Three-year outcomes of surgical valve replacement with Dafodil™ pericardial bioprosthesis: Dafodil™-1 trial.

Background: The Dafodil™-1 trial was designed to evaluate the clinical safety and performance of Dafodil™ pericardial bioprosthesis for replacing diseased native or prosthetic aortic or mitral valves in patients with advanced valvular heart disease (VHD). Methods: The Dafodil™-1 trial was a prospective, multicenter, first-in-human clinical trial. Patients were enrolled if they had advanced VHD requiring aortic valve replacement (AVR) or mitral valve replacement (MVR) with or without concomitant valve surgery and having surgical risk scores <4%. Major adverse cardiac events (MACE), including all-cause death, myocardial infarction (MI), and stroke; and hemodynamics were analyzed. Results: A total of 136 patients (aortic: 67 and mitral: 69) were enrolled in the trial (with mean age-AVR group: 60.2 ± 8.3 years and MVR group: 49.7 ± 14.4 years). A total of 134 patients (aortic: 66 and mitral: 68) completed the 3-year follow-up (total 300 per 100 patient-years of follow-up). The AVR group demonstrated a significant reduction in the mean pressure gradients from 51.2 ± 24.1 mmHg at baseline to 11.1 ± 6.0 mmHg at the 3-year follow-up (p < 0.0001). The mean effective orifice area (EOA) improved from baseline (0.9 ± 0.6 cm2) to 3-year follow-up (1.8 ± 0.4 cm2) (p < 0.0001). In the MVR group, the mean indexed EOA (iEOA) increased significantly from baseline (0.7 ± 0.4 cm2/m2) to 3-year follow-up (1.1 ± 0.4 cm2/m2) (p < 0.001). There was significant improvement in New York Heart Association functional class and mean SF-12 scores in both groups. At 3-year follow-up, the MACE incidence was 2.3% per 100 patient-years (1.3% strokes per 100 patient-years and 1.3% deaths per 100 patient-years) for AVR group and 4.7% per 100 patient-years (0.6% strokes per 100 patient-years and 4.0% deaths per 100 patient-years) for MVR group. No cases of MI, structural valve deterioration and prosthetic valve endocarditis were reported. The AVR and MVR groups achieved 89.6% and 79.7% MACE-free survival, respectively at 3-year follow-up. Conclusions: The Dafodil™-1 trial demonstrated satisfactory outcomes of clinical safety, hemodynamic performance, and quality-of-life metrics. Additionally, no incidence of structural valve deterioration and very low rates of valve thrombosis during the 3-year follow-up period of Dafodil™-1 first-in-human trial indicated acceptable valve durability up to three years and similar outcomes are warranted for longer follow-ups as a primary goal. Clinical Trial Registration Number: https://www.ctri.nic.in/Clinicaltrials/showallp.php?mid1=18377&EncHid=&userName=CTRI/2017/07/009008, CTRI/2017/07/009008.

Cervicodorsal spine tuberculosis-- surgical approach.

Background: Tuberculosis (TB) of CT junction is uncommon (5 % of all spinal TB), and difficult to approach surgically in view of its deep location with sternum in front and scapula in the back. We present 7 consecutively treated cases of cervico-thoraccic TB for outcome of treatment and discuss rationale of choosing surgical approach. Methods: Present study includes 7 freshly diagnosed cases of CT junction TB. Plain radiographs, sagittal reconstruction of CT spine that included sternum on CT/MRI was performed in all cases. Disc space below the distal healthy vertebrae was identified and a line parallel to disc space was drawn. If this line passes above suprasternal notch, it was inferred that this VB can be accessed by anterior cervical approach. If disease focus was at or below suprasternal notch level, manubriotomy/sternotomy was added for better visualization of the lesion. Results: All seven cases were female, with mean age of 20 years (9-45 years). The vertebral lesion involved 2VB (n = 3), 3VB (n = 2) and >3 VB (n = 2). The average Cervico-thoracic kyphosis was 15° (range 10-25°). All 7 cases were operated for anterior decompression, kyphotic deformity correction and instrumented stabilization. Anterior cervical approach and manubriotomy/sternotomy approach was performed in three cases each. In two pan-vertebral cases we performed 360° procedure. Six cases have shown first sign of neural recovery within 3 weeks of surgery and almost complete neural recovery at 3 months follow-up while one case showed partial recovery. ATT was stopped after 12 months once healed stage was demonstrated on contrast MRI in all. Conclusions: CT junction TB usually presents with severe kyphotic deformity/neural deficit. These cases require anterior decompression/corpectomy, deformity correction, gap grafting and instrumented stabilization with anterior cervical plate. Lesion with pan-vertebral disease is stabilized 360°. These lesions can be decompressed by lower anterior cervical approach with/without manubriotomy. The Karikari method was useful in deciding the need for manubriotomy to decompress the lesion.

Outcomes of coronary artery bypass grafting based on myocardial perfusion imaging.

Introduction: Coronary artery disease (CAD) is the foremost single cause of mortality and loss of disability-adjusted life years globally and a large percentage of this burden is found in low and middle income countries, with the treatment strategies based on revascularisation, based on studies that have shown that on revascularisation of viable myocardium there is an improvement of function over a period of time. Aim: To evaluate the utilization of myocardial perfusion imaging (MPI) for identifying viable myocardium and assessing the improvement. Material and methods: This prospective observational study was conducted in patients having CAD planned for coronary artery bypass grafting. The patients were evaluated using 2D ECHO and MPI preoperatively and postoperatively after 1 year. Results: Mean ejection fraction preoperatively was 40.6 ±9.72% and postoperatively it improved to 41.32 ±10.64% and ejection fraction was calculated using MPI and an average improvement from 35.98 ±12.72% to 45.51 ±12.61% (p ≤ 0.0001). Summed rest score was calculated and an improvement was noted from 24.28 ±8.47 to 18.02 ±8.75 (p ≤ 0.0001). Total perfusion deficit was calculated and was found to have reduced from 32.44 ±11.98 to 25.61 ±12.23 (p ≤ 0.0001). Conclusions: MPI was able to accurately assess the improvement, which correlated not only with the 2D echocardiography data but also with the clinical wellbeing of the patients. Being a non-invasive, quick procedure, it should be added to the arsenal of the cardiac surgeon for evaluation of patients with diffuse diseases, low ejection fractions, patients who might generally be considered inoperable.

Incidence and Patterns of Drug Resistance in Patients with Spinal Tuberculosis: a Prospective, Single-Center Study from a Tuberculosis-Endemic Country.

Background: There is paucity of data on incidence and pattern of drug resistance in spinal TB. This prospective observational study was conducted to document the incidence and drug-resistance pattern among primary and presumptive resistant cases. Methods: 59 consecutive cases diagnosed clinico-radiologically (imaging) were grouped into Group A (n = 51, primary cases) and Group B (n = 8, presumptive resistant cases) based on pre-defined criteria (INDEX-TB guidelines). Tissue samples obtained percutaneously (37.29%, 22/59) and on surgery (62.71%, 37/59) were subjected to genotypic DST (CBNAAT, LPA) and phenotypic DST (BACTEC MGIT 960 culture and sensitivity using fixed critical concentration of drugs). Results: Etiological diagnosis was ascertained in all. 13/51 (25.49%) in Group A, while 3/8 (37.5%) in Group B and 16/59 (27.12%) overall demonstrated drug resistance. 12/16 (75%) had no prior history of ATT intake. 4 demonstrated INH (Isoniazid) mono-resistance. 12 polydrug resistance demonstrated: 5MDR, 3pre-XDR, while RIF + FQ (fluoroquinolones), FQ + Lz (linezolid), only SLID (second-line injectable drugs), and only FQ resistance observed in 1 case each. Isolated RIF (Rifampicin) resistance and XDR pattern were not observed. Overall frequency of RIF resistance was 16.4% (9/55) and INH was 25% (12/48) with low-(n-2) and high-level INH resistance (n-10). Among second-line drugs, FQ resistance was more than SLID resistance and within FQ, levofloxacin resistance was more frequent than moxifloxacin. MGIT demonstrated positive growth in 16/59 samples, out of which 1 sample was positive for nontuberculous mycobacteria (M. chelonae) but on genotypic testing demonstrated MTB resistant to RIF and FQ. Conclusion: This is the first report on incidence and drug-resistant pattern in culture-positive/negative cases. High (25.49%) primary drug resistance is worrisome. This being the first study in  spinal TB cases which document prevalent drug-resistant pattern as evaluated for consecutive culture-positive/negative cases. The tissue obtained must be submitted for AFB culture and molecular tests to ascertain drug resistance in culture-positive/negative cases. However, in the presence of insufficient tissue sample histology and CBNAAT can ascertain etiological diagnosis in 100% cases. INH resistance is more than RIF with isolated RIF resistance unreported.

Drug Resistance in Osteoarticular Tuberculosis: A Study From an Endemic Zone.

BACKGROUND: The present study was undertaken to determine the incidence of drug resistance against anti-tubercular drugs among patients from an endemic zone.  Methodology: Forty consecutive clinico-radiologically diagnosed patients of osteoarticular tuberculosis (29: spine, 11: extraspinal) were enrolled. Pus from needle aspiration was taken in 31 cases, tissue following spinal decompression in seven, synovial in one, and sinus edge biopsy in one. The pus/tissue was subjected to acid-fast bacilli (AFB) staining and liquid culture, sensitivity to 13 anti-tubercular drugs (Isoniazid (INH), rifampicin (RIF), kanamycin (KAN), amikacin (AMK,) capreomycin (CAP), ethionamide (ETH), levofloxacin (LEV), moxifloxacin (MOX), linezolid (LNZ), para-amino-salicylic acid (PAS), bedaquiline (BDQ), delamanid (DLM), and clofazimine (CFO)) were checked, and histopathological/cytopathological examination and molecular tests were performed.   Results: The mean age of patients was 29.07(9-65) years; 21 were female and 19 were male. The diagnostic accuracy for tuberculosis was 20% by AFB smear, 65% by liquid culture, 82.5% by histopathology, and 90% by cartridge-based nucleic acid amplification testing (CBNAAT). All culture-positive isolates were identified as Mycobacterium tuberculosis with no non-tubercular Mycobacterium. The drug resistance detected on CBNAAT was 11.1%, line probe assay (LPA) first line was 15.4%, LPA second line was 4%, and liquid drug susceptibility testing (DST) 11.5%. We detected 15.4% INH resistance, 11.1% RIF, 7.6% LEV, 3.8% MOX and PAS. No resistance was detected against second-line injectable drugs (SLID), ETH, LNZ, BDQ, DLM, and CFO.    Conclusions: No single laboratory modality can ascertain the diagnosis in all cases; hence, samples should be sent for all tests in tandem. In the presence of insufficient samples, tissue may be subjected to CBNAAT and histopathology to arrive at tissue diagnosis. In this subset, overall drug resistance incidence was 12.5% (5/40) with one patient each of isolated INH and RIF resistance, one of multidrug-resistance (MDR), and two of pre-extensively drug-resistant (pre-XDR). Primary drug resistance came out to be 11.1% (4/36) with one patient each of isolated INH and RIF resistance, one of MDR, and one Pre-XDR.

Automated Closed-Loop Propofol Anesthesia Versus Desflurane Inhalation Anesthesia in Obese Patients Undergoing Bariatric Surgery: A Comparative Randomized Analysis of Recovery Profile.

INTRODUCTION: Precision general anesthesia (GA) techniques that minimize the presence of residual anesthetic and facilitate recovery, are desirable in patients with morbid obesity. Automated administration of propofol total intravenous anesthesia (TIVA), which facilitates precision propofol delivery by factoring in continuous patient input variable (bispectral index) to establish a closed feedback loop system, may help mitigate concerns related to propofol's lipid solubility and adverse accumulation kinetics in patients with morbid obesity. This randomized study evaluated the recovery of patients with morbid obesity undergoing bariatric surgery under propofol TIVA automated by a closed-loop anesthesia delivery system (CLADS) versus desflurane GA. METHODS: Forty patients, randomly allocated to receive propofol TIVA (CLADS group) or desflurane GA (desflurane group), were evaluated for postoperative recovery (early and intermediate) (primary objective); they were evaluated for intraoperative hemodynamics, anesthesia depth consistency, anesthesia delivery performance characteristics, patient satisfaction, and incidence of adverse events (sedation, pain, postoperative nausea, and vomiting) (secondary objective). RESULTS: No difference was found for the time-to-eye-opening (CLADS group: 4.7 [3.0, 6.7] min vs. desflurane group: 5.6 [4.0, 6.9] min, P = 0.576), time-to-tracheal-extubation (CLADS group: 6.7 [4.7, 9.3] min vs. desflurane group: 7.0 [5.8, 9.2] min, P = 0.528), ability-to-shift score from operating room table to the transport bed (CLADS group: 3 [3.0, 3.5] vs. desflurane group: 3 [3.0, 4.0], P = 0.703), and time to achieve a modified Aldrete score 9/10 (CLADS group: 15 [15.0, 37.5] min vs. desflurane group: 15 [15.0, 43.7] min, P = 0.867). CONCLUSION: Automated propofol TIVA as administered by CLADS, which matched desflurane GA with respect to depth of anesthesia consistency and postanesthesia recovery profile, can be explored further as an alternative anesthesia technique in patients with morbid obesity.

Insulator-to-metal-like transition in thin films of a biological metal-organic framework.

Temperature-induced insulator-to-metal transitions (IMTs) where the electrical resistivity can be altered by over tens of orders of magnitude are most often accompanied by structural phase transition in the system. Here, we demonstrate an insulator-to-metal-like transition (IMLT) at 333 K in thin films of a biological metal-organic framework (bio-MOF) which was generated upon an extended coordination of the cystine (dimer of amino acid cysteine) ligand with cupric ion (spin-1/2 system) - without appreciable change in the structure. Bio-MOFs are crystalline porous solids and a subclass of conventional MOFs where physiological functionalities of bio-molecular ligands along with the structural diversity can primarily be utilized for various biomedical applications. MOFs are usually electrical insulators (so as our expectation with bio-MOFs) and can be bestowed with reasonable electrical conductivity by the design. This discovery of electronically driven IMLT opens new opportunities for bio-MOFs, to emerge as strongly correlated reticular materials with thin film device functionalities.

Context and priorities for health systems strengthening for pain and disability in low- and middle-income countries: a secondary qualitative study and content analysis of health policies.

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care.

Stage-Specific Effect of Inositol Hexaphosphate on Cancer Stem Cell Pool during Growth and Progression of Prostate Tumorigenesis in TRAMP Model.

Herein, we assessed the stage-specific efficacy of inositol hexaphosphate (IP6, phytic acid), a bioactive food component, on prostate cancer (PCa) growth and progression in a transgenic mouse model of prostate cancer (TRAMP). Starting at 4, 12, 20, and 30 weeks of age, male TRAMP mice were fed either regular drinking water or 2% IP6 in water for ~8-15 weeks. Pathological assessments at study endpoint indicated that tumor grade is arrested at earlier stages by IP6 treatment; IP6 also prevented progression to more advanced forms of the disease (~55-70% decrease in moderately and poorly differentiated adenocarcinoma incidence was observed in advanced stage TRAMP cohorts). Next, we determined whether the protective effects of IP6 are mediated via its effect on the expansion of the cancer stem cells (CSCs) pool; results indicated that the anti-PCa effects of IP6 are associated with its potential to eradicate the PCa CSC pool in TRAMP prostate tumors. Furthermore, in vitro assays corroborated the above findings as IP6 decreased the % of floating PC-3 prostaspheres (self-renewal of CSCs) by ~90%. Together, these findings suggest the multifaceted chemopreventive-translational potential of IP6 intervention in suppressing the growth and progression of PCa and controlling this malignancy at an early stage.

Clinico-hematological profile of pancytopenic adult patients in a tertiary care teaching hospital.

OBJECTIVE: The causes of pancytopenia vary in different populations depending on age, gender, nutrition, geographic location, standard of living, and exposure to certain infections and drugs. As the severity of pancytopenia and its underlying etiology determine the management and prognosis, identifying the correct etiology in a given case is crucial and helps in implementing timely and appropriate treatment. The objectives of this study were to study the clinical profile and hematological parameters of pancytopenic adults and to identify different etiologies of pancytopenia. This observational study was conducted in the Medicine department of a tertiary care teaching hospital. MATERIALS AND METHODS: The study was conducted on 100 adult patients aged 18-65 years presenting with pancytopenia. All the participants were subjected to detailed clinical examination and relevant investigations including bone marrow (BM) examination. Categorical variables were presented in number and percentage (%). Qualitative variables were correlated using the Chi-square test. A P =0.05 was considered statistically significant. RESULTS: A female preponderance was observed, and the majority of patients were aged between 18 and 40 years. The most common clinical features were generalized weakness, fever, and pallor. Seventy-four percent of patients were vegetarians; 58% had vitamin B12 deficiency, 25% had folic acid deficiency and 19% had a deficiency of both. The most common cause of pancytopenia was megaloblastic anemia (MA) (37%), followed by dimorphic anemia (DA) (26%), aplastic anemia (AA) (20%), and hematological malignancies (11%). CONCLUSION: MA, DA, and AA are the most prevalent etiologies of pancytopenia. BM examination is of utmost importance in the definitive diagnosis of pancytopenia and is useful in initiating timely treatment as a significant number of causes of pancytopenia are potentially curable.

Clinical outcome and computer tomography based tunnel placement evaluation following arthroscopic anteromedial portal anterior cruciate ligament reconstruction in non-athletic population.

BACKGROUND: The morphology of distal femur and proximal tibia varies between different ethnicities, and it can affect the tunnel dimensions and positions while doing ACL reconstruction which may affect the clinical outcome. There is limited data on the clinical outcome and CT based tunnel placement evaluation in femur and tibia of Indian nonathletic population. METHODS: Thirty non-athletic patients with mean age of 25.50±6.9 years and ACL rupture who underwent single bundle hamstring autograft arthroscopic ACL reconstruction by anteromedial portal were included in the study. Their preoperative IKDC Score, Lysholm-Tegner score, Tegner activity level were calculated and knee stability was assessed clinically using anterior drawer test, Lachman test and pivot shift test. The CT scan of the operated knee was done once the complete extension of the knee was achieved. Using the multimodality workstation available at the department of radio-diagnosis the tunnel parameters of femoral and tibial tunnel was calculated. After 6 months the patients were reassessed for clinical and radiological outcome. The postoperative outcome was compared with preoperative outcome. RESULTS: There was a significant difference in preoperative and postoperative score, the difference in IKDC score was 15.08 points, improvement of 14.65 points was seen in Lysholm-Tegner score and there was marked improvement in Tegner activity level. Tests for knee stability were normal in >90% of patients postoperatively. The CT evaluation showed that the femoral tunnels were positioned at 28.45%±3.69% (20.16%-38.35%) along the deep-shallow axis and 25.81%±3.819% (20.69%-37.35%), the mean tunnel obliquity compared to the femoral shaft axis were 47.34°±5.427° (37.68°-58.16°) in the coronal plane and 47.93°±7.023° (35.11°-63.95°), the mean tunnel length was 3.38 cm±0.331 cm (2.79 cm-4.18 cm). The tibial tunnel were positioned at 45.63%±5.832% (32.23%-58.23%) along the anterior-posterior axis and 47.70%±2.26% (42.40%-51.96%) along the medio-lateral axis. The tibial tunnel length was found to be 3.89 cm±0.519 cm (3.05 cm-5.06 cm). CONCLUSION: This study helps to ascertain that the ACL reconstruction via anteromedial portal technique using femoral offset zig followed by postoperative home-based rehabilitation technique gives favorable clinical outcomes in Indian non-athletic patients. All patients had improvement in stability of knee after the surgery. The position of femoral tunnels was anatomical but in comparison to Caucasian patients its placement was deeper and higher. Hence, we conclude that the anteromedial portal technique of ACL reconstruction provides favorable clinical outcome and adequate anatomical tunnel placement in Indian non athletic patients.

Evaluation of Hearing Loss in Congenital Hypothyroid Children at a Tertiary Care Hospital in Central India.

Hearing loss has long been associated with congenital hypothyroidism and, if not noticed and treated early, may result in delayed language acquisition and difficulties in comprehension. In light of the implications of congenital hypothyroidism and its associated hearing loss, we decided to conduct this study. The aim of this study was to identify the prevalence of hearing loss in congenital hypothyroidism and its relation to the severity of the disease and age of initiation of treatment. This study was conducted from July 2016 to June 2021 at a tertiary care hospital in Bhopal. The hearing status of congenital hypothyroid children and matched controls was assessed by pure tone audiometry or free field audiometry and, in selected cases, with brainstem evoked response audiometry. Eight children (25%) with congenital hypothyroidism had hearing loss, compared to one (3.12%) in the control group (p < 0.05). No statistically significant difference has been found in the gender, mean age of diagnosis, mean age of initiation of levothyroxine treatment, mean screening FT4 levels, and mean screening TSH levels between congenital hypothyroid children with and without hearing loss. Due to the high prevalence of hearing loss in congenital hypothyroidism and its impact on language and cognitive development, it is critical to create awareness among healthcare professionals that children diagnosed with congenital hypothyroidism must undergo audiological evaluation at the time of diagnosis and periodically thereafter. Alternatively, children with unexplained hearing loss must be screened for congenital hypothyroidism.

Osteochondroma of the talus: three varying cases.

Osteochondroma of the talus is a rare entity that can cause pain, swelling, restriction of movements, synovitis and tarsal tunnel syndrome (TTS). We present three such cases with varying presentation. Case 1 presented with synovitis of the ankle along with a bifocal origin of the talar osteochondroma. Case 2 presented with TTS as a result of compression of the posterior tibial nerve. Case 3 presented with deformity of the foot. In all the three cases, the mass was excised en bloc and histologically proven to be osteochondroma. In case 3, the ankle joint was reconstructed with plate, bone graft and arthrodesis of the inferior tibiofibular joint. All the three cases had good clinical outcomes.

Clinical outcomes and hemodynamic performance of Dafodil™ aortic and mitral pericardial bioprosthesis: 1-year results from Dafodil-1 first-in-human trial.

BACKGROUND: Bioprosthesis has been increasingly implanted for the treatment of transvalvular disease across the world. A new Dafodil™ pericardial bioprosthesis (Meril Life Sciences Pvt. Ltd., India) recently approved by Conformité Européenne (CE) is a tri-leaflet, stented, bovine valve. The purpose of Dafodil-1 first-in-human trial was to evaluate clinical safety and performance (including hemodynamic parameters) of the Dafodil pericardial bioprosthesis in patients who underwent aortic or mitral valve replacement. METHODS: This prospective, multicenter clinical trial enrolled 60 patients (Aortic: 30 patients; Mitral: 30 patients) from seven sites across India. Safety endpoints were early (≤30 days) and late (> 30 days) mortality and valve-related morbidity. The performance endpoints were hemodynamic performance, improvement in NYHA functional class, and change in the quality of life using SF-12v1 health survey. RESULTS: From July 2017 to July 2018, 60 patients underwent implantation of the Dafodil pericardial bioprosthesis. Post-operatively, NYHA functional class significantly improved in all the patients (Aortic: 90% NYHA class-I and 10% NYHA class-II; Mitral: 96.55% NYHA class-I and 3.45% NYHA class-II; P < 0.001). There was no death in aortic valve replacement patients till 12-month. In mitral valve replacement patients, early mortalities occurred in three patients, and late mortality occurred in one patient; none of these were valve-related. Freedom from all-cause mortality reported was 93.33% at 12-month. Mean aortic pressure gradient decreased from 52.71 ± 24.47 mmHg [with 0.89 ± 0.70 cm2 effective orifice area (EOA)] pre-operatively to 14.49 ± 6.58 mmHg (EOA: 1.85 ± 0.27 cm2) at 12-month. Overall, the mitral mean pressure gradient and EOA were 4.41 ± 1.69 mmHg and 2.67 ± 0.48 cm2, respectively, at 12-month. Significant improvement (P < 0.05) in the patients' quality of life was reported at all follow-ups. CONCLUSIONS: The clinical safety and performance of the Dafodil pericardial bioprosthesis were favourable at 12-month. Moreover, a study with a larger patient population and longer follow-up is warranted to further assess the device. TRIAL REGISTRATION: Dafodil-1 trial has been prospectively registered on 10/07/2017 under Clinical Trial Registry-India (http://www.ctri.nic.in). (Registration number: CTRI/2017/07/009008).

Extended Curettage and Fibular Grafting in Enchondroma of the Acromion.

We report the case of a six-year-old male child with progressive pain and swelling of the right shoulder for six months. On examination, there was a 7x7 cm globular, tender swelling with firm consistency over the posterolateral corner of the right shoulder. Radiographs showed an expansile lytic lesion in the acromion process of the scapula. Biopsy showed lobules of hypocellular cartilage separated by fibroconnective stroma suggestive of an enchondroma. Extended curettage and fibular bone grafting of the lesion was done. At one-year follow-up, the patient was symptom-free and had full, painless shoulder range of motion. To the best of our knowledge, there is no published record of an enchondroma of the acromion.

Exosomes secreted by prostate cancer cells under hypoxia promote matrix metalloproteinases activity at pre-metastatic niches.

Approximately, 30 000 men die from prostate cancer (PCa) every year in the United States, mainly due to the metastasis. Thus, the key events associated with PCa metastasis are under rigorous investigation, with recent studies showing that preparation of pre-metastatic niches (PMN) in distant organs is an important step. However, the molecular basis for PMN preparation is still unclear. Hypoxia in primary tumors promotes aggressiveness; however, its precise role in metastasis is not clear. We recently reported that exosomes secreted by PCa cells under hypoxia promote stemness and invasiveness in naïve PCa cells; however, whether these extracellular vesicles also influence PMN remains unknown. In the present study, we isolated exosomes from human PCa PC3 cells under normoxic (21% O2 , exosomes secreted under normoxic condition [ExoNormoxic ]) and hypoxic (1% O2 , exosomes secreted under hypoxic condition [ExoHypoxic ]) conditions, and characterized their effect (10 µg exosomes, intraperitoneal (IP) treatment every 48 hours for 4 weeks) on key biomarkers associated with PMN in nude mice. Whole animal fluorescence imaging showed that ExoHypoxic treatment promotes matrix metalloproteinases (MMPs) activity in several putative metastatic sites. Histological studies confirmed that ExoHypoxic treatment enhanced the level of MMP2, MMP9, and extracellular matrix proteins (fibronectin and collagen) as well as increased the number of CD11b+ cells at selective PMN sites. Furthermore, proteomic profiling of exosomes by liquid chromatography/mass spectrometry identified cargo proteins in ExoNormoxic and ExoHypoxic as well as distinct canonical pathways targeted by them. These results suggest that exosomes secreted by PCa cells under hypoxia plausibly remodel distant PMN, and thus, could be a potential target to control metastatic PCa.

Use of Peripheral Nerve Blocks in Perioperative Management of Cases with Hypertrophic Cardiomyopathy Undergoing Lower Limb Orthopedic Surgeries.

Hypertrophic obstructive cardiomyopathy is a type of hypertrophic cardiomyopathy (HCM) that involves the left ventricular outflow tract obstruction. Most important parameters are preload, afterload, and ventricular contractility that are prone to fluctuations in HOCM patients in the perioperative period due to the surgical procedure, anesthetic agents and changes in intravascular volume. These lead to increased chances of arrhythmias and myocardial ischemia and can pose significant morbidity and mortality in HCM patients perioperatively. Here, we report three challenging cases of HCM with comorbidities who underwent successful operative management of lower limb fractures using regional nerve blocks. Although general anaesthesia is usually preferred in cases of HCM, this was not the preferred choice in these cases due to the asthmatic status, extremes of age, and also associated comorbidities such as chronic kidney disease Stage IV on maintenance hemodialysis. We selected Ultrasonography and peripheral nerve stimulator (PNS) guided regional nerve blocks including lumbar plexus and parasacral approach of sciatic nerve block in the first two patients and fascia iliaca compartment block with parasacral sciatic nerve block in the third case to successfully manage the patients perioperatively. Postoperative pain management was satisfactory. All the patients were discharged in a hemodynamically stable condition with advice for follow-up.

Conventional Tracheostomy Versus Percutaneous Tracheostomy: A Retrospective Study.

Objectives Emergency Tracheostomy is a life saving surgical procedure. With the advent of newer instruments and equipments in the critical care units, there is marked improvement in the quality of care of the critically ill patients and such patients are able to survive for a longer period. Elective tracheostomy is being done in those patients who needs positive pressure ventilation, for a longer duration. Objectives of our study are to compare conventional tracheostomy (CT) to percutaneous tracheostomy (PcT) and to identify the strategy with the lowest frequency of potentially life threatening events. Study Design Retrospective comparative study. Patients Included 30 patients who met inclusion criteria. Study Settings Tertiary care centre (medical college). Results 15 patients underwent CT and 15 underwent PcT. Blood loss, mean operation time and complications were compared. Blood loss and operation time was lesser in CT compared to PcT. There were no reported complications in both the techniques. Conclusion In our study CT took lesser time with lesser blood loss and without any complications. But statistically, this difference was not significant. Thus person with refined skill in the technique is of utmost importance in deciding the choice of a technique.

Microscopic Versus Endoscopic Myringoplasty: A comparative study.

To compare the results of myringoplasty by using operating microscope (postaural) with that of myringoplasty by using endoscope (permeatal). Our study was conducted in Department of ENT of in Chirayu Medical College and Hospital. Total 60 patients of age group 18-60 were taken for study having chronic otitis media or trauma with central perforation. Patients were randomly selected microscopic or endoscopic myringoplasty. 30 patients for Microscopic Myringoplasty and 30 patients for endoscopic Myringoplasty were selected. Out of total 60 patients 35 were females and the 25 were males, 27 were in the age group 15-30 and 23 were in age group 31-45 and only 10 in the age group of 46-60. 18-30 age group cohort was predominant. The average time taken for endoscopic myringoplasty was 65.5 ± 3.45 min and for microscopic myringoplasty 85.7 ± 3.42 min. 26 were having Large central perforation (LCP), of which 13 underwent microscopic and 13 underwent endoscopic myringoplasty. The graft was taken up in situ in 22 patients while 4 patients had small residual central perforation. Out of these four residual perforations 3 were done by endoscopy and 1 by microscopy. 19 (of 60) were having Medium size central perforation (MCP), 10 were operated with endoscope and 9 with microscope. 15 (60) were having Small central perforation (SCP), 7 done with endoscope and 8 with microscope. In all patient graft take up was well. Large central perforation present in maximum patient and had least graft uptake as compared to MCP and SCP. Out of the 30 these endoscopic myringoplasty 27 patients had good graft uptake and 3 had small central residual perforation after 3 months. Out of the 30 microscopic myringoplasty 29 patients had good graft uptake and 1 patient had small central residual perforation after 3 months. In our study pre operative and post operative Air Bone Gaps (ABGs) were 22.05 ± 2.04 and 9.05 ± 1.36 db respectively in endoscopic myringoplasty and 21.81 ± 1.85 and 8.55 ± 1.44 db respectively in microscopic myringoplasty. Microscopic myringoplasty has greater success rate in larger perforations that is LCP and MCP and equal result in SCP. Advantage of microscope is depth perception and both hands are free for procedure which is limitation of endoscopic myringoplasty (need to use endoscope holder). Advantage of endoscopic permeatal myringoplasty is superior visualization, least tissue trauma and better cosmetic outcome, almost equal graft uptake and hearing outcome with less operative time. Endoscope system is portable, so convenient for surgeon where microscope is not available. Also endoscope is a less costly armamentarium. Our study shows better result in myringoplasty can be achieved if both methods of surgery are used in combination.