Intraoperative Transesophageal and Postoperative Transthoracic Echocardiographic Evaluation of a Mechanical Heart Valve Prosthesis Implanted at Aortic Position

OBJECTIVE

The aims of this study were to evaluate the intraoperative transesophageal echocardiographic (iTEE) characteristics and Doppler flow profile of aortic Chitra heart valve prosthesis (CHVP) under stable hemodynamic and loading conditions, and to compare and correlate the iTEE data with the postoperative transthoracic echocardiography (TTE) data obtained at 48 hours (TTE₁) and 3 months (TTE₂) after the surgery.

DESIGN

Prospective, observational study.

SETTING

University-level tertiary referral hospital.

PARTICIPANTS

Forty patients between 18 years and 65 years of age undergoing elective aortic valve replacement (AVR) using CHVP during the period January 2015 to August 2016.

INTERVENTIONS

After obtaining permission from institutional ethics committee, 40 patients undergoing elective AVR were studied prospectively. The iTEE examination was performed in the pre-cardiopulmonary bypass (CPB) and post-CPB period in all the study subjects. CHVP was subjected to iTEE two-dimensional (2D) echo, color Doppler, and spectral Doppler evaluation under stable hemodynamic and loading condition in the post-CPB period after the administration of protamine. The CHVP were re-evaluated using TTE in all the patients 48 hours after the surgery (TTE₁) and 3 months after the surgery (TTE₂). The iTEE and postoperative TTE Doppler values were compared and correlated.

MEASUREMENTS AND MAIN RESULTS

The CHVP could be imaged adequately and interrogated with Doppler in all the patients. None of the patients had restriction of occluder mobility or unstable seating of the valve. The intraoperative flow dependent (peak velocity [PV] and mean pressure gradient [MPG]) and less flow dependent (Doppler velocity index, acceleration time, acceleration time/ejection time, effective orifice area [EOA] and indexed EOA) Doppler parameters of CHVP were measured as per the American Society of Echocardiography recommendations. The PV and MPG of CHVP measured by iTEE showed no statistical difference (p > 0.05) and were in limits of agreement when compared with TTE₁ and TTE₂ data.

CONCLUSION

The iTEE features of CHVP were found compliant with the criteria set by the ASE defining normal functioning of an aortic valve prosthesis. The iTEE Doppler parameters obtained under stable loading conditions strongly predicted the postoperative values of Doppler parameters on TTE examination. The iTEE Doppler values can be used as the reference values for the postoperative follow up studies.

Concentration-dependent studies of Nd3+ -doped zinc phosphate glasses for NIR photoluminescence at 1.05 μm

Nd³⁺ -doped lead-free zinc phosphate glasses with the chemical compositions (60-x) NH₄ H₂ PO₄  + 20ZnO + 10BaF₂  + 10NaF + xNd₂ O₃ (where x = 0.5, 1.0, 1.5, 2.0 and 2.5 mol%) were prepared using a melt quenching technique. Vibrational bands were assigned and clearly elucidated by Raman spectral profiles for all the glass samples. Judd-Ofelt (J-O) intensity parameters (Ω_λ : λ = 2, 4, 6) were obtained from the spectral intensities of different absorption bands of Nd³⁺ ions. Radiative properties such as radiative transition probabilities (A_R ), radiative lifetimes (τ_R ) and branching ratios (β_R ) for different excited states were calculated using J-O parameters. The near infrared (NIR) photoluminescence spectra exhibited three emission bands (⁴ F_3/2 level to ⁴ I_13/2 , ⁴ I_11/2 and ⁴ I_9/2 states) for all the concentrations of Nd³⁺ ions. Various luminescence properties were studied by varying the Nd³⁺ concentration for the three spectral profiles. Fluorescence decay curves of the ⁴ F_3/2 level were recorded. The energy transfer mechanism that leads to quenching of the ⁴ F_3/2 state lifetimes was discussed at higher concentration of Nd³⁺ ions. These glasses are suggested as suitable hosts to produce efficient lasing action in NIR region at 1.05 μm.

An audit of cytoreductive surgeries in ovarian cancer from a rural based cancer center

BACKGROUND AND OBJECTIVE

Ovarian cancers are frequently seen at an advanced stage in our center. This audit was planned to see the morbidity and efficacy of different types of cytoreductive surgeries (radical vs. ultra-radical) done in such patients.

METHODS

This was a retrospective analysis of all ovarian cancer patients who underwent cytoreductive surgery at our center from January 2009 to August 2013. The case records of these patients were reviewed and the demographic, disease-related and treatment-related data were extracted.

RESULTS

Fifty-fivepatients were identified. Ten (18.2%) patients underwent primary cytoreduction while 45 patients had (81.8%) interval cytoreduction. The resections achieved were optimal in 50 patients (90.9%) and suboptimal in five patients (9.1%). The postoperative median blood loss was 400 (350-600) mL. The median time interval for surgery was 4.0 h (3-5 h). The type of resection achieved (optimal vs. suboptimal) was the only factor affecting the progression free survival (PFS) (Hazard ratio = 0.08 95% confidence interval 0.02-0.3). There was no significant difference in postoperative morbidity in patients undergoing the ultra-radical surgery as compared to those who underwent radical surgery.

CONCLUSION

Optimal cytoreduction may improve PFS in advanced ovarian cancer patients and needs to be done even if it mandates an ultra-radical surgery.

Optical properties and spectroscopic study of different modifier based Pr(3+):LiFB glasses as optical amplifiers

In this paper, we report the preparation and optical characterization of Pr(3+) doped lithium fluoro borate (LiFB) glasses for six different chemical compositions of Li2B4O7-BaF2-NaF-MO (where M=Mg, Ca, Cd and Pb), Li2B4O7-BaF2-NaF-MgO-CaO and Li2B4O7-BaF2-NaF-CdO-PbO. The structural and optical properties of these glasses were characterized by X-ray powder diffraction (XRD), scanning electron microscope (SEM), Fourier transform infrared spectroscopy (FTIR), optical absorption and photoluminescence techniques. The optical absorption spectra of Pr(3+) ions in LiFB glasses have been recorded in the UV-VIS-NIR region. The optical absorption data are used to calculate various spectroscopic parameters such as Racah (E(1), E(2), E(3)) and spin-orbit interaction (ξ4f) parameters. Judd-Ofelt (J-O) (Ωλ where λ=2, 4 and 6) intensity parameters were determined by applying J-O theory, which in turn used to calculate the radiative properties such as radiative transition probabilities (A), radiative lifetimes (τR), integrated absorption cross-sections (Σ) and branching ratios (βr) for all emission levels of Pr(3+) ion in different LiFB glass matrices. By using the J-O theory and luminescence parameters, stimulated emission cross sections (σp) of prominent transitions, (3)P0→(3)H4 and (1)D2→(3)H4 of Pr(3+) ion in all LiFB glasses were calculated. (3)P0→(3)H4 possesses higher branching ratios and stimulated emission cross-sections for the Pr(3+):LiFB(Mg-Ca) glass, which can be used as a best laser excitation. The optical gain parameter (σpxτR) was noticed higher in Pr(3+):LiFB(Mg-Ca) and Pr(3+):LiFB(Cd-Pb) glasses for the transition (3)P0→(3)H4 transition, and these glasses have potential for optical amplification at 488 nm wavelength.

Warden repair for superior sinus venosus atrial septal defect and anomalous pulmonary venous drainage in children: Anesthesia and transesophageal echocardiography perspectives

Objective:

Review of intraoperative anesthetic challenges and the role of transesophageal echocardiography in children with sinus venosus atrial septal defect and partial anomalous pulmonary venous drainage undergoing Warden repair.

Design:

A retrospective observational case series.

Methodolgy:

Pediatric patients who underwent Warden repair between October 2011-September 2015 were recruited. Their preoperative clinical details, anesthetic techniques, intraoperative TEE findings and postoperative events were recorded from the medical records. The categorical variables and the continuous variables were expressed as number (percentages) and mean ± SD respectively.

Results:

A total of 35 patients were operated for Warden repair during the study period. Anesthesia was induced with the aim to prevent any fall in pulmonary vascular resistance. The right internal jugular vein was cannulated under ultrasound guidance using a short length cannula to monitor right superior vena cava pressure. Intraoperative TEE revealed the drainage of PAPVC high into RSVC in 22 patients. Persistent LSVC was found in 9 patients. After repair, TEE imaging detected a high gradient at Warden anastomotic site in 5 patients and 3 of them required revision of surgery. Rerouted pulmonary veins required surgical correction in 2 patients in view of obstruction. None of them had pulmonary venous and SVC obstruction in the postoperative period.

Conclusion:

The primary aim of anesthesia is to avoid any fall in PVR. Right IJV cannulation can be beneficial. The intraoperative TEE can help in delineating the anatomy of lesion and detecting anastomotic site obstruction.

Comparison of I-gel versus Endotracheal Tube in Patients Undergoing Elective Cesarean Section: A Prospective Randomized Control Study

Background and Aim:

Physiological changes during pregnancy and the sympatho adrenalstimulation during larynoscopy and intubation leads to evaluation of safe devices to secure airway during cesarean section under general anesthesia. I-gel, recently emerging effective supra glottic device found safe during general anesthesia in cesarean section. Aim of the study is to compare the hemodynamic disturbances and airway related complications of I-gel and Endotracheal tube in patients undergoing cesarean section under general anesthesia.

Material and Methods:

Eighty ASA II pregnant patients posted for elective LSCS were randomly divided into two groups of 40 each (n = 40). According to the group they were inserted either I-gel (Group I) or ETT (Group E). Insertion time, ease of intubation, hemodynamics during insertion and Extubation, airway related complications like sore throat, blood on the device, dysphagia, regurgitation, nausea, vomiting, aspiration and laryngospasm were noted and compared. Statistical analysis was done by using unpaired t test, chi square test and fisher's test. P value of <0.05 was considered as significant.

Results:

The demographic parameters, ease of insertion, insertion times and adequacy of ventilation were comparable between the groups (P > 0.05). 8 out of 40 patients in Group E had difficult intubation (P < 0.01). More than 20% of rise in MAP and HR were found during intubation and Extubation in Group E (40 out of 40 patients) which was statistically significant when compared to Group I (P < 0.001). Post operative sore throat significantly high in Group E (30 out of 40) (P < 0.001) when compared to Group I (4 out of 40).

Conclusion:

Easier insertion with less hemodynamic disturbances and very low incidence of sore throat I-gel found to be safer device to secure the airway in patients undergoing LSCS under general anesthesia.

A Comparative Study for Post Operative Analgesia in the Emergency Laparotomies: Thoracic Epidural Ropivacaine with Nalbuphine and Ropivacaine with Butorphanol

BACKGROUND

Adequate postoperative pain therapy for emergency abdominal surgeries is important far beyond the perioperative period because sensitization to painful stimuli can cause postoperative morbidity. A prospective, double-blind, randomized study was carried out to compare the quality of postoperative analgesia and side-effect profile between epidurally administered butorphanol and nalbuphine as an adjuvant to 0.2% ropivacaine.

MATERIALS AND METHODS

A total of eighty patients, 43 men and 37 women between the age of 18 and 65 years of American Society of Anesthesiologists (ASA) Class I E and II E, who underwent intestinal perforation repair surgery were randomly allocated into two groups ropivacaine with butorphanol (RB) and ropivacaine with nalbuphine (RN), comprising of 40 patients each. Group RB received 0.2% ropivacaine containing 2 mg butorphanol while Group RN received 0.2% ropivacaine containing 10 mg nalbuphine through thoracic epidural catheter. Quality of analgesia, cardiorespiratory parameters, side-effects, and the need of rescue intravenous analgesia were observed.

RESULTS

The demographic profile and ASA Class were comparable between the groups. RN group had good quality of analgesia and stable cardiorespiratory parameters for the initial 6 h of postoperative period, after which they were comparable in both groups. Furthermore, the need of rescue analgesia was higher (20%) in the RB group during the first 6 h. The side-effect profile was comparable with a little higher incidence of nausea in both groups.

CONCLUSION

Thoracic epidurally administered ropivacaine with nalbuphine is more effective than ropivacaine with butorphanol for immediate postoperative pain relief in patients undergoing emergency exploratory laparotomy.

Patterns of care in geriatric cancer patients - An audit from a rural based hospital cancer registry in Kerala

BACKGROUND

There is deficit of data from India on elderly patients with cancer. Comprehensive geriatric assessment may lead to a better decision making capacity in this population. However, routine implementation of such assessment is resource consuming.

AIM

The aim of this study was to determine the patterns of care in elderly patients treated at a tertiary rural cancer center in India.

MATERIALS AND METHODS

All patients with age 70 or above with solid tumors without any definitive treatment prior to the registration at our center and registered between 01/01/2010 and 31/12/2011 were selected for this study. The baseline demographic pattern and the pattern of care of treatment were analyzed. SPSS version 16 (IBM Inc, Armonk, New York, U.S.) was used for analysis. Descriptive data are provided.

RESULTS

A total of 761 patients were evaluable subject to the aforementioned inclusion criteria. The median age of this cohort was 75 years (70-95 years). The most frequent primary sites of malignancies in 451 males were head neck (32.4%), lung (23.3%) and gastrointestinal (23.3%). In 310 females, the most common sites were head neck (31.6%), gynecological (18.4%) and gastrointestinal (24.5%). 228 (30%) of the patients had localized disease, 376 (49.4%) had loco-regionally advanced disease and 145 (19.1%) had distant metastases at presentation. 334 (46.32%) of patients were treated with curative intent. On logistic regression analysis the factors that predicted use of curative intent treatment were age <75 years, performance status 0-1, primary site and clinical extent of disease.

CONCLUSION

Routine comprehensive geriatric assessment needs to be implemented in our setting as almost 50% of our geriatric patients undergo curative intent treatment.

Association of Anaesthetists of Great Britain and Ireland: Safe vascular access 2016

Safe vascular access is integral to anaesthetic and critical care practice, but procedures are a frequent source of patient adverse events. Ensuring safe and effective approaches to vascular catheter insertion should be a priority for all practitioners. New technology such as ultrasound and other imaging has increased the number of tools available. This guidance was created using review of current practice and literature, as well as expert opinion. The result is a consensus document which provides practical advice on the safe insertion and removal of vascular access devices.

Idiopathic nodular glomerulosclerosis: Report of two cases and review of literature

Nodular glomerulosclerosis, a pathological finding characterized by areas of marked mesangial expansion with accentuated glomerular nodularity can be seen in a number of conditions including diabetic nephropathy, amyloidosis, light chain deposition disease, fibrillary and immunotactoid glomerulopathy, collagen type III disease, nodular membranoproliferative glomerulonephritis, and Takayasu's arteritis. Idiopathic nodular glomerulosclerosis is a diagnosis of exclusion and is reported in patients with hypertension, smoking, chronic obstructive pulmonary disease, obesity, metabolic syndrome, etc. We report two cases of idiopathic nodular glomerulosclerosis, one in obese hypertensive male and the other in nonhypertensive, nonobese female patient.

Retrospective audit of clinico-pathologic features and treatment outcomes in a cohort of elderly non-Hodgkin's lymphoma patients in a tertiary cancer center

INTRODUCTION

There is limited data from India regarding elderly non-Hodgkin's lymphomas (NHL) patients. Hence, this audit was planned to study the clinic-pathological features and treatment outcomes in elderly NHL patients.

METHODS

Retrospective analysis of all NHL patients above age of 59 years treated at the author's institute, between December 2010 and December 2013 was done. Case records were reviewed for baseline details, staging details, prognostic factors, treatment delivered, response, toxicity and efficacy. SPSS version 16 (IBM, Newyork) was used for analysis. Descriptive statistics was performed. Kaplan-Meir survival analysis was done for estimation of progression-free survival (PFS) and overall survival (OS). Univariate analysis was done for identifying factors affecting PFS and OS.

RESULTS

Out of 141 NHL patients, 67 patients were identified subjected to the inclusion criteria. The median age was 68 years (60-92). Majority were B-cell NHL (86.6%). The commonest subtype in B-cell was diffuse large B-cell lymphoma (55.2%). Fifty-four patients took treatment. The treatment intent was curative in 41 patients (61.2%). Among the patients receiving curative treatment, 16 patients couldn't receive treatment in accordance with NCCN guidelines due to financial issues. Two years PFS was 55%. Two years PFS for B-cell NHL and T-cell NHL were 55% and 50% respectively (P = 0.982). Two years PFS for standard Rx and nonstandard Rx were 62% and 50% respectively, but it didn't reach statistical significance (P = 0.537). Two years OS for the entire cohort was 84%.

CONCLUSION

Standard treatment in accordance with guidelines can be delivered in elderly patients irrespective of age. There is a need for creating financial assistance for patients, so that potentially curative treatments are not denied.

Does the use of induction chemotherapy in oral cavity cancer compromise subsequent loco-regional treatment delivery: Results from a matched pair analysis

BACKGROUND

Neoadjuvant chemotherapy is being increasingly used in patients with unresectable oral cavity cancers to make them resectable. However, its impact on locoregional treatment delivery in such setting remains poorly studied.

AIMS

To evaluate the impact of neoadjuvant chemotherapy on delivery of further locoregional treatment.

SETTINGS AND DESIGN

Mono institutional retrospective audit of patients with oral cavity squamous cell cancers treated with neoadjuvant triplet chemotherapy in India.

MATERIALS AND METHODS

Patients receiving neoadjuvant chemotherapy (n = 14) from May 2012 to April 2014 were matched 1:2 to patients undergoing upfront surgery (n = 28) based on age (>60 or 60 and less), gender (male or female) and subsite site (tongue and floor of mouth or buccoalveolar complex). Data regarding factors related to the delivery of locoregional treatment and toxicities were compiled.

STATISTICAL ANALYSIS

Descriptive analysis in the form of median (range) for continuous variables and frequencies for categorical variables.

RESULTS

Patients undergoing neoadjuvant chemotherapy required more extensive resections and had greater operative time (460 vs. 415 min, P < 0.001). A greater incidence of locoregional wound complications was seen as a consequence (57.1% vs. 14.3%, P, 0.01). However, toxicities during radiotherapy were not substantially different between the two groups and compliance to radiation was also similar. Total package time of 100 days or less, was maintained in 90% of patients in both groups.

CONCLUSIONS

Delivery of neoadjuvant chemotherapy does not impair the ability to deliver locoregional treatment.

Molecular Docking and Molecular Dynamics to Identify a Novel Human Immunodeficiency Virus Inhibitor from Alkaloids of Toddalia asiatica

Background:

Acquired immunodeficiency syndrome caused by human immunodeficiency virus (HIV) is an immunosuppressive disease. Over the past decades, it has plagued human health due to the grave consequences in its harness.

Objective:

For this reason, anti-HIV agents are imperative, and the search for the same from natural resources would assure the safety.

Materials and Methods:

In this investigation we have performed molecular docking, molecular property prediction, drug-likeness score, and molecular dynamics (MD) simulation to develop a novel anti-HIV drug. We have screened 12 alkaloids from a medicinal plant Toddalia asiatica for its probabilistic binding with the active site of the HIV-1-reverse transcriptase (HIV-1-RT) domain (the major contributor to the onset of the disease).

Results:

The docking results were evaluated based on free energies of binding (ΔG), and the results suggested toddanol, toddanone, and toddalenone to be potent inhibitors of HIV-1-RT. In addition, the alkaloids were subjected to molecular property prediction analysis. Toddanol and toddanone with more rotatable bonds were found to have a drug-likeness score of 0.23 and 0.11, respectively. These scores were comparable with the standard anti-HIV drug zidovudine with a model score 0.28. Finally, two characteristic protein-ligand complexes were exposed to MD simulation to determine the stability of the predicted conformations.

Conclusion:

The toddanol-RT complex showed higher stability and stronger H-bonds than toddanone-RT complex. Based on these observations, we firmly believe that the alkaloid toddanol could aid in efficient HIV-1 drug discovery.

SUMMARY

In the present study, the molecular docking and MD simulations are performed to explore the possible binding mode of HIV 1 RT with 12 alkaloids of T. asiatica. Molecular docking by AutoDock4 revealed three alkaloids toddanol, toddanone, and toddalenone with highest binding affinity towards HIV 1 RT. The drug likeness model score revealed a positive score for toddanol and toddanone which is comparable to the drug likeness score of the standard anti HIV drug zidovudine. Results from simulation analysis revealed that toddanol RT complex is more stable than toddanone RT complex inferring toddanol as a potential anti HIV drug molecule.

Abbreviations used: HIV: Human immunodeficiency virus, HIV 1 RT: HIV 1 reverse transcriptase, RNase H: Ribonuclease H, MD: Molecular dynamics, PDB: Protein databank, RMSD: Root mean square deviation, RMSF: Root mean square fluctuation.