Deep Vein Thrombosis in A Post-Coronary Artery Bypass Grafting Patient: Successful Conservative Management.

Deep vein thrombosis is an alarming medical emergency. Deep vein thrombosis or deep venous thrombosis (DVT) is the formation of a blood clot (thrombus) within a deep vein predominantly in the legs. Post-Coronary Artery Bypass Grafting deep vein thrombosis is a very rare medical condition relatively in Asian. Approximately 80% of deep vein thrombosis (DVTs) is clinically asymptomatic, 20% of those that actually demonstrate signs and symptoms can be easily confused with symptoms of other commonly presenting musculoskeletal disorders. Proper medical management can reduce patient's morbidity and further burden. A 50 years old diabetic Post-Coronary Artery Bypass Grafting gentleman had been suffering for left leg swelling, high grade fever and calf muscle pain for 5 days. He had absent Arteria Dorsalis Paedis pulse on left foot, Positive Homan sign and Wells score is 7. His left leg was hugely swelled. He had normal leg hair distribution. Duplex study of Left Leg-Deep Vein Thrombosis in left lower limb (Popliteal segment) with sign of recanalization. He is also a patient of anemia of chronic disease due to hemorrhoid. Several investigations have done to find the cause of his chronic anemia. His treatment was meticulous with complete bed rest, elevation of left lower limb, heparinization, oralrivaroxaban. He had rapid recovery following treatment. Post-Coronary Artery Bypass Grafting patient should be given post-operative enoxaparin (Low molecular weight Heparin) or Heparin for 3-5 days. Early diagnosis of the disease condition reduces morbidity. Combined treatment with Rivaroxaban and Heparin is of great clinical value and outcome in a case of Post-Coronary Artery Bypass Grafting Deep Vein Thrombosis patient.

Right Atrial Myxoma: An Uncommon Presentation.

There are two types of tumors found in the cardiac chamber. These are divided into primary intra-cardiac tumors and secondary intra-cardiac tumors. Primary intra cardiac tumors are rare and among them 29% are myxomas. Majority of them are found in the left atrium. Here, we report a case of a myxoma in the right atrium with hepatomegaly and Hepatitis B virus infection. The coexistence of all these conditions is very rare. A 52 years old patient presented with history of shortness of breath on exertion along with fever and generalized weakness for 6 months which aggravated lately for last 2 months. He was then taken for better medical care and hospitalization. On cardiac evaluation he had soft S1 and S2 over the tricuspid region on the right lower parasternal region. He had bilateral mild pitting pedal edema. On further examination, it was revealed that he had mild tender hepatomegaly with jaundice. His blood analysis for HBsAg was positive. Echocardiogram showed right atrial myxoma of 14.3cm² almost completely occupying the right atrium and even protruding into the Inferior Venacava however not fully obstructing it. The inferior vena cava size was mildly dilated (22mm). Abdominal ultrasound report showed hepatomegaly (17.6cm) with coarse hepatic parenchyma. In this report, we emphasize the rarity of myxoma in the Right Atrium, its difficult diagnosis because of the location and the atypical presentation in the echocardiograph.

Outcome of Extended Thymectomy in Myasthenia Crisis Patient.

Myasthenic crisis is a life-threatening condition. We studied the demographic, frequency, causes and clinical presentation of isolated Myasthenic crisis, steps of treatment and to review our experience of extended thymectomy on patients with at least one episode myasthenic crisis. A prospective and retrospective study was conducted on patients with at least one episode of myasthenic crisis, from March 2010 to September 2014, at the Department of Cardiac Surgery, BSMMU, Dhaka, Bangladesh who were referred for thymectomy. Eighteen patients (13.6% of the total 132 patients with myasthenia gravis were admitted with single to multiple episodes of myasthenic crisis, median crisis was 2.5 episodes. Mean age of the patient was 35.5 (18-72) years with male predominance. All eighteen patients had undergone extended thymectomy after completion of 5 cycle plasmapheresis, of which 2 had experienced postoperative respiratory crisis, required invasive ventilator support for median 14 days. One patient required invasive ventilator support after third post operative day. Six patients had thymoma and 12 had thymic hyperplasia. Three patients needed Intravenous immunoglobin. Nine patients needed post operative anti acetylcholinesterase inhibitor after median 2.5 post days. Post thymectomy remission and decreases the frequency of myasthenic crisis was seen in follow up and post operative medication requirement reduced significantly as compared to the preoperative requirement. This report highlights that the patients who had extended thymectomy after episodes of myasthenia crisis are benefitted even in the histhopathology report does not confirmed thymoma. After thymectomy, there was remission of myasthenic crisis. Patients with myasthenic crisis should have judicious drug adjustments under supervision and should be treated aggressively during impending myasthenic crisis. With modern management of myasthenia gravis, early surgery with myasthenic crisis is safe with good long-term outcomes.

Ruptured Aneurysm of Sinus of Valsalva: A Case Report.

We have presented a case of ruptured aneurysm of sinus of valsalva, in a female of 24 years old, with the symptoms and signs of right heart failure. Diagnosis made by echocardiography. For further evaluation, cardiac catheterization was done. After improvement of her general condition, she was undergone operation. Per-operative findings were bicuspid aortic valve having no calcification. A fistulous tract having windsock appearance found in between fused RCC & NCC extending into the RV cavity, which was opened inferior to the tricuspid valve. Fistulous tract was excised and the opening in the root of the aorta was closed with PTFE patch by 5/0 polypropylene and RV side was closed by direct suture. Patient was symptomless after operation. Patient discharged on eighth postoperative day in stable condition.

Surgical Closure of Atrial Septal Defect with High Pulmonary Vascular Resistance--A Case Report.

We have reported a case of successful pericardial patch closure of atrial septal defect with high pulmonary vascular resistance in a 32 years aged male. Diagnosis was confirmed by Doppler Echocardiography, Cardiac catheterization and lung biopsy. Before starting (orally) bosentan pulmonary arterial pressure was 105 mm Hg and pulmonary vascular resistance was 8 wood's unit. Bosentan was started at a dosage of 125 mg per day (62.5 mg twice a day) for 4 months before operation in this case. Just day before operation pulmonary arterial pressure was 87 mm Hg. Bosentan lowered pulmonary arterial pressure and reversed remodeling of pulmonary arteries and allowed surgical correction. During the post operative course, partial pressure of oxygen was significantly decreased and bilateral radiolucent opacity was present in lower zone of both lungs. All these were managed successfully in postoperative period. This case report has demonstrated that surgical correction of an atrial septal defect is feasible but requires long time pre and post operative treatment with pulmonary vasodilators.

Left Atrial Myxoma in a Late Case of Lung Carcinoma.

Concomitant occurrence of lung carcinoma and an atrial myxoma is rare. We are reporting such a case, a 55 year old male, farmer, smoker for 30 years was under evaluation for his recent episode of stroke with hemiparesis during which an echocardiography showed presence of a left atrial myxoma and chest x-ray showed a lesion in the midzone of right lung. Fine needle aspiration cytology (FNAC) from enlarged right supraclavicular lymphnode revealed metastatic adenocarcinoma. Patient was referred to a tertiary cancer care hospital thereafter.

A Case of Massive Pleural Effusion: Pleurodesis by Bleomycin.

Malignant pleural effusion is a common complication of primary and metastatic pleural malignancies. Pleurodesis for the management of malignant pleural effusion is intended to achieve symphysis between parietal and visceral pleura, and to prevent relapse of pleural effusion. Many chemical agents are tried to induce inflammation and damage of the pleural mesothelial layer to achieve this symphysis. Hemorrhagic pleural effusion, especially in the right hemithorax commonly occurs as presentation of primary and metastatic pleural malignancies. This case reports massive right-sided hemorrhagic pleural effusion as the sole manifestation of primary lung cancer in a 45 year old man. Patient attended our department of thoracic surgery complaining of cough, shortness of breath and right sided chest pain. A chest X-ray and chest computer tomography (CT) radiograph shows right sided massive pleural effusion. Right sided tube thoracotomy done. Pleural fluid study was done. Fluid for cytopathology was positive for malignant cell. Computed tomography guided fine needle aspiration cytology from right lung lesion was also done. Diagnosis was as small cell carcinoma. Pleural effusion resolved after 9(th) post operative day of chest tube insertion. Bleomycin pleurodesis was done. Day after pleurodesis intra thoracic tube was removed and patient was discharged from hospital on 10(th) Post operative day with an advice to attend the oncology department for further treatment. The protocol of tube thoracostomy and chemical pleurodesis was almost always successful in giving symptomatic relief of respiratory distress for a considerable period of time. However, chemical pleurodesis is not possible in all cases of malignant pleural effusion because it has got potential complication including death.

A Rapid and Reliable End-To-End Anastomosis Technique for Emergency Vascular Surgery--A Case Report.

A 28 year old male presented to us with 8 hours old open fracture of distal shaft of left femur which was already stabilized with external fixator but had no palpable distal pulse both clinically and on doppler examination. He underwent a primary repair following limited segmental resection. Commonly end-to-end anastomosis techniques following transection of arteries include interrupted and continuous suturing with or without 'parachuting' of the vessel or graft. Here we offer a rapid and reliable technique with following advantages: i) operating system always towards the surgeon, ii) posterior row of suture placed as both ends are well visualized, iii) less chance of catching posterior wall, iv) flushing performed easily before completing anterior row suture. Upto 2nd post operative day anticoagulant used in the form of inj. Heparin 2500 IU subcutaneously 8 hourly and patient was discharged from hospital on 3rd post operative day with presence of good distal pulses both on clinical and Doppler examination. Fourteen days later, on follow up Duplex study showed normal arterial flow without any stenosis or occlusion.

Ice test in diagnosis of ocular myasthenia.

This observational, non-control, non equivalent pretest and post test descriptive study was carried out at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from June 2009 to December 2009 to compare the efficacy of ice test and repetitive nerve stimulation (RNS) in diagnosis of ocular myasthenia gravis. Ten patients with fluctuating ptosis (4 male and 6 female) who were suspected of having ocular myasthenia were included in the study. Male and female ratio in the study was 2:3. The mean age of the patients was 28.1 years. Positive response to pyridostigmine was taken as confirmation of ocular myasthenia. A piece of ice (2cm × 1cm) was placed over the upper eyelid for 2 minutes and the vertical eye lid fissure height was noted before and after the application of ice. Repetitive nerve stimulation was performed in the same subjects subsequently. Results of two tests were compared. Eight patients shows good (>2mm) elevation of eyelid with ice and three patients had abnormal RNS. In conclusion, ice test appears as more sensitive clinical test to detect ocular myasthenia than RNS test.

Distribution Pattern and Outcome of the Patients in the Intensive Care Unit of Bangabandhu Sheikh Mujib Medical University: A Short Term Analysis.

The aim of the study was to describe the characteristics of patients admitted to intensive care unit and their outcome in Bangabandhu Sheikh Mujib Medical University, Bangladesh. This retrospective, descriptive study was conducted in the intensive care unit of Bangabandhu Sheikh Mujib Medical University (BSMMU) from January 2016 to June 2016. Data was retrieved from hospital records of all admitted patients regarding age, gender, admission source, reason for admission, length of ICU stay, requirement of mechanical ventilation, number of organ failure and their outcome. During this study period, the total number of patients admitted was 225; most of them were males (148, 65.7%). Among the 225 patients, the highest number of admission was comprised of intracranial haemorrhage (22.6%), followed by sepsis (12.4%), acute respiratory distress syndrome (10.2%), acute renal failure (9.3%) malignancy (8.8%) and ischemic stroke (8.0%). Mean age of the patient was 54±18 years and mean length of ICU stay was 6.8±3 days. Out of 225 patients, 87 expired (38.6%). Majority of the patients required mechanical ventilation (69.3%) and had multi organ failure (59.8%). Most of the expiries were due to intracranial haemorrhage (24.1%); followed by acute respiratory distress syndrome (12.6%), malignancy (12.6%) and sepsis (11.4%). Elderly age (>65 years), requirement of mechanical ventilation and multiorgan failure had significant relationship (p<0.05) with overall ICU mortality. Intracranial haemorrhage, sepsis, acute respiratory distress syndrome were the main reasons for admissions in ICU, while mortality was highest for intracranial haemorrhage. Developing a well equipped neurological ICU with adequately trained staff will help to improve the outcome of patients.

Duplex evidence of recanalization of deep venous thrombosis with conservative management.

A female patient was admitted in vascular surgery department of Bangabandhu Sheikh Mujib Medical University (BSMMU) after confirmation of diagnosis with duplex ultrasonographic examination. The patient was treated with intra-venous heparin for 10 (ten) days and elevation of the affected limb with application of crepe bandage. Later on the patient was discharged with oral anti-coagulant e.g. Tab. Warfarin for 06 (six) months along with application of crepe bandage on the affected limb. During the patient received oral anti-coagulant therapy the patient was asked to do Prothrombin time every week for adjustment of dose of oral anti-coagulant therapy. After 01 (one) month duplex ultrasonographic examination of deep veins of the affected limb was performed, which showed good recanalization of deep and superficial veins of right lower limb. It can be stated that, serious complications like pulmonary embolism can be avoided with effective and timely treatment of deep venous thrombosis with complete recanalization.

Increase in the calcium level following anodal polarization in the rat brain.

The accumulation of calcium ions (Ca) was examined in the rat brain by means of 45Ca autoradiography following the application of a weak anodal direct current to the surface of the sensorimotor cortex. Repetition of the anodal polarization with 3.0 microA for 30 min caused more Ca to accumulate in the cerebral cortex. The degree and extent of accumulation was greater in the hemisphere ipsilateral to the polarization than in the other. Accumulation was also noted in the hippocampus and thalamus. Ca accumulation was detected after 24 h and it remained virtually constant up to 72 h after the last polarization. The results suggest that a long-lasting disturbance of Ca homeostasis is involved in the cortical plastic changes seen following anodal polarization.

Detection of DNA damage induced by apoptosis in the rat brain following incomplete ischemia.

To clarify the pathogenesis and molecular basis of ischemia-related nerve cell death, we examined the occurrence of DNA fragmentation as a hallmark of apoptotic cell death following incomplete ischemia in the rat brain by means of in situ end labeling of fragmented DNA. Incomplete ischemia was produced by permanently occluding one carotid artery, while temporarily occluding the other. The condensed nuclei of ischemic neurons in the neocortex, and in the subiculum and CA1 area of the hippocampus were positively stained 24 h and 3 days following vessel occlusion, respectively, and their morphology was typically apoptotic. The ischemic neurons with condensed nuclei gradually increased in number and were clearly stained for fragmented DNA in these areas. The labeled nuclei in the neocortex became pyknotic 72 h later, and in the hippocampus 7 days later incomplete ischemia. After attaining a peak, the number of labeled nuclei decreased with the duration of recovery in all areas. These results suggest that an apoptotic process plays, at least primarily, a role in the degeneration of neurons associated with incomplete forebrain ischemia in rat.

Induction of N-methyl-D-asparate receptor mediated c-fos protein in the rat brain by incomplete ischaemia.

The expression of c-fos protein was examined by means of immunocytochemistry in the rat brain following incomplete ischaemia, to elucidate the molecular mechanisms of post-ischaemic neuronal death and of the modulated neurotransmission of surviving neurons. Incomplete ischaemia was produced by permanent unilateral or bilateral common carotid artery (CCA) occlusion. After 1 h of unilateral occlusion, the level of c-fos protein-like nuclear immunoreactivity increased in cortical neurons ipsilateral to the insult, especially in cingulate and piriform cortices. The reactivity peaked at 3-6 h, and was undetectable after 3 days. A number of scattered immunostained neurons in the ipsilateral subiculum, CA 1 and dentate gyrus became visible after 1 day. The effect reached a peak between 1-3 days, then returned to basal levels by 7 days. Bilateral CCA occlusion showed a similar distribution of immunoreactivity, but on both hemispheres. Immunoreactive neurons were more numerous and intensely stained but more transient. The induction of c-fos was completely blocked or reduced by treatment with MK-801. Our results suggest that c-fos expression after CCA occlusion is NMDA receptor mediated, and that it has a specific role in neurons after ischaemic insult.

Carotid artery occlusion causes reversible brain damage in rat.

In order to assess the density and distribution of brain damage after pure focal ischemia uncomplicated by hypotension or hypoxia, ischemia was produced by occlusion of one and/or both common carotid arteries (CCA) temporarily or permanently in the rat, followed by 3 months recovery. The brains were perfusion-fixed with formaldehyde, embedded in paraffin, subserially sectioned, and stained with hematoxylin-eosin/cresyl violet. Mild ipsilateral neuronal damage was observed after unilateral permanent occlusion, but confined only to the hippocampus. Damage of neocortical neurons began to appear after 1 day following bilateral permanent occlusion. Damage was worst over the superolateral convexity of both hemispheres, CA 4 and subiculur neurons; subsequently other sectors of hippocampus and other brain structures were affected. Some damaged neurons in the superficial cortex and CA 1 sector of hippocampus, and almost all in the other regions of brain reverted to normal profile by 3 months of recovery. All brain structures showed normal profiles, except a relative neuronal rarefication in neocortex and CA 1 sector of hippocampus after 3 months of recovery. These results suggests that only CCA occlusion causes partial/incomplete ischemia in the rat brain, where damaging effects are counterbalanced by metabolic and circulatory adjustments.

Cardiac malignant lymphoma in severe combine immunodeficient mice.

Extranodal malignant lymphomas are known to occur with increased frequency in patients with human immunodeficiency virus infection. Although cardiac malignant lymphomas are rare, recently an increasing number of patients with acquired immune deficiency syndrome (AIDS) and cardiac lymphoma have been reported. To clarify the relationship between AIDS and cardiac lymphomas, we used 60 severe combine immunodeficient (SCID) mice as animal models in whom five different types of human lymphoma cell lines were injected. Primary lymphomas at the site of cell line injection developed within 14-30 days in 58 mice. Cardiac malignant lymphoma was detected in 10 cases (17%), among which tumour was macroscopically evident in 2. Tumour was present on the pericardial aspects of the heart extending into the myocardium in most cases, but no intracavitary lesion was observed. In one case, obstructive features were marked near the root of the great vessels by direct pressure of the growth. This study indicates that lymphomas have a predilection to invade the heart in immunocompromised conditions.

Acute myocardial infarction: A complication of left atrial myxoma.

A 58-year-old female patient, immediately after an acute myocardial infarction underwent an echocardiographic examination and emergency coronary arteriography which led to the discovery of left atrial infarction. Successful emergency coronary arterial by-pass graft (CABG) and excision of the myxoma was done within 24 h of the onset.

Effects of anodal polarization on protein kinase Cγ (PKCγ) in the rat brain.

An anodal direct current of 0.3 microA or 30.0 microA was unilaterally applied for 30 min or 3 hr to the surface of the sensorimotor cortex of rats, and the effects of anodal polarization on protein kinase C (PKCgamma) activity were examined. The brains were processed by means of immunocytochemistry using the monoclonal antibody 36G9 raised against purified PKCgamma. In sham-operated animals, PKCgamma-like-immunoreactivity (PKCgamma LI) was noted in neuronal cytoplasm, as well as in processes in the cerebral cortex and in the hippocampus. Anodal polarization with 3.0 miroA for 30 min resulted in a pronounced increase in the number of PKCgamma-like-positive neurons in accordance with the intensity of immunostaining in the cerebral cortex, and an increase in the polarized hemispheres was highlighted by repeated applications of the currents. Polarization with 0.3 microA for 3 hr also increased the PKCgamma LI, but 0.3 microA for 30 min or 30.0 microA for any duration had no effects. The effect of polarization on PKCgamma activity, as evaluated by the intensity of immunostaining and the number of neurons, began to increase 1 h after polarization, peaked at 3 hr and thereafter decreased to the control levels by 72 hr. These results indicated the involvement of the gamma-isoform of PKC in the neurochemical mechanism of long-standing central and behavioral changes induced by anodal polarization.

Immunocytochemical distribution of gamma isoform of protein kinase C (PKC-gamma) following incomplete ischaemia.

Immunocytochemical distribution of PKC-gamma was examined in rat brain in relation to molecular mechanisms of post-ischaemic neuronal modulation following incomplete ischaemia. Incomplete ischaemia was developed by either permanent occlusion of one common carotid artery (CA) or permanent occlusion of one CA with temporary occlusion of opposite CA. Unilateral CA (UCA) occlusion resulted in a pronounced increase in the intensity of staining and number of PKC-gamma positive neurons in the neocortex ipsilateral to the insult after 3 h. The effect was maximum at 6-12 h and was undetectable after 7 days. CA1 neurons showed an increase immunoreactivity (IR) after 1 day, reached to a peak by 3 days, then reduced to basal levels after 7 days. Bilateral CA (BCA) occlusion showed almost similar changes in the neocortex, but on both sides and short durated. The altered patterns of PKC-gamma IR in the neocortex and hippocampus following CA occlusion may reflect activation and/or down-regulation of PKC-gamma in ischaemic neurons. PKC-gamma may, therefore, potentially play an important role in the post-ischaemic modulation of synaptic efficacy in these neurons and in the neuronal damage following incomplete ischaemia.

Blood glucose and ischemic brain damage.

The effect of hyperglycemia on ischemic brain damage was studied in a rat model of incomplete ischemia. Incomplete ischemia was produced by permanent occlusion of one (either left or right) common carotid artery (CCA). Hyperglycemia was induced by intraperitoneal injection of 50% glucose, and same volume of physiological saline was injected in the controls 40 min before CCA ligation. Serum glucose level, at the time of vessel ligation, was 33.3 mMol/L. After CCA ligation, the rats were allowed to wake up and survive for upto 1 month. Perfusion-fixed brains were embedded in paraffin, subserially sectioned, and stained with haematoxylin-eosin/cresyl violet. Brain from sham-operated animals showed no damage neurons. Only mild neuronal damage was observed in saline pre-treated rats in CA1 area. Histological examination 24 h after CCA occlusion revealed ischemic neuronal cell damage to be more extensive in hyperglycemic rats. Neuronal damage was found in the major brain structures vulnerable to several insults. Some of those damaged neurons recovered well, but presence of some damaged neurons at 1 month of recovery suggesting delayed recovery. The results indicate that increased blood glucose level (hyperglycemia) during brain ischemia exaggerates structural alterations and leads to delay in recovery.