Effect of steroids on inflammatory markers and clinical parameters in congenital open heart surgery: a randomised controlled trial.

BACKGROUND: Cardiopulmonary bypass is associated with systemic inflammatory response. Steroids suppress this response, although the therapeutic evidence remains controversial. We hypothesised that intravenous steroids in children undergoing open-heart surgery would decrease inflammation leading to better early post-operative outcomes. We conducted a randomised controlled trial to evaluate the trends in the levels of immunomodulators and their effects on clinical parameters. OBJECTIVE: To assess the effects of intravenous steroids on early post-operative inflammatory markers and clinical parameters in children undergoing open-heart surgery. MATERIALS AND METHODS: A randomised controlled trial involving 152 patients, from one month up to 18 years of age, who underwent open-heart surgery for congenital heart disease from April 2010-2012 was carried out. Patients were randomised and administered either three scheduled intravenous pulse doses of dexamethasone (1 mg/kg) or placebo. Blood samples were drawn at four time intervals and serum levels of inflammatory cytokines - Interleukin-6, 8, 10, 18, and tumour necrosis factor-alpha - were measured. Clinical parameters were also assessed. RESULTS: Blood cytokine levels were compared between the dexamethasone (n=65) and placebo (n=64) groups. Interleukin-6 levels were lower at 6 and 24 hours post-operatively (p<0.001), and Interleukin-10 levels were higher 6 hours post-operatively (p<0.001) in the steroid group. Interleukin-8, 18, and tumour necrosis factor-alpha levels did not differ between the groups at any time intervals. The clinical parameters were similar in both the groups. CONCLUSION: Dexamethasone caused quantitative suppression of Interleukin-6 and increased Interleukin-10 activation, contributing to reduced immunopathology, but it did not translate into clinical benefit in the short term.

The word-length effect in reading: a review.

The finding that visual processing of a word correlates with the number of its letters has an extensive history. In healthy subjects, a variety of methods, including perceptual thresholds, naming and lexical decision times, and ocular motor parameters, show modest effects that interact with high-order effects like frequency. Whether this indicates serial processing of letters under some conditions or indexes low-level visual factors related to word length is unclear. Word-length effects are larger in pure alexia, where they probably reflect a serial letter-by-letter strategy, due to failure of lexical whole-word processing and variable dysfunction in letter encoding. In pure alexia, the word-length effect is systematically related to mean naming latency, with the word-length effect becoming proportionally greater as naming latency becomes more delayed in severe cases. Other conditions may also generate enhanced word-length effects. This occurs in right hemianopia: Computer simulations suggest a criterion of 160 ms/letter to distinguish hemianopic dyslexia from pure alexia. Normal reading development is accompanied by a decrease in word-length effects, whereas persistently elevated word-length effects are characteristic of developmental dyslexia. Little is known about word-length effects in other reading disorders. We conclude that the word-length effect captures the efficiency of the perceptual reading process in development, normal reading, and a number of reading disorders, even if its mechanistic implications are not always clear.

Learning to read upside-down: a study of perceptual expertise and its acquisition.

Reading is an expert visual and ocular motor function, learned mainly in a single orientation. Characterizing the features of this expertise can be accomplished by contrasts between reading of normal and inverted text, in which perceptual but not linguistic factors are altered. Our goal was to examine this inversion effect in healthy subjects reading text, to derive behavioral and ocular motor markers of perceptual expertise in reading, and to study these parameters before and after training with inverted reading. Seven subjects engaged in a 10-week program of 30 half-hour sessions of reading inverted text. Before and after training, we assessed reading of upright and inverted single words for response time and word-length effects, as well as reading of paragraphs for time required, accuracy, and ocular motor parameters. Before training, inverted reading was characterized by long reading times and large word-length effects, with eye movements showing more and longer fixations, more and smaller forward saccades, and more regressive saccades. Training partially reversed many of these effects in single word and text reading, with the best gains occurring in reading aloud time and proportion of regressive saccades and the least change in forward saccade amplitude. We conclude that reading speed and ocular motor parameters can serve as markers of perceptual expertise during reading and that training with inverted text over 10 weeks results in significant gains of reading expertise in this unfamiliar orientation. This approach may be useful in the rehabilitation of patients with hemianopic dyslexia.

The visual representations of words and style in text: an adaptation study.

While the nature of face representations in the human perceptual system has been extensively studied using adaptation, there has been little investigation using this technique of the neural basis of another parallel class of high-level objects, words. We used the perceptual-bias technique to determine if aftereffects could be generated for either the word content or stylistic properties of textual stimuli, and if these aftereffects showed invariance for the non-adapted dimension. In a first experiment, we examined adaptation for word versus handwriting style. In a second experiment we contrasted adaptation for words with adaptation for computer font. The third experiment performed a similar study of aftereffects for words and case. In all three experiments we consistently found adaptation for words, which were not diminished by changing the style between the adapting and probe stimuli: hence word aftereffects are invariant for handwriting, font and case. Aftereffects were negligible for style. Additional analyses showed that discriminative ability was better for word than for style content. These results confirm that the neural representations of words can be probed with the adaptation technique and suggest that adaptation accesses word representations at an abstract level, where the identity of a word is invariant for stylistic properties.

Giant pseudoaneurysm of the aortic arch and successful surgical repair.

A 50-year-old woman presented with fever, cough, shortness of breath, and left-sided chest pain. Computed tomography with contrast showed a pseudoaneurysm occupying the upper half of the left hemithorax. Surgical repair with a Dacron patch was performed after considering the risk of pseudoaneurysmal rupture.

Major thoracic vessels and cardiac trauma: case series from a center in a developing country.

BACKGROUND: Seventy-five percent of all trauma-related deaths are related to thoracic trauma. Very few penetrating cardiac trauma patients arrive to the hospital alive. Due to its high prevalence, an understanding of the pathogenesis, manifestations and management of cardiac trauma by the medical personnel is becoming increasingly important. METHODS: We retrospectively reviewed the files of 169 patients with a preoperative diagnosis of vascular injury who underwent management at the Aga Khan University Hospital from 2001 to 2006. Of these patients, 13 had cardiovascular and cardiac injuries. RESULTS: 23% (n=3) had cardiac injuries; 2 had right ventricle injuries and 1 had injury to both ventricles. Great vessel injuries included: pulmonary artery (n=2), inferior vena cava (n=1), left carotid artery (n=1), left subclavian artery (n=2), and right subclavian artery (n=3). 53.8% of the patients suffered from postoperative complications. The overall mortality of patients with major thoracic vessel and cardiac trauma was found to be 15.4%. CONCLUSION: We believe that, in the past, the inevitable delay in diagnosis led to unsuccessful thoracotomies, late transfers to the operating room and physiological deterioration of the patient. As the incidence of trauma is increasing worldwide, it is essential for surgeons to be prepared to handle cardiovascular and cardiac trauma injuries immediately, as delay can adversely affect the outcome in terms of both morbidity and mortality. All patients presenting with trauma to the chest should be assessed with a high index of suspicion for major cardiovascular injuries. Early diagnosis, prompt transfer to the operating room and speedy and perfect surgery influence a favorable outcome.

Perceptual and anatomic patterns of selective deficits in facial identity and expression processing.

Whether a single perceptual process or separate and possibly independent processes support facial identity and expression recognition is unclear. We used a morphed-face discrimination test to examine sensitivity to facial expression and identity information in patients with occipital or temporal lobe damage, and structural and functional MRI to correlate behavioral deficits with damage to the core regions of the face-processing network. We found selective impairments of identity perception in two patients with right inferotemporal lesions and two prosopagnosic patients with damage limited to the anterior temporal lobes. Of these four patients one exhibited damage to the right fusiform and occipital face areas, while the remaining three showed sparing of these regions. Thus impaired identity perception can occur with damage not only to the fusiform and occipital face areas, but also to other medial occipitotemporal structures that likely form part of a face recognition network. Impaired expression perception was seen in the fifth patient with damage affecting the face-related portion of the posterior superior temporal sulcus. This subject also had difficulty in discriminating identity when irrelevant variations in expression needed to be discounted. These neuropsychological and neuroimaging data provide evidence to complement models which address the separation of expression and identity perception within the face-processing network.

Outcomes of surgical management of tracheobronchial injuries---a case series from a developing country.

OBJECTIVE: Tracheobronchial injuries are defined as injuries involving the trachea and/or bronchi from the level of the cricoid cartilage extending up to the division of the bronchi. We present a case series with most of the tracheobronchial injuries found to be sustained after penetrating trauma. METHODS: A retrospective review was performed at the Aga Khan University, Karachi, Pakistan. From January 2004 to December 2009, 168 patients with thoracic trauma were treated, of whom 15 were recognized to have major tracheobronchial and pulmonary injuries. RESULTS: The average age was 31 years with most of the patients being male (14:1). Among them,11 patients had penetrating trauma as the main cause of injury, 3 patients had blunt trauma from road traffic accidents, only 1 patient had combined trauma (blunt and penetrating trauma). Eight patients were diagnosed based on radiological findings. All the patients were treated surgically. Lobectomy was the most common intervention performed in 7 patients. The mortality rate was 7% (1 patient). Most patients survived with no sequelae (10 patients) while 5 survived with disability. We found that penetrating trauma was the leading cause of injury in our series. The severity of injury depends upon the weapon causing the trauma. Patients in our series had multiple injuries and required surgical management. CONCLUSIONS: Tracheobronchial injuries are rare but potentially life threatening. They require quick diagnosis and management. Diagnosis tends to be difficult since there are no specialised diagnostic modalities available at present.

Synovial sarcoma of the lung presenting late with compression of mediastinal structures and its successful resection: A case report.

Synovial sarcoma accounts for 5-14% of all soft tissue tumours. We present a case of 35 year-old male who presented with five months history of progressively increasing shortness of breath and cough. On evaluation, there was no air entry on the left side. CAT scan chest showed a large necrotic mass involving the entire left hemi-thorax. The tru-cut biopsy of this mass was done and it showed synovial sarcoma. The entire tumour along with the lung and the pericardium was removed completely. The patient had an uneventful recovery and was discharged home in 10 days with follow-up for adjuvant chemotherapy. Due to the rarity of this disease, no guidelines for the treatment are available. Main existing treatment includes surgery followed by either radiation, chemotherapy or both. Synovial sarcoma should be considered in the differentials of an adolescent or adult male patient presenting with a mass in the thorax.

Acute traumatic subclavian artery thrombosis and its successful repair via resection and end-to-end anastomosis.

Subclavian artery thrombosis is a rare complication of clavicle fractures. We reported a 20-year-old man who was admitted to the emergency room after a road traffic accident. He was a pedestrian who was initially hit by a bus and after he fell down on the road, he was run over by a car. On evaluation, he was found to have multiple facial and rib fractures, distal right humerus and right clavicle fracture. Significantly, right radial pulse was absent. After further evaluation including Doppler studies and an angiography which revealed complete obstruction of right subclavian artery just distal to its 1st portion, the patient was urgently taken to the operation room. A midclavicular fracture was adjacent to the injured vessel. We established proximal and distal control, removed damaged part. After mobilizing the subclavian artery, an end-to-end anastomosis was made. Then open reduction and internal fixation of right distal humerus was performed. The rest of the postoperative course was unremarkable. To prevent complications of subclavian artery thrombosis, different treatment modalities can be used, including anticoagulation therapy, angioplasty, stenting and bypass procedures.

Ruptured hydatid cyst presenting as pneumothorax.

Patients with echinococcus infection are mostly asymptomatic. The documented rates of simple pneumothorax in patients with pulmonary hydatidosis ranged from 2.4% - 6.2%. We report a case of a forty-year-old male patient who was referred to our hospital for management of recurrent pneumothorax. A video assisted thoracoscope (VATS) was first introduced which showed a large amount of pus in the pleural cavity and a perforated hydatid cyst. The VATS was converted to an open thoracotomy and decortication was done with removal of the ruptured hydatid. The patient made an unremarkable recovery and was discharged after one week with empyema tubes. The empyema tubes were gradually removed over a period of six weeks. An extraordinary number of management options for pulmonary hydatid disease have been offered. This case report highlights surgical treatment as the management opti.

Secondary prevention of heart disease--knowledge among cardiologists and omega-3 (omega-3) fatty acid prescribing behaviors in Karachi, Pakistan.

BACKGROUND: The use of omega-3 fatty acids is a currently proven strategy for secondary prevention of heart disease. The prescription practices for this important nutraceutical is not currently known. It is imperative to assess the knowledge of cardiologists regarding the benefits of omega-3 fatty acids and to determine the frequency of its prescription. The aim of the study was to determine the practices and associations of dietary fish prescribing among cardiologists of Karachi and to assess their knowledge of fish oil supplementation and attitudes toward dietary practices. METHODS: A cross sectional survey was conducted during the period of January to March, 2008. A self report questionnaire was employed. All practicing cardiologists of Karachi were included in the study. Multiple logistic regression analysis was performed to determine the independent factors associated with high fish prescribers. RESULTS: The sample comprised of a total of 163 cardiologists practicing in Karachi, Pakistan. Most (73.6%) of the cardiologists fell in the age range of 28-45 years and were male (90.8%). High fish prescribers only comprised 36.2% of the respondents. After adjusting for age and gender, multivariate analysis revealed that only the variable of knowledge about fish oil's role in reducing sudden cardiac death was independently associated with high fish prescribers OR = 6.38 [95% CI 2.58-15.78]. CONCLUSION: The level of knowledge about the benefits of omega-3 fatty acids is high and the cardiologists harbor a favorable attitude towards dispensing dietary fish advice. However, the prescription practices are less than optimal and not concordant with recommendations of organisations such as the American Heart Association and National Heart Foundation of Australia. The knowledge of prevention of sudden cardiac death in CVD patients has been identified as an important predictor of high fish prescription. This particular life-saving property of omega-3 fatty acids should be the focus of any implemented educational strategy targeted to improve secondary CVD prevention via omega-3 fatty acid supplementation.