Outcome of Obstructed Total Anamalous Pulmonary Venous Connection (TAPVC) Repair Patients with Milrinone Versus Milrinone and Inhaled Nitric Oxide (INO): A Prospective Randomized Observational Study

Background: Obstructed total anomalous pulmonary venous connection (TAPVC) typically present with severe cardiovascular decompensation and requires urgent surgical management. Pulmonary arterial hypertension (PAH) is a major risk factor affecting mortality. Perioperative management focuses on providing inotropic support and managing potential pulmonary hypertensive episodes. Milrinone and inhaled nitric oxide (iNO) efficiently reduce pulmonary artery pressure (PAP) and help to improve the outcome. The aim was to determine the outcome of patients with high PAP with milrinone alone and a combination of iNO and milrinone. Material and Method: After ethical committee approval, the study was conducted over a period of 3 years in 80 patients with obstructed TAPVC repair. A total of 80 patients having severe PAH (supra systemic arterial pressure) randomly divided into two groups with 40 patients in each (M & MN). Group M (milrinone) patients received milrinone and Group MN (milrinone & iNO) patients received both milrinone (after opening aortic cross clamp) and iNO (post operative ICU). Ventilation time, hospital stay, ICU stay, complications, in hospital mortality were compared between both groups. Result: Ventilation time, Intensive Care Unit (ICU) stay, hospital stay for group M was 8.02 � 5.74 days, 11.25 � 7.33 day, 14.92 � 8.55 days, respectively, and for group MN was 5.02 � 1.78 days, 8.27 � 3.24 days, 10.3 � 3.18 days, respectively. In hospital mortality for group M and MN was 10% and 2.5%, respectively. P value for each variable was significant < 0.05 (except mortality). Conclusion: Most of the patients with obstructed TAPVC had severe PAH. Management of severe PAH with a combination of milrinone with iNO had a better outcome than milrinone alone.

A Cross Sectional Study on Impact of Anti Tuberculosis Treatment in Tuberculosis (TB) Human Immunodeficiency Virus (HIV) Co-Infection

Introduction: TB is the most common opportunistic infection in HIV positive people. HIV-TB co-infection is a fatal combination with higher death rates in developing countries. In cured TB cases in HIV positive people, chances of recurrent also high. ART prevents the progression of HIV, reduces the chances of another opportunistic infection that could make management of care more complicated, and reduces the chances of TB recurring. Objectives: To document the profile of HIV positive TB patients availing both Anti-Retroviral (ART) and Anti Koch's Treatment (AKT) at a tertiary care hospital. Method: A retrospective descriptive study was conducted using available records of 198 HIV positive TB patients enrolled at an ART Centre of South Gujarat from November 2016 to November 2017. Age at enrollment at ART Centre, sex, native place, ART status, CD4 count were recorded along with detection, category, previous history and treatment of TB. Test of significance (t test) was applied to analyze the difference between CD4 count before and after treatment with AKT. Results: Mean age of male (n=123) and female (n=75) patients at the time of HIV detection was mean 37.62 (SD±11.61) years and mean 34.05 (SD±8.85) years respectively. Majority (86.87 %) were migrants from states other than Gujarat, of which 31.31% were from Maharashtra. Among them, 66% patients were on CAT-I AKT and 10.6% had previous history of TB. Among 56.1% patients who had extra-pulmonary TB, common were abdominal TB (47.75%), lymphadenopathy (18.02%) and pleural effusion (16.22%). While 32% of patients had completed their AKT regimen, 68% were on AKT. Among those were missed out (8.6%) and lost to follow up (3.5%) from ART, almost half (41.67%) had been initiated under CAT-II AKT. Mean CD4 count for 84 patients who completed their AKT was increase, this was statistically significant (p=0.001). Conclusion: Majority of patients were migrants and extra pulmonary TB was more common in this study group. Mean CD4 count increased significantly after completion of AKT. Prompt treatment and preventing loss to follow up are key to successful treatment completion and cure.

An Innovative Method to Demonstrate Nerve – Muscle Physiology Experiments Using Finger Muscle Twitch Recording in a Human Subject

Purpose of the study: Demonstration of nerve-muscle experiments play a vital role for teaching Physiologyto undergraduate medical students. In recent days, procuring frogs for the conduction of these experimentshave become a major concern. Therefore, we have designed an innovative method to carry out nerve-musclePhysiology experiments in human subjects.Methodology: We designed a simple and feasible method to demonstrate the effect of increasing strengthof stimuli, two successive stimuli and tetanic stimuli on human finger muscle twitch response.Main findings: Results of four nerve-muscle experiments performed in a human subject using an innovativemethod has been presented in this article. First, recording of finger muscle twitch by ulnar nerve stimulation.Second, effect of subthreshold, threshold, maximal and supramaximal stimulus with increase in the strengthof stimulus. Third, effect of two successive stimuli on finger twitch response. Four, effect of tetanizingstimuli on finger twitch response.Conclusion: Here we propose a simple innovative practical for effective demonstration of nerve-musclePhysiology experiments using human subject for under-graduate teaching.

Techniques, timing & prognosis of post infarct ventricular septal repair: a re-look at old dogmas

Abstract Objective: The study aimed to identify the factors affecting the prognosis of post myocardial infarction (MI) ventricular septal rupture (VSR) and to develop a protocol for its management. Methods: This was a single center, retrospective-prospective study (2009-2014), involving 55 patients with post MI VSR. The strengths of association between risk factors and prognosis were assessed using multivariate logistic regression analysis. The UNM Post MI VSR management and prognosis scoring systems (UPMS & UPPS) were developed. Results: Thirty-day mortality was 52.5% (35% in the last 3 years). Twenty-eight (70%) patients underwent concomitant coronary artery bypass grafting. Residual ventricular septal defect was found in 3 (7.5%) patients. The multivariate analysis showed low mean blood pressure with intra-aortic balloon pump (OR 11.43, P=0.001), higher EuroSCORE II (OR 7.47, P=0.006), higher Killip class (OR 27.95, P=0.00), and shorter intervals between MI and VSR (OR 7.90, P=0.005) as well as VSR and Surgery (OR 5.76, P=0.016) to be strong predictors of mortality. Concomitant coronary artery bypass grafting (P=0.17) and location (P=0.25) of VSR did not affect the outcome. Mean follow-up was 635.8±472.5 days and 17 out of 19 discharged patients were in NYHA class I-II. Conclusion: The UNM Post-MI VSR Scoring Systems (UPMS & UPPS) help in management and prognosis, respectively. They divide patients into 3 groups: 1) Immediate Surgery - Patients with scores of <25 require immediate surgery, preferably with extracorporeal membrane oxygenation support, and have poor prognosis; 2) Those with scores of 25-75 should be managed with "Optimal Delay" and they have intermediate outcomes; 3) Patients with scores of >75 can undergo Elective Repair and they are likely to have good outcomes.

Cervical cannulation for surgical repair of congenital cardiac defects in infants and small children

Abstract INTRODUCTION: The biggest challenge faced in minimally invasive pediatric cardiac surgery is cannulation for cardiopulmonary bypass. Our technique and experience of cervical cannulation in infants and small children for repair of congenital cardiac defects is reported in this study. METHODS: From January 2013 to June 2015, 37 children (22 males) with mean age of 17.97±8.63 months and weight of 8.06±1.59 kg were operated on for congenital cardiac defects through right lateral thoracotomy. The most common diagnosis was ventricular septal defect (18 patients). In all patients, right common carotid artery, right internal jugular vein and inferior vena cava were cannulated for institution of cardiopulmonary bypass and aorta was cross clamped through right 2nd intercostal space. RESULTS: There were no deaths or any major complications related to cervical cannulation. Common carotid artery cannulation provided adequate arterial inflow while internal jugular vein with inferior vena cava provided adequate venous return in all patients. No patient required conversion to sternotomy or developed vascular, neurological or wound related complications. Three patients had residual lesions (small leak across ventricular septal defect patch-2, Grade II left atrio-ventricular valve regurgitation-1) and one patient had mild left ventricular dysfunction. At discharge, both common carotid artery and internal jugular vein were patent on color Doppler ultrasonography in all patients. In a mean follow-up period of 11.4±2.85 months, all patients were doing well. No patient had any wound related, neurological or vascular complication. No patient had residual leak across ventricular septal defect patch. CONCLUSION: Cervical cannulation of common carotid artery and internal jugular vein is a safe, reliable, efficient and quick method for institution of cardiopulmonary bypass in minimally invasive pediatric cardiac surgery.

Pathophysiology & genetics of obstructive sleep apnoea.

Obstructive sleep apnoea (OSA) is a highly prevalent condition with proven neurocognitive and cardiovascular consequences. OSA patients experience repetitive narrowing or collapse of the pharyngeal airway during sleep. Multiple factors likely underlie the pathophysiology of this condition with considerable inter-individual variation. Important risk factors for OSA include obesity, male gender, and ageing. However, the mechanisms underlying these major risk factors are not well understood. We briefly review the state-of-the-art knowledge regarding OSA pathogenesis in adults and highlight the potential role of genetics in influencing key OSA pathophysiological traits.