Dietary supplementation of Nile tilapia (Oreochromis niloticus) diets with bay laurel (Laurus nobilis): alleviation of oxidative stress and amelioration of immune response, serum biochemistry, and resistance against Aeromonas hydrophila.

Herbal plants can enhance immunity and alleviate oxidative stress in fish. Therefore, the present work was performed to evaluate the effects of bay laurel (Laurus nobilis) on growth, immunity, antioxidant activities, disease resistance, and hematology in Nile tilapia (Oreochromis niloticus). A total of 225 Nile tilapia fingerlings (average weight 15.36 ± 0.04 g) were divided into five treatment groups and fed with bay laurel at 0, 10, 15, 20, and 25 g/kg diet for 90 days. A completely randomized design with three replications was applied. The significantly (p < 0.05) improved weight growth (WG), food conversion ratio (FCR), average daily growth (ADG), protein efficiency ratio (PER), and survival rate were observed in fish fed with bay laurel-supplemented diet at the rate of 15 g/kg. Significantly improved red blood cells (RBCs) count, white blood cells (WBCs), hemoglobin (Hb), and significantly declined alanine aminotransaminase (ALT) and aspartate transaminase (AST) were found in the same diet-fed group. The immune response parameters such as nitro blue tetrazolium (NBT), lysozyme activity, phagocytic activity, total serum protein, serum albumin, serum globulin, and albumin-globulin ratio were found significantly improved at 15 g/kg bay laurel supplemented diet. The improved antioxidant response (catalase, glutathione peroxidase, malondialdehyde, total antioxidant activity) was also observed in the same diet-fed group. Relative percent survival after the fish challenged against Aeromonas hydrophila was significantly (p < 0.05) different. Overall, bay laurel supplementation at a 15 g/kg diet improved the nutritional physiology and immunity and, therefore, could be a potential growth-promoting feed additive for aquaculture development.

Outcomes of accelerated collagen cross linking in progressive paediatric keratoconus.

Purpose: To determine the efficacy and safety of pediatric accelerated cross linking (CXL). Methods: A prospective study on progressive keratoconus (KC) cases under ≤18 years of age. Sixty four eyes of thirty nine cases underwent epithelium-off accelerated CXL protocol. Visual acuity (VA), slit-lamp examination, refraction, pentacam reading of keratometry (K), corneal thickness, and thinnest location pachymetry were noted. Cases were followed up on days 1, 5, and at 1st, 3rd, 6th, and 12th-month post procedure. Results: Statistically, significant improvement of the mean aided VA, K, and mean corneal astigmatism (p < 0.0001) was noted. Mean Kmax reading reduced from 55.5 ± 5.64 (47.4-70.4) diopter (D) preoperatively to 54.41 ± 5.51 (46-68.3) D at 12 months postaccelerated CXL. Two cases had progression. Complications encountered were sterile infiltrate and persistent haze. Conclusion: Accelerated CXL is effective and efficacious in pediatric KC.

Pneumopericardium- An Unusual Complication Following Transseptal Puncture: A Series of 3 Cases.

Transseptal puncture (TSP) is performed to access the left side of the heart from the venous circulation. Performed under fluoroscopy with echocardiographic guidance, it is a procedure associated with complications. Pneumopericardium leading to cardiac tamponade is rare following TSP. We present 3 cases of pneumopericardium during TSP and its identification, probable mechanism, and management. (Level of Difficulty: Advanced.).

Fibrinolysis in left-sided mechanical prosthetic valve thrombosis with high INR.

BACKGROUND: A significant number of patients with prosthetic valve thrombosis have a prothrombin time international normalised ratio in the therapeutic range at presentation. Surgery may not be possible in many patients and traditionally a high international normalised ratio is considered a relative contraindication for fibrinolysis. METHODS: We conducted an observational study in patients with left-sided obstructive prosthetic valve thrombosis with international normalised ratio at or above the therapeutic range at presentation who received fibrinolysis. The fibrinolytic regimens, timing of initiation, success of fibrinolysis, risk of major and minor bleeding and ischaemic stroke were evaluated in the study. RESULTS: Of 30 patients included in the study 70% received immediate fibrinolysis and in 30% it was delayed. The majority of patients (90%) presented with New York Heart Association class III/IV symptoms. The mean international normalised ratio at fibrinolysis was 3.04 ± 0.70 in the immediate group and 2.42 ± 0.89 in the delayed group. Haemodynamically stable patients who had delayed initiation of fibrinolysis had a trend towards less bleeding without an increase in mortality. The rates of intracranial haemorrhage (0% vs. 7.7%), minor bleeding (12.5% vs. 25.1%) and ischaemic stroke (0% vs. 30.7%) were lower in patients who received low dose infusion compared to a conventional dose. CONCLUSIONS: Fibrinolysis can be considered in patients with prosthetic valve thrombosis with high international normalised ratio at presentation. For haemodynamically stable patients, delayed initiation of fibrinolysis is associated with a marginally lower bleeding risk without an increase in mortality. Low dose infusion may be considered over a conventional dose as it is associated with a lower incidence of ischaemic stroke and a good rate of valve function restoration with a trend towards less bleeding.

The 2017 International Joint Working Group recommendations of the Indian College of Cardiology, the Academic College of Emergency Experts, and INDUSEM on the management of low-risk chest pain in emergency departments across India.

There have been no published recommendations for the management of low-risk chest pain in emergency departments (EDs) across India. This is despite the fact that chest pain continues to be one of the most common presenting complaints in EDs. Risk stratification of patients utilizing an accelerated diagnostic protocol has been shown to decrease hospitalizations by approximately 40% with a low 30-day risk of major adverse cardiac events. The experts group of academic leaders from the Indian College of Cardiology and Academic College of Emergency Experts in India partnered with academic experts in emergency medicine and cardiology from leading institutions in the UK and USA collaborated to study the scientific evidence and make recommendations to guide emergency physicians working in EDs across India.

Transcatheter closure of ruptured sinus of Valsalva: Different techniques and mid-term follow-up.

OBJECTIVES: The aim of the present study was to study the feasibility and approaches to device closure of ruptured sinus of Valsalva (RSOV). We have compared the advantages and disadvantages of different devices and techniques and discussed complications which might occur during or after the procedure. BACKGROUND: There are only a few case series of transcatheter closure of RSOV, with most cases being traditionally referred for surgery. We have employed different devices used for treatment of congenital shunt lesions to achieve closure. Reasons for failure and need for surgical referral have also been analyzed. METHODS: Transcatheter closure was attempted in a total of 25 patients of RSOV who presented to us over a period of 4 years. Different devices were deployed using antegrade and retrograde approaches. All patients have been on regular follow-up. RESULTS: The procedural success rate was 84%. Two patients presenting in cardiogenic shock were effectively treated by device closure. There was one case of device embolization and two patients had residual leak. Three patients were referred for surgery. There was one case of device induced severe aortic regurgitation. Ventricular septal defect and RSOV were closed simultaneously in one patient. CONCLUSIONS: Different approaches and devices may be used for transcatheter closure of RSOV. We prefer antegrade closure using duct occluders in most cases while muscular VSD occluders may be used in select situations. ADO II devices should hardly ever be used on their own for device closure of RSOV.

Anomalous mitral arcade variant with accessory mitral leaflet and chordae presenting for the first time with acute decompensated heart failure in an adult.

The anomalous mitral arcade is a rare congenital malformation of the mitral valve and its tensor apparatus. It is characterized by enlarged papillary muscles connected to each other and to the free edge of the anterior mitral leaflet by a bridge of fibrous tissue. We report a rare variant of anomalous mitral arcade that was associated with accessory mitral leaflet in subaortic area and accessory chordae. Our patient was asymptomatic till the age of 18 years, when he presented for the first time in acute decompensated heart failure secondary to severe mitral regurgitation and left ventricular dysfunction. The patient had rapid deterioration with fatal outcome.

Inferior vena cava obstruction: long-term results of endovascular management.

BACKGROUND: Hepatic venous outflow obstruction (HVOO) can have acute or chronic presentation. In the chronic variety of inferior vena cava (IVC) obstruction, endovascular management with balloon angioplasty and stent implantation has emerged as a feasible, safe alternative to surgery which has high incidence of mortality and morbidity. AIMS AND OBJECTIVES: To study the feasibility and long-term follow-up of endovascular management of chronic IVC obstruction. METHODS: We studied 12 cases of HVOO who underwent endovascular management (balloon dilatation ± stenting). In most of the cases, the cause of obstruction was not obvious, but one case had metastatic hepatic nodules compressing on IVC. Diagnosis was established by clinical examination, venous Doppler and was confirmed by venography and/or computed tomography (CT) angiography. Cases underwent balloon dilatation and/or stenting. RESULTS: Out of 12 cases, six had membranous obstruction (four complete and two incomplete), five cases had segmental stenosis and one case had tumour compression. The lesion was crossed with either guide wire or Brockenbrough needle with Mullins sheath assembly and balloon dilatation was done with Inoue or Mansfield balloon. Seven cases underwent balloon dilatation alone while five cases underwent stenting. There was procedural success in all cases with reduction of gradient by 84%, disappearance of collaterals and clinical improvement. During the follow-up of 13 years, one case had restenosis, which was managed by stenting. CONCLUSION: Endovascular management of IVC obstruction is safe with good long-term patency rates.

Balloon mitral valvotomy in patients with mitral stenosis and left atrial thrombus.

OBJECTIVES: To evaluate the safety and efficacy of balloon mitral valvotomy (BMV) in symptomatic rheumatic mitral stenosis (MS) patients with left atrial (LA) thrombus and to address the technical issues. BACKGROUND: LA thrombus in patients with MS has long been regarded as a contraindication for BMV. There are few reports of BMV in presence of LA appendage (LAA) thrombus and reports of BMV in presence of LA body thrombus are still rare. METHODS: 2,763 patients with suitable valve morphology were screened for BMV. 194 patients had LA/LAA thrombus and were put on adequate anticoagulation for 8-12 weeks. A total of 108 patients with persistent LA thrombus who satisfied the inclusion criteria (LA thrombus type Ia, Ib, and IIa) formed the study group and the remaining 2,622 patients who did not have any LA thrombus constituted the control group. All patients in the study group underwent BMV by modified over the wire technique. RESULTS: There was significant and comparable improvement in the mitral valve area, mitral valve gradient, LA mean and pulmonary artery systolic pressure following the procedure in both groups. In the study group, there were no thromboembolic episodes during the procedure. However, there was one case of transient ischemic attack in the study group which occurred 6 hr after a successful BMV. In the study group, one patient had cardiac tamponade needing aspiration and there was no in-hospital death. CONCLUSIONS: In selected patients of mitral stenosis with LA thrombus (type Ia, Ib, and IIa), BMV can be performed safely with the modified over the wire technique. Systemic thromboembolism, technical failures and other complications are very rare when performed by experienced operators.

Transesophageal Doppler echocardiographic study of pulmonary venous flow pattern in severe mitral stenosis and the changes following balloon mitral valvuloplasty.

The studies of pulmonary venous flow-pattern in mitral stenosis (MS) have given conflicting data about the type of abnormality. This study was undertaken to assess the pulmonary venous flow-pattern in severe MS and to study the changes occurring after balloon mitral valvuloplasty (BMV). There were 51 patients of MS with sinus rhythm with the mean age of 32.5+/-9.35 years, 18 males and 33 females. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were performed before and after BMV. Pulmonary venous flow was recorded by TEE from left upper pulmonary vein (PV). Peak velocities (V) and velocity time integrals (VTI) of systolic wave (S), diastolic wave (D), and atrial reversal wave (A) were measured. The S(v)/D(v) and S(VTI)/D(VTI) were calculated. Mitral valve area (MVA) increased from 0.81+/-0.18 cm(2) to 2.02+/-0.46 cm(2), left atrium (LA) mean decreased from 28.55+/-6.68 mmHg to 13.88+/-4.89 mmHg, and cardiac output increased from 3.1+/-0.86 L/min to 3.7+/-1.02 L/min. The S, D, and A velocities increased from 33.84+/-13.55 cm/s, 37.24+/-11.55 cm/s, and 20.53+/-6.7 cm/s to 59.86+/-18.25 cm/s, 48.43+/- 12.55 cm/s, and 24. 94+/-9.14 cm/s, respectively. The VTIs of S, D, and A waves increased from 4.88+/-2.24 cm, 6+/-2.45 cm, and 2+/-0.88 cm to 10.46+/-4.23 cm, 8.82+/-3.61 cm, and 2.34+/-1.29 cm, respectively. MS leads to reduction in pulmonary flow velocities during all the phases. Successful BMV resulted in improvement of all these velocities, with improvement in systolic fraction being the maximum. These improved flows after BMV appear to be secondary to reduction in LA pressure and improved cardiac output.

Balloon mitral valvuloplasty: our experience with a modified technique of crossing the mitral valve in difficult cases.

The efficacy and safety of percutaneous transvenous mitral commissurotomy performed by the Inoue technique is well known. In cases with critical mitral stenosis and when there is abnormal bulge of the interatrial septum, the usual direct method of crossing the mitral valve may not be successful. In such cases alternative over-the-wire techniques to cross the mitral valve have been advocated by various authors. In this report of 32 cases, we present our experience with the modified and simplified version of over-the-wire technique of crossing the mitral valve in technically difficult cases. This technique involves direct positioning of a pigtail Inoue wire into the left ventricle through the Mullin sheath followed by introduction of an Inoue catheter over the wire. The mitral valve could be crossed in 30 cases (93.75%). There were no major complications attributable to this technique. Frequent ventricular premature beats (100%) and episodes of nonsustained ventricular tachycardia (90%) were seen in most of the cases. We conclude that our modification of the over-the-wire technique is safe, effective, and does not require any additional accessories. Using this technique, percutaneous transvenous mitral commissurotomy could be performed, even in difficult cases wherein the conventional method of crossing the mitral valve has failed.