Role of Cardiac MRI Including LGE, T1 and T2 Mapping in the Assessment of Cardiac Involvement in Patients of Nonspecific Aorto-arteritis: A Prospective Study

Objective Nonspecific aorto-arteritis (NSAA) may involve the myocardium in the form of edema and fibrosis. We conducted this study to investigate role of cardiac MRI including late gadolinium enhancement (LGE), T1 and T2 mapping in the assessment of cardiac involvement in NSAA.

Methods and Materials Over the period between 2016 and 2019, 36 patients with NSAA presenting with uncontrolled hypertension, left ventricular dysfunction, congestive cardiac failure, or tachyarrhythmia were included in the study. We also had 16 voluntary control patients for providing normal T1 and T2 mapping values.

Results The average age of patients was 27.1 years and the majority were females. MRI is more sensitive than echocardiography in the detection of LV dysfunction and RWMA. Out of 36 patients, 10 (27.8%) had LGE. The most common pattern of midmyocardial enhancement was present in 5 out of 10 patients. Five (13.8%) patients show mid-myocardial enhancement, followed by epicardial enhancement, which was seen in four (11.11%) patients. The values of post-gad T1 mapping values were significantly lower than pre-gad T1 mapping values. At a cut-off global native T1 mapping value of 1019 milliseconds had the sensitivity of 83.3% and specificity of 81.2% in detecting an abnormal T1 map. No significant association of MRI contrast enhancement with elevated ESR and CRP levels. There was no significant relation of myocardial T2 mapping values between NSAA and control groups.

Conclusion Quantitative tissue characterization in the myocardium with native T1 mapping values help in the detection of cardiac involvement in patients with NSAA. T1 mapping may provide incremental value in the assessment of myocardial involvement in NSAA in addition to LGE imaging.

The Outcomes of Tracheostomy in Pediatric Cardiac Surgical Patients

Objectives To describe the outcomes of postoperative tracheostomy and determine the predictors of survival.

Design Prospective, observational study.

Setting Cardiac surgical intensive care unit of a tertiary care hospital.

Participants All pediatric patients below 10 years of age who underwent tracheostomy after cardiac surgery from January 2019 to December 2019. Different variables were compared between survivors and nonsurvivors.

Intervention Tracheostomy.

Results Among 1084 pediatric patients who underwent cardiac surgery during the study period, 41 (3.7%) received tracheostomy. Survival rate was 71%.

Earlier, sternal closure (SC) (p = 0.04), acute kidney injury (AKI) (p = 0.001), serum C-reactive protein (CRP) (p = 0.007), duration of total parenteral nutrition (TPN) (p = 0.005) and days of feed interruption (FI) (p = 0.02), activated partial thromboplastin time (aPTT) before tracheostomy (p = 0.006), and bleeding from tracheostomy site (p = 0.02) were significantly low in the survivor group.

Among the peritracheostomy variables taken at different time points, the levels of pH on tracheostomy day 1 (p = 0.03), serum lactate on tracheostomy day 2 (p = 0.01) and day 3 (p = 0.01), and random blood sugar (RBS) on tracheostomy day 3 (p = 0.04) were significantly lower in the survivor group.

The arterial oxygen saturation (SaO2) on tracheostomy day 1 (p = 0.04) and the platelet count before tracheostomy (p = 0.02) were significantly higher in the survivor group.

Conclusions Our study demonstrated a survival of 71% among the study cohort. Lesser duration of open sternum, lower incidence of AKI, less number of days on TPN and FI, lower posttracheostomy aPTT, bleeding, RBS, lactate, and higher pretracheostomy platelet count and posttracheostomy SaO2 were found to be the predictors of survival.

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.

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.

Peritoneal Dialysis in Pediatric Postoperative Cardiac Surgical Patients

Background

We determined the prevalence of acute kidney injury requiring peritoneal dialysis (PD), the factors associated with early PD initiation, prolonged PD and mortality among pediatric postoperative cardiac surgical patients.

Materials and Methods

The hospital records of 23 children, aged 12 years or younger, who had undergone cardiac surgery and required PD subsequently, during a 1-year period were reviewed. Demographic data, intraoperative variables, and postoperative complications were compared between survivors and nonsurvivors of PD, between the short and long duration PD groups, and between the early and late PD initiation groups.

Results

Six hundred and eight pediatric patients who underwent open heart surgery were enrolled in this study. 23 (3.78%) of them required PD. When compared with survivors (n = 11), non survivors (n =12) were more likely to have a higher serum procalcitonin (p = 0.01), higher serum potassium on day 2 (p = 0.001), day 3 (p = 0.04), day of termination of PD (p = 0.001) and a lower urine output on day 3 of PD (p = 0.03). Prolonged PD was associated with time of PD initiation (p = 0.01), a higher postoperative serum creatinine on day 3 (p = 0.01) of PD initiation as well on the day of PD termination (p = 0.01) and the final outcome in terms of survival (p = 0.02). Factors significantly associated with an early PD initiation were CPB time (p = 0.04), sepsis (p = 0.02) and shorter PD duration (p = 0.003).

Conclusion

PD is very useful mode of renal replacement therapy among pediatric postoperative cardiac surgical patients. The intraoperative and postoperative variables have important association with the time of PD initiation, PD duration and patient survival.

How to cite this article

Sahu MK, Bipin C, Arora Y, Singh SP, Devagouru V, Rajshekar P, et al. Peritoneal Dialysis in Pediatric Postoperative Cardiac Surgical Patients. Indian J Crit Care Med 2019;23(8):371-375.

Ectopia Cordis: Two Different Cases with Literature Review

Ectopia cordis is a rare congenital anomaly with thoracic exteriorization of the heart. With few exceptions, it is universally fatal. Surgical correction is the only final treatment option for this defect but with a very high mortality. The authors present two cases of ectopia cordis, both were operated upon in urgent basis, and one baby survived.

Microinvasion: A Clinical Dilemma

Microinvasive oral squamous cell carcinoma (MIOSCC) is an early stage malignant tumour,showing invasion of the epithelial cells confined to the superficial lamina propria. This is matter of debate in respect to the clinical presentation, metastasis, therapeutic intervention and prognosis. A 32-year female reported to the department with chief complaint of wound and burning sensation in her left back region of lower gums. Clinical diagnosis of erosive oral lichen planus was made and topical steroid was started. The lesion clinically healed with the use of topical medicine. After stopping the medication the lesion recurred, following which, excisional biopsy was done. On histopathological evaluation diagnosis of microinvasive oral squamous cell carcinoma was made. Recurrence of similar symptom in the same site was seen 10 weeks later, which now showed features of moderate dysplasia. Clinical features of microinvasive oral squamous cell carcinoma resembles premalignant lesion, leading to difficulty in diagnosis, treatment and prognostic assessment. Thus, adequate representation of this entity is necessary.

Effect of graded levels of soapnut (Sapindus mukorossi) shell powder on reproductive performance in broiler breeders

Objective

This study investigated the effects of soapnut (Sapindus mukorossi) shell powder (SSP) on serum hormone level, egg quality, semen characteristics and reproductive performance of broiler breeders fed with a maize-soybean meal based diet.

Methods

Ninety six female and twenty four male CARIBRO-VISHAL broiler breeders, 38-week old, were individually caged and randomly allocated to four treatment groups (24 female breeders/treatment and 6 male breeders/treatment): an un-supplemented control (T1) and three groups with 0.0176% SSP (group T2), 0.026% SSP (group T3) and 0.0528% SSP (group T4), to have supplementary saponin at 0, 50, 75, and 150 ppm, respectively, for 42 days.

Results

The results indicated that serum (p<0.001) and seminal plasma (p<0.05) testosterone level, semen volume (p<0.001), mass motility (p<0.001), and live spermatozoa count (p<0.001) was increased in groups T3 and T4 compared to T2 and control groups. Compared with control group, total sperm count was increased (p<0.001) and dead spermatozoa count was decreased (p<0.001) in SSP supplemented groups. Supplementation of SSP did not affected the quality of egg lay. Compared with control group, fertility (p<0.01) and hatchability (total eggs set and fertile eggs set) (p<0.001) were significantly improved in SSP supplemented groups with the highest improvement in T3 treatment group. Embryonic death was decreased (p< 0.001) in SSP supplemented groups compared to control; lowest embryonic death was recorded in T3 treatment group.

Conclusion

Thus, it was concluded that dietary supplementation of 0.026% SSP (saponin equivalent 75 ppm) improved the reproductive performance of broiler breeders.

Immunohistochemical characterization of glandular elements in glandular cardiac myxoma: Study of six cases

Back ground: Glandular cardiac myxoma has varying clinical presentation with uncertain histogenesis and debatable immunohistochemical profile. Glandular epithelial differentiations are rare phenomenon known to be present as an intrinsic component of the tumor. The origin of the glands has been attributed to epithelial differentiation of a totipotent cardiomyogenic precursor cells or the entrapped foregut rests in the tumor.

MATERIALS AND METHODS

Retrospective study includes six cases of glandular cardiac myxoma collected over a perior of 4 years. Sections were examined to define the histogenesis, histological and immunohistochemical profile of the glandular elements.

RESULTS

Incidence of glandular cardiac myxoma was 6.6% with a male to female ratio of 1:2.Mean age was 49.9 years. Left atrium was the commonest site. Five were sporadic and one was familial. Chest pain and dyspnea were the commonest clinical symptoms. Histologically all myxoma showed well formed glandular structures with typical myxomatous area. No atypia, mitosis or necrosis was identified in the glandular elements. Markers in six cases of glandular cardiac myxoma were immunopositive for CK7, CK 19, EMA, CEA, focally for E-cadherin while immunonegative for CK20, Chromogranin, Synaptophysin, calretenin, vimentin, B-catenin, TTF-1 and GCDFP-15 favoring enteric differentiation.

CONCLUSION

Glandular cardiac myxoma is a rare entity which shows characteristics similar to those of classical cardiac myxoma with benign glandular elements showing enteric differentiation. Complete surgical excision is the treatment of choice with good prognosis. It is important to recognize this entity to avoid an erroneous diagnosis of metastatic adenocarcinoma.

Familial biatrial cardiac myxoma with glandular elements: A Rare entity with review of literature

Cardiac myxomas are benign neoplasm of the heart with an incidence of 0.3%. Glandular cardiac myxomas are very rare and accounts for less than 3% of all cardiac myxomas. Here, we report a case of familial glandular cardiac myxoma in a 35 year old male who complained of exertional dyspneoa and weakness of right side of body on clinical presentation. Associated features of Carney's complex were not present. Family history revealed presence of cardiac myxoma in younger brother and sister. Transthoracic echocardiography detected biatrial myxoma. Excision of both lesions was done under cardiopulmonary bypass. Histopathology confirmed myxoma with glandular elements. Postoperative course was uneventful.

Factors Affecting the Success Rate of External Dacryocystorhinostomy at B. P. Koirala Institute of Health Sciences, Dharan, Nepal

IntroductionAny disturbance to the normal ouVlow of tears through the nasolacrimal passage causes overflow known as epiphora. The clinical symptoms of epiphora range from mild dribble to the continuous ouVlow of tears. Watering of eyes caused by the nasolacrimal drainage  obstruction  is  managed  by surgery. One of the many surgeries to treat this is external dacryocystorhinostomy.ObjectiveThe objective of this study was to evaluate the success rate of external dacryocystorhinostomy as well as factors affecting it.MethodologyThis is a retrospective cross-sectional study, conducted in the Department of Ophthalmology, B. P. Koirala Institute of Health Sciences (BPKIHS), Dharan with the approval of Institutional Review Committee, BPKIHS. The medical records of patients who underwent external Dacryocystorhinostomy surgery from April 2011 to April 2016 at BPKIHS were retrospectively reviewed. Statistical analysis was performed using SPSS for windows, version 11.5 (SPSS Inc., Chicago, IL). Binary logistic regression models were used to investigate the association of the surgical outcome with various predicting variables.ResultsThe success rate of the external dacryocystorhinostomy was 78.09%. Factors studied were: age, with a range of 2-81 years; duration of symptoms with a range of 1-84 months; and gender of the patients. The intra-operative factors studied were use of silastic tube, types of flap, and osteotomy size. Among these factors, the duration of symptoms and osteotomy size had significant association with the outcome of the surgery p<0.05.ConclusionOur study yielded high success rate in patients with shorter duration of watering of eyes and larger osteotomy size during surgery. Hence, a larger osteotomy size and early intervention is recommended for better surgical outcome. Birat Journal of Health Sciences Vol.2/No.1/Issue 2/ Jan - April 2017, Page: 196-200

Bulk synthesis of multi-walled carbon nanotubes by AC arc discharge method

This work proposes the production of multi-walled carbon nanotubes by AC arc discharging of spectroscopically pure graphite electrodes of different shapes, that is, movable cylindrical and stationary rectangular electrode by manual metal arc welding setup. Continuous arc was generated by maintaining the gap of about 3 mm between the electrodes which in turn formed the plasma zone. Vaporization of carbon cations followed by sudden quenching paved the way for formation of carbon nantotubes. Nanotubes produced were deposited on the stationary graphite electrode in the form of soot. Further extraction of the nanoparticles from the soot was performed by conducting series of purification processes which will be discussed in upcoming chapters. Morphology and purity of the extracted nanotubes were investigated by X-ray diffraction, scanning electron microscopy, field-emission scanning electron microscopy, transmission electron microscopy and Raman spectroscopy. Following the characterization process, it was observed that the so-produced nanotubes were of different shapes, that is, carbon cone nanotubes, nanocapsules, nanoparticles and branching type and randomly oriented. The length of the nanotubes varied from 231 to 561 nm, whereas diameter was found to be in the range of 14–55 nm.

Leiomyosarcoma of inferior vena cava involving bilateral renal veins: Surgical challenges and reconstruction with upfront saphenous vein interposition graft for left renal vein outflow

Leiomyosarcoma of inferior vena cava (IVC) involving bilateral renal veins presents a surgical challenge. Herein, we report the successful management of two such cases using restoration of left renal venous outflow by saphenous vein interposition graft as first step of surgery. Then radical resection of tumor and right kidney was done. IVC was lastly reconstructed using Gore-Tex graft. This report highlights the surgical challenges to ensure radical resection. Furthermore, the importance of restoring left renal outflow in presence of concomitant right nephrectomy is discussed. Both the patients were disease free at six months with no loss of left renal glomerular filtration rate.

Acute renal failure in Nepal Medical College Teaching Hospital

Total 45 patients (male 27 and female 18) of acute renal failure (ARF) admitted in Nepal Medical College Teaching Hospital over a period of 12 months (1st of Baisakh 2064 BS to 31st of Chaitra 2064 BS) were enrolled in the study. Sixty four percent of study population were of age group 21-60 years. Acute Gastroenteritis 33, sepsis 5, hemorrhage 2, others 5 were the different causes of ARF. Serum creatinine of the study population before and after treatment was 4.35 +/- 2.72 and 1.38 +/- 0.72 mg/dl respectively. Similarly serum urea before and after treatment was 101.78 +/- 57.56 and 42.60 +/- 30.46 mg/dl respectively. Thirty three patients were managed by non dialytic modality of therapy and 12 patients needed hemodialysis. Blood urea of those patients who underwent nondialytic therapy was significantly less than of those who underwent hemodialysis (80.65 +/- 38.21 vs. 151.08 +/- 66.22; p = 0.004). Serum creatinine was also significantly lower in nondialytic therapy group (3.15 +/- 1.15 vs. 7.64 +/- 3.10; p = 0.000) ARF patients with very high urea, creatinine and disturbed electrolytes required dialysis. Average session of hemodialysis was 3.4. Thirty five patients were cured, 6 left against medical advice, 3 were discharged on request, and one patient of sepsis expired during the course of treatment. Acute gastroenteritis was the leading cause of ARF and outcome was excellent even without dialysis in most of the cases provided the treatment was started early and appropriately.

Modified circuit for retrograde cerebral perfusion

A modified circuit for delivery of retrograde cerebral perfusion during ascending aortic or aortic arch surgery is described. The technique was applied in 15 patients who showed good postoperative recovery.

Profound hypothermic circulatory arrest in management of aortic aneurysms

A total of 15 patients having aneurysms of aorta were operated from June 1997 to December 1998 using deep hypothermic circulatory arrest as a modality of brain protection. There were 12 males and 3 females. The age ranged from 19 years to 74 years and the mean age was 44.9 years. Nine patients had aneurysms of ascending aorta (group I), one had aneurysm of ascending aorta and arch of aorta (group II), four had aneurysm of the distal aortic arch (group III) and one patient had thoracoabdominal aortic aneurysm (group IV). In group I, six patients underwent Bentall procedure, two underwent Wheat procedure and one patient had repair of pseudoaneurysm of ascending aorta. The only patient in group II had his ascending aorta and arch replaced, with reimplantation of left common carotid and innominate artery. In group III, three patients had interposition Gelseal graft and one had repair of the tear in distal aortic arch. The lone patient in group IV had interposition Gelseal graft of thoracoabdominal aorta. The hypothermic circulatory arrest was used in all of them for brain and/or spinal cord protection. Retrograde cerebral perfusion was used in two patients. There were two (13%) operative deaths. One patient died of cerebrovascular accident on eighth post-operative day and second died of inadequate surgical repair. There was one instance of left hemiparesis secondary to an infarct in right frontoparietal region. To conclude, hypothermic circulatory arrest could provide an adequate brain protection for aortic aneurysm surgery. Retrograde cerebral perfusion could be an adjuvant when the anticipated time of hypothermic circulatory arrest is likely to exceed 45 minutes.

Sequential pathological studies in Japanese quails infected experimentally with Aspergillus fumigatus

Intratracheal inoculation of young quail chicks with Aspergillus fumigatus spores resulted in the development of characteristic gross and microscopic lesions. The lesions were restricted to respiratory tract and there was no dissemination of infection to other tissues of the body. Gross changes in lungs and air sacs were observed within 24 hours and continued up to 20 days while in trachea these were noticed from the 3rd to the 9th day post-infection. The lesions, in general, included congestion and focal haemorrhages in the first 2 days followed by the development of varying-sized greyish-white nodules in the lungs, air sacs and trachea. Microscopic changes consisted of congestion, haemorrhages and a diffuse cellular infiltration in the first 2 days followed by granulomatous reaction with well developed granulomas in lungs, air sacs and trachea. Spores and developing hyphae of Aspergillus could be demonstrated in sections from 24 hours to 20 days of infection. Reisolation of the fungus was consistently achieved from the lungs, air sacs and trachea up to 14 days.

Experimental aspergillosis in Japanese quails (Coturnix coturnix japonica). Clinical signs and haematological changes

Intratracheal inoculation of 2-week-old quail chicks with Aspergillus fumigatus resulted in the development of clinical signs within 24 h of infection. These were characterized by anorexia, depression, accelerated respiration and gasping followed by death. The acute course of the disease lasted for 7-10 days followed by recovery in the surviving chicks. The overall mortality during a 6-week observation period was 20%. Although the mean body weight of A. fumigatus infected quail chicks continued to be slightly lower throughout the experiment but the difference, in comparison to controls, was not significant except at 42 days post-infection. There was no appreciable difference in the mean values of Hb, TEC, PCV, MCV, MCH and MCHC between the infected and control chicks at any stage of infection but TLC revealed a leucocytosis from 2-7 days which was the result of increase in the relative percentage of heterophils and decrease in lymphocytes.

Oxypeucedanin, a Major Furocoumarin in Parsley, Petroselinum crispum

Fresh parsley leaves and roots were analyzed by HPLC and photobiological assay for photoactive furocoumarins. Oxypeucedanin ( 7), not previously reported from parsley, was found to be the major component (70-100 ppm wet weight). Although only moderately photoactive, its high concentration in parsley may be partially responsible for contact photodermatitis. Other photoactive compounds, namely 5-MOP ( 2), 8-MOP ( 3), psoralen ( 1), isopimpinellin ( 4) and imperatorin ( 5) were also present and quantified.