Clinical, echocardiographic and microbiological study, and analysis of outcomes of infective endocarditis in tropical countries: a prospective analysis from India.

BACKGROUND AND AIM OF THE STUDY: The aim of this prospective observational study was to evaluate the clinical, echocardiographic, microbiological profile and outcomes of patients with definitive infective endocarditis (IE) in tropical countries. METHODS: Between September 2010 and March 2013, a total of 109 patients with 111 episodes of definitive IE (as per the modified Duke's criteria) was enrolled in the study. The mean age at presentation was 32.7 ± 17.2 years (range: 2-70 years), and there was a male preponderance (3:1). RESULTS: Native valve disease was identified in 57 cases of IE, followed by congenital heart disease (n = 35), prosthetic valve disease (n = 11), normal valves (n = 5) and pacemaker lead infection (n = 1). Echocardiography was diagnostic in all patients except one. Positive blood cultures were obtained in 68 episodes, with streptococci (n = 34) and staphylococci (n = 11) the most common organisms. At least one major complication was identified in 60 patients. Ultimately, only 15 patients underwent surgery for IE, but 25 died during their hospital stay. On multivariate analysis, prosthetic valve involvement, combined mitral and aortic valve involvement, male gender, and leukocytosis were independent predictors of mortality. CONCLUSION: IE in India is associated with a higher mortality and lower rates of culture positivity compared to the west; rates of surgery for IE in India are unacceptably low. Changing epidemiological trends may pose newer challenges in the near future.

Persistent left superior vena cava draining into left atrium as a cause of persistent systemic desaturation after surgery.

Persistent left superior vena cava (LSVC) is a rare congenital anomaly which usually produces no physiologic derangements if it drains into the right atrium via the coronary sinus, but it may cause significant desaturation when it drains into the left atrium (LA). Failure to diagnose LSVC communicating with the LA preoperatively may lead to serious consequences. We are describing an interesting case of a boy who presented with systemic desaturation due to an undetected LSVC after having undergone corrective surgery for atrioventricular canal defect. We have demonstrated that echocardiography with agitated saline contrast is a simple, accurate, and inexpensive diagnostic modality.

Perceptions of Dental Undergraduates Towards Online Education During COVID-19: Assessment from India, Nepal and Sri Lanka.

PURPOSE: The social distancing mandates instituted during COVID-19 pandemic mark the sudden transition in the mode of dental education's delivery to the virtual instruction. It is vital to assess students' perceptions towards virtual learning environments, particularly among those gaining education in resource-strained countries. This cross-sectional study aims to assess the perceptions of dental undergraduates towards online education, environment and transferable skills and patient care during COVID-19 in India, Nepal, and Sri Lanka. MATERIALS AND METHODS: Dental preclinical and clinical undergraduate students from India, Nepal and Sri Lanka were recruited from November 2020 to March 2021 through a 47-item web-based survey consisting of psychometrically valid subscales of Dundee Ready Educational Environment Measure (DREEM) and Transferable Skills Questionnaire. The mean scores of students' perceptions of learning, environment, and patient care skills were compared among preclinical and clinical students of the participating countries. RESULTS: Of total 930 participants, 44.4% were from India, 26.1% from Sri Lanka and 29.5% responses from Nepal. Sri Lanka reported the highest mean scores across all domains of perception indicative of positive attitude. Clinical students from all participating countries had statistically significantly higher positive perception of transferable skills in patient care as opposed to their preclinical counterparts. On the contrary, perception towards learning was higher among preclinical students as opposed to clinical students. These differences were statistically significant for Nepal and Sri Lanka. CONCLUSION: The findings of this study underscore the need to develop and implement effective online dental educational interventions to foster academic growth and essential practical skills without compromising academic rigor and continuity in the dental education curriculum.

Effect of Hand Held Vibrating Tools on Nerve Conduction Study in Dental Residents.

BACKGROUND: Repetitive exposure to vibration has been shown to induce peripheral nerve dysfunction. Dentists are exposed to handheld vibrating tools in their daily clinical practice. Most of the studies are done in dentists who have symptoms such as paresthesia and numbness of the hands. Thus, we conducted the study to explore the effect of vibration on nerve conduction variables in apparently healthy asymptomatic dental residents. METHODS: This cross-sectional study enrolled 22 dental residents and age matched 22 medical residents as controls. Nerve conduction study was performed in median and ulnar nerves of both hands. RESULTS: Anthropometric and cardiorespiratory variables were comparable between the groups. There were no statistically significant differences between dental and medical residents in the sensory conduction variables (right median onset latency=2.05±0.27 vs 1.91±0.21, p value=0.07; right median amplitude =27.80±8.11 vs 29.55±7.04, p=0.45; right median conduction velocity = 59.54±7.05 vs 61.06±5.15, p= 0.42) and motor conduction variables (right median distal latency = 2.87±0.38 vs 2.87±0.38, p= 0.94; right median distal amplitude=10.71±2.19 vs 11.10±2.37, p=0.58; right median conduction velocity= 70.57±13.16 vs 68.53±7.73, p= 0.54) of median and ulnar nerves. Further, there was no significant difference between the dominant and non-dominant hands of dental residents. CONCLUSIONS: Hand held vibration tools did not alter nerve conduction study parameters of dental residents.

Prevalence of Different Types of Apical Root Canal Morphology and their Treatment Recommendations in an Institute.

INTRODUCTION: Canals can be of different shapes in cross section including round canals, oval canals, long oval canals or ribbon shaped canals. Recesses of nonround canals may not be included in the round preparation created by rotary instruments and thus they remain unprepared. The aim of this study included determination of shape and taper of the apical root canal based on diameter at different levels. Measurement of the diameter of the root canal at one, two and three mm cross sections from the apex of the tooth were done such that apical instrumentation in root canal treatment could be modified based on the results obtained. METHODS: This was a cross sectional study which used convenient sampling technique to determine the sample size. Seventy extracted teeth were sectioned horizontally at one, two and three millimeter from the apex using the diamond disc which was observed under trinocular research microscope for the determination of diameter of root canal under 10x magnification. Digital images of the sections were taken by a camera attached to the research microscope and analysis done using DigiPro 4.0 software. RESULTS: The most common canal configuration was oval. The taper of the canals was 25% in mesial root and 20% in distal in bucco-lingual orientation and 14% in mesial root and 15% in distal in mesio-distal orientation. CONCLUSIONS: The most prevalent canal configuration in this study was non round, however, most of the rotary instruments tend to prepare root canals into round shape making their use questionable. The taper of the root canals was found to be higher in our study than what most of the shaping instruments have to offer. So it would be advisable to consider this fact while selecting instruments and preparing these non-round canals as far as the Nepalese subpopulation is considered.

Rare Association of Klippel-Trenaunay Syndrome with Large Pulmonary Embolism and Asymmetrical Emphysematous Bullae.

Klippel-Trenaunay syndrome is a rarely encountered congenital disease characterized by a triad of enlarged arteries and veins, limb hypertrophy and capillary malformations. We are presenting an interesting case of a 23-year male who had been previously diagnosed to have Klippel-Trenaunay syndrome. The patient presented with large pulmonary embolism after having undergone laser surgery for varicose veins. The diagnostic chest computed tomography (CT) performed also revealed the co-existence of severe destructive pulmonary parenchymal disease involving large areas of the pulmonary parenchyma and formation of large emphysematous bullae having an asymmetric involvement of the left lung field. The patient was managed with thrombolysis with a bolus fibrinolytic agent and subsequently underwent an inferior vena cava (IVC) filter implantation to prevent further episodes of embolism in the presence of a compromised lung. The association of Klippel-Trenaunay syndrome with recurrent pulmonary embolism and unexplained pulmonary parenchymal disease leading to almost complete destruction of large areas of lung fields is interesting and has never been previously described.

Thrombolysis With Single Bolus Tenecteplase Compared With Streptokinase Infusion in the Treatment of Acute Pulmonary Embolism: A Pilot Study.

OBJECTIVE: This study was planned to compare the efficacy of bolus regimens of tenecteplase (TNK) and 24 hours infusion of streptokinase (STK) in acute pulmonary embolism (APE) in a resource-poor setting. INTERVENTIONS: In all, 25 patients received injection of TNK, and 75 patients received infusion of STK over 24 hours. RESULTS: Pulmonary artery systolic pressure and right ventricular function were improved separately and significantly (P = .01) in both the study groups of patients from baseline at 24 hours or at seventh day and was comparable among the TNK and STK groups of patients. Mean duration of stay in intensive care unit was significantly less (2.2 ± 0.8 vs 3.2 ± 1.3 days; P = .04), and bleeding risk was also found to be nonsignificantly less in the TNK group. CONCLUSION: These results suggest that a 24-hour infusion regimen of STK is as effective as bolus TNK in the treatment of patients with APE in countries with limited resources.

An atypical presentation of an extremely late stent thrombosis after more than 7 years (2634 days) of DES implantation in a patient without obvious risk factors on regular dual antiplatelet therapy.

Very late stent thrombosis is a rare complication of percutaneous coronary intervention in the era of dual antiplatelet therapy. The risk factors for stent thrombosis are drug default, age, diabetes, renal dysfunction, left ventricular dysfunction, smoking or procedure-related factors and complications. We are describing the case of a 55-year-old non-smoker patient without the conventional risk factors for stent thrombosis maintaining good compliance with dual antiplatelet (aspirin and clopidogrel) drugs in standard doses. The patient had a history of having received a Cypher stent more than 7 years (2634 days) ago in the left circumflex artery for the management of in-stent restenosis of a bare metal stent implanted previously. He was referred with acute stent thrombosis with an atypical presentation of non-ST elevation myocardial infarction having unexplainable spontaneous resolution of electrocardiographic changes. The patient was successfully managed with newer generation drug-eluting stents reimplantation. The presence of acute onset of symptoms and thrombus containing soft lesion as documented during intervention supported the diagnosis of acute stent thrombosis. To the best of our knowledge this case is one of the longest duration of presentation with acute stent thrombosis after stent implantation ever reported in literature and is also unique in its unusual mode of presentation.

Gemella morbillorum endocarditis in hypertrophic cardiomyopathy: a rare organism causing a large vegetation and abscess in an uncommon setting.

Mitral valve endocarditis complicating hypertrophic cardiomyopathy is rare especially in the absence of significant mitral regurgitation. The occurrence of large vegetation and an abscess formation is even rarer. Endocarditis occurs predominantly on the left ventricular aspect of the anterior mitral leaflet. We report a case of a 34-year-old woman with asymptomatic obstructive hypertrophic cardiomyopathy who developed mitral valve endocarditis with large vegetation and subsequently an abscess caused by a rare organism Gemella morbillorum, following dental extraction. The patient underwent antibacterial therapy followed by successful mitral valve replacement for severe mitral regurgitation and her postoperative course has been asymptomatic so far. This case is unique in describing endocarditis by a rare organism as a cause of large vegetation and an abscess on an unusual site on the mitral valve leaflet without predisposition of haemodynamically significant mitral regurgitation and illustrates the potential lifesaving role of timely intervention.

An extraordinary survival at the age of 67 years in an unoperated case tetralogy of Fallot presenting as systemic hypertension despite RV dysfunction.

Tetralogy of Fallot is a cyanotic congenital heart disease characterised by a tetrad of four anomalies including ventricular septal defect, pulmonary stenosis, over-riding of aorta and right ventricular hypertrophy with high incidence of infant and early childhood mortality with middle age survival less than 5%. Most cases require treatment in infancy and are symptomatic early on. Rare cases of survival to middle age have been reported especially after the fourth decade. We report an unoperated case of tetralogy of Fallot diagnosed at the age of 67 which is one of the longest time periods of diagnosis of a life-threatening congenital heart disease. Despite tetralogy and having right ventricular dysfunction manifested in the form of congestive symptoms, this patient presented with systemic hypertension along with cyanosis and clubbing which is considered to be a relatively rare presentation in this syndrome. The patient wished to be managed conservatively.

Absent pulmonary valve: a case with rare presentation treated with bioprosthetic valve replacement.

Congenital absence of the pulmonary valve is a rare congenital cardiac malformation, usually seen in association with tetralogy of Fallot. Patients generally present early in life with respiratory distress or recurrent respiratory tract infections, failure to thrive, cyanosis, infective endocarditis, or heart failure. Isolated absent pulmonary valve is quite rare and may be discovered in older age-group as in our patient, a nine-year-old male child who presented with atypical symptoms of exertional chest pain. Unusual echocardiographic features in this case include intact ventricular septum and prominent trabeculations of the right ventricle. Surgical implantation of a bioprosthetic valve was followed by hemodynamic and symptomatic improvement.

Percutaneous closure of pseudoaneurysm of common iliac artery with amplatzer duct occluder II.

Seven-year-old boy presented with pain in right lower limb and abdomen after a fall from a bullock cart. He was referred for management of pseudoaneurysm of the right common iliac artery. After CT angiogram, the vascular surgeon opined that child was not suitable for surgical patch or graft or endovascular stenting as there was no landing zone for the stent. Hence the child was treated with transcatheter closure with two Amplatzer duct occluder II (ADO II). On follow-up the symptoms and bruit disappeared. To the best of our knowledge this is the first case of pseudoaneurysm, treated with ADO II.

Predictors of inhospital prognosis in acute pulmonary embolism: keeping it simple and effective!

The assessment of commonly available demographic, clinical, and easily calculable investigational parameters instead of the conventional complicated indices for prognosis in acute pulmonary embolism may help in triage in a simple and cost-effective way. Clinical, demographic, and investigational parameters were collected and utilized for the assessment of inhospital prognosis of acute pulmonary embolism in 200 consecutive patients admitted to our institute. Overall mortality was 18% and poor outcome at discharge was seen in another 18.5%. In univariate analysis, predominant presenting symptom of fatigue, sudden onset of symptoms, overt right ventricular failure, hypoxemia at admission, low SBP and DBP, coexistent pulmonary or cardiac illness, ECG evidence of right axis deviation, SIQ3T3 pattern, conduction blocks, echocardiographic evidence of right ventricular dysfunction, decreased inspiratory collapse of inferior vena cava, severe pulmonary arterial hypertension, visible thrombus in pulmonary artery, significant tricuspid regurgitation, computed tomographic evidence of total occlusion of major pulmonary arteries, diameter of main pulmonary artery, acute or chronic pulmonary embolism, renal and hepatic dysfunction, hyponatremia, hyperkalemia, troponin elevation, use of fibrin-specific agent, requirement of inotropic support, and mechanical ventilation were the variables found to significantly predict adverse outcome. In multivariate analysis, hypoxemia, no improvement after lysis, deranged liver function test, conduction blocks, and signs of right ventricular failure were the significant variables, while inotropic support requirement had a trend toward significance. Clinical, demographic, and routine investigational parameters help to risk-stratify the patients presenting with acute pulmonary embolism and to prognosticate and manage in a simpler yet effective way.

Thrombolytic therapy in the treatment of acute sub-massive pulmonary embolism: a prospective observational study.

The use of thrombolytic therapy in haemodynamically stable patients with sub-massive pulmonary embolism is still controversial. We conducted this study to observe the safety and efficacy of thrombolytic therapy in acute pulmonary embolism patients with normal blood pressure in a tertiary cardiac centre. In this study, 130 patients with sub-massive pulmonary embolism who had right-ventricular dysfunction were included and treated with thrombolytic therapy. Forty-one percent of patients in our study were within 40 years of age. Eighty-three percent of patients had clinical improvement. Both right-ventricular dysfunction and pulmonary artery systolic pressure were improved significantly following thrombolytic therapy from baseline (49 vs. 28 mmHg; P = 0.01; 95% confidence interval -13 to -56). Only 9% patients had died and two patients had intra-cerebral haemorrhage during this study. Thrombolytic therapy may be helpful in improving clinical course following sub-massive acute pulmonary embolism, especially for those who had low risk of bleeding. Further randomized study with large sample size is needed for final conclusion.

Occurrence of Guillain-Barré syndrome as an immune mediated complication after thrombolysis with streptokinase for acute anterior wall myocardial infarction: a caution to be vigilant.

Guillain-Barré syndrome (GBS) constitutes a heterogeneous group of immune-mediated peripheral neuropathic disorders that can be triggered by a variety of antecedent events. Clinical symptoms are thought to result from streptokinase antibody-mediated damage to the local blood-nerve barrier. We report the case of a 50-year-old man with acute anterior wall myocardial infarction who developed GBS as a manifestation of autoimmune hypersensitivity reaction to the drug 17 days after thrombolytic therapy with streptokinase. The patient was treated with a 5-day course of intravenous γ globulin and his symptoms improved and there was no residual deficit. The case forms a reminder of the autoimmune complications of non-fibrin specific agents that can sometimes be catastrophic and require persistent and vigilant in-hospital and immediate postdischarge follow-up and immediate management.

Successful catheter directed thrombolysis in postpartum deep venous thrombosis complicated by nicoumalone-induced skin necrosis and failure in retrieval of inferior vena caval filter.

Venous thromboembolism is an important cause for maternal morbidity and mortality in postpartum period. Though catheter-directed thrombolysis (CDT) is now considered as a safe and effective therapy for the management of deep venous thrombosis (DVT) but still it is not indicated in postpartum DVT. We are presenting a case of 22-year-old female patient who presented with post-partum lower limb DVT and managed successfully with CDT by using injection streptokinase and temporary inferior vena caval filter was inserted as prophylactic for pulmonary embolism as she had extensive DVT extending into inferior vena cava (IVC). During follow-up, she developed large skin necrosis in left lower limb which was managed by adding injection low-molecular-weight heparin. IVC filter also could not be retrieved even after trying all manoeuvres during follow-up after 2 weeks.

The retrieval of the diagnostic catheter which broke and embolised twice.

We are presenting a nightmare case of successful retrieval of the broken distal tip of a multipurpose catheter which embolised into the left pulmonary artery (LPA) during atrial septal defect device closure. During the course of snaring it initially slipped once in the LPA and subsequently while snaring it into the delivery sheath it slipped again in the inferior vena cava and yet again embolised into the LPA!! Subsequent attempt was successful but the distal fragment itself broke into two parts while being pulled inside the delivery sheath. Luckily the fragments did not embolise again as they were stuck at the tip of the sheath. The distal fragments were pulled out en masse along with the delivery sheath maintaining negative pressure at the side port of the delivery sheath using a 20 mL syringe. The final outcome was successful and the patient was unharmed by this potentially grave complication.

Successful retrieval of a fractured and embolised Judkin's catheter during a coronary angiogram.

We report the successful retrieval of a large broken segment of right Judkin's catheter using a snare catheter by a retrograde approach. A 69-year-old woman presented with an anterior wall myocardial infarction. A coronary angiogram revealed severe stenosis of distal left main coronary artery, ostio-proximal portion of the left anterior descending artery and the ostial left circumflex artery. During right shoot, the Judkin's right catheter was broken at almost 15 cm from the distal end. The distal end of the broken catheter was lying in the ascending aorta, whereas proximal end was in the left subclavian artery. First, we snared the distal end and pulled out the catheter in right common iliac artery but owing to the curvature of the fragment, this attempt was unsuccessful. Finally, we were successful in removing the fractured segment retrogradely through the arterial sheath placed in left femoral artery.

Acute coronary syndrome in a patient with Eisenmenger's syndrome.

Eisenmenger's syndrome is a complex multisystem disease which occurs as a consequence of large left to right shunt affecting the pulmonary vasculature causing suprasystemic pulmonary artery pressures and subsequent right to left shunt. Usually Eisenmenger's syndrome is characterised by coronary artery dilation but coronary artery disease and occurrence of acute coronary syndrome is a rare association seldom described in literature. We present the case of a 33-year-old man who presented with an anterior wall ST elevation mycocardial infarction and was thrombolysed. The occurrence of acute coronary event in a case of Eisenmenger's syndrome is a rare event and needs to be discussed and kept in mind by physicians and cardiologists who deal with such cases so that a high index of suspicion may be developed and emergent management may be possible.