An unusual case of recurrence of papillary fibroelastoma: a case report.

Background: Papillary fibroelastomas (PFEs) are uncommon primary cardiac tumours and their recurrence after resection is rare. Case summary: A 32-year-old woman, who was evaluated for recurrent embolic stroke, was found to have lesions on mitral leaflets on echocardiography. The mitral leaflets were otherwise normal with no clinical or laboratory evidence of infective endocarditis. Transthoracic, as well as transesophageal echocardiography, revealed masses on mitral leaflets, which remained almost the same over 3 years. A tentative diagnosis of PFE on the mitral valve was made. She had undergone intra-cardiac excision of mitral valve mass along with ring annuloplasty in February 2020. In November 2021, during her regular follow-up visit, transthoracic echocardiography revealed the recurrence of the masses on mitral leaflets with severe mitral regurgitation. She underwent mitral valve replacement and excision of tumour masses. Histopathological examination confirmed the diagnosis of recurrent PFE. Discussion: Recurrence of PFEs is rare. We report a rare case of histologically proven recurrence of PFE of the mitral valve. This highlights the importance of routine post-operative echocardiographic follow-up in patients with PFE.

Consensus and development of document for management of stabilized acute decompensated heart failure with reduced ejection fraction in India.

AIM: Ensuring adherence to guideline-directed medical therapy (GDMT) is an effective strategy to reduce mortality and readmission rates for heart failure (HF). Use of a checklist is one of the best tools to ensure GDMT. The aim was to develop a consensus document with a robust checklist for stabilized acute decompensated HF patients with reduced ejection fraction. While there are multiple checklists available, an India-specific checklist that is easy to fill and validated by regional and national subject matter experts (SMEs) is required. METHODOLOGY: A total of 25 Cardiology SMEs who consented to participate from India discussed data from literature, current evidence, international guidelines and practical experiences in two national and four regional meetings. RESULTS: Recommendations included HF management, treatment optimization, and patient education. The checklist should be filled at four time points- (a) transition from intensive care unit to ward, (b) at discharge, (c) 1st follow-up and (d) subsequent follow-up. The checklist is the responsibility of the consultant or the treating physician which can be delegated to a junior resident or a trained HF nurse. CONCLUSION: This checklist will ensure GDMT, simplify transition of care and can be used by all doctors across India. Institutions, associations, and societies should recommend this checklist for adaptability in public and private hospital. Hospital administrations should roll out policy for adoption of checklist by ensuring patient files have the checklist at the time of discharge and encourage practice of filling it diligently during follow-up visits.

Staged Anterior Release and Posterior Instrumentation in Correction of Severe Rigid Scoliosis (Cobb Angle >100 Degrees).

PURPOSE: Severe rigid curves present a big challenge to the treating spine surgeon. We evaluated the outcome of staged anterior release and posterior instrumentation for rigid scoliosis. METHODS: Twenty-one patients with an average age of 14.4 years (range 11-17) having a rounded severe rigid scoliosis (Cobb angle >100 degrees) underwent surgical correction. Six patients had congenital scoliosis, 13 idiopathic scoliosis, and 2 syndromic. All patients underwent anterior release in Stage I with one or more Ponte osteotomies and in Stage II with all pedicle screw instrumentation, and 13 of the patients underwent an asymmetric pedicle subtraction osteotomy at the apex. Patients were assessed for deformity correction, operative time, blood loss, and any complications. RESULTS: The preoperative Cobb angle of 116.6 degrees (range 101-124 degrees) improved to 74.0 degrees (range 54-86 degrees) after anterior release: 29.4% correction and the final postoperation Cobb angle after posterior instrumentation was 26.5 degrees (range 22-32 degrees), with final 76% correction. The average blood loss in anterior release was 585.95 mL (range 400-980 mL; % estimated blood volume = 19.5%), whereas the mean operative time was 223 minutes (165-315 minutes). One patient had prolonged chest drain and two, basal atelectasis following anterior release. The mean operative time for the posterior procedure was 340 minutes (range 280-420 minutes) and average blood loss was 2,066 mL (range 1,200-3,200 mL). The mean apical axial rotation of 56 degrees (range 26-79 degrees) improved to 28 degrees (range 9-42 degrees) (p < .05). There was loss of motor evoked potential signal in one and hook pullout, superficial infection, and local skin necrosis one case each. CONCLUSION: The staged approach to the management of severe, rigid scoliosis helps get an excellent correction. Anterior release loosens up the rigid apex and provides with nearly 30% correction so that the extent of the osteotomies in the second stage from the back is substantially reduced, allowing for a final good correction.

Early onset scoliosis with intraspinal anomalies: management with growing rod.

OBJECTIVE: To evaluate clinical and radiological outcomes of growing rod (GR) in the management of Early Onset Scoliosis (EOS) with intraspinal anomalies. BACKGROUND DATA: The effect of repeated distractions following GR, in the presence of intraspinal anomalies has not been studied. METHODS: During 2007-2012, 46 patients underwent fusionless surgery. Out of these 46 patients, 13 patients had one or more intraspinal anomalies. 11 patients had undergone prior neurosurgical procedure while 2 (filum terminale lipoma and syringomyelia) did not. A total of 88 procedures were conducted during the treatment period; 13 index surgeries, 74 distractions of GR and 1 unplanned surgery. RESULTS: The age at surgery was 6.8 ± 2.5 years (3.5-12 years). 11 patients had congenital scoliosis and 2 had idiopathic scoliosis. A total of 19 (41.30 %) intraspinal anomalies [Tethered Cord Syndrome (TCS) 08, Split Cord Malformation (SCM) 08, Syringomyelia 01, Meningomyelocele 01, Filum terminale Lipoma 01] were seen. The average lengthening procedures per patient were 5.7 (4-9) with distraction interval of 6.7 (6-7.25) months. Pre-operative Cobb angle was 78.50 ± 18.1 (54-114°) and improved to 53.10 ± 16.70 (36-84°) at final follow-up. A total of 15 complications related to implant (9), wound (2), anesthesia (2) and neurological (2) occurred in 7 patients. Among the two neurological complications, one patient sustained fall in the post-op period and reported to the emergency department with paraplegia and broken proximal screw. While other patient experienced MEP changes during index procedure. None of the patients had any neurological complications during repeated lengthening procedures. CONCLUSION: The most common cord anomalies associated with EOS in our study are TCS and SCM. Although presence of previous intraspinal anomaly does not seem to increase the incidence of neurological deficit, use of neuromonitoring is advisable for all index procedure and selected distractions. STUDY DESIGN: Level 4 (case series).

Enhanced energy transfer between Co-dopants Pyronin-Y and Thionine incorporated into modified polymethyl methacrylate with addition of ZnO nanoparticles.

Using a prism dye cell arrangement, the study investigated spectral energy transfer between co-dopants Pyronin-Y and Thionine incorporated into ethanol-modified polymethyl methacrylate. The spectral parameters of the absorption and fluorescence spectra of the donor and acceptor dyes in the so designed solid-state dye laser were calculated theoretically. Fluorescence lasing properties and slope efficiency of the solid-state dye laser were investigated both with and without addition of ZnO nanoparticles. The dye pair generally improved lasing efficiency and tunability in the range from 582 to 689 nm.

Back Pain in Children- How Sinister?

Incidence of back pain among children and adolescents is gradually increasing. Children undergo extensive diagnostic workup that ultimately results in a nonconfirmative diagnosis. A good history and clinical examination can, to a large extent help differentiate non-specific from organic causes of backache. Diagnostic workup may be initiated if symptoms are severe and/or persistant. The authors review some of the common causes of back pain in pediatric population, clinical presentations, and the relevant investigations along with their management.

Management of Tuberculous Infection of the Spine

Spinal tuberculosis accounts for nearly half of all cases of musculoskeletal tuberculosis. It is primarily a medical disease and treatment consists of a multidrug regimen for 9-12 months. Surgery is reserved for select cases of progressive deformity or where neurological deficit is not improved by anti-tubercular treatment. Technology refinements and improved surgical expertise have improved the operative treatment of spinal tuberculosis. The infected spine can be approached anteriorly or posteriorly, in a minimally invasive way. We review the various surgical techniques used in the management of spinal tuberculosis with focus on their indications and contraindications.

Single-cell genetic analysis reveals the composition of initiating clones and phylogenetic patterns of branching and parallel evolution in myeloma.

Although intratumor heterogeneity has been inferred in multiple myeloma (MM), little is known about its subclonal phylogeny. To describe such phylogenetic trees in a series of patients with MM, we perform whole-exome sequencing and single-cell genetic analysis. Our results demonstrate that at presentation myeloma is composed of two to six different major clones, which are related by linear and branching phylogenies. Remarkably, the earliest myeloma-initiating clones, some of which only had the initiating t(11;14), were still present at low frequencies at the time of diagnosis. For the first time in myeloma, we demonstrate parallel evolution whereby two independent clones activate the RAS/MAPK pathway through RAS mutations and give rise subsequently to distinct subclonal lineages. We also report the co-occurrence of RAS and interferon regulatory factor 4 (IRF4) p.K123R mutations in 4% of myeloma patients. Lastly, we describe the fluctuations of myeloma subclonal architecture in a patient analyzed at presentation and relapse and in NOD/SCID-IL2Rγ(null) xenografts, revealing clonal extinction and the emergence of new clones that acquire additional mutations. This study confirms that myeloma subclones exhibit different survival properties during treatment or mouse engraftment. We conclude that clonal diversity combined with varying selective pressures is the essential foundation for tumor progression and treatment resistance in myeloma.

Pulsed laser deposition and ferroelectric characterization of nanostructured perovskite lead zirconate titanate (52/48) thin films.

Perovskite lead zirconate titanate nanostructured (PZT) thin films with Zr/Ti ratio of 52/48 were deposited on Pt/TiO2/SiO2/Si(100) substrate using pulsed laser deposition method. A metal/ ferroelectric/metal (MFM) structure was used for ferroelectric property measurements, formed by depositing gold electrode on top of the film. A Nd:YAG UV laser having a wavelength of 355 nm and an energy fluence of -2.7 J/cm2 was used to deposit the film. The film was deposited on platinum (Pt) coated silicon substrate at the substrate temperature of 600 degrees C and the base vacuum of 10(-6) mbar. The scanning electron microscopy (SEM) images revealed well-crystallized films with a fine microstructure and an average grain size of - 50 nm. The ferroelectric properties of the film were studied and the results were discussed. The voltage dependent Polarization versus Electric field hysteresis measurements of PZT (52/48) pellet showed a well-defined hysteresis loop with a fairly high remnant polarization (P(r)) and low coercive field (E(c)).

Tropical endomyocardial fibrosis in India: a vanishing disease!

Tropical endomyocardial fibrosis in India was a common medical problem in the coastal districts of south India, especially the Kerala State. The clinical and autopsy studies have shown left and right ventricular apical fibrosis, with varying degree of atrioventricular valve regurgitation. Left ventricular endomyocardial fibrosis presents with severe pulmonary hypertension and right ventricular endomyocardial fibrosis presents very high systemic venous pressure and congestive cardiac failure. Surgical management improved the natural history of the disease to some extent. Various infectious and toxic factors were postulated regarding its aetiology. During the last few years, incidence of the disease has decreased considerably. The only explanation identified is the significant improvement in the living standards of the people with the corresponding decline in the childhood malnutrition, infections, worm infestation and associated eosinophilia.

Imaging of brown fat associated with adrenal pheochromocytoma.

The association of adrenal pheochromocytoma and brown fat has been described in the pathology literature and scantily in the radiology literature. We present a case of diffuse collection of brown fat in both perinephric spaces associated with left adrenal pheochromocytoma, and describe the computed tomography and magnetic resonance imaging findings.

Heparin induced thrombocytopenia management with bivalirudin.

We report a case of Heparin Induced Thrombocytopenia (HIT) following percutaneous coronary intervention. The case is unique in that thrombocytopenia occurred very early after heparin administration and responded well to a regime of bivalirudin-a direct thrombin inhibitor readily available in India. Heparin, Thrombocytopenia, Bivalirudin Acute HIT, occurring within few hours of heparin therapy have been reported in patients previously exposed to unfractionated heparin (UFH) or low molecular weight heparin (LMWH) 1. Prompt recognition of the condition and timely intervention with direct thrombin inhibitors, can result in salvaging patients from this potentially fatal complication.

Reno-protective effect of N-acetyl cysteine in patients with impaired renal function undergoing coronary angiography and interventions.

BACKGROUND: The increasingly frequent use of contrast enhanced imaging for diagnosis or interventions in patients with CAD has generated concern about avoidance of contrast induced nephropathy (CIN). Reactive oxygen species have been shown to cause CIN. OBJECTIVES: Angiographic contrasts worsen the renal function in patients with renal failure. We studied the reno-protective action of the antioxidant N-Acetyl cysteine (NAC) in patients undergoing coronary procedures. METHODS: Retrospective analysis of 51 patients with elevated serum creatinine levels (> or = 15mg%) was done, 24 of whom received NAC prior to the procedure(NAC group) and 27 who did not (Non NAC group). NAC was administered in a dose of 400 mg twice daily for four doses starting on the day prior to the procedure. Both groups of patients were hydrated with 0.45% saline at 1 ml/kg/hr for 12 hours prior to and 12 hours following the procedure. Both groups were comparable with regard to age, sex, coronary risk profile, myocardial infarction history, left ventricular function and the drugs received. Serum urea and creatinine were measured on the day prior to and the day following the angiographic procedure. RESULTS: Nine out of 51 patients developed more than 0.5mg% rise in serum creatinine level; 1 in the NAC group and 8 in the non NAC group (p<0.05), 24 hours after injection of the contrast medium. In the NAC group mean serum creatinine level decreased from 1.94 +/- 0.56 to 1.67 +/- 0.56 and blood urea from 47.58 +/- 20 to 41.58 +/- 15.1. In the non NAC group serum creatinine increased from 1.75 +/- 0.31 to 1.98 +/- 0.56 and blood urea from 44.96 +/- 15.5 to 52.85 +/- 20.1 (p<0.05). This corresponds to an increase in creatinine clearance from 30ml/min to 35.92ml/min in the NAC group and a decrease from 34.42ml/min to 29.87ml/min in the non NAC group. There was no significant difference in the levels of sodium and potassium before and after the procedure in both the groups. CONCLUSION: We conclude that prophylactit administration of N-Acetyl Cysteine along with hydration diminishes the incidence of deterioration of renal function induced by contrast agents in patients with renal insufficiency during coronary angiographic procedures.

Pattern of cardiac calcification in tropical endomyocardial fibrosis.

Over a two-year period we investigated 55 patients with endomyocardial fibrosis, using two-dimensional echocardiography, color-coded echocardiography, and image intensifier fluoroscopy, to delineate the regional distribution of cardiac calcification. Thirty five patients (64%) were found to have calcification of the ventricular walls. Calcific deposits were seen in the right ventricle in 26(59%) patients and in the left ventricle in 16(44%) patients. All patients who showed calcification were in severe cardiac failure indicating late stage of the disease. When image intensifier fluoroscopy was taken as the gold standard, echocardiography had a sensitivity of 100% and a specificity of 98% in detecting cardiac calcification. The high incidence of calcification in the ventricular walls in the present study is apparently due to the systematic use of two-dimensional echocardiography and image intensifier fluoroscopy.

Direct communication between the left pulmonary artery and the left atrium.

A 17-year-old patient was found to have cyanosis. A right-to-left shunt was suspected clinically and confirmed by noninvasive techniques such as perfusion lung scan and contrast echocardiography. Angiography showed this shunt to be between the left pulmonary artery and the left atrium. We believe this to be the first report of a hitherto undescribed congenital anomaly.