A case of "acquired" cor triatriatum

Cor triatriatum sinister is a rare congenital cardiac anomaly. It consists of a fibro-muscular membrane that separates the left atrium into two chambers resulting in a tri-atrial heart. It is often found in association with other structural cardiac anomalies. The "acquired" form is extremely rare and only anecdotal reports are found in literature. We describe a case of acquired cor triatriatum following surgical repair of coronary sinus type of total anomalous pulmonary venous connection (TAPVC), which presented 11 years after initial repair of TAPVC.

Insights into complex nanopillar-bacteria interactions: Roles of nanotopography and bacterial surface proteins

Nanopillared surfaces have emerged as a promising strategy to combat bacterial infections on medical devices. However, the mechanisms that underpin nanopillar-induced rupture of the bacterial cell membrane remain speculative. In this study, we have tested three medically relevant poly(ethylene terephthalate) (PET) nanopillared-surfaces with well-defined nanotopographies against both Gram-negative and Gram-positive bacteria. Focused ion beam scanning electron microscopy (FIB-SEM) and contact mechanics analysis were utilised to understand the nanobiophysical response of the bacterial cell envelope to a single nanopillar. Given their importance to bacterial adhesion, the contribution of bacterial surface proteins to nanotopography-mediated cell envelope damage was also investigated. We found that, whilst cell envelope deformation was affected by the nanopillar tip diameter, the nanopillar density affected bacterial metabolic activities. Moreover, three different types of bacterial cell envelope deformation were observed upon contact of bacteria with the nanopillared surfaces. These were attributed to bacterial responses to cell wall stresses resulting from the high intrinsic pressure caused by the engagement of nanopillars by bacterial surface proteins. Such influences of bacterial surface proteins on the antibacterial action of nanopillars have not been previously reported. Our findings will be valuable to the improved design and fabrication of effective antibacterial surfaces.

Impact of COVID-19 pandemic on pediatric cardiac services in India

BACKGROUND

COVID-19 pandemic has disrupted pediatric cardiac services across the globe. Limited data are available on the impact of COVID.19 on pediatric cardiac care in India.

AIMS

The aims are to study the impact of COVID-19 pandemic on the care of children with heart disease in India in terms of number of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries.

SETTINGS AND DESIGN

This is a retrospective, multicentric, observational study.

METHODS

We collected monthly data on the number and characteristics of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries and major hospital statistics, over a period of 5 months (April to August 2020), which coincided with the first wave of COVID-19 pandemic in India and compared it with data from the corresponding months in 2019.

RESULTS

The outpatient visits across the 24 participating pediatric cardiac centers decreased by 74.5% in 2020 (n = 13,878) as compared to the corresponding period in 2019 (n = 54,213). The reduction in the number of hospitalizations, cardiac surgeries, and catheterization procedures was 66.8%, 73.0%, and 74.3%, respectively. The reduction in hospitalization was relatively less pronounced among neonates as compared to infants/children (47.6% vs. 70.1% reduction) and for emergency surgeries as compared to elective indications (27.8% vs. 79.2%). The overall in-hospital mortality was higher in 2020 (8.1%) as compared to 2019 (4.8%), with a higher postoperative mortality (9.1% vs. 4.3%).

CONCLUSIONS

The current COVID-19 pandemic significantly impacted the delivery of pediatric cardiac care across India with two-third reduction in hospitalizations and cardiac surgeries. In an already resource-constrained environment, the impact of such a massive reduction in the number of surgeries could be significant over the coming years. These findings may prove useful in formulating strategy to manage subsequent waves of ongoing COVID-19 pandemic.

Basic gait pattern and impact of fall risk factors on gait among older adults in India

BACKGROUND

An unstable gait pattern is an indicator of an increased risk of falls among older adults. Data on basic gait parameters is useful in the early identification of gait impairment. However, reference gait measurements are not available in low- and middle-income countries.

RESEARCH QUESTION

What are the normative reference values of gait parameters and do fall risk factors such as impaired balance, functional difficulty, and multimorbidity affect the gait patterns of older adults in India?

METHODS

A cross-sectional data of 659 older adults were collected using a semi-structured schedule. Gait parameters were measured using wearable sensors. Descriptive statistics, independent t-test, and one-way ANCOVA were used to determine the significant difference (p < 0.05) in gait parameters across the risk factors.

RESULTS

A mean stride length of 123.00 ± 15.19 cm, stride velocity of 110.57 ± 17.57 cm/s, and a cadence of 106.14 ± 11.44 steps/minute were reported in the study. Functional difficulties and balance impairment were the two major risk factors that affected stride velocity, stride length, and cadence after adjusting for age and height. No difference in gait parameters was observed among participants with and without multimorbidity.

SIGNIFICANCE

This study provides a baseline or reference values of various gait parameters measured on a large sample of population aged 60 and above from India. Assessment of gait patterns and associated risk factors in a clinical setup will help identify the older adults at risk of falls and reduce the enormous burden of fall injuries. Since gait parameters show a large variation across geographical regions, it is important to have region-specific reference values.

Outcome of COVID-19-positive children with heart disease and grown-ups with congenital heart disease: A multicentric study from India

BACKGROUND

Outcome data of children with heart disease who acquired COVID-19 infection are limited.

AIMS

We sought to analyze outcome data and identify risk factors associated with mortality in children with heart disease and grown-ups with congenital heart disease (GUCH) who had a laboratory-confirmed COVID-19 infection.

SETTINGS AND DESIGN

This is a retrospective, multicentric, observational study.

MATERIALS AND METHODS

The study included children with heart disease and GUCH population, who presented with either symptomatic or asymptomatic COVID-19 infection to any of the participating centers. COVID-19-negative patients admitted to these centers constituted the control group.

RESULTS

From 24 pediatric cardiac centers across India, we included 94 patients with a median age of 12.5 (interquartile range 3-96) months and 49 (52.1%) patients were males. Majority (83 patients, 88.3%) were children. One-third of the patients (n = 31, 33.0%) had acyanotic congenital heart disease, and 41.5% (n = 39) were cyanotic, with > 80% of the patients being unoperated. Only 30 (31.9%) patients were symptomatic for COVID-19 infection, while the rest were incidentally detected positive on screening. A total of 13 patients died (case fatality rate: 13.8%). The in-hospital mortality rate among hospitalized patients was significantly higher among COVID-19-positive cases (13 of 48; 27.1%) as compared to COVID-negative admissions (9.2%) during the study period (P < 0.001). On multivariate analysis, the independent predictors of mortality among COVID-19-positive cases were severity of illness at admission (odds ratio [OR]: 535.7, 95% confidence interval [CI]: 6.9-41,605, P = 0.005) and lower socioeconomic class (OR: 29.5, 95% CI: 1.1-814.7, P = 0.046).

CONCLUSIONS

Children with heart disease are at a higher risk of death when they acquire COVID-19 infection. Systematic preventive measures and management strategies are needed for improving the outcomes.

Annular pancreas causing pyloric stenosis in a 66-year-old patient treated with gastrojejunostomy: a case report

Annular pancreas is defined by a ring of pancreatic tissue encircling the descending portion of the duodenum. It is exceptionally rare in adults and commonly diagnosed during the investigation of symptoms arising due to its complications. Treatment usually involves the surgical correction with a duodenoduodenostomy, gastrojejunostomy or duodenojejunostomy. We discuss the case of a 66-year-old male patient who presented with symptoms of gastric outlet obstruction and was found to have an annular pancreas encircling the pylorus and the first and second portions of the duodenum and was treated by performing a gastrojejunostomy. Upper gastrointestinal series, computerized tomography (CT) scans, and magnetic resonance cholangeopancreatographys can all be used for preoperative diagnosis; however, endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic modality of choice. Nonetheless, many patients may only be diagnosed intraoperatively, especially those who cannot undergo an ERCP due to stenosis proximal to the duodenum or patients in whom the annulus may not be visible on CT scan.

Potts shunt as an effective palliation for patients with end stage pulmonary arterial hypertension

BACKGROUND

Potts shunt has been suggested as an effective palliative therapy for patients with pulmonary artery hypertension (PAH) not associated with congenital heart disease.

MATERIALS AND METHODS

This is a prospective single-center study performed to assess outcomes of Potts shunt in patients with PAH who are in functional class III or IV.

RESULTS

52 patients in functional class III/IV with pulmonary arterial hypertension without significant intra or extracardiac shunt on maximal medical therapy were evaluated and counseled for undergoing Potts shunt/patent ductus arteriosus (PDA) stenting. 16/52 patients (13 females) consented for the procedure; 14 patients underwent surgical creation of Potts, and 2 underwent transcatheter stenting of PDA, which physiologically acted like a Potts shunt. Standard medical therapy was continued in patients who did not consent for the procedure. 12/16 patients survived the procedure. Patients who did not survive the procedure were older, with severe right ventricular systolic dysfunction, and functional class IV. Patients who survived the procedure were followed up in the pulmonary hypertension clinic. The Median follow-up was 17 months (1-40 months). 11/13 patients discharged after the operation showed sustained clinical, echocardiographic, and biochemical improvement, which reduced need for pulmonary vasodilator therapy in 10/13 patients. There was one death in the follow-up period 16 months post-surgery due to lower respiratory tract infection.

CONCLUSION

Potts shunt is feasible in patients with PAH without significant intra or extracardiac shunts. It can be done safely with an acceptable success rate. Patient selection, preoperative stabilization, and meticulous postoperative management are essential. It should be performed at the earliest sign of clinical, echocardiographic, or laboratory deterioation for optimal outcomes. Long-term follow-up is required to see a sustained improvement in functional class and the need for a lung transplant in the future.

Congenital extrahepatic portocaval malformation: Rare but potentially treatable cause of pulmonary hypertension

OBJECTIVE

Abernethy malformation (congenital extrahepatic portosystemic shunt) is a rare anomaly of the splanchnic venous system. Though rare, it is an important cause of pulmonary artery hypertension (PAH) which is often missed. All patients with PAH should be carefully evaluated for presence of Abernethy malformation before labelling them as Idiopathic PAH.

METHODS

This is a retrospective analysis of prospectively collected data. We reviewed the data of all patients referred to our center for evaluation of PAH. 10 patients were diagnosed to have an extrahepatic portocaval malformation. We reviewed their presentation, diagnosis, catheterization data, intervention and their outcome along with review of literature.

RESULTS

10/104 patients with pulmonary hypertension and no intra or extracardiac shunt were found to have extrahepatic portocaval shunt (EHPCS). 3 patients had EHPCS type 1 and 7 had type 2 EHPCS. 6/7 patient with EHPCS type 2 underwent closure of the shunt. There was no procedure related complication. There was one death 3 months post procedure and one patient who was advised surgical closure was lost to follow up. Closure of the shunt resulted in normalization of the pulmonary artery pressures in 4/5 patients.

CONCLUSION

Congenital portosystemic malformations form an important and potentially treatable cause of pulmonary hypertension.

Elective delayed sternal closure portends better outcomes in congenital heart surgery: a retrospective observational study

Introduction

Delayed sternal closure is used in paediatric cardiac surgery as a management strategy for patients with unstable hemodynamics or postoperative bleeding routinely. We hypothesise that planned postponement of sternal closure leads to better outcomes than emergent reopening in the intensive care unit (ICU) in patients exhibiting some hemodynamic indication for the same.

Methods

We retrospectively analysed the outcomes of delayed sternal closure 220/2111 (10.42%) out of which 14 sternums were opened in the ICU after shifting the patients.

Results

A total of 220/2111 (10.42%) sternums were left open postoperatively, out of which 14 were opened after shifting to the ICU. Total mortality of the delayed sternal closure was 33/220, i.e. 15%. The patients whose sternums were left open from the theatre had a mortality of 23/206, i.e. 11.16%, whereas those patients whose sternums were opened in the ICU had a mortality of 10/14, i.e. 71.42%.

Conclusion

In doubtful postoperatively hemodynamic, the choice of leaving the sternum open electively has better outcomes, rather than opening the sternum as a terminal bail out procedure.

Correlates of Functional Limitations in Midlife: A Cross-Sectional Study in Middle-Aged Men (45-59 Years) from Pune

Background and Objective

The present article aims to determine the correlates of functional limitation in middle-aged men (45-59 years age) in the slums of Pune, India.

Materials and Methods

A total of 553 community-dwelling middle-aged men were randomly selected from the study area. Data on demographic characteristics, health-related conditions, and social and psychological determinants of health were collected using a pretested, structured questionnaire. Functional ability was assessed using the Pune-Functional Ability Assessment Tool. Univariate analyses and bivariate logistic regression analyses were carried out to examine the associations between various correlates and functional limitations.

Results

A total of 55.2% of the respondents displayed functional limitations. Univariate analysis identified significant correlates of functional limitations, which were increasing age, nature of the occupation, presence of chronic diseases, self-reported aches and pains, vision problems, previous hospital admission, and stress. Binary logistic regression displayed the higher odds of having functional decline in men with age above 55 years (odds ratio [OR] = 2.592; 95% confidence interval [CI] = 1.597-4.207), unskilled occupation (OR = 1.681; 95% CI = 1.050-2.692), chronic disease (OR = 2.608; 95% CI = 1.553-4.378), and reporting aches and pains (OR = 6.605; 95% CI = 3.732-11.689) as compared to their counterparts.

Conclusion

This study has identified the magnitude of functional decline and its risk factors for midlife men. These study findings suggest that men having several risk factors should be monitored to protect against accelerated functional loss. These findings are important because functional decline has implications on older adult's health and disease conditions. A better understanding of these factors will help to develop health promotion interventions for men in midlife.

Point-of-care lung ultrasound in intensive care during the COVID-19 pandemic

Coronavirus disease 2019 has spread to every inhabited continent in the world. So far, plain radiography and computed tomography have been the mainstay of imaging methods used. The present analytical paper on the role of point-of-care lung ultrasound in this pandemic examines its diagnostic accuracy, clinical utility, and physical practicality in the intensive care unit.

•

POCUS has a high sensitivity for pulmonary manifestations of COVID-19.

•

POCUS minimises nosocomial spread.

•

POCUS can prognosticate and assess response to therapy.

•

Healthcare providers with skills in POCUS are encouraged to help provide this service.

Single-Stage Repair of Interrupted Aortic Arch With Aortopulmonary Window and Bovine-Type Aortic Arch Complicated by Left Subclavian Artery Origin Stenosis-A Case Report

An aortopulmonary window is known to be associated in 5% of interrupted aortic arch cases. The combination of these lesions with a bovine-type aortic arch is much more uncommon. We report its embryological explanation and successful single-stage surgical repair in a three-month-old infant.

Bio-social determinants of health-related quality of life of middle aged (45-59 years) population in India

Purpose

Inadequate research on midlife health-related quality of life particularly in low-and-middle-income countries has often led to poor recognition of the issues in health programmes and policy. To address these concerns, this study was aimed at examining health-related quality of life and its determinants in middle-aged (45–59 years) men and women in low-resource settings in India.

Methods

Data on health-related quality of life and other relevant parameters were collected from 1112 individuals between 45 and 59 years of age from an urban agglomeration of Pune, India. Independent t-test was used to determine the association between means of Short Form-12 and other variables. Multilinear regression analyses were conducted to study the direction of these associations.

Results

The mean physical and mental component scores were 45.33 (±8.88) and 51.48 (±9.87), respectively. After adjusting for other variables, functional impairment emerged as a common factor that was negatively associated with physical and mental component scores of men (PCS: −5.557, 95%CI = −6.793 to −4.322; MCS:−1.816, 95% CI = −3.443 to −0.189) and women (PCS: −7.985, 95%CI = −9.782 to −6.188; MCS;  = −2.289, 95% CI = −4.160–0.419). Good life satisfaction was positively associated with physical scores in men (2.300, 95%CI =  1.180 to 3.421) and mental scores in women (3.066, 95%CI  =  1.333 to 4.798). Unemployment, sitting hours (>3) and no physical activity affected men, while lower education, marital status, body mass index and chronic illness affected health-related quality of life of women at midlife.

Conclusions

Functional decline, level of life satisfaction and stress affected health-related quality of life of middle-aged individuals in India.

Botulinum toxin in the management of temporomandibular disorders: a systematic review

The aim of this review was to critically investigate and assess the evidence relating to the use and efficacy of botulinum toxin (BTX) in the management of temporomandibular joint disorders (TMD) and masticatory myofascial pain. A comprehensive search was conducted of PubMed, Scopus, Embase, and Cochrane CENTRAL, to find relevant studies from the last 30 years up to the end of July 2018. Seven were identified. Three showed a significant reduction in pain between the BTX and placebo groups and one showed a clinical, but not a significant, difference. In one that compared BTX with another novel treatment, myofascial pain reduced equally in both groups, and in the remaining two there was no significant difference in pain reduction between the BTX and control groups. Of the four studies that assessed mouth opening, two reported that BTX had resulted in a slight improvement; one reported no improvement, and the other a worsening of the condition. A meta-analysis was not possible because of the considerable variation in the studies' designs, the heterogeneity between the groups, and the different assessment tools used. Despite showing benefits, consensus on the therapeutic benefit of BTX in the management of myofascial TMD is lacking. Further randomised controlled trials with larger sample sizes, minimal bias, and longer follow-up periods are now needed.

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

JUSTIFICATION

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 when recommending an intervention for congenital heart diseases, as often these patients present late in the course of the disease and may have co-existing morbidities and malnutrition.

PROCESS

Guidelines emerged following expert deliberations at the National Consensus Meeting on Management of Congenital Heart Diseases in India, held on 10th and 11th of August 2018 at the All India Institute of Medical Sciences, 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 heart diseases; (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 congenital heart diseases, including left-to-right shunts (atrial septal defect, ventricular septal defect, atrioventricular septal defect, patent ductus arteriosus and others), obstructive lesions (pulmonary stenosis, aortic stenosis and coarctation of aorta) and cyanotic congenital heart diseases (tetralogy of Fallot, transposition of great arteries, univentricular hearts, total anomalous pulmonary venous connection, Ebstein anomaly and others). In addition, protocols for follow-up of post surgical patients are also described, disease wise.

P4396Patients explanations of self-care in chronic heart failure: a grounded theory analysis of qualitative data from PANACEA-HF Phase 1

Background

Sub-optimal self-care and non-adherence to treatments are important predictors of poor clinical outcomes in patients with heart failure. Task-sharing and technology have each contributed modest improvements, but the combined effect on outcomes is unknown. We aim to develop a complex intervention package to improve self-care predicated on task sharing and smartphone based remote monitoring among heart failure patients.

Purpose

As a formative step, we conducted a qualitative study among heart failure patients and their caregivers to explore self-care and to inform the development of a contextualized intervention package.

Methods

We conducted in-depth interviews among 22 patients admitted to in-patient wards with a clinical diagnosis of chronic heart failure (diagnosis made at least 1 month prior to index hospitalization) and 18 caregivers (n=40), sampled from 4 states in southern India. Patients were purposively sampled based on sex, socioeconomic status, health literacy and past one month's history of adherence to heart failure medications. The middle range theory of self-care informed the drafting of the interview guide. We recorded and transcribed interviews translated from 5 regional languages. We inductively coded the data from a social constructionist viewpoint, created categories, prepared memos, compared extreme cases, identified key emergent themes and their inter-relationships.

Results

Patients' mean age was 60.5 (±13.4), with representation from socioeconomic strata, urban and rural areas. Patients had a high pill burden [median 10; IQR (6, 31)] and 8 (44%) reported irregular adherence to prescribed medications in the last month. Key categories associated with sub-optimal self-care included “Passivity”, “Entrenched Belief systems”, “Negative Emotions/Affect”, “Ageing causes disease”, and “inability to control situations” across all socioeconomic strata. These themes appear to impair self-actualization that negatively impacts self efficacy/confidence and in turn self-care reciprocally (Refer Figure). Key facilitators of self-care were: Intrinsic patient distinctive facilitators (situational awareness, resilience) and extraneous facilitators (insurance/financial protection, positive caregiver relationships and ease of healthcare access). Patients and caregivers generally expressed their readiness to use mobile technology for remote monitoring and to be counseled by trained lay workers to address beliefs and be trained on self-care.

Framework explaining self-care in HF

Conclusions

Findings from this formative study show opportunities for providers and community-based care workers to address task-sharing of beliefs by educating patients on self-care, including through the use of technology-based solutions. These findings regarding a self-care framework identify opportunities to improve self-care among heart failure patients using task-sharing and technology to support the patient-caregiver-provider triad.

Acknowledgement/Funding

India Alliance - Wellcome Trust and Department of Biotechnology