Temporary pacing through umbilical venous route for neonatal heart failure due to complete atrioventricular block.

We present a case of a neonate who presented with worsening heart failure due to congenital complete atrioventricular (AV) block, secondary to maternal anti Ro/SSA and anti-LA/SSB antibodies. The patient was implanted a temporary pacemaker in view of hemodynamic deterioration and subsequently was weaned off ionotropic support and referred for permanent epicardial pacemaker implantation. We report temporary pacemaker implantation in a neonate with hemodynamic instability as a stabilizing measure and discuss technical challenges for the same.

ECG manifestations of occlusion of septal perforator of left anterior descending artery.

The fourth universal definition of MI defines requires presence of j point elevation in two contiguous leads except v2-3 where the elevation should be equal to or >2 mm in men (2.5 mm in <40 years) and 1.5 mm in women.(1) We present two cases of patients who presented with electrocardiographic manifestations of occlusion of septal perforator of left anterior descending artery and discuss the salient feature of ECG in such patients. We also present the limitations of STEMI criteria given the dynamic nature of acute coronary occlusion and stress on early recognition of this MI.

Clinical effectiveness of periosteal pedicle graft for the management of gingival recession defects-a systematic review and meta-analysis.

OBJECTIVE: The purpose of this systematic review and meta-analysis was to evaluate the effectiveness of periosteal pedicle graft (PPG) in terms of root coverage and patient related outcomes. To the best of our knowledge this is the first systematic review with meta-analysis on PPG. MATERIAL AND METHODS: A comprehensive search was performed using electronic and hand searches upto January 2023. Primary outcomes were Recession depth Reduction (Rec Red), mean root coverage (mRC) and complete root coverage (CRC). Secondary outcomes were gain in width of keratinized gingiva (WKG) and patient reported outcome measures (PROMs). Meta-analysis was performed when possible. The risk bias assessment was done using RevMan5.4.1 and Joanna Briggs institute scale for the included RCTs and case series respectively. RESULTS: A total of 8 RCTs and 2 case series (538 recession sites) were included based upon the predefined inclusion and exclusion criteria. The follow up period ranged from 6 months to 18 months. Results demonstrated that mRC of PPG + Coronally advanced flap (CAF) was 87.7% for localized gingival recession defects (GRDs) and 84.83% for multiple GRDs. An overall gain in WKG (Weighted Mean =1.49 ± 0.27 mm) was observed among all the included studies in the PPG + CAF group with mean difference (-0.10 (95% CI [-0.52, 0.33], p = 0.66)). Sub-group meta-analysis comparing PPG + CAF with sub-epithelial connective tissue graft (SCTG) + CAF resulted in similar outcomes in terms of Rec Red (0.10 (95% CI [-0.56 to 0.77], p = 0.76)) and gain in WKG (-0.03 (95% CI [-0.25 to 0.18], p = 0.76)). In terms of PROMs systematic review revealed better patient satisfaction with PPG + CAF than SCTG + CAF. CONCLUSION: PPG + CAF is a viable treatment modality for management of GRDs. The primary and secondary outcomes achieved utilizing PPG + CAF were found to be comparable to other conventional techniques including the gold standard i.e., SCTG.

Experts' Consensus on Use of Long-Acting Nitroglycerine in the Management of Angina and Chronic Coronary Syndrome in India.

AIM: To address the existing gaps in knowledge about long-acting nitroglycerine (LA-NTG) and provide recommendations to address these issues. METHODOLOGY: Approved LA-NTG questionnaire that included 17 questions related to the role of LA-NTG in the management of angina and chronic coronary syndrome (CCS) was shared with 150 expert cardiologists from different regions from India. Results of these survey questionnaires were further discussed in 12 regional level meetings. The opinions and suggestions from all the meetings were compiled and analyzed. Further, recommendations were made with the help of attending national cardiology experts and a consensus statement was derived. RESULTS: This is the first consensus on LA-NTG, summarizing the clinical evidence from India and suggesting recommendations based on these data. The experts recommended early use of LA-NTG as a first-line antianginal therapy in combination with beta-blocker since it improves exercise tolerance in patients with CCS. A strong consensus was observed for using LA-NTG in patients with co-morbid hypertension, diabetes, chronic kidney disease and post-percutaneous coronary intervention angina. As a part of cardiac rehabilitation, LA-NTG allows patients with angina to exercise to a greater functional capacity. CONCLUSIONS: A national consensus was observed for several aspects of LA-NTG in the management of angina and CCS. The clinical experience of the experts confirmed an extremely satisfied patient perception about the efficacy of LA-NTG.

Advanced Data Analytics for Improved Decision-Making at a Veterans Affairs Medical Center.

EXECUTIVE SUMMARY: This article reports on a data-driven methodology for decision-making at a Veterans Affairs medical center (VAMC) to improve patient outcomes, specifically the 30-day standardized mortality ratio (SMR30). The quarterly strategic analytics for improvement and learning (SAIL) reports are used to visualize the data, study trends, provide actionable recommendations, and identify potential consequences.A case study using more than 4 years of data demonstrates the power of the methodology. After reviewing data and studying trends at other VAMCs, a decision is made to reduce the SMR30 value by 1%. In running correlation algorithms, in-hospital complications (IHC) are shown to be most closely correlated with SMR30. Modeling the results from 17 quarters' worth of data shows that a desired 1% change in SMR30 would require a targeted 18.6% decrease in IHC. This change, if accomplished, would yield good consequences on methicillin-resistant Staphylococcus aureus mitigation but potentially unintended consequences with catheter-associated urinary tract infections and patient safety indicators that would need to be monitored. This knowledge could enable healthcare leaders to make informed decisions of both potentially positive and unintended consequences that can be monitored and minimized. This study lays the groundwork for a healthy discussion among leaders, staff, and clinicians on the path forward, resources required, and-most importantly-a dashboard that reflects the progress each week rather than a quarterly SAIL report.

Three-Dimensional Numerical Simulations of Peristaltic Contractions in Obstructed Ureter Flows.

Ureteral peristalsis can be considered as a series of waves on the ureteral wall, which transfers the urine along the ureter toward the bladder. The stones that form in the kidney and migrate to the ureter can create a substantial health problem due to the pain caused by interaction of the ureteral walls and stones during the peristaltic motion. Three-dimensional (3D) computational fluid dynamics (CFD) simulations were carried out using the commercial code ansys fluent to solve for the peristaltic movement of the ureter, with and without stones. The effect of stone size was considered through the investigation of varying obstructions of 5%, 15%, and 35% for fixed spherical stone shape. Also, an understanding of the effect of stone shape was obtained through separate CFD calculations of the peristaltic ureter with three different types of stones, a sphere, a cube, and a star, all at a fixed obstruction percentage of 15%. Velocity vectors, mass flow rates, pressure gradients, and wall shear stresses were analyzed along one bolus of urine during peristalsis of the ureteral wall to study the various effects. It was found that the increase in obstruction increased the backflow, pressure gradients, and wall shear stresses proximal to the stone. On the other hand, with regard to the stone shape study, while the cube-shaped stones resulted in the largest backflow, the star-shaped stone showed highest pressure gradient magnitudes. Interestingly, the change in stone shape did not have a significant effect on the wall shear stress at the obstruction level studied here.

Successful Thrombolysis of a Large Pulmonary Artery Thrombosis.

A 32 yrs old man presented with shortness of breath and syncopal episode with preceding history of DVT 15days above. Patient has tachycardia hypoxia and hypotension, on evaluation ECG Showed S1 Q3 T3 Pattern, bedside Echo Showed visible thrombus of 3cm in pulmonary artery, successfully thrombolysed with tenecteplase and streptokinase. This case study is presented to stress importance of urgent bedside echo in all sudden onset dysponea and hypoxia to rule out pulmonary Embolism which can be successfully thrombolysed without delay.

Congenital left atrial appendage aneurysm associated with a systemic embolism.

A 20 year-old woman presented with systemic embolisation. On subsequent investigation, she was diagnosed with a congenital left atrial appendage aneurysm. Few case reports are reported in the literature. This cardiac malformation presents a diagnostic challenge in patients with cardiomegaly.

Left ventricular function by echocardiogram in children with sickle cell anaemia in Mumbai, Western India.

INTRODUCTION: Cardiovascular events and complications are the leading cause of mortality and morbidity in patients with sickle cell disease. Cardiac abnormalities occur frequently and at an early stage in sickle cell anaemia patients, despite being more evident in adulthood. Sickle cell anaemia patients are increasingly able to reach adulthood owing to improved healthcare, and may, therefore, suffer the consequences of chronic cardiac injury. Thus, the study of cardiac abnormalities is essential in children OBJECTIVE: The aim of this study was to determine the echocardiographic changes in left ventricular function in children suffering from sickle cell disease in Mumbai, Western India. METHODS: The study comprised of 48 cases of sickle cell anaemia and 30 non-anaemic controls with normal haemoglobin and electrophoresis pattern. M-mode, two-dimensional, and Doppler echocardiographic measurements of patients and controls were performed according to the criteria of the American Echocardiography Society. RESULTS: On Doppler study, the A wave height was increased and the E/A ratio was decreased, whereas the deceleration and isovolumetric relaxation times were prolonged, which is typically seen in slowed or impaired myocardial relaxation (p<0.001). Although chamber dilatations were present, echocardiographic parameters showed no statistically significant correlation with severity of anaemia and age among the sickle cell patients. CONCLUSIONS: We conclude that the increased left ventricular stiffness, compared with controls, might be due to fibrosis related to ischaemia caused by SS disease in addition to wall hypertrophy.

The 'who are all these people?' study.

BACKGROUND: Overcrowding of emergency departments (EDs) adversely affects the delivery of emergency care and results in increased patient mortality. OBJECTIVE AND METHODS: To examine what contributes to the ED crowd and to specifically examine the patient associated population. The ED in which the research was performed is consistently one of the most overcrowded in Ireland. RESULTS: On average 66.7% of the patients in the ED during the study period were boarded awaiting a hospital bed following full processing by the ED staff and agreement by the on-call team that admission was required. The most overcrowded part of the department was the majors area. In this area 55.5% of those present were patients, visitors accounted for 16.6% of occupants, nursing staff 11%, on-call teams 7% and the ED doctors 6.3%. CONCLUSIONS: Knowing who the people in the crowd are helps to guide management decisions about how the crowd might be reduced. Our department now has a strict accompanying person/visitor policy that limits the number of visitors to patients and limits visiting times for those relatives with a patient who is experiencing a prolonged stay in the ED.

Higher Incidence of Pulmonary Hypertension in Antiphospholipid Antibody Positive Lupus.

BACKGROUND: Antiphospholipid antibodies (APAs) are detected in 30-40% of SLE patients, but only few develop APLA syndrome. Incidence of pulmonary hypertension (PH) is reportedly high in APA positive patients; however, Indian data is missing. MATERIALS AND METHODS: This cross-sectional, observational study was conducted from Jan 2009 - Dec 2011, on 50 SLE patients, fulfilling ACR criteria. SLE patients were selected serially from OPD and IPD. Pregnant females and children were excluded.Tests for presence of anticardiolipin antibody, lupus anticoagulant and anti-ß2 glycoprotein antibody were performed in all patients. Pulmonary artery pressure, was measured on transthoracic 2DECHO, by TR jet and graded as, mild (25-40mm), moderate (40-60) and severe (> 60mm). CT - pulmonary angiography and lower limb venous Doppler were performed in patients of moderate and severe PH. RESULTS: Out of 50 patients, 46 were females, 4 males, aged 17-50 yrs. Twenty-three were positive for at least one APA, 14/23 ACLA positive, 3/23 positive for LA, 16/23 positive for anti ß2 glycoprotein antibodies, 11 were positive for 2 or more antibodies. Pulmonary hypertension was present in 11 out of 23 APA and 2 out of 27 APA negative patients, with moderate to severe PH in 7 out of 11 APA positive patients. Four out of 7 patients with moderate to severe PH tested positive for more than one APA and in higher titers. CT pulmonary angiography and lower limb venous Doppler were performed in 4 out of 7 patients with moderate and severe PH and were normal. Three patients with moderate PH expired. CONCLUSIONS: Lupus patients with APAs are more prone to develop PH, with a possibility of formation of microthrombi in the pathogenesis of PH. As regards treatment of PH, in addition of PH lowering drugs, place for anticoagulants or antiplatelet agents needs to be studied in PH with APA positive patients.

Atrial Tachycardia Ablated Successfully from the Aorta.

We present a case of recurrent highly symptomatic atrial tachycardia. During electrophysiology (EP) study, this was found to arise close to the AV node. To avoid conduction system damage by radiofrequency (RF) ablation, the aortic cusps were mapped. The tachycardia focus was close to the non-coronary cusp and ablated safely and successfully from this site.

Maintaining ear aesthetics in helical rim reconstruction.

BACKGROUND: Wedge resections of the helical rim may result in a significant deformity of the ear with the ear not only smaller but cupped and prominent too. Our technique involves resection of the wedge in the scaphal area without extending into the concha followed by advancement of the helical rim into the defect. This technique is most suitable for peripheral defects of the helical rim, in the middle third. METHODS: Our modified surgical technique was applied to reconstruction of the pinna after resection of the tumor in 12 patients. Free cartilaginous helical rim, length of helical rim to be resected, and projection of the ear from the mastoid was measured. This was then compared with measurements after the operation, and the patient satisfaction assessed with a visual analog scale. RESULTS: The free cartilaginous rim was 91.67 ± 5.61 mm. Of this, 21.92 ± 3.78 mm was resected, which amounted to 23.84% ± 3.35% of the rim. Although this resulted in a mean increase in ear projection of 6.42 ± 1.68 mm, the aesthetic outcome was good (visual analog scale, 9.08 ± 0.9). CONCLUSIONS: This technique reduces cupping and does not make the ear as prominent as it may do after a conventional wedge resection and results in high patient satisfaction.

Creation of a Prototype Cochlear Training Model.

OBJECTIVE: Creation of a novel 3D-printed physical cochlear model that demonstrated the feasibility of creating the model, and impact of a Graphical User Interface (GUI) system on training insertion metrics. STUDY DESIGN: Feasibility study with a pilot prospective data collection. SETTING: Tertiary academic center. METHODS: The study was IRB exempt. Five resident trainees (PGY1-PGY5) practiced electrode insertions in cadaveric temporal bones before using the simulator. Nine students were educated on how to hold the electrodes and position them, and then allowed to use the simulator. All trainees were instructed that slower insertions were favorable. One cochlear implant (CI) surgeon used the simulator. The GUI captured the real video feed, but also provided distance, trajectory, and velocity measurements. The program is designed to plot the real-time depth of insertion and speed of insertion of the electrode; the user is also provided real-time occurrence of any kinks and back-outs. RESULTS: A total of 14 trainees and 1 CI surgeon inserted the electrode at least 5 times without the use of the GUI (before) and then at least 5 times with the use of the GUI (after). Average Speed before and after (100.84 and 53.23 mm/s); Average minimum speed before and after (59.34 and 9.65 mm/s); and Average maximum speed before and after (416 and 285.81 mm/s). Statistically significant improvements were noted in all the measured speeds of insertion (P < .001). The other variables improved but not to a statistical significance. CONCLUSIONS: Real-time training using the 3D-printed model and GUI for cochlear implantation can help improve surgical resident training and comfort levels with electrode insertion for surgical trainees. The advantage of this model is that surgeons/trainees can use it as many times as they like, as the whole set-up is easy, economical, and reusable. The real time graphical user interface enhances training and retention of the practiced skills.

Private Doctors' Perspective towards "Patient First" in TB Diagnostic Cascade, Hisar, India.

TB diagnosis has been simplified in India following advances in available diagnostic tools. This facilitates private doctors' "patient first" approach toward early diagnosis; however, costs remain high. India's NTEP established a TB diagnostic network, which is free for patients and incentivizes private doctors to participate. Drawing from this context led to the design and implementation of the One-Stop TB Diagnostic Solution model, which was conducted in the Hisar district, Haryana, allowing specimens from presumptive TB patients from private doctors to be collected and tested as per NTEPs diagnostic algorithm. A subset of data pertaining to private doctors was analyzed for the project period. Qualitative data were also collected by interviewing doctors using a snowball method to capture doctors' perception about the model. Out of 1159 specimens collected from 60 facilities, MTB was detected in 32% and rifampicin resistance was detected in 7% specimens. All specimens went through the diagnostic algorithm. Thirty doctors interviewed were satisfied with the services offered and were appreciative of the program that implements this "patient centric" model. Results from implementation indicate the need to strengthen private diagnostics through a certification process to ensure provision of quality TB diagnostic services.

Interspecies communication and periodontal disease.

More than 500 bacterial strains may be found in dental plaque. In the beginning, the emphasis was laid on the isolation of bacteria in pure culture to define their properties. However, now, it has been well established that in nature the bacteria exist as a member of polymicrobial community or consortium of interacting species. Interactions among human oral bacteria are integral to the development and maturation of the plaque. These interactions occur at several levels including physical contact, metabolic exchange, small-signal molecule-mediated communication, and exchange of genetic material. This high level of interspecies interaction benefits the microorganism by providing a broader habitat range, effective metabolism, increasing the resistance to host defence, and enhancing their virulence. This generally has a detrimental effect on the host and is attributed to many chronic infections which poses a therapeutic challenge.

Stromal Vascular Fraction Cells from Individuals Who Have Previously Undergone Radiotherapy Retain Their Pro-Wound Healing Properties.

Beneficial effects have been observed following the transplant of lipoaspirates containing adipose-derived stem cells into chronic wounds caused by oncologic radiotherapy. It is not yet certain whether adipose-derived stem cells are resistant to radiation exposure. Therefore, the aims of this study were to isolate stromal vascular fraction from human breast tissue exposed to radiotherapy and determine the presence of adipose-derived stem cells. Stromal vascular fraction from irradiated donor tissue was compared to commercially sourced pre-adipocytes. Immunocytochemistry was used to determine the presence of adipose-derived stem cell markers. Conditioned media from stromal vascular fraction isolated from irradiated donors was used as a treatment in a scratch wound assay of dermal fibroblasts also isolated from irradiated donors and compared to pre-adipocyte conditioned media and serum free control. This is the first report of human stromal vascular fraction being cultured from previously irradiated breast tissue. Stromal vascular fraction conditioned media from irradiated donors had a similar effect in increasing the migration of dermal fibroblasts from irradiated skin to pre-adipocyte conditioned media from healthy donors. Therefore, the ability of adipose-derived stem cells in the stromal vascular fraction to stimulate dermal fibroblasts in wound healing appears to be preserved following radiotherapy. This study demonstrates that stromal vascular fraction from irradiated patients is viable, functional and may have potential for regenerative medicine techniques following radiotherapy.

Diagnostic reproducibility of the 2018 Classification of Gingival Recession Defects and Gingival Phenotype: A multicenter inter- and intra-examiner agreement study.

BACKGROUND: The aim of this study was to investigate the inter- and intra-examiner agreement among international experts on the diagnosis of gingival recession defects using the 2018 Classification of Gingival Recession Defects and Gingival Phenotype as proposed in the 2017 World Workshop. METHODS: Standardized intraoral photographs from 28 gingival recession defects were evaluated twice by 16 expert periodontists. Recession type (RT), recession depth (RD), keratinized tissue width (KTW), gingival thickness (GT), detectability of the cemento-enamel junction (CEJ), and presence of root steps (RS) were recorded and used for the analysis. Intra- and inter-examiner agreements were calculated for individual variables and for the overall classification. Intraclass correlation coefficient with 95% CI was used for RD and KTW; Kappa with 95% CI was used for GT, CEJ, and RS; quadratic weighted Kappa with 95% CI was used for RT. RESULTS: Overall intra- and inter-examiner agreements were highest for KTW (0.95 and 0.90), lowest for GT (0.75 and 0.41), with the other variables in between (RD: 0.93 and 0.68, RS: 0.87 and 0.65, RT: 0.79 and 0.64, CEJ: 0.75 and 0.57). Overall intra- and inter-examiner agreements for the matrix were 62% and 28%, respectively. Significant effects existed between one variable's measurement and other variables' agreements. CONCLUSIONS: The 2018 Classification of Gingival Recession Defects and Gingival Phenotype is clinically reproducible within the examiners, and when the variables forming the matrix are analyzed individually. The between-examiner agreement for the complete matrix showed lower reproducibility. The agreement was highest for KTW and RD, and least for GT.