VATS thoracic duct clipping in post-CABG with chylothorax.

Post-coronary artery bypass graft (CABG) surgery, chylothorax is a rare, but a serious, complication. We report a case of 49-year-old female who underwent CABG, and developed pleural effusion on post-operative day 2 which was milky in nature. Chylothorax was confirmed based on the biochemical analysis of the pleural fluid. As the medical line of management failed, video-assisted thoracoscopic surgery (VATS) was done and thoracic duct clipped on the right side. Close to the proximal portion of the left internal thoracic artery, disrupted tributaries of thoracic duct were noted and clipped. Rarity of the case and management is highlighted.

Orthodontic-surgical management of severe skeletal class iii malocclusion: A case report.

Skeletal Class III malocclusion possess a difficult challenge to treat for clinicians. They are multifactorial and include genetic and environmental factors. Early intervention of Class III needs orthopedic correction, whereas, in adults, orthodontic camouflage can be done to treat mild cases while severe skeletal discrepancies demand orthognathic surgery along with orthodontic therapy. In this case report, a case of mandibular prognathism with Bilateral Sagittal Split Osteotomy (BSSO) setback was presented.

Assessment of gingival biotype in different facial patterns: A cross-sectional study.

Objective: The aim of the present study is to evaluate the relationship of gingival biotype in different malocclusions. Methods: A total of 157 periodontally healthy subjects (88 males and 69 females) were enrolled in this cross-sectional study. The study participants were divided into three groups of skeletal class I, class II, and class III. The probe transparency method was used to determine the quality and gingival tissue into thick and thin biotype. Results: There was significant difference in gingival biotype among different skeletal malocclusion with high prevalence of thin gingival biotype in class I subjects and more prevalence of thick biotype in class II and class III individuals (P-value: 0.022). Pairwise comparison of gingival biotype in class I versus class II showed significant difference (P-value: 0.032); however in class I versus class III and class II versus class III, the test result was nonsignificant. The overall frequency of thin gingival biotype was significantly less in female subjects with respect to males (P-value: 0.025). Conclusion: A significant relationship is present between skeletal malocclusion and quality of gingival biotype. The prevalence of thick gingival biotype is found more in females as compared to male individuals. The thin gingival biotype is more commonly seen in skeletal class I than class II and class III.

Multiple subtypes of coxsackievirus group B can cause congenital heart disease.

BACKGROUND: Different serotypes of coxsackievirus B (CVB), which is the most common cause of viral myocarditis, target cardiomyocytes through Coxsackie and Adenovirus Receptor and Decay-Accelerating Factor. Both receptors are expressed in the fetal heart. We hypothesized that infection with different serotypes of CVB during early pregnancy plays a role in pathogenesis of congenital heart defect (CHD). METHODS: In this study, we use a murine model to infect with CVB1, CVB4, and combination of CVB3 + CVB4 during a critical period in gestation. We examined offspring of pregnant mice for fetal death and heart defects following viral infection. RESULT: Fetuses from uninfected control dams showed normal heart development, while maternal CVB infection precipitates CHD: majorly ventricular septal defects (VSD) and non-compaction of ventricular myocardium (NC), with some infrequent cases of double outlet right ventricle, left ventricle wall rupture, right ventricle hypertrophy, and thickened/dysplastic semilunar valves. Infection of pregnant dams with CVB1 leads to 44% VSD and 41.2% NC cases, while with CVB4 leads to 31.7% VSD and 13.3% NC cases. Co-infection with CVB3 + CVB4 increases fetal pathology to 51.3% VSD and 41% NC cases. Infection can also result in fetal death, with higher incidences with CVB3 + CVB4 with 46.2% cases, compared to 33.3% by CVB1 and 21.7% by CVB4. Male fetuses were more susceptible to all phenotypes. CONCLUSION: Our report shows that prenatal CVB infections can lead to pathogenesis of certain heart defects in mouse model, particularly exacerbated with co-infections. This data confirms a link between prenatal CVB infection and CHD development and highlights it is not unique to just one serotype of CVB.

Comparative evaluation of high-flow nasal cannula oxygenation vs nasal intermittent ventilation in postoperative paediatric patients operated for acyanotic congenital cardiac defects.

Background: This study aimed to compare high-flow nasal cannula (HFNC) oxygenation vs nasal intermittent ventilation (NIV) oxygenation for respiratory care after extubation in postoperative paediatric cardiac patients. Methods: This study was a randomised controlled trial. One hundred twenty-one paediatric patients with acyanotic congenital heart disease undergoing corrective cardiac surgery on cardiopulmonary bypass were included in the study. Patients were randomised to receive either HFNC (AIRVO) or NIV (RAM Cannula) postextubation. Arterial blood gas was analysed at different time points perioperatively. Results: Patients in both the groups were matched with respect to diagnosis and demographic profiles. Baseline hemodynamic and respiratory parameters were also similar in both the groups. Patients in HFNC/AIRVO group did not show improved carbon dioxide (CO2) washout but showed improved pO2 and pO2/FiO2 ratio immediate postextubation. Reintubation rate and other intensive care unit (ICU) complications were similar in both the groups. Conclusion: Postcardiopulmonary bypass respiratory complications in paediatric patients with congenital acyanotic heart disease can be minimised with newer oxygen therapy devices such as AIRVO (HFNC) or RAM cannula (NIV). In comparison between these two, AIRVO did not show improved CO2 washout over RAM cannula; however, it did provide better oxygenation as measured by pO2 in arterial blood and pO2/FiO2 ratio immediate postextubation. Also, long-term results such as duration of mechanical ventilation and ICU stay were not affected by the choice of device.

Fast-tracking with continuous thoracic epidural analgesia in paediatric congenital heart surgeries: an institutional experience.

Objective: To assess the success of fast-tracking in infants and small children undergoing paediatric cardiac surgery under general anaesthesia with continuous thoracic epidural analgesia (TEA). Methodology: It is a retrospective study at a tertiary care hospital. A total of 461 children, aged 12 years or younger, were operated for congenital heart disease over a 2-year period from January 2018 to December 2019. After the exclusion of 71 patients, data from the remaining 390 patients were analysed. Measurements and main results: The median time for extubation after intensive care unit admission was 2 h and 25 min (0-20 h). Extubation within 6 h was achieved in 215 patients (~ 55%). Patients in the early extubation group had significantly shorter hospital stay (4.1 ± 2.3 vs 6.9 ± 3.9 days, p = 0.004) than patients in the ventilated group. Reintubation was required in 27 (6.9%) patients. Thirteen patients died postoperatively on ventilator. Patients with low nadir temperature intraoperatively and cardiopulmonary bypass time > 90 min significantly predicted failure in fast-tracking with an odds ratio (OR) = 1.27; CI: 1.18-1.38 and OR = 2.3; CI: 1.8-2.96 respectively. The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery mortality score, younger age, Down syndrome and high vasopressor inotropic score did not adversely affect early extubation, contrary to contemporary concerns. Conclusions: A multimodal approach for perioperative pain relief and sedation consisting of propofol and dexmedetomidine infusion along with TEA ensures early extubation in 59% of the cases undergoing paediatric cardiac surgery. Our data suggests that fast-tracking is feasible with safe and superior outcomes in a subset of appropriate patients undergoing paediatric cardiac surgery. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-022-01373-8.

Assessment of chin morphology in different skeletal dysplasia - A cross-sectional study.

Objective: The objective of the study is to evaluate the morphology of the symphyseal region of adult skeletal Class II and Class III malocclusion as compared with Skeletal Class I subjects. Materials and Methods: The symphyseal width and height were evaluated using data from 80 lateral cephalograms of the age range of 18 years to 25 years. Average growing Skeletal Class II (n = 30) and Class III (n = 20) subjects were used as a comparison group. Average growing normal occlusion samples (n = 30) were used as controls. Results: Alveolar height was similar in all groups. The width of the symphyseal region including basal width, the width of the cervical region of the lower central incisor at the cementoenamel junction, and symphysis width were found to be similar in all groups. There is no significant difference in gonial angle in both Class II and III groups as compared to control. Articular angle showed no significant difference. Mandibular incisor dentoalveolar height (L1-AH) was found to be significantly higher in the Class II group (P < 0.05). Conclusions: There are no definite morphological differences in the symphyseal region between average grower Class I, Class II, and Class III skeletal malocclusions except mandibular incisor dentoalveolar height (L1-AH) and incisor mandibular plane angle which is higher whereas ramus length and body length which is lesser in Class II group as compared with controls. Width of the cervical region of the lower central incisor at the cementoenamel junction (Id-Id') and incisor mandibular plane angle was lower than control in Class III subjects.

Comparative analysis of proficiencies of various textures and geometric features in breast mass classification using k-nearest neighbor.

This paper introduces a comparative analysis of the proficiencies of various textures and geometric features in the diagnosis of breast masses on mammograms. An improved machine learning-based framework was developed for this study. The proposed system was tested using 106 full field digital mammography images from the INbreast dataset, containing a total of 115 breast mass lesions. The proficiencies of individual and various combinations of computed textures and geometric features were investigated by evaluating their contributions towards attaining higher classification accuracies. Four state-of-the-art filter-based feature selection algorithms (Relief-F, Pearson correlation coefficient, neighborhood component analysis, and term variance) were employed to select the top 20 most discriminative features. The Relief-F algorithm outperformed other feature selection algorithms in terms of classification results by reporting 85.2% accuracy, 82.0% sensitivity, and 88.0% specificity. A set of nine most discriminative features were then selected, out of the earlier mentioned 20 features obtained using Relief-F, as a result of further simulations. The classification performances of six state-of-the-art machine learning classifiers, namely k-nearest neighbor (k-NN), support vector machine, decision tree, Naive Bayes, random forest, and ensemble tree, were investigated, and the obtained results revealed that the best classification results (accuracy = 90.4%, sensitivity = 92.0%, specificity = 88.0%) were obtained for the k-NN classifier with the number of neighbors having k = 5 and squared inverse distance weight. The key findings include the identification of the nine most discriminative features, that is, FD26 (Fourier Descriptor), Euler number, solidity, mean, FD14, FD13, periodicity, skewness, and contrast out of a pool of 125 texture and geometric features. The proposed results revealed that the selected nine features can be used for the classification of breast masses in mammograms.

Coxsackievirus B3 Infection Early in Pregnancy Induces Congenital Heart Defects Through Suppression of Fetal Cardiomyocyte Proliferation.

Background Coxsackievirus B (CVB) is the most common cause of viral myocarditis. It targets cardiomyocytes through coxsackie and adenovirus receptor, which is highly expressed in the fetal heart. We hypothesized CVB3 can precipitate congenital heart defects when fetal infection occurs during critical window of gestation. Methods and Results We infected C57Bl/6 pregnant mice with CVB3 during time points in early gestation (embryonic day [E] 5, E7, E9, and E11). We used different viral titers to examine possible dose-response relationship and assessed viral loads in various fetal organs. Provided viral exposure occurred between E7 and E9, we observed characteristic features of ventricular septal defect (33.6%), abnormal myocardial architecture resembling noncompaction (23.5%), and double-outlet right ventricle (4.4%) among 209 viable fetuses examined. We observed a direct relationship between viral titers and severity of congenital heart defects, with apparent predominance among female fetuses. Infected dams remained healthy; we did not observe any maternal heart or placental injury suggestive of direct viral effects on developing heart as likely cause of congenital heart defects. We examined signaling pathways in CVB3-exposed hearts using RNA sequencing, Kyoto Encyclopedia of Genes and Genomes enrichment analysis, and immunohistochemistry. Signaling proteins of the Hippo, tight junction, transforming growth factor-ß1, and extracellular matrix proteins were the most highly enriched in CVB3-infected fetuses with ventricular septal defects. Moreover, cardiomyocyte proliferation was 50% lower in fetuses with ventricular septal defects compared with uninfected controls. Conclusions We conclude prenatal CVB3 infection induces congenital heart defects. Alterations in myocardial proliferate capacity and consequent changes in cardiac architecture and trabeculation appear to account for most of observed phenotypes.

Role of coxsackie-adenovirus receptor in cardiac development and pathogenesis of congenital heart disease.

The coxsackie-adenovirus receptor (CAR) is a cell surface transmembrane protein originally recognized for its role as a binding site for coxsackie- and adeno-viruses. As such, it is believed to play an important role in pathogenesis of myocarditis. Other studies have suggested that CAR also plays an important role in embryonic development, which is not surprising given the strong expression of the receptor in heart, brain, liver, pancreas, kidney, small intestine, and various epithelia during development. A number of studies have looked at downregulation and upregulation of CAR and have confirmed the central role of CAR during critical periods of development. These studies all demonstrated embryonic lethality with variable phenotypes: electrophysiological abnormalities, cardiac structural deformations, and extracardiac abnormalities, such as lymphatic malformations. The purpose of this review is to summarize the existing literature about CAR and formulate some questions for future studies, with an emphasis on the role of CAR during embryonic heart development.

An evolving anesthetic protocol fosters fast tracking in pediatric cardiac surgery: A comparison of two anesthetic techniques.

BACKGROUND: The past two decades have seen rapid development of new surgical techniques for repair as well as palliation of complex congenital heart diseases. For a better patient outcome, minimal postoperative ventilation remains one of the most important endpoints of an effectual perioperative management. AIMS AND OBJECTIVES: The aim of this randomized open-label trial was to compare postoperative extubation time and intensive care unit (ICU) stay when two different anesthetic regimens, comprising of induction with ketamine and low-dose fentanyl versus high-dose fentanyl, are used, in pediatric patients undergoing corrective/palliative surgery. MATERIALS AND METHODS: Patients with congenital cardiac defects, under 14 years of age undergoing cardiac surgery under cardiopulmonary bypass (CPB) and epidural analgesia, were enrolled into two groups - Group K (ketamine with low-dose fentanyl) and Group F (high-dose fentanyl) - over a period of 10 months, starting from January 2018. The effect of both these drugs on postoperative extubation time and ICU stay was compared using Mann-Whitney U-test. RESULTS: A total of 70 patients were assessed with equal distribution in both the groups. In Group K, 32 of 35 patients were extubated in the operation room, whereas extubation time in Group F was18.1 ± 11 h. Total ICU stay in Group K and Group F was 45.2 ± 30.1 and 60.1 ± 24.5 h, respectively (P = 0.02). Systolic blood pressure was significantly higher in Group K. CONCLUSION: Ketamine along with low-dose fentanyl, when used for anesthetic induction, in comparison to high-dose fentanyl, reduces postoperative extubation time and ICU stay, in pediatric patients undergoing corrective/palliative surgery under CPB and epidural analgesia for congenital cardiac defects.

Ivabradine as an Adjunct for Refractory Junctional Ectopic Tachycardia Following Pediatric Cardiac Surgery: A Preliminary Study.

OBJECTIVES: Junctional ectopic tachycardia (JET) is a relatively common narrow complex rhythm typically characterized by atrioventricular dissociation or retrograde atrial conduction in a 1:1 pattern. Junctional ectopic tachycardia can be a life-threatening disorder, causing severe hemodynamic compromise and increased morbidity and mortality. The treatment of refractory JET can be very difficult, even with multimodal therapeutic interventions. The purpose of this study was to assess the role of ivabradine in cases of JET refractory to amiodarone and esmolol. METHODS: A total of 480 congenital heart surgeries were carried out at our center in 2017. Twenty (4.16%) patients had postoperative JET. Among these, five infants, aged 7 to 12 months (median: 8 months), had refractory JET. These patients (three tetralogy of Fallot, one ventricular septal defect, one complete atrioventricular septal defect) were treated with oral ivabradine in the dose range of 0.1 to 0.2 mg/kg/12 h as an adjunct to amiodarone. RESULTS: All five patients achieved rate reduction and eventual conversion to sinus rhythm. Mean duration to achieve heart rate of <140 bpm after initiation of ivabradine therapy was 16.8 hours (±7.2 hours), while mean duration to achieve sinus rhythm was 31.6 hours (±13.6 hours). No patient had any recurrence of JET. No patient exhibited any hemodynamic derangement nor side effects attributable to oral ivabradine. CONCLUSION: Oral ivabradine has the potential to be used as an adjunct to amiodarone in the treatment of JET in infants after surgery for congenital heart disease.

Cardiac Calcified Amorphous Tumor in a Newborn.

Calcified amorphous tumors (CATs) of the heart are rare, nonneoplastic, intracavitary lesions, previously thought of as pseudotumors, hamartomas, or calcified thrombi, only reported in few adults in the available literature. This report describes a case of a pedunculated oscillating CAT arising from the left atrial appendage that prolapses through the mitral valve and causes severe mitral regurgitation in a newborn. This is the only case of cardiac CAT described in a neonate.

Ivabradine for junctional ectopic tachycardia in post congenital heart surgery.

We report two cases of malignant junctional ectopic tachycardia (JET), in infants following congenital heart surgery. After the failure of conventional therapy the arrhythmia was controlled by oral Ivabradine, a drug which is routinely used to lower heart rate in angina and heart failure in adult practice.

Extradigital glomus tumor: a rare etiology for wrist soft tissue mass.

Glomus tumors are rare benign hamartomas arising from the neuromyoarterial glomus body, a highly specialized arteriovenous anastomosis responsible for thermoregulation. Although classically associated with a subungual location, less common extradigital glomus tumors can present a diagnostic challenge because of their rarity and nonspecific presentation. This case report adds to the literature of proven extradigital glomus tumors with documented pathologic and magnetic resonance imaging characteristics and describes their place in the differential for soft tissue mass of the wrist. Occasionally, a combination of imaging findings and clinical history as described may help suggest the diagnosis prospectively.

Unusual Case of Left Bronchial Compression by Aneurysmal Pulmonary Arteries in a Child With Atrial Septal Defect.

We report an uncommon case of large ostium secundum atrial septal defect (ASD) with severe pulmonary arterial hypertension, with associated aneurysmal dilatation of the pulmonary arteries (PAs) leading to compression of the left main bronchus and collapse of the entire left lung in a 15-month-old female child. The patient was managed by surgical closure of the ASD, translocation of the right PA anterior to the aorta with PA aneurysmorrhaphy. Left bronchial compression was relieved with complete lung expansion on the third postoperative day.

Does intravenous sildenafil clinically ameliorate pulmonary hypertension during perioperative management of congenital heart diseases in children? - a prospective randomized study.

BACKGROUND: Pulmonary hypertension (PHT), if present, can be a significant cause of increased morbidity and mortality in children undergoing surgery for congenital heart diseases (CHD). Various techniques and drugs have been used perioperatively to alleviate the effects of PHT. Intravenous (IV) sildenafil is one of them and not many studies validate its clinical use. AIMS AND OBJECTIVES: To compare perioperative PaO 2 - FiO 2 ratio peak filling rate (PFR), systolic pulmonary artery pressure (PAP) - systolic aortic pressure (AoP) ratio, extubation time, and Intensive Care Unit (ICU) stay between two groups of children when one of them is administered IV sildenafil perioperatively during surgery for CHDs. MATERIALS AND METHODS: Patients with ventricular septal defects and proven PHT, <14 years of age, all American Society of Anesthesiologists physical status III, undergoing cardiac surgery, were enrolled into two groups - Group S (IV sildenafil) and Group C (control) - over a period of 14 months, starting from October 2013. Independent t-test and Mann-Whitney U-test were used to compare the various parameters between two groups. RESULTS: PFR was higher throughout, perioperatively, in Group S. PAP/AoP was 0.3 and 0.4 in Group S and Group C, respectively. In Group S, mean group extubation time was 7 ± 7.34 h, whereas in Group C it was 22.1 ± 10.6. Postoperative ICU stay in Group S and Group C were 42.3 ± 8.8 h and 64.4 ± 15.9 h, respectively. CONCLUSION: IV sildenafil, when used perioperatively, in children with CHD having PHT undergoing corrective surgery, improves not only PaO 2 - FiO 2 ratio and PAP - AoP ratio but also reduces extubation time and postoperative ICU stay.

An overview of surgery-first approach: Recent advances in orthognathic surgery.

The disadvantages of having orthodontic interventions both before and after orthognathic surgery include a long treatment time of 7-47 months and temporary worsening of facial appearance. Nowadays, the concept of surgery-first, followed by orthodontic treatment is applied to orthognathic surgery cases in different orthodontic centers in the world. This concept and technique is called "surgery-first-orthognathic-approach" or "surgery-first approach" (SFA) rigid fixation (skeletal anchorage system) of the bony segments and regional acceleratory phenomenon were keys to broad implementation of the SFA. This article is intended to provide an overview of SFA including indications, general and specific guidelines, different protocol variations, success rate and potential problems.

CFS-SMO based classification of breast density using multiple texture models.

It is highly acknowledged in the medical profession that density of breast tissue is a major cause for the growth of breast cancer. Increased breast density was found to be linked with an increased risk of breast cancer growth, as high density makes it difficult for radiologists to see an abnormality which leads to false negative results. Therefore, there is need for the development of highly efficient techniques for breast tissue classification based on density. This paper presents a hybrid scheme for classification of fatty and dense mammograms using correlation-based feature selection (CFS) and sequential minimal optimization (SMO). In this work, texture analysis is done on a region of interest selected from the mammogram. Various texture models have been used to quantify the texture of parenchymal patterns of breast. To reduce the dimensionality and to identify the features which differentiate between breast tissue densities, CFS is used. Finally, classification is performed using SMO. The performance is evaluated using 322 images of mini-MIAS database. Highest accuracy of 96.46% is obtained for two-class problem (fatty and dense) using proposed approach. Performance of selected features by CFS is also evaluated by Naïve Bayes, Multilayer Perceptron, RBF Network, J48 and kNN classifier. The proposed CFS-SMO method outperforms all other classifiers giving a sensitivity of 100%. This makes it suitable to be taken as a second opinion in classifying breast tissue density.