses of cardioplegia (P < 0.001) were significantly lower with Del Nido group. Though vasoactive inotropic score (VIS) (P = 0.036) was high during the first 24 h in the immediate postoperative period in group A, there was no difference in early mortality among both groups (P = 0.749). Both groups did not show significant differences related to various postoperative and discharge variables. Conclusion: When compared to St. Thomas solution, the use of Del Nido cardioplegia solution in neonates is associated with a significant decrease in CPB and ACC times and VIS in the first 24 h after surgery. The choice of cardioplegia (St Thomas/Del Nido) in neonates does not affect early mortality and early postoperative clinical outcomes.

A systematic review of preclinical animal studies on fenofibrate's potential role in type 1 diabetic micro-vascular complications

Abstract Fenofibrate is a peroxisome-proliferator-activator α agonist and it is a widely used drug for hyperlipidemia since its approval in 2004. So, in this review we are focusing on the effect of fenofibric acid's mechanism to alleviate type 1 diabetic micro vascular complications like diabetic retinopathy, diabetic cardiomyopathy in animal models, since the drug is safe, efficacious and more economical when compared with the currently available treatment strategies for juvenile diabetic complications and also a profound observation is needed due to the rarity of research in these therapeutic areas. Important preclinical animal studies published from January 2001 to June 2020 were recognised from databases like PubMed and Cochrane central register of controlled trials. Reviewers screened the articles based on the selection criteria and risk of bias was determined using Systematic Review Centre for Laboratory animal Experimentation risk of bias tool for animal studies. Our literature search yielded a total of 5 studies and after pooling up the data from the 5 preclinical studies, we found that Fenofibrate have the efficacy to prevent type 1 diabetic complications, chiefly diabetic retinopathy and those mechanisms are dependent on peroxisome-proliferator-activator and fibroblast growth factor-21 pathways. Fenofibrate is a well safe and moreover, cost effective medication in preventing type 1 diabetic micro vascular complications especially diabetic retinopathy and also in maintaining the glucose homeostasis in apart from its anti-dyslipidemic effect.

Successful Pregnancy in a Patient With Recurrent Pregnancy Loss Due to Afibrinogenemia Managed With Cryoprecipitate Prophylaxis in a Resource-limited Setting

@#Recurrent pregnancy loss (RPL) can be defined as loss of pregnancy on or before 20 weeks of gestation. About half of the cases, cause of recurrent miscarriage is unknown. Bleeding disorders induced miscarriage has to be thoroughly investigated for the sake of both mother and fetus. Here is an interesting case report of a 24-year-old patient who was diagnosed to have afibrinogenemia after three consecutive miscarriages. Fibrinogen level was 5 mg/dl with prolonged prothrombin time greater than 180 seconds and activated thromboplastin time greater than 180 seconds. We managed with periodic cryoprecipitate transfusion. Pregnancy course was uneventful and delivered a healthy female child at 34 weeks of gestation under supervision of multidisciplinary team. Here we are discussing the management and how we approached the case to have a successful pregnancy outcome.

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.

Correlation between vascular cognitive dysfunction and ankle-brachial index in the elderly / 中国医师杂志

Objective:To investigate the clinical value of ankle-brachial index (ABI) in evaluating vascular cognitive dysfunction (VCI) in the elderly.Methods:According to the mini mental state examination (MMSE) and Montreal cognitive assessment (MoCA), 200 elderly inpatients from May 2016 to February 2018 in our hospital were selected. MoCA scale was used to evaluate the cognitive function of the patients. The patients were divided into cognitive dysfunction group ( n=110) and cognitive normal group ( n=90). The clinical data of the two groups were analyzed and compared. The correlation between ABI and MMSE, MOCA and clinical indicators was observed. The receiver operating characteristic (ROC) curve of ABI value to the predictive value of VCI in the elderly was drawn. Results:⑴ There was no significant difference between the two groups in terms of gender, the first fasting blood glucose value in hospital and the situation of diabetes, hypertension and hyperlipidemia ( P>0.05); there was significant difference in age, low-density lipoprotein cholesterol (LDL-C) level, history of small cerebral vessels and ABI between the two groups ( P<0.05). ⑵ Logistic regression analysis showed that ABI was the related factor of VCI in the elderly ( P<0.01). ⑶ Pearson correlation analysis showed that MMSE score was positively correlated with ABI ( r=0.887, P<0.01), MOCA score was positively correlated with ABI ( r=0.843, P<0.01). ⑷ The area under ROC curve of ABI prediction value for VCI in the elderly was (0.965±0.01) [95% CI (0.945, 0.985), P<0.01]. When ABI ≤0.9, the sensitivity and specificity were 88.2%, 91.1% respectively; the accuracy and the yordan index were 89.5% and 0.793. Conclusions:⑴ ABI is an influencing factor of VCI in the elderly and is positively correlated with the severity of cognitive impairment in patients. ⑵ ABI has a high predictive value for VCI of the elderly, and ABI≤0.9 can be used as an early warning factor for VCI of the elderly.

Malocclusion-Related Quality of Life Questionnaire (MRQoLQ): Development and validation of a new psychometric tool for older adolescents with malocclusion

ABSTRACT Objective: To develop and validate a new psychometric tool for assessing malocclusion-related quality of life among older Indian adolescents. Methods: Item generation involved analysis of existing validated tools, followed by development of new items using various qualitative steps. A draft item pool of 41 questions was initially generated and subjected to item reduction through sequential steps involving two clinical studies to ensure reliability and validity. 431 subjects aged between 15 to 18 years took part in the validation study. Principal component analysis with varimax rotation was performed to get a psychometric tool with good factorial structure and maximum variance. Results: Rotated component matrix resulted in a 20 item psychometric tool containing 4 domains with a total variance of 61.57%. Inter item, item total correlation and Cronbach α (α = 0.88) ensured good reliability. A positive correlation of the scale with global question ensured convergent validity. Independent t test showed statistically significant difference (p< 0.05) between mean score of IOTN-DHC and DAI with MRQoLQ, ensuring good construct validity. Conclusions: The newly developed psychometric tool is named as Malocclusion-Related Quality of Life Questionnaire (MRQoLQ) having 20 questions, including 2 socioeconomic items. The scale showed good reliability and initial validity, hence can be used among older adolescents with malocclusion to assess their malocclusion-related quality of life.

RESUMO Objetivo: desenvolver e validar uma nova ferramenta psicométrica para avaliar o impacto da má oclusão na qualidade de vida em pacientes indianos ao final da adolescência. Método: o delineamento do conjunto de itens desse questionário envolveu a análise de ferramentas existentes já validadas, seguida da criação de novos itens, usando vários passos qualitativos. Um conjunto provisório de itens, com 41 perguntas, foi inicialmente formulado e submetido à redução de itens por meio de passos sequenciais envolvendo dois estudos clínicos, para garantir sua validade e confiabilidade. Nesse estudo de validação, participaram 431 pacientes com idades entre 15 e 18 anos. Foi realizada uma análise do componente principal pelo método Varimax, para se obter uma ferramenta psicométrica com boa estrutura fatorial e variância máxima. Resultados: a matriz, após as rotações dos fatores, resultou em uma ferramenta psicométrica com 20 itens, contendo 4 domínios, com uma variância total de 61,57%. As correlações interitens e item-total e o alfa de Cronbach (α = 0,88) confirmaram uma boa confiabilidade. Uma correlação positiva da escala com a questão global assegurou validade convergente. O teste t independente demonstrou diferença estatisticamente significativa (p< 0,05) entre a pontuação média do IOTN-DHC e do DAI com o MRQoLQ, assegurando uma validade bem construída. Conclusões: essa nova ferramenta psicométrica desenvolvida, denominada Questionário "Impacto da Má Oclusão na Qualidade de Vida" (MRQoLQ, do inglês Malocclusion-Related Quality of Life Questionnaire), com 20 perguntas, incluindo 2 itens socioeconômicos, demonstrou boa confiabilidade e validade inicial. Assim, pode ser utilizado em pacientes no final da adolescência, para avaliar o impacto da má oclusão em sua qualidade de vida.

Geographical variation in the clinical presentation of endomyocardial fibrosis in India?

Objectives To compare the clinical presentation, clinical profile and survival of two groups of endomyocardial fibrosis patients. Methods The study was a prospective cohort study, or a prospective case series, comparing all consecutive echocardiographically proven patients with endomyocardial fibrosis seen in Medical College Trivandrum with the patients seen in Medical College Hospital, Alappuzha(Alleppey) (or TD Medical College). In all patients the clinical details like age, sex, type of endomyocardial fibrosis, the presence of anaemia, eosinophilia, neutrophilia and type of rhythm(Sinus or atrial fibrillation) etc were compared by both simple X2 and by Kaplan Meier survival curves. Results The mean age and the sex distribution was same in both places Briefly the incidence of biventricular endomyocardial fibrosis was more from Trivandrum than Alleppey, 64.9% vs 14.3% (p < 0.0.001), the incidence of atrial fibrillation was more in Trivandrum 44.2% vs 16.3%. (p < 0.001)The overall survival of Trivandrum patients was poorer (p < 0.0001). The six year survival was 61% in the Trivandrum population whereas it was 91.5% in the Alleppey population. Conclusions These differences may have been due to the better nutrition of the Alleppey patients due to a higher exposure to fish compared to the Trivandrum population. Better nutrition would protect against Magnesium deficiency and prevent the absorption of Cerium in the patients from Alleppey, compared to those from Trivandrum.

Clinical Observation of Leonurus artemisia Injection Combined with Carboprost Tromethamine for Prevent-ing Postpartum Hemorrhage after Cesarean Section / 中国药房

OBJECTIVE:To observe therapeutic efficacy and safety of Leonurus artemisia injection combined with carboprost tromethamine for preventing postpartum hemorrhage (PPH) of pregnant women after cesarean section. METHODS:177 pregnant women undergoing cesarean section were randomly divided into control group(87 cases)and observation group(90 cases). Preg-nant women of both groups received cesarean section. Control group was given intramuscular injection of oxytocin 20 U in uterine muscle wall above the incision after the foetus parturition,and given intravenous dripping of oxytocin 20 U added into 0.9% sodi-um chloride 250 mL;4 h after the operation,the pregnant women received intramuscular injection of oxytocin 10 U,every 12 hours,for 3 days. Observation group was given intramuscular injection of L. artemisia injection 2 mL and Carboprost tromethamine injection 1 mL in uterine incision after the foetus parturition;4 h after the operation,the pregnant women received intramuscular in-jection of L. artemisia injection 2 mL and Carboprost tromethamine injection 1 mL,and then give L. artemisia injectien 2 mL,ev-ery 12 hours,for 3 days. Clinical efficacies of 2 groups were observed as well as blood loss during operation,2 h after operation and 24 h after operation,the amount of hemoglobin(Hb)before operation and 24 h after operation,height of uterine fundus 3,7 d after operation,the occurrence of ADR. RESULTS:The total response rate of observation group was significantly higher than that of control group;blood loss during operation,2 h after operation and 24 h after operation,height of uterine fundus 3,7 d af-ter operation were also significantly than control group,with statistical significance(P0.05). 24 h after operation,Hb of pregnant women in control group was significantly lower than before operation and observation group,with statistical significance(P0.05). There was no statisti-cal significance in the incidence of ADR between 2 groups(P>0.05). CONCLUSIONS:L. artemisia injection combined with car-boprost tromethamine shows significant therapeutic efficacy for PPH of pregnant women underwent cesarean section,can signifi-cantly reduce intraoperative and postoperative blood loss,accelerates the recovery of uterus without increasing the rate of ADR.

Warden repair for superior sinus venosus atrial septal defect and anomalous pulmonary venous drainage in children: Anesthesia and transesophageal echocardiography perspectives.

Objective: Review of intraoperative anesthetic challenges and the role of transesophageal echocardiography in children with sinus venosus atrial septal defect and partial anomalous pulmonary venous drainage undergoing Warden repair. Design: A retrospective observational case series. Methodolgy: Pediatric patients who underwent Warden repair between October 2011-September 2015 were recruited. Their preoperative clinical details, anesthetic techniques, intraoperative TEE findings and postoperative events were recorded from the medical records. The categorical variables and the continuous variables were expressed as number (percentages) and mean ± SD respectively. Results: A total of 35 patients were operated for Warden repair during the study period. Anesthesia was induced with the aim to prevent any fall in pulmonary vascular resistance. The right internal jugular vein was cannulated under ultrasound guidance using a short length cannula to monitor right superior vena cava pressure. Intraoperative TEE revealed the drainage of PAPVC high into RSVC in 22 patients. Persistent LSVC was found in 9 patients. After repair, TEE imaging detected a high gradient at Warden anastomotic site in 5 patients and 3 of them required revision of surgery. Rerouted pulmonary veins required surgical correction in 2 patients in view of obstruction. None of them had pulmonary venous and SVC obstruction in the postoperative period. Conclusion: The primary aim of anesthesia is to avoid any fall in PVR. Right IJV cannulation can be beneficial. The intraoperative TEE can help in delineating the anatomy of lesion and detecting anastomotic site obstruction.

The Effect of Flowable Composite Lining Thickness With Various Curing Techniques On Internal Voids In Class ii Composite Restorations - An Invitro Study.

Aim of this study was to compare class II composite restoration using flowable composites as lining with various thickness and curing techniques by evaluating internal voids. Fifty intact molars, each prepared with two box-only class II cavities, were randomly divided into five groups: Group I, P 60 filling alone; Group II, ultra thin flowable composite lining (0.5-1mm) co-cured with overlying composite; Group III, thin lining (1-1.5) co-cured with overlying composite; Group IV, ultra thin lining (0.5-1mm) precured and Group V, thin lining (1-1.5) precured. Internal voids were recorded in the gingival interface, cervical and occlusal halves of restorations. Precured techniques for flowable composite lining showed the least number of interface and cervical voids where as the co-cured technique of flowable and packable composites showed the least number of occlusal voids

Entropy score, patent ductus arteriosus (PDA), and cardiopulmonary bypass (CPB): Ligation of PDA on CPB can compromise cerebral blood flow.

A patent ductus arteriosus (PDA) is often present in patients undergoing correction of congenital heart disease. It is well appreciated that during cardiopulmonary bypass (CPB), a PDA steals arterial inflow into pulmonary circulation, and may lead to systemic hypoperfusion, excessive pulmonary blood flow (PBF) and distention of the left heart. Therefore, PDA is preferably ligated before initiation of CPB. We describe acute decreases of arterial blood pressure and entropy score with the initiation of CPB and immediate increase in entropy score following the PDA ligation in a child undergoing intracardiac repair of ventricular septal defect and right ventricular infundibular stenosis. The observation strongly indicates that a PDA steals arterial inflow into pulmonary circulation and if the PDA is dissected and ligated on CPB or its ligation on CPB is delayed the cerebral perfusion is potentially compromised.

Esthetic Rehabilitation of Discouloured Anteriors By Ceramic Veneers- A Case Report.

Porcelain laminate veneers were first introduced by Charles Pinacus in 1930 s. Since then gained popularity in the field of esthetic dentistry because of the optimal esthetics, minimal preparation and durability. The advancement in dental adhesives also contributed the successes of ceramic laminates. This article highlights the improved esthetics of a patient who came with a complaint of discolored teeth, restoring them with ceramic veneers

A Comparison of Bond Strengths of Amalgam, Composite And Glass Cermet Cores When Restored With A Prefabricated Parallel Post - An Invitro Study.

Dentists have come to realize that with proper endodontic therapy and adequate restoration, pulpless teeth can continue indefinitely as an integral part of the dental apparatus. And yet endodontic therapy should not be done on teeth that can not be restored. In this study 45 freshly extracted maxillary premolars were restored with prefabricated parallel post and subsequently restored with Amalgam, composite and Glass cermet. The teeth in each of the restoration groups were allocated to three different loading conditions, load at an angle of 100, 450 and 900 to long axis of the specimen. It is observed that glass cermet core showed a mean failure load that was lower for all three loading conditions than those of Amalgam and composite cores. The aim of the study was to compare the bond strengths of Amalgam, composite and glass cermet cores restored with a pre-fabricated parallel post when subjected to simulated occlusal forces from varying angles.

Delayed extradural hematoma: a case report.

Three patients of delayed extradural hematoma (EDH) were seen in the last one year among forty eight consecutively treated cases of EDH. All the three hematomas were evacuated. Awareness of this entity and a high degree of vigilance are strongly recommended to detect such cases. Repeat CT should always be done, especially after decompression by either surgical or medical means, recovery from shock or whenever there is evidence of even minimal bleeding under a skull fracture on initial CT scan.

Current research in diagnostic methods for assessing periodontal disease.

The management of chronic periodontal disease is beset with a numbers of diagnostic as well as therapeutic problems. Assessment of periodontal disease progression has been made mainly based on the conventional methods such as clinical parameters and radiographic interpretation. A high level interest in the development of diagnostic tests capable of detecting factors associated with progressing periodontal disease has continued in the past years. Recent research has shown evidence that certain microbial species and specific genetic and related factors are some strong indicators of susceptibility to severe periodontitis. Here an attempt is made to review the current trends and diagnostic tests used to assess the disease activity and predict its progression.