Destination left ventricular assist devices in island states: asking too much or the inevitable solution

Background

Destination left ventricular assist device placement is increasing as a result of donor shortages and changing patient attitudes. As organ shortages become critical, LVAD programs become fundamental even in more remote regions of the world including island states. Here, we provide a look into the current state and availability of LVAD programs in island states.

Main body

A narrative review was performed using the World Health Organization Global Index Medicus and PubMed/MEDLINE databases to identify articles describing the island states having reported LVAD placements and programs. Additionally, INTERMACS reports were used. Data were retrieved and a review is presented describing the current state of LVADs in island states. The Caribbean region as a whole has a heart failure (HF) prevalence of 814 per 100,000 and Oceania 667 per 100,000 people. We estimate that over 3000 people in these islands need either a heart transplant or an LVAD.

Short conclusion

For HF patients living in island regions, special attention should be paid to the inability of having access to specialized mainland medical care. The continuous quest for a solution to HF in island regions should include the establishing of high-quality LVAD programs in a transfer-network centralized/regionalized system to care for those patients not candidates for long-distance air-bridging.

Assessment of hydrochemical backgrounds and threshold values of groundwater in a part of desert area, Rajasthan, India

Natural background levels (NBLs) and threshold values (TVs) are crucial parameters for identification and the quantification of groundwater pollution, and the evaluation of pollution control measures. The cumulative probability distribution technique was used for the evaluation of NBLs for 36 samples collected during two climate conditions in the part of the desert area from Rajasthan, India. The NBLs for Na⁺, Cl^-, SO₄^2-, HCO₃^-_, NO₃^- and F^- ions were assessed and compared with the natural and anthropogenic processes. The TVs were also calculated for Na⁺, Cl^-, SO₄^2-, HCO₃^-_, NO₃^- and F^- ions, and compared with the drinking limits of the Bureau of Indian Standards. Additionally, the pollution percentage (%) at the individual well was estimated and identified the polluted zones. Results indicate that most of the polluted areas were situated in the southern part, which was influenced by the natural and anthropogenic factors. The sodium concentrations above the TVs, in indicating the saline nature of water. Chloride threshold value above the drinking water limit was mainly observed in the dry season, related to intensive evaporation and industrial waste, which leads to groundwater quality degradation. The NO₃^- concentration (∼56% samples) above the TVs indicates extensive use of nitrate fertilizers and sewage effluent. The values of total dissolved solids (TDS) shows the suspicious scenario as about 84% of the samples in the dry period and about 89% in the wet season exceeding the drinking limit. Assessment of background concentrations and threshold values on regional and local scale assigns the basis for the identification of groundwater pollution, and helpful for better water quality guidelines to protecting of water resources.

Total arterial multivessels minimal invasive direct coronary artery bypass grafting via left minithoracotomy

BACKGROUND

Minimal Invasive Direct Coronary Artery Bypass Surgery (MIDCAB) is becoming popular and an important armamentarium for cardiac surgeons. We aimed to evaluate the result of MIDCAB total arterial revascularization.

METHODS

We have evaluated 216 patients who underwent MIDCAB multivessel total arterial revascularization through a left anterolateral mini thoracotomy. LIMA harvested in every patient, RIMA or radial artery used as second conduit. LIMA-RIMA Y or LIMA-RADIAL Y was made to accomplish multivessels total arterial revascularization. Post-operative graft patency was evaluated in all patients by CT coronary angiography at 6 months following discharge.

RESULTS

Mean age of patients was 52.5 ± 9.8 years. Average number of anastomosis performed were 2.34 ± 0.75. Multivessels total arterial CABG was accomplished in all individuals. There was no mortality or deep wound infection. Re-exploration was done in two patients for bleeding. In one patient emergency CPB was required. Average ICU and hospital stay was 1.52 ± 0.77 and 4.92 ± 1.46 days, respectively. Patients were mobilized earlier due to less pain. Wound healing of anterolateral thoracotomy was faster. In the follow up CT angiography 100% of the LIMA grafts were patent.

CONCLUSIONS

Multivessels total arterial MIDCAB can be accomplished safely in selected individuals. RIMA can be harvested in long standing diabetic patients with no concern for sternal wound healing. MIDCAB patients experience better cosmetics and early return to daily activities.

Challenges and possibilities of developing cardiac surgery in a peripheral hospital of low- and middle-income countries

OBJECTIVE

Over a million cardiac surgeries are performed every year around the globe. However, approximately 93% of world population living in low- and middle-income countries have no access to cardiac surgery. The incidence of rheumatic and congenital heart disease is high in Nepal, while only 2,500-3,000 cardiac surgeries are performed annually. The aim of our study is to analyze challenges and opportunities of establishing a cardiac surgery program in a peripheral hospital of Nepal.

METHODS

We analyzed our effort to establish a cardiac surgery program in a peripheral hospital in Nepal.

RESULTS

Out of 2,659 consulted and diagnosed patients, we performed 85 open-heart surgeries in 4 years. Mean age of patients was 38.35 ± 14.13 years. The majority of patients were male (62.4% of patients) with 65.9% suffering from rheumatic heart disease. Average intensive care unit stay and hospital stay were 2.32 ± 1.1 and 8.29 ± 2.75 days, respectively. No in-hospital mortality was observed.

CONCLUSION

We conclude that developing cardiac surgical care in a peripheral hospital of a developing country is feasible with support from government, foreign colleagues, local teams, and non-governmental organizations. The availability of a regular cardiac surgery service in the periphery of the country makes such services more accessible for the patients and helps in reducing the long waiting lists and unmanageable workload in the established cardiac centers in the capital city.

Rheumatic Heart Disease Screening Among School Children in Central Nepal

Rheumatic heart disease is the most common heart disease in developing countries. This Global Health Report uses the results of screening 28,050 school children clinically with 2-dimensional echocardiography. A total of 1,739 students had cardiac murmur, with the most dominant lesion being rheumatic mitral regurgitation. This report concluded that the burden of rheumatic heart disease is decreasing, but it is still significant in Nepal. That is why echocardiographic screening is important in early diagnosis and management. (Level of Difficulty: Beginner.)

Non-Surgical Pneumoperitoneum

Pneumoperitoneum is mostly caused by visceral perforation and surgical intervention; however non-surgical pneumoperitoneum has been reported without evidence of visceral disease. Blunt chest trauma causing an abrupt rise in thoracic pressure can leak air through the microscopic diaphragmatic defects or the mediastinum along perivascular connective tissue and cause pneumoperitoneum. We hereby present a case of non-surgical pneumoperitoneum after blunt chest trauma that was brought to the emergency department of college of medical sciences teaching hospital with features of bilateral pneumothorax with subcutaneous emphysema and abdominal distension which was diagnosed and managed promptly with bilateral chest drain and other supportive treatments.

Evaluation of Distensibility and Stiffness of Ascending Aortic Aneurysm using Magnetic Resonance Imaging

INTRODUCTION

Magnetic resonance imaging emerging as a new tool for the diagnosis and evaluation of ascending aortic aneurysm. The aim of our study is to evaluate in vivo distensibility and pulse wave velocity of the aortic wall using functional magnetic resonance imaging technique.

METHODS

We enrolled 25 patients undergoing surgery for ascending aortic aneurysm and or aortic valve replacement for a period of 8 months. Preoperatively, all the patients underwent functional MRI study of the aorta. Aortic wall distensibility and pulse wave velocity of ascending aorta was evaluated.

RESULTS

Mean age of the patient was 66 years (66.68 ± 5.62 years) with 60% (15) male patients. More than fifty percentages of patients were smoker (52%), hypertensive (64%) and diabetic (56%). We have observed significant decrease of distensibilty in the patients with aortic diameter above 50 mm (p-0.0002). Furthermore, we have found a significant inverse correlation between aortic distensibility and pulse wave velocity (R= -0.650, R2= 0.42, p-0.0004). Similarly, we have found a significant inverse correlation between ascending aortic diameter and distensibility of the aorta (R= -0.785, R2= 0.61, p-0.00001). Statistically significant positive correlation was observed between aortic diameter and pulse wave velocity (R= 0.865, R2= 0.74, p-0.00001).

CONCLUSIONS

MRI measurement of aortic diameters, distensibility, and flow wave velocity is an easy, reliable and reproducible technique. Distensibility and pulse wave velocity define the elasticity of the aorta. We have observed that elasticity of aortic wall is decreased in ascending aorta aneurysm patients.

Treatment of Chronic Venous Ulcers Using New Four Layers Compressive Bandage Dressing

Introduction: Lower-extremity ulcers represent the largest group of ulcers presenting to an outpatient department. It is a cumbersome, difficult to treat disease, which causes high morbidity and huge cost for the patient and healthcare system. Current standard treatment includes compression therapy. However, majority of patients need long term treatment with minimal efficacy. Aim of our study is to evaluate efficacy of four layers compressive bandages for the management of chronic venous ulcers. Methods: In Group A, we have prospectively included 20 patients with chronic venous ulcers on lower limbs for four layers hosiery bandage using Velfour bandage. Other 15 patients, Group B, were treated with conventional wound dressing. Velfour and crepe bandage were done once weekly for three weeks. Results: DVT was cause of chronic venous ulcer in 70% patient in group A and in 73.3% in Group B. Majority of patients were having left sided chronic venous ulcers. The mean duration of the ulcers was 15.6 vs 10.86 months (group A vs. group B). At the end of 3rd week, in 55% wounds in Group A were healed except few big and deep wounds remained. Most of these wounds also became smaller with minimal discharge. Size of wounds significantly decreased in Group A vs. Group B patients (0.7±0.81 cm vs. 1.73±0.77 cm, p<0.00031). However, cost of treatment in group A remained higher than group B. Conclusions: Our study has shown that four layer compressive bandage using Velfour is an easy, effective, and reproducible method of treatment for the chronic venous ulcer.  Keywords: compression bandage; treatment; venous ulcer.

Treatment of Chronic Venous Ulcers Using New Four Layers Compressive Bandage Dressing

INTRODUCTION

Lower-extremity ulcers represent the largest group of ulcers presenting to an outpatient department. It is a cumbersome, difficult to treat disease, which causes high morbidity and huge cost for the patient and healthcare system. Current standard treatment includes compression therapy.  However, majority of patients need long term treatment with minimal efficacy. Aim of our study is to evaluate efficacy of four layers compressive bandages for the management of chronic venous ulcers.

METHODS

In Group A, we have prospectively included 20 patients with chronic venous ulcers on lower limbs for four layers hosiery bandage using Velfour bandage. Other 15 patients, Group B, were treated with conventional wound dressing. Velfour and crepe bandage were done once weekly for three weeks.

RESULTS

DVT was cause of chronic venous ulcer in 70% patient in group A and in 73.3% in Group B. Majority of patients were having left sided chronic venous ulcers. The mean duration of the ulcers was 15.6 vs 10.86 months (group A vs. group B). At the end of 3rd week, in 55% wounds in Group A were healed except few big and deep wounds remained. Most of these wounds also became smaller with minimal discharge. Size of wounds significantly decreased in Group A vs. Group B patients (0.7±0.81 cm vs. 1.73±0.77 cm, p<0.00031). However, cost of treatment in group A remained higher than group B.

CONCLUSIONS

Our study has shown that four layer compressive bandage using Velfour is an easy, effective, and reproducible method of treatment for the chronic venous ulcer.

Chromium phytotoxicity in radish (Raphanus sativus): effects on metabolism and nutrient uptake

In the present investigation, chromium (VI) induced toxicity on metabolic activity and translocations of nutrients in radish were evaluated under controlled glass house conditions. Chromium was found to induce toxicity and significantly affect plant growth and metabolic activity. Excess of chromium (0.4 mM) caused a decrease in the concentration of iron in leaves (from 134.3 to 71.9 μg g(-1) dw) and significant translocation of sulphur, phosphorus and zinc. Translocation of manganese, copper and boron were less affected from root to stem. After 15 days of Cr exposure, maximum accumulation of Cr was found in roots (327.6 μg g(-1) dw) followed by stems (186.8 μg g(-1) dw) and leaves (116.7 μg g(-1) dw) at 0.4 mM Cr concentration. Therefore, Cr may affect negatively not only production, but also the nutritive quality of the radish; likewise, higher Cr content may cause health hazards for humans.

Aorta-to-right ventricular outflow tract fistula with coronary cusp prolapse

We describe a rare case of aorta-to-right ventricular fistula in a 20-year-old man who presented with signs and symptoms of congestive heart failure. He was successfully treated by closing the fistula with a Dacron patch from the aortic side. At follow-up, he was asymptomatic with no left-to-right shunt.

Development and characterization of microsatellite markers from tropical forage Stylosanthes species and analysis of genetic variability and cross-species transferability

A limited number of functional molecular markers has slowed the desired genetic improvement of Stylosanthes species. Hence, in an attempt to develop simple sequence repeat (SSR) markers, genomic libraries from Stylosanthes seabrana B.L. Maass & 't Mannetje (2n=2x=20) using 5' anchored degenerate microsatellite primers were constructed. Of the 76 new microsatellites, 21 functional primer pairs were designed. Because of the small number of primer pairs designed, 428 expressed sequence tag (EST) sequences from seven Stylosanthes species were also examined for SSR detection. Approximately 10% of sequences delivered functional primer pairs, and after redundancy elimination, 57 microsatellite repeats were selected. Tetranucleotides followed by trinucleotides were the major repeated sequences in Stylosanthes ESTs. In total, a robust set of 21 genomic-SSR (gSSR) and 20 EST-SSR (eSSR) markers were developed. These markers were analyzed for intraspecific diversity within 20 S. seabrana accessions and for their cross-species transferability. Mean expected (He) and observed (Ho) heterozygosity values with gSSR markers were 0.64 and 0.372, respectively, whereas with eSSR markers these were 0.297 and 0.214, respectively. Dendrograms having moderate bootstrap value (23%-94%) were able to distinguish all accessions of S. seabrana with gSSR markers, whereas eSSR markers showed 100% similarities between few accessions. The set of 21 gSSRs, from S. seabrana, and 20 eSSRs, from selected Stylosanthes species, with their high cross-species transferability (45% with gSSRs, 86% with eSSRs) will facilitate genetic improvement of Stylosanthes species globally.

Metal contamination of soil and translocation in vegetables growing under industrial wastewater irrigated agricultural field of Vadodara, Gujarat, India

The present investigation was carried out to evaluate metals concentration in ten vegetable crops growing in mixed industrial effluent irrigated agricultural field near Vadodara, Gujarat, India. Differential accumulation and translocation of various metals in selected vegetables plant species was observed. A higher concentration of metals were found in order of Fe>Mn>Zn>Cd>Cu>Pb>Cr>As in soil irrigated with industrial effluent than soil irrigated with tube well water; however, the concentration of As, Cr and Pb found below detection limit in tube well water irrigated soil. Metal accumulation in root and top of vegetables varied significantly both in relations to metal concentration in the soil and the plant genotype. Among ten vegetable species studied five vegetable species, i.e. Spinach, Radish, Tomato, Chili and Cabbage growing in mixed industrial effluent irrigated agricultural field showed high accumulation and translocation of toxic metals (As, Cd, Cr, Pb and Ni) in their edible parts, thus, their cultivation are unsafe with respect to possible transfer in food chain and health hazards. However, it is suggested that vegetable crops restricting toxic metal in non-edible port may be recommended for cultivation in such metal contaminated agricultural field.

Assessment of the Initial and Modified Parsonnet score in mortality prediction of the patients operated in the Sarajevo Heart center

This study has been conducted in an effort to establish more suitable and accurate scoring model we use in everyday practice. Among the specific outcome prediction models, in 1989 Parsonnet et al elaborated a method of uniform risk stratification for evaluation of the results of cardiac surgery procedures. We have tested two forms of the Parsonnet score, Initial and Modified Parsonnet score, in our patients. In the first half of the year 2007, 145 patients were operated in Sarajevo Heart center. All operated patients in that period, have participated in this study. The overall hospital mortality was 4,13 (6 deaths). This study shows that the initial and modified Parsonnet's scores are predictive for operative mortality in adult cardiac surgery patients.

Delayed Retrograde Type A Aotic Dissection After Endografting of Descending Thoracic Aorta

We report a case of a delayed retrograde dissection occurred after endovascular repair of ruptured type B aortic dissection. A 75-year-old male, presented with acute hemothorax and aortic arch fissuration. He was successfully treated with descending aorta and aortic arch stenting. After six days, he developed retrograde type A dissection with aortic root involvement and aortic valve incompetence. The entire ascending aorta and the ventral part of the arch were successfully replaced by a composite graft; in addition, aortic valve was replaced with prosthesis. Patient had an uncomplicated course and radiologic follow-up at one month revealed a sealed fissuration and no signs of endoleak. Endovascular repair of acute ruptured aorta, although life saving may be associated with potentially lethal complications, and it requires close monitoring with prolonged hospital stay to recognize and treat promptly these fatal complications.

Biodegradation of phenol by native microorganisms isolated from coke processing wastewater

The present investigation was undertaken to assess the biodegradation of phenol by native bacteria strains isolated from coke oven processing wastewater. The strains were designated ESDSPB1, ESDSPB2 and ESDSPB3 and examined for colony morphology Gram stain characters and biochemical tests. Phenol degrading performance of all the strains was evaluated initially. One of the strains namely ESDSPB2 was found to be highly effective for the removal of phenol, which was used as sole carbon and energy source. From an initial concentration of 200 mg I(-1) it degraded to 79.84 +/- 1.23 mg l(-1). In turn the effect of temperature (20 to 45 degrees C), pH (5-10) and glucose concentration (0, 0.25 and 0.5%) on the rate of phenol degradation by that particular strain was investigated. Observations revealed that the rate of phenol biodegradation was significantly affected by pH, temperature of incubation and glucose concentration. The optimal conditions for phenol removal were found to be pH of 7 (84.63% removal), temperature, 30 degrees C (76.69% removal) and 0.25% supplemented glucose level (97.88% removal). The main significance of the study is the utilization of native bacterial strains from the waste water itself having potential of bioremediation.

Delayed retrograde type A aortic dissection after endografting of descending thoracic aorta

We report a case of a delayed retrograde dissection occurred after endovascular repair of ruptured type B aortic dissection. A 75-year-old male, presented with acute hemothorax and aortic arch fissuration. He was successfully treated with descending aorta and aortic arch stenting. After six days, he developed retrograde type A dissection with aortic root involvement and aortic valve incompetence. The entire ascending aorta and the ventral part of the arch were successfully replaced by a composite graft; in addition, aortic valve was replaced with prosthesis. Patient had an uncomplicated course and radiologic follow-up at one month revealed a sealed fissuration and no signs of endoleak. Endovascular repair of acute ruptured aorta, although life saving may be associated with potentially lethal complications, and it requires close monitoring with prolonged hospital stay to recognize and treat promptly these fatal complications.

Chromium (VI) induced phytotoxicity and oxidative stress in pea (Pisum sativum L.): biochemical changes and translocation of essential nutrients

Due to widespread industrial use, chromium (Cr) is considered a hazardous environmental pollutant. It is known to inhibit plant growth and development. The present study provides the evidence of the phytotoxicity of this metal on the pea (Pisum sativum L. cv Azad) plants. The plants of pea (Pisum sativum L.) were grown in refined sand under different concentrations i.e. 0.05, 0.1, 0.2, 0.3 and 0.4 mM of Cr (VI) in order to study the effect on growth and yield, photosynthetic pigments, relative water content, non-reducing sugar and protein with activity of certain enzymes like catalase, peroxidase, starch phosphorylase and ribonuclease. The analysis of the results showed that photosynthetic pigments (68.68%), relative water contents (62.77%), non-reducing sugar (66.66%) and protein (81.57%) were decrease along with reduction in plant height (52.69%) and leaf area (50.81%) of the pea plants. However, in response to various concentration of Cr exposed plants showed significant induction of reducing and total sugars with enzymes like catalase, starch phosphorylase and ribonuclease. The translocation of Cr in various part of pea plant have been found in order of root> stem> leaves>seeds which ranged between 34.8 to 217.3 mg g(-1) d.wt. (dry weight) in roots, 6.5 to 173.13 mg g(-1) d.wt. in shoot, 4.2 to 74.43 mg g(-1) d.wt. in leaves and 0.94 to 8.64 mg g(-1) d.wt. in seeds, that is also reflected by the transfer factor of Cr from refined sand to tested species.

Phytoremediation efficiency of Portulaca tuberosa rox and Portulaca oleracea L. naturally growing in an industrial effluent irrigated area in Vadodra, Gujrat, India

Phytoremediation is a novel, solar-driven and cost-effective technology for the remediation of heavy metal contaminated environments through exploitation of plants ability to accumulate heavy metals in their harvestable shoot parts. In the present investigation, we collected plants of two species of Portulaca i.e. P. tuberosa and P. oleracea from field sites in Vadodra, Gujrat, India. At one site, field was being irrigated with industrial effluent while at other with tube well water. Analysis of heavy metals was performed in industrial effluent, tube well water, soils irrigated with them, and in different parts viz., roots, stem, leaves and flowers of the plant samples. Industrial effluent and soil irrigated with it had very high level of heavy metals (Fe, Zn, Cd, Cr and As) as compared to the tube well water and soil irrigated with that. Plants of both the species growing in effluent irrigated soils showed high accumulation of metals in all plant parts with the maximum being in roots and the least in flowers. Interestingly, both species of Portulaca hyperaccumulated more than one heavy metal viz., Cd, Cr and As. The total shoot concentrations (microg g(-1) dw) of Cd, Cr and As in P. tuberosa were 1,571, 7,957 and 3,118, respectively while in P. oleracea, these were 1,128, 7,552 and 2,476, respectively. Portulaca plants have good biomass and high regeneration potential; hence appear to be suitable for the remediation of effluent (metal) contaminated areas.

Growth performance and biochemical responses of three rice (Oryza sativa L.) cultivars grown in fly-ash amended soil

The disposal of fly-ash (FA) from coal-fired power stations causes significant economic and environmental problems. Use of such contaminated sites for crop production and use of contaminated water for irrigation not only decreases crop productivity but also poses health hazards to humans due to accumulation of toxic metals in edible grains. In the present investigation, three rice cultivars viz., Saryu-52, Sabha-5204, and Pant-4 were grown in garden soil (GS, control) and various amendments (10%, 25%, 50%, 75% and 100%) of FA for a period of 90 days and effect on growth and productivity of plant was evaluated vis-a-vis metal accumulation in the plants. The toxicity of FA at higher concentration (50%) was reflected by the reduction in photosynthetic pigments, protein and growth parameters viz., plant height, root biomass, number of tillers, grain and straw weight. However, at lower concentrations (10-25%), FA enhanced growth of the plants as evident by the increase of studied growth parameters. The cysteine and non-protein thiol (NP-SH) content showed increase in their levels up to 100% FA as compared to control, however, maximum content was found at 25% FA in Saryu-52 and Pant-4 and at 50% FA in Sabha-5204. Accumulation of Fe, Si, Cu, Zn, Mn, Ni, Cd and As was investigated in roots, leaves and seeds of the plants. Fe accumulation was maximum in all the parts of plant followed by Si and both showed more translocation to leaves while Mn, Zn, Cu, Ni and Cd showed lower accumulation and most of the metal was confined to roots in all the three cultivars. As was accumulated only in leaves and was not found to be in detectable levels in roots and seeds. The metal accumulation order in three rice cultivars was Fe > Si > Mn > Zn > Ni > Cu > Cd > As in all the plant parts. The results showed that rice varieties Saryu-52 and Sabha-5204 were more tolerant and could show improved growth and yield in lower FA application doses as compared to Pant-4. Thus, Sabha-5204 and Saryu-52 are found suitable for cultivation in FA amended agricultural soils for better crop yields.

Titrimetric microdetermination of silver, lead and cadmium with thioglycollic acid and of mercury(II) with 2-mercaptopropanoic acid

A simple and rapid titrimetric method is described for the microdetermination of Ag(+), Cd(2+) and Pb(2+), based on their formation of mercaptides with a measured excess of 2-mercaptopropanoic acid, and similar determination of Hg(2+) with thioglycollic acid. Univalent and bivalent metal ions release one and two thiol protons respectively, which along with the carboxyl protons of the thiol reagent are titrated with standard alkali. The difference from the blank titration gives the increase in acidity which is a function of the metal-ion concentration. The proposed procedure is applicable to samples containing 0.025-0.25 mmole of these ions, the average deviation being in the range 0.2-0.5%.