Subtalar joint middle facet agenesis: a case report and literature review.

Articular facet morphology plays a fundamental role in subtalar joint biomechanics and stability, and likely influences the development of hindfoot osteoarthritis. While multiple anatomical studies have shown wide variation in articular facet configuration, the clinico-radiological findings are rarely presented. We illustrate a case of bilateral subtalar joint middle facet agenesis in a 45-year-old woman, which was missed despite several presentations. We demonstrate the imaging findings to enable clinicians to distinguish this from the more common middle facet coalition. We summarise the developmental anatomy and discuss the potential implications on biomechanical function. Recognition of middle facet agenesis within the complex subtalar joint is important to prevent misdiagnosis and unnecessary surgery.

Right atrial synovial sarcoma with thrombocytopenia: A deceptive presentation.

INTRODUCTION: Primary cardiac synovial sarcoma is an exceedingly rare soft tissue malignant tumor, involving either the pericardium or chambers, with a striking male predominance, prevalently seen in the fourth decade. These tumours most commonly present as breathlessness on exertion. These patients readily exhibit gastrointestinal and systemic symptoms but sometimes the presentation can be fallacious. METHODS: A 37-year old male presented with fever, breathlessness on exertion and hematuria who was managed for dengue feverat another hospital. Patient also had features of right heart failure and congestive hepatomegaly. Patient was evaluated thoroughlyand diagnosed as right atrial tumour mass for which surgical resection was done. RESULTS: The tumour mass was diagnosed as right atrial biphasic synovial sarcoma after immunohistochemistry. Patient also had thrombocytopenia which was due to increased consumption of platelets. CONCLUSIONS: Right heart biphasic synovial sarcoma, arising from the tricuspid valve in association with thrombocytopenia and right heart failure is an extremely rare entity and that can have a deceptive presentation.

HyPE study: hydroxychloroquine prophylaxis-related adverse events' analysis among healthcare workers during COVID-19 pandemic: a rising public health concern.

BACKGROUND: The rising burden of Coronavirus disease (COVID-19) has led to the mass use of hydroxychloroquine by healthcare workers (HCWs). Adverse event profile of this drug when used as prophylaxis is not well known in the literature. METHODS: A retrospective, cross-sectional study was conducted across the country using semi-structured web-based questionnaire among COVID-19 negative and asymptomatic healthcare workers, taking hydroxychloroquine prophylaxis. Descriptive and multivariate logistic-regression models were applied for analysis. RESULTS: Of the 166 participants, at least one adverse event was experienced by 37.9% participants, gastrointestinal being the most common (30.7%). Risk was higher in participants <40 years age (odd's ratio (OR): 2.44, 95% confidence interval (CI): 1.18-5.05) and after first dose of hydroxychloroquine (51.2%, OR: 2.38, 95%CI: 1.17-4.84). Hydroxychloroquine prophylaxis was initiated without electrocardiography by 80.1% of HCWs. Only 21.6% of those with cardiovascular disease could get prior ECG. CONCLUSIONS: A higher incidence of adverse events was observed when results were compared with studies involving patients on long-term hydroxychloroquine therapy. Younger age and first dose were associated with greater incidence of adverse events though all were self-limiting. Monitoring prior and during prophylaxis was inadequate even among those with cardiovascular disease and risk-factors. However, no serious cardiovascular events were reported.

Expanding treatment horizons: transcatheter mitral valve-in-valve replacement in bridging to heart transplant.

Transcatheter mitral valve (MV) replacement is an option in complex MV disease with potentially more predictable treatment outcomes and less invasiveness that increases the treatment spectrum to high-risk or non-surgical patients. We present an interesting case of failed MV bioprosthesis who presented with progressively worsening heart failure for heart transplant evaluation, but was successfully managed with transcatheter mitral valve-in-valve replacement (TMViVR). This case illustrates the pivotal role of TMViVR utilization in addressing complex cardiac scenarios, particularly when re-operative surgical MV replacement poses a high risk and also bridging the gap between the present and future heart transplantation preparations by paving the way for a well-prepared patient in the subsequent phase. The lifetime disease management and patient-centric approach with meticulous risk assessment reinforces the importance of shared decision-making in complex cases.

Late Presentation of Right Coronary Artery Stent Infection as Left Empyema and Pleuropericardial Fistula.

Coronary stent infection (CSI) is a rare but potentially life-threatening disease, the incidence of which has been on a rise over the past 2 decades. Surgery seems the treatment of choice, providing a definitive diagnosis of CSI and removing the source of infection, repairing aneurysms, and providing bypass vascular grafts if feasible. Thorough evaluation and a multidisciplinary approach lead to detection and a better outcome. We report a patient who presented with symptoms of heart failure and shock, who received a diagnosis of CSI complicated by empyema with pleuropericardial fistula. He was treated by stent removal and decortication.

Late presenting complicated coronary stent infection of left anterior descending artery with antero-posterior communication.

Coronary stent infections (CSI) are rare but a potentially life-threatening disease, the incidence of which has been on a rise over the last two decades. We report the case of a patient who presented with episodes of fever and discharging sternal wound. The patient was diagnosed as CSI arising from the left anterior descending artery stent which was communicating anteriorly to the skin and posteriorly as lobar-fistula. He was treated by stent removal and plication of the fistula. Blood culture, culture of the pus and infected stent, and coronary angiography are the preferred diagnostic modalities, followed by positron emission tomography (PET) scan and cardiac magnetic resonance imaging (MRI) for delineating the extent of pathology. Surgery seems to be the treatment of choice, providing a definitive diagnosis of CSI and removing the source of infection, repairing aneurysms, and providing bypass vascular grafts if feasible. Thorough evaluation and a multidisciplinary approach with the institution of appropriate medical and surgical therapy lead to timely detection and good outcome.

Off-Pump Resection of Giant Intramural Left Ventricular Hydatid Cyst by Pleuropericardial Approach: a Case Report.

Primary cardiac hydatid cyst is a rare and fatal pathology, especially when involving the left ventricular free wall. A 44-year-old male was diagnosed with large intramural left ventricular hydatid cyst with wall thickness of 6 mm at the thinnest point. Cyst was accessed through pleuropericardial approach (left pleura opened, followed by entry into cyst directly through adjacent pericardium without removing the pericardial adhesions) which resulted in easy entry into the cyst, mitigating the risk of mechanical injury. This case report highlights that with detailed evaluation, cardiac hydatidosis can be addressed with off-pump technique, reducing the anaphylaxis risks and cardiopulmonary bypass-related effects.

Corydalis and Drug-Induced Liver Injury: A Series of 2 Cases.

Corydalis is an herbal plant found in Asian countries. Research has demonstrated multiple health benefits. It has also been implicated in drug-induced liver injury. Cannabis dispensaries market a sleep aid which has corydalis as an active ingredient. We present 2 cases of corydalis-induced hepatotoxicity. An asymptomatic female patient exhibited a rise and fall of her transaminases coinciding with the consumption and rechallenge of this sleep aid. A man with symptoms consistent with liver dysfunction began taking the same sleep aid. With discontinuance, his liver function returned to normal. These 2 clinical cases provide evidence for corydalis-induced liver injury.

Hydroxyapatite crystal deposition disease around the hip: a rare cause of piriformis syndrome and ischiofemoral impingement.

Hydroxyapatite crystal deposition disease (HADD) around the hip is typically described involving the gluteal tendons. However, HADD can occur in any location and result in varied clinical presentations. Even with small deposits, symptoms can be significant and imaging findings may appear aggressive, mimicking infection and malignancy particularly when in an atypical location. We illustrate cases of both common and rare locations of HADD around the hip, in particular presenting as greater trochanteric pain syndrome, piriformis syndrome and ischiofemoral impingement. The latter two manifestations have not been previously described in the literature. Low signal deposits were identified on MRI at the greater trochanter (gluteus medius tendon), proximal piriformis (adjacent to the sciatic nerve), and quadratus femoris (in the ischiofemoral space), respectively. Associated inflammatory changes with tendinopathy, bursitis and oedema were also demonstrated. The patient with piriformis syndrome underwent steroid injections and shockwave therapy with significant symptom improvement. HADD should be within the differential diagnosis for hip pain and nerve compression syndromes. Knowledge of tendon anatomy and correlation with radiographs or CT, even after MRI, is crucial in recognising unusual manifestations and preventing unnecessary investigation. Therefore, we review the spectrum of imaging features of HADD, as well as the current evidence on its management, to confidently diagnose this condition.

Giant Epicardial Cyst Eroding Left Ventricular Wall Mimicking as Simple Pericardial Cyst.

Epicardial cysts are rarer benign tumors than pericardial cysts. There have been few reports on surgical management of epicardial cysts. A 17-year-old normotensive boy presented with chest pain and palpitations, which on evaluation was found to be a mediastinal mass (pericardial cyst). Surgical resection of the cyst via thoracotomy was planned. The cyst was diagnosed as an epicardial cyst intraoperatively. However, due to the epicardial origin of cyst and posterior adhesions, resection was done via midline approach. The base was formed by visceral pericardium and eroding into myocardium of left ventricle, so the resection was concluded with on-pump surgery. In case of erroneous diagnosis or undesirable finding, a safer midline approach with on-pump surgery, as an alternative to minimally invasive approach for complicated epicardial cysts (erosion into ventricle/lying in close proximity to important structures or near to coronary arteries) should be considered.

Comparative effectiveness of metoprolol, ivabradine, and its combination in the management of inappropriate sinus tachycardia in coronary artery bypass graft patients.

BACKGROUND: Inappropriate sinus tachycardia (IST) is an arrhythmic complication observed after coronary artery bypass graft (CABG) surgery which left untreated, commonly increases chances of postoperative stroke. The primary study objective was comparing effectiveness of beta blocker-metoprolol; a specific If blocker-ivabradine and its combination in patients who develop IST as a complication following CABG. MATERIALS AND METHODS: An open-labeled, investigator initiated, clinical study was conducted on 150 patients who developed IST (heart rate [HR] >100 beats/min) following elective CABG surgery. The patients were randomized into three treatment groups. Group I - received ivabradine (5 mg), Group II - metoprolol (25 mg), and Group III - ivabradine (5 mg) and metoprolol (25 mg). Treatment was given orally, twice a day for 7 days in all the three groups postoperatively. Primary endpoints were comparative effectiveness in HR and blood pressure reduction following treatment. RESULTS: IST was diagnosed by an electrocardiogram (12-lead) considering morphological features of P-wave and with 32% increase from baseline HR in all the three groups. Compared to IST arrthymic rate, HR was reduced in all groups following respective treatment (P = 0.05). Reduction in HR was significant (P < 0.05) in combination group followed by ivabradine which was significantly greater than metoprolol treated group. None of the treatments clinically changed the systolic, diastolic and mean blood pressure till discharge. No surgery/treatment-related complications were observed in any groups. CONCLUSION: Ivabradine stands as a pharmacological option for controlling HR and rhythm without associated side effects in postoperative CABG patients with IST.

Dengue fever after coronary artery bypass grafting with ventricular dysfunction.

A 67-year-old man who had undergone a percutaneous coronary intervention, presented with cardiac symptoms. He was managed for acute coronary syndrome and left ventricular dysfunction. After stabilization, he underwent coronary artery bypass grafting but developed dengue hemorrhagic fever postoperatively. He was monitored for hematocrit, platelet count, liver enzymes, and daily fluid balance. His platelet count fell below 40,000/µL, and due to the increased risk of bleeding, warfarin was discontinued and single antiplatelet therapy (aspirin) was continued. After 2 weeks, parameters had normalized. Regular monitoring of hematocrit, platelet count, liver enzymes, and fluid balance played a vital role in the patient's successful recovery.

Who Benefits From a Prostate Rectal Spacer? Secondary Analysis of a Phase III Trial.

PURPOSE: Previously a phase III trial of a hydrogel rectal spacer during prostate radiation therapy found decreased toxicity and a clinically significant improvement in bowel quality of life (QOL) at 3 years by the Expanded Prostate Cancer Index. We performed a secondary analysis to identify men less likely to benefit. METHODS AND MATERIALS: Clinical and dosimetric data for the 222 patients enrolled on the SpaceOAR phase III trial were analyzed. The volume of rectum treated to 70 Gy (V70) and the quantitative analysis of normal tissue effects in the clinic (QUANTEC) rectal dose goals were used as surrogates for clinical benefit and plan quality. Mean bowel QOL was assessed at 15 and 36 months posttreatment and the likelihood of 1× (5 points) or 2× (10 points) minimally important difference changes were assessed. RESULTS: Rectal V70 was correlated with physician scored toxicity (P = .033) and was used as a surrogate for plan quality. There was no correlation between prostate volume and rectal V70 (r = 0.077). Rectal V70 pre- and post-hydrogel was 13% and 3% for the smallest prostates (<40 mL) and 12% and 2% for the largest (>80 mL). The relative reduction in rectal V70 of 78% did not vary by prespacer V70, but the absolute reduction was greater for a higher V70. All spacer plans met the 5 QUANTEC rectal dose constraints, although 92% of control plans met all constraints. At 3 years, those not meeting all QUANTEC goals had a 15.0-point (standard deviation 15.1) decline, control patients meeting QUANTEC goals had a 4.0-point (9.5) decline, and spacer had >0.5 (7.6; P < .01). Previous surgery was not correlated with QOL (P = .8). Across prognostic groups, including age, body mass index, previous surgery, target volume, or quality of radiation plans, there was no statistically significant heterogeneity in the relative benefit of spacer in decreasing the risk of 1× or 2× the minimally important difference declines. CONCLUSIONS: There was little heterogeneity in the likelihood of spacer reducing the risk of declines in bowel QOL across clinical and dosimetric variables. Even for the >95% of plans meeting QUANTEC rectal criteria, hydrogel spacer provided potentially meaningful benefits.

Transabdominal sonography in assessment of the bowel in adults.

OBJECTIVE: We describe the key sonographic features and technical aspects of assessment of bowel disorders in adults. CONCLUSION: Initial imaging with transabdominal sonography in the radiologic evaluation of bowel disease in adults often is reserved for patients with equivocal historical, physical, and laboratory findings related to the gastrointestinal tract. Because of technologic advances and accumulated experience in interpretation of the images, sonography yields substantial information about gastrointestinal disorders.

Late coronary stent infection: a difficult to diagnose rare complication after percutaneous coronary intervention.

Percutaneous transluminal coronary angioplasty (PTCA) with drug-eluting stent placement is a well-established treatment modality for coronary stenotic lesions. Although infection involving implanted stent is rare, it can occur at any point of time, leading to high morbidity and mortality. We describe a rare case of infected coronary stents complicated with recurrent stent thrombosis, sepsis, and myocardial abscess formation after 2 years of percutaneous cornary intervention (PCI). Using multi-modality imaging final diagnoses to evaluate the precise location, extent and morphology of myocardial abscess (MA) was done. "On pump" coronary artery bypass graft (CABG) was performed, left anterior descending (LAD) artery intramyocardially was opened up, about 7-10 ml of pus was evacuated, and two drug-eluting stents (DES) were removed. The isolated identified organism was Pseudomonas aeruginosa which had remained dormant and restricted to the stent area for almost 2 years thinning the myocardium; an unusual trait of a very virulent bacterium which otherwise spreads fast to cause septicemia. The present case exemplifies the high index of clinical sensitivity with early multi-modality diagnosis, aggressive medical therapy, multidisciplinary care, and timely surgical intervention saving the patient's life in otherwise fatal condition.

Optical markers in duodenal mucosa predict the presence of pancreatic cancer.

PURPOSE: Pancreatic cancer remains one of the most deadly cancers and carries a dismal 5-year survival rate of <5%. Therefore, there is urgent need to develop a highly accurate and minimally invasive (e.g., without instrumentation of the pancreatic duct given high rate of complications) method of detection. Our group has developed a collection of novel light-scattering technologies that provide unprecedented quantitative assessment of the nanoscale architecture of the epithelium. We propose a novel approach to predict pancreatic cancer through the assessment of the adjacent periampullary duodenal mucosa without any interrogation of the pancreatic duct or imaging of the pancreas. EXPERIMENTAL DESIGN: Endoscopically and histologically normal-appearing periampullary duodenal biopsies obtained from 19 pancreatic cancer patients were compared with those obtained at endoscopy from 32 controls. Biopsies were analyzed using our newly developed optical technologies, four-dimensional elastic light-scattering fingerprinting (4D-ELF) and low-coherence enhanced backscattering (LEBS) spectroscopy. RESULTS: 4D-ELF- and LEBS-derived optical markers from normal-appearing periampullary duodenal mucosa can discriminate between pancreatic cancer patients and normal controls with 95% sensitivity and 91% specificity. Moreover, the diagnostic performance of these optical markers was not compromised by confounding factors such as tumor location and stage. CONCLUSIONS: Here, we showed, for the first time, that optical analysis of histologically normal duodenal mucosa can predict the presence of pancreatic cancer without direct visualization of the pancreas.

Evaluation of mucilage of Hibiscus rosasinensis Linn as rate controlling matrix for sustained release of diclofenac.

This article reports the exploitation of novel hydrophilic excipient, that is, mucilage from Hibiscus rosasinensis Linn, for the development of sustained release tablet. Swelling ratio and flow properties analyses of dried mucilage powder were carried out. A 3(2) full factorial design was used. In factorial design, amounts of dried mucilage and dibasic calcium phosphate (DCP) were taken as independent factors and percentage drug release in 60 and 300 min and time for 80% drug release as dependent variables. Matrix tablet containing dried mucilage and diclofenac sodium (DS) was prepared through direct compression techniques. DS tablets were evaluated for hardness, friability, weight variation, in vitro drug release and water uptake, and mass loss study. The dried mucilage powder shows superior swelling capacity and excellent flow properties. Prepared tablets have acceptable hardness, friability, and uniformity in weight. It was found that batch HD8 fulfills all selected criteria. Drug release kinetics from these formulations corresponded best to the zero-order kinetics. Water uptake was independent whereas mass loss was dependent on agitation speed. The concept of similarity factor (f(2)) was used to prove similarity of dissolution profile in distilled water and phosphate buffer and was found to be 90.68. It was concluded that mucilage can be used as release-retarding agent for 12 h when the drug-mucilage ratio was 1:1.5. So, matrix tablet containing dried mucilage is most suitable for sustained release of DS.

Off-Pump Resection of Giant Intramural Left Ventricular Hydatid Cyst by Pleuropericardial Approach: a Case Report

ABSTRACT Primary cardiac hydatid cyst is a rare and fatal pathology, especially when involving the left ventricular free wall. A 44-year-old male was diagnosed with large intramural left ventricular hydatid cyst with wall thickness of 6 mm at the thinnest point. Cyst was accessed through pleuropericardial approach (left pleura opened, followed by entry into cyst directly through adjacent pericardium without removing the pericardial adhesions) which resulted in easy entry into the cyst, mitigating the risk of mechanical injury. This case report highlights that with detailed evaluation, cardiac hydatidosis can be addressed with off-pump technique, reducing the anaphylaxis risks and cardiopulmonary bypass-related effects.

Early hemodynamic performance of the Trifecta™ surgical bioprosthesis aortic valve in Indian patient population: 12 month outcomes of the EVEREST post-market study.

BACKGROUND: Indian patients undergoing surgical aortic valve replacement (SAVR) differ from western populations with respect to aortic annulus size and valve disease morphology. The purpose of this post-market, non-randomized observational study was to evaluate the early hemodynamic performance of the Trifecta™ bioprosthesis (Abbott, previously St. Jude Medical, Minneapolis, US) in an Indian patient population. METHODS: From January 2014 to September 2015, 100 patients (mean age 64.4 ± 7.1 years, 62% male) undergoing SAVR for valve disease (68% stenosis, 7% insufficiency, 25% mixed pathology) were enrolled across 10 centers in India. Patients implanted with a 19-27 mm Trifecta™ valve were eligible to participate and were prospectively followed for 12-months post-implantation. Echocardiographic hemodynamic performance was evaluated at pre-implant, pre-discharge and at 12-months by an independent core laboratory. Adverse events were adjudicated by the study sponsor. Functional status at 12-months was assessed according to NYHA classification. Continuous data was summarized using descriptive statistics (mean &standard deviation,) and categorical data was summarized using frequencies and percentages. RESULT: Ninety patients (mean age 64.5, 62.2% male) completed the 12-month follow up. Significant improvements in hemodynamic valve performance were reported in 81 patients with available echocardiographic data at 12 months. Compared to baseline at 12-month follow up visit, mean effective orifice area increased from 0.75cm2 to 1.61cm2 (p < 0.0001), mean pressure gradient reduced to 10.42 mmHg from 51.47 mmHg (p < 0.0001), cardiac output increased from 4.46 l/min to 4.85 l/min (P 0.9254). Compared to baseline, functional status improved by ≥1 NYHA class in 75% of patients at 12 months (95% Clopper-Pearson (Exact) confidence limit [64.6%, 83.6%]). No instances of early mortality (< 30 days from index procedure) or structural valve dysfunction were reported. CONCLUSION: In an Indian patient population, implantation of the Trifecta™ bioprosthesis is shown to be safe and associated with favorable early hemodynamic performance and improved functional status at 12 months. TRIAL REGISTRATION: The clinical study has been registered under Clinical Trial Registry-India ( http://www.ctri.nic.in ) and registration number is CTRI/2014/02/004434 registered on 25 February 2014 retrospectively registered.