Clear Cell Carcinoma of Salivary Gland with Intracranial Extension Through Jugular Foramen

Clear cell carcinoma not otherwise specified type affecting the parotid gland is rare and extension of this tumor through the jugular foramen presenting as an intracranial space occupying lesion is extremely uncommon. We report a case of clear cell carcinoma of the parotid gland presenting as a left cerebellopontine angle tumor.

Hydrothermal fabrication of selectively doped organic assisted advanced ZnO nanomaterial for solar driven photocatalysis

Hydrothermal fabrication of selectively doped (Ag(+)+Pd(3+)) advanced ZnO nanomaterial has been carried out under mild pressure temperature conditions (autogeneous; 150°C). Gluconic acid has been used as a surface modifier to effectively control the particle size and morphology of these ZnO nanoparticles. The experimental parameters were tuned to achieve optimum conditions for the synthesis of selectively doped ZnO nanomaterials with an experimental duration of 4 hr. These selectively doped ZnO nanoparticles were characterized using powder X-ray diffraction (XRD), Fourier transform infrared spectroscopy (FT-IR), UV-Vis spectroscopy and scanning electron microscopy (SEM). The solar driven photocatalytic studies have been carried out for organic dyes, i.e., Procion MX-5B dye, Cibacron Brilliant Yellow dye, Indigo Carmine dye, separately and all three mixed, by using gluconic acid modified selectively doped advanced ZnO nanomaterial. The influence of catalyst, its concentration and initial dye concentration resulted in the photocatalytic efficiency of 89% under daylight.

Evaluation of prolonged safety and efficacy of biodegradable polymer coated sirolimus-eluting coronary stent system: 1-year outcomes of the INDOLIMUS Registry

BACKGROUND

The main aim is to evaluate prolonged safety and efficacy of the Indolimus (Sahajanand Medical Technologies Pvt. Ltd.) sirolimus-eluting coronary stent system.

METHODS

It was a single center, non randomized, retrospective registry. Out of total 530 patients involved in the INDOLIMUS Registry, follow-up of 523 patients were obtained at 1-year The primary end-point of this was major adverse cardiac events, which is a composite of cardiac death, target lesion revascularization, target vessel revascularization, myocardial infarction and stent thrombosis, at 1-year follow-up.

RESULTS

Cardiac death, target lesion revascularization and myocardial infarction at 1-year were reported in 19 (3.6%), 2 (0.4%), and 2 (0.4%) patients respectively, while stent thrombosis was reported in 1 (0.2%) patient. The resultant major adverse cardiac events at 1-year were reported to be 24 (4.5%).

CONCLUSIONS

The lower incidence of MACE in uncontrolled and more complex cohorts at 1-year follow-up clearly depicts the prolonged safety and efficacy of the Indolimus sirolimus-eluting stent (SES) system.

Hemorrhage from lumbar artery following percutaneous renal biopsy

We present a 58-year-old lady who underwent ultrasound-guided renal biopsy for suspected acute glomerulonephritis. Within minutes, the radiologist noticed an echogenic band around left kidney and in the muscular planes. Computerized tomography revealed focal active contrast extravasation from arcuate or interlobular artery in lower pole of left kidney and lumbar artery at third lumbar vertebra. The bleeding vessel was occluded with gelfoam.

Prognostic significance of NT-proBNP, 3D LA volume and LV dyssynchrony in patients with acute STEMI undergoing primary percutaneous intervention

OBJECTIVES

The aim of the present study was to assess the short term prognostic significance of N-terminal pro BNP (NT-proBNP), 3D left atrial volume (LAV) and left ventricular (LV) dyssynchrony in patients of acute ST-elevation myocardial infarction (STEMI) who underwent primary Percutaneous intervention (PCI).

BACKGROUND

NT-proBNP, LV dyssynchrony and LAV in patients with acute coronary syndrome have been associated with PCI outcomes and predict the short and long-term prognosis.

METHODS

This study consisted of 142 patients with a first STEMI who underwent primary PCI. Baseline echocardiographic data was collected at admission and at 6 months follow up. Left ventricular dyssynchrony was measured by tissue Doppler imaging and LAV by real time 3D-echocardiography, plasma NT-proBNP levels were estimated between 72 and 96 h of admission.

RESULTS

During study period 3 patients expired and 4 developed congestive heart failure (CHF). Baseline NT-proBNP and LV dyssynchrony correlated with LV size and LV ejection fraction (LVEF) at baseline and during follow up. Patients with higher NT-proBNP levels and higher LV dyssynchrony showed significant increase in LV size with decrease in LVEF during follow-up. Baseline Left atrial volume index (LAVI) showed significant correlation with LV size but no association with LVEF at baseline and during follow-up.

CONCLUSIONS

Higher levels of NT-proBNP and higher LV dyssynchrony can predict patients with increase in LV size, worsening of LV systolic and diastolic function during follow-up. Patients with higher NT-proBNP levels at baseline developed CHF during follow-up.

Study of clinical, radiological and echocardiographic features and correlation of Qanadli CT index with RV dysfunction and outcomes in pulmonary embolism

BACKGROUND

There are no Indian studies correlating the CT pulmonary embolism index (Qanadli) with right ventricular function and outcome. In the present study we aimed to study the clinical manifestations of patients presenting with acute pulmonary thromboembolism and correlate the radiographic features with echocardiographic features and outcome.

METHODS

Thirty five patients presenting with symptomatic acute pulmonary thromboembolism in between 2011 and 2013 were studied for clinical, radiological and echocardiographic features and outcome (in-hospital & 1 month follow up).

RESULTS

The mean duration of presentation after onset of symptoms was 5.7 ± 3.7 days. Right ventricular dysfunction was observed in 11 (31.4%) patients. Out of 35 patients in whom CT pulmonary angiogram performed, 14 patients had Qanadli PE index >60% of whom 11 (78.6%) patients had right ventricular dysfunction. None had right ventricular dysfunction when PE index was <60% (p < 0.001). There was significant correlation between pulmonary vascular obstruction index and right ventricular dysfunction (p < 0.0001). Nine (25.7%) patients were thrombolysed with Streptokinase. Total mortality including in-hospital and 1 month follow up was 11.4% (4 patients). The mortality in patients with PE index >60% was 21.4% and was nil with <60% (p = 0.02). The mortality in patients with right ventricular dysfunction was 27.2% and was nil without right ventricular dysfunction (p = 0.0075).

CONCLUSION

A PE index which was shown to be a strong independent predictor of right ventricular dysfunction in PE, correlating linearly with different variables associated with higher morbidity and mortality, enabling accurate risk stratification and selection of patients for more aggressive treatment.

Multiple ruptures of left sinus of Valsalva aneurysm into main pulmonary artery

Sinus of Valsalva aneurysm is a rare congenital glitch. We report an extremely rare case of left sinus of Valsalva aneurysm compressing and rupturing into the main pulmonary artery with 2 communications. The 34-year-old man also had severe aortic regurgitation and severe tricuspid regurgitation. He underwent successful polytetrafluoroethylene patch repair and aortic valve replacement. The rarity of this case highlights the need for a precise preoperative diagnosis, the roles of transthoracic echocardiography, transesophageal echocardiography, and 3-dimensional echocardiography, and the importance of prompt surgical management.

The real world experience of the biodegradable polymer-coated sirolimus-eluting coronary stent system: Results From an "All-Comers" Clinical Experience

OBJECTIVES

This INDOLIMUS Registry sought to evaluate the safety and efficacy of the biodegradable polymer coated Indolimus(®) sirolimus-eluting coronary stent for the treatment of coronary artery disease across a wide range of patients treated in routine clinical practice, including those with high-risk characteristics and complex lesions.

BACKGROUND

First-generation drug-eluting stents utilize nonbiodegradable polymeric coatings, whose persistent presence in the arterial wall may negatively affect long-term outcomes. It has been hypothesized that persistent presence of polymer may compromise the safety of drug-eluting stents, and that therefore biodegradable polymer coatings might reduce late adverse events in an unselected patient population.

METHODS

All 530 consecutive unselected patients (415 males and 115 females) included who underwent percutaneous coronary intervention at the Sri Venkateswara Institute of Medical Sciences, Tirupati, India between August 2012 and March 2013, with an in-hospital, at 30-days and at 6-months follow-up. Retrospective analysis of those data had been done.

RESULTS

A total of 617 lesions were treated in 530 enrolled patients (mean age 54.9 ± 10.8 years) with average stent length of 18.8 ± 6.0 mm. An average of 1.18 stents was implanted per patient. The patients' characteristics are noted as having 169 (31.9%) patients of diabetics and 215 (40.6%) hypertension. Smoking, alcoholism and tobacco chewing were found in 273 (51.5%), 130 (24.5%) and 17 (3.2%), respectively. The indications for intervention were unstable angina in 77 (14.5%) and previous myocardial infarction in 56 (10.6%) of the patients. Lesions were of type B2 in 264 (42.7%) and type C in 127 (20.6%). Stent delivery was successful in all cases and in-hospital, 30-days and 6-months follow-up of all 530 patients was obtained. The incidence of any major adverse cardiac events at in-hospital, at 30-days and at 6-months were 5 (0.94%), 8 (1.52%), and 18 (3.40%), respectively. Long term follow-up of this registry is ongoing to confirm safety and efficacy profiles.

CONCLUSIONS

The relatively low event rate that was observed in INDOLIMUS Registry indicates that the biodegradable polymer coated Indolimus(®) sirolimus-eluting coronary stent can achieve excellent clinical performances in a large group of patients. © 2013 Wiley Periodicals, Inc.

Three-dimensional echocardiographic assessment before and after percutaneous transvenous mitral commissurotomy in patients with rheumatic mitral stenosis

BACKGROUND AND AIM OF THE STUDY

Real-time three-dimensional transthoracic echocardiography (RT3DE) is a relatively recent imaging technique that provides excellent image quality of the mitral valve. It has been suggested that this new echocardiographic modality, which allows a precise cross-section of the mitral orifice at the tips of the leaflets with correct plane orientation, may provide a more accurate assessment of rheumatic mitral stenosis (MS) than two-dimensional echocardiography (2DE), before and after percutaneous transvenous mitral commissurotomy (PTMC).

METHODS

A total of 50 patients with symptomatic mitral stenosis who underwent PTMC was evaluated prospectively. Patients in all age groups, with evidence of severe MS admitted to the authors' institution, in whom PTMC was feasible were included.

RESULTS

A good valve opening was observed in 45 patients (90%). The mitral valve area (MVA) assessed before PTMC with 3DE (3D-MVA) correlated well with that assessed with 2DE (2D-MVA) (0.85 +/- 0.12 cm2 versus 0.86 +/- 0.13 cm2, p < 0.001); the mean difference between methods was small (0.01 +/- 0.11 cm2) and correlation excellent (r = 0.64, p < 0.001). After PTMC, values of 3D-MVA did not differ from, and correlated well with, values of 2D-MVA (1.79 +/- 0.20 cm2 versus 1.74 +/- 0.18 cm2, p = 0.006); the mean difference between methods was small (0.05 +/- 0.02 cm2) and correlation excellent (r = 0.76, p = 0.0001). Before PTMC, Bland-Altman analysis showed a good agreement between methods (mean difference -0.01 +/- 0.11 cm2, lower limit -0.24, upper limit 0.22). After PTMC, Bland-Altman analysis showed a good agreement between methods (mean difference -0.05 +/- 0.13 cm2, lower limit -0.3, upper limit 0.2). Evaluation of the commissural opening after PTMC, using RT3DE, showed that excellent commissural evaluation was possible in all patients. Compared with RT3DE, an underestimation of the degree of commissural fusion using 2DE was observed in 32%, with a weak agreement between methods.

CONCLUSION

RT3DE provided accurate measurements of MVA, similar to 2D planimetry. RT3DE also improved the description of valvular anatomy and provided a unique assessment of the extent of commissural splitting.

Magnetic resonance angiography vs. angiography in tetralogy of Fallot

AIM

: To determine whether gadolinium-enhanced three-dimensional magnetic resonance angiography can provide a noninvasive alternative to diagnostic catheterization for evaluation of pulmonary artery anatomy in tetralogy of Fallot.

PATIENTS AND METHODS

Thirty-five consecutive patients with tetralogy of Fallot, who attended the cardiology outpatient department between January 2008 and December 2009, were included in the study. There were 21 males and 14 females, with a mean age of 9 ± 4.15 years (range, 3-21 years). Thirty-two patients had tetralogy of Fallot with varying severities of valvular and infundibular stenosis. Three patients had tetralogy of Fallot with pulmonary atresia. All patients underwent both cardiac catheterization with X-ray angiography and 3-dimensional magnetic resonance angiography within one month.

RESULTS

Measurements of right and left pulmonary arteries and aortopulmonary collaterals were equal by both methods. There was a good correlation between magnetic resonance angiography and catheterization measurements of branch pulmonary arteries.

CONCLUSION

Gadolinium-enhanced three-dimensional magnetic resonance angiography can be used as a reliable noninvasive alternative to X-ray cineangiography for delineation of pulmonary arterial anatomy in sick infants and young children, obviating the need for catheterization.

Genome-based approaches to develop epitope-driven subunit vaccines against pathogens of infective endocarditis

Infective endocarditis (IE) has emerged as a public health problem due to changes in the etiologic spectrum and due to involvement of resistant bacterial strains with increased virulence. Developing potent vaccine is an important strategy to tackle IE. Complete genome sequences of eight selected pathogens of IE paved the way to design common T-cell driven subunit vaccines. Comparative genomics and subtractive genomic analysis were applied to identify adinosine tri phosphate (ATP)-binding cassette (ABC) transporter ATP-binding protein from Streptococcus mitis (reference organism) as common vaccine target. Reverse vaccinology technique was implemented using computational tools such as ProPred, SYFPEITHI, and Immune epitope database. Twenty-one T-cell epitopes were predicted from ABC transporter ATP-binding protein. Multiple sequence alignment of ABC transporter ATP-binding protein from eight selected IE pathogens was performed to identify six conserved T-cell epitopes. The six selected T-cell epitopes were further evaluated at structure level for HLA-DRB binding through homology modeling and molecular docking analysis using Maestro v9.2. The proposed six T-cell epitopes showed better binding affinity with the selected HLA-DRB alleles. Subsequently, the docking complexes of T-cell epitope and HLA-DRBs were ranked based on XP Gscore. The T-cell epitope (208-LNYITPDVV-216)-HLA-DRB1(∗)0101 (1T5 W) complex having the best XP Gscore (-13.25 kcal/mol) was assessed for conformational stability and interaction stability through molecular dynamic simulation for 10 ns using Desmond v3.2. The simulation results revealed that the HLA-DRB-epitope complex was stable throughout the simulation time. Thus, the epitope would be ideal candidate for T-cell driven subunit vaccine design against infective endocarditis.

Assessment of mitral valve commissural morphology by transoesophageal echocardiography predicts outcome after balloon mitral valvotomy

BACKGROUND

Balloon mitral valvotomy (BMV) is a safe and an effective treatment in patients with symptomatic rheumatic mitral stenosis. This study was conducted to validate the importance of assessing the morphology of mitral valve commissures by transoesophageal echocardiography and thereby predicting the outcome after balloon mitral valvotomy [BMV].

MATERIALS AND METHODS

Study consisted of 100 patients with symptomatic mitral stenosis undergoing BMV. The Commissural Morphology and Wilkins score were assessed by transoesophageal echocardiography. Both the commissures (anterolateral and posteromedial) were scored individually according to whether non-calcified fusion was absent (0), partial (1), or extensive (2) and calcification (score 0) and combined giving an overall commissural score of 0-4. Outcome of BMV was correlated with commissural score and Wilkins score.

RESULTS

The commissural score and outcome after BMV correlated significantly. 66 of 70 patients (94%) with a commissural score of 3-4 obtained a good outcome compared with only six (20%) patients of 30 with a commissural score of 0-2 (positive and negative predictive accuracy 94% and 80%, respectively, p < 0.001). Increase in 2DMVA post BMV was more in patients with higher commissural score (score of 3-4). Wilkins score <8 usually predicts a good outcome but even in patients with Wilkins score >8 a commissural score >2 predicts a 50% chance of a good result.

CONCLUSIONS

A higher commissural score predicts a good outcome after BMV hence it can be concluded that along with Wilkins score, commissural morphology and score should be assessed with TOE in patients undergoing BMV.

Factor V Leiden mutation is not a predisposing factor for acute coronary syndromes

BACKGROUND

The prevalence of Coronary artery disease (CAD) in India has increased considerably over the past few years and could become the number one killer disease if interventions are not done. Factor V Leiden (FVL) mutation and FII G20210A polymorphism are two recently described genetic factors with a propensity towards venous thrombosis. This warrants the investigations for thrombophilia in myocardial infarction patients in India.

METHODS

The study cohort consisted of 51 patients aged below 50 years presenting with acute coronary syndromes. In both patient group and normal individuals the major risk factors Protein C deficiency, Protein S deficiency, anticardiolipin antibodies, Fibrinogen and Lipoprotein [a] were studied. Factor V Leiden (FVL) G1691A mutation in both control and patient group was looked by using Polymerase chain reaction (PCR) followed by sequencing of the PCR products.

RESULTS

Our results indicated significantly higher levels of anticardiolipin antibodies and fibrinogen in the patients and absence of FVL (G1691A) mutation in our study cohort. One of the patients (H5) showed insertion of an extra A nucleotide in exon 10 of the Factor V gene resulting in frame shift mutation in this patient.

CONCLUSION

The results of present study showed absence of FVL mutation in our population. However, there is a need to confirm the above findings on patients from different populations from different parts of the country. The insertion of an extra A in exon 10 in the patient needs to be ascertained to confirm that it is one of its kinds or is prevalent in the population.

Lipoprotein (A): Better assessor of coronary heart disease risk in south Indian population

In an attempt to search for risk factors which can explain the increasing prevalence of coronary heart disease (CHD) in Indian population, we conducted a case-control study to assess the association of Lipoprotein (a)(Lp(a)) with CHD. One hundred and fifty one consecutive patients with clinical and angiographic evidence of CHD and forty-nine healthy controls were drawn for the study. Triglycerides, very low density cholesterol (VLDL-C), total cholesterol (total-C)/high density cholesterol (HDL-C) ratio, low density cholesterol (LDL-C)/HDL cholesterol ratio and Lp(a) were found to be higher in patients than controls. In female sex and in those with family history of CHD, higher total and LDL cholesterol levels were observed to be associated with higher Lp(a) levels. Lp(a) levels were also found to be higher in triple vessel disease than other vessel disease patients. Significant difference in Lp(a) levels were observed between normal coronaries vs. single and triple vessel disease(P<0.05) and also between single vs. double and triple vessel disease (P<0.01).Lp(a) levels correlated positively with vessel severity(P<0.005). Lp(a) levels >25 mg/dl were associated with coronary heart disease (Odds ratio 1.98 P<0.05 95% CI 0.007-1.18). Our findings suggest a cut-off level of 25mg/dl for determination of risk of CHD. Studies from different areas involving larger sample size are needed to confirm the findings of the present study.

Effect of percutaneous mitral balloon valvuloplasty on left atrial appendage function: transesophageal echo study

BACKGROUND

To compare left atrial appendage (LAA) function by Doppler and Doppler tissue imaging (DTI) before and after percutaneous balloon mitral valvuloplasty (PBMV).

MATERIALS AND METHODS

Fifty-nine patients with symptomatic rheumatic mitral stenosis who underwent PBMV were included in this study. LAA function was measured before and after PBMV. To study LAA function, LAA late emptying (LAALE) velocity, LAA late filling (LAALF) velocity, and LAA area change percentage (LAAAC %) were measured. In the DTI study, tissue Doppler velocities of the LAA, including peak early diastolic (E(LAA)), peak late diastolic (A(LAA)), and peak systolic (S(LAA)), were measured.

RESULTS

There was significant increase in LAALE velocity, LAALF velocity, E(LAA), A(LAA), S(LAA) waves measured by Doppler and DTI after PBMV compared with baseline (p < 0.001) but there was no significant change in LAAAC% (p = not significant). Spontaneous echo contrast was present in 10 of the 59 patients before the procedure. It completely disappeared (6 patients) or decreased (4 patients) after PBMV.

CONCLUSIONS

Our results suggest that PBMV improves LAA function and, thereby, may have a favorable influence on future thromboembolic complications.