Incidence and Risk Factors for Postoperative Visual Loss after Cardiac Surgical Procedures: A Systematic Review.

ABSTRACT: Postoperative visual loss (POVL) is an infrequent yet consequential complication that can follow cardiac surgical interventions. This systematic review aims to provide a comprehensive analysis of the incidence of POVL after cardiac surgery and to delineate the associated risk factors. A comprehensive search was conducted in major medical databases for relevant studies published up to September 2022. Eligible studies reporting on the incidence of POVL and identifying risk factors in patients undergoing cardiac surgery were included. Data extraction was performed independently by two reviewers. The pooled incidence rates and the identified risk factors were synthesized qualitatively. POVL after cardiac surgery has an overall incidence of 0.015%, that is, 15 cases per 100,000 cardiac surgical procedures. Risk factors for POVL include patient characteristics (advanced age, diabetes, hypertension, and preexisting ocular conditions), procedural factors (prolonged surgery duration, cardiopulmonary bypass time, and aortic cross-clamping), anesthetic considerations (hypotension, blood pressure fluctuations, and specific techniques), and postoperative complications (stroke, hypotension, and systemic hypoperfusion). Ischemic optic neuropathy (ION) is an uncommon complication, associated with factors like prolonged cardiopulmonary bypass, low hematocrit levels, excessive body weight gain, specific medications, hypothermia, anemia, raised intraocular pressure, and micro-embolization. Diabetic patients with severe postoperative anemia are at increased risk for anterior ischemic optic neuropathy (AION). Posterior ischemic optic neuropathy (PION) can occur with factors like hypertension, postoperative edema, prolonged mechanical ventilation, micro-embolization, inflammation, hemodilution, and hypothermia.While the overall incidence of POVL postcardiac surgery remains modest, its potential impact is substantial, necessitating meticulous consideration of modifiable risk factors. Notably, prolonged surgical duration, intraoperative hypotension, anemia, and reduced hematocrit levels remain salient contributors. Vigilance is indispensable to promptly detect this infrequent yet visually debilitating phenomenon in the context of postcardiac surgical care.

Intraoperative kidney replacement therapy in acute liver failure.

Paediatric acute liver failure (PALF) is often characterised by its rapidity of onset and potential for significant morbidity and even mortality. Patients often develop multiorgan dysfunction/failure, including severe acute kidney injury (AKI). Whilst the management of PALF focuses on complications of hepatic dysfunction, the associated kidney impairment can significantly affect patient outcomes. Severe AKI requiring continuous kidney replacement therapy (CKRT) is a common complication of both PALF and liver transplantation. In both scenarios, the need for CKRT is a poor prognostic indicator. In adults, AKI has been shown to complicate ALF in 25-50% of cases. In PALF, the incidence of AKI is often higher compared to other critically ill paediatric ICU populations, with reports of up to 40% in some observational studies. Furthermore, those presenting with AKI regularly have a more severe grade of PALF at presentation. Observational studies in the paediatric population corroborate this, though data are not as robust-mainly reflecting single-centre cohorts. Perioperative benefits of CKRT include helping to clear water-soluble toxins such as ammonia, balancing electrolytes, preventing fluid overload, and managing raised intracranial pressure. As liver transplantation often takes 6-10 h, it is proposed that these benefits could be extended to the intraoperative period, avoiding any hiatus. Intraoperative CKRT (IoCKRT) has been shown to be practicable, safe and may help sicker recipients tolerate the operation with outcomes analogous with less ill patients not requiring IoCKRT. Here, we provide a comprehensive guide describing the rationale, practicalities, and current evidence base surrounding IoCKRT during transplantation in the paediatric population.

An intriguing case report of follicular lymphoid hyperplasia of tongue with the detailed review of literature.

Follicular lymphoid hyperplasia is a rare reactive benign lesion of the oral mucosa. This is also known as pseudolymphoma as the features mimic the malignant counterpart Follicular lymphoma. In present case, a 34 year old male patient came with a nodular swelling in the posterior-lateral left side of tongue. Medical or dental history was non contributory. Swelling was painless, well demarcated, and about peanut sized. The swelling was provisionally diagnosed as either neurilemmoma, mucocele, or traumatic fibroma. Complete excision was performed, and tissue was sent to a private laboratory. Histopathological findings seen were germinal centers having a core of monotonous cells of the same size and demarcated mantle area mimicking the lymphoma. Immunophenotyping revealed diffused positivity for kappa and lambda expressions. CD10 was diffusely positive in germinal centers and BCl 2 was positive in the mantle area while negative in germinal centers. The final diagnosis given was follicular lymphoid hyperplasia. The entity mentioned in the present paper is an unusual variant of the benign lymphoproliferative lesion and very few cases are reported in the tongue area. Thus, it is important to understand the nature of this benign lesion in all aspects to avoid diagnostic dilemmas due to its malignant mirroring characteristics.

Occurrence of Oral Premalignant Lesions Among Tobacco Users in a Tribal Population: A Systematic Review and Meta-Analysis.

This review aimed to comprehensively assess the association between tobacco use and oral health outcomes, specifically the presence of premalignant lesions (PMLs), through a synthesis of multiple assessments conducted in diverse populations. A systematic search of relevant literature was performed, and studies meeting the inclusion criteria were selected using appropriate Medical Subject Headings (MeSH) words and Boolean operators. Data from these studies was pooled and analysed using Review Manager 5.4 (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen). The Newcastle-Ottawa scale was used to assess the methodological quality of the studies included. The pooled analysis of the five selected papers revealed a significant correlation between tobacco use and an increased prevalence of PMLs among tobacco users. Tobacco users had an odds ratio of 15.22 (95% CI: 10.01-23.15) as compared to non-user cohorts, significant at p 0.0001. This comprehensive synthesis of assessments underscores the detrimental impact of tobacco use on oral health, particularly in terms of potentially malignant lesions. The findings emphasise the urgency of targeted public health interventions to address tobacco consumption and promote oral health awareness, especially in populations with high tobacco consumption rates. Standardisation of methodologies and representation of diverse populations in future research would strengthen the evidence base and facilitate more effective strategies to improve oral health outcomes globally.

Emergency retrieval of embolised patent ductus arteriosus device from the right pulmonary artery.

Percutaneous closure of patent ductus arteriosus using a duct occluder has become standard of care in its management especially in children more than 6 months of age, weighing more than 6 kg but device embolisation is a potential life-threatening complication and may require immediate open-heart surgery. We describe a case of successful surgical management of a patient in early childhood, in which device has embolised deep into the right pulmonary artery.

Role of Nebulized Heparin in Clinical Outcome of COVID-19 Patients with Respiratory Symptoms: A Systematic Review.

Coronavirus disease-2019 (COVID-19) is an extremely contagious illness caused by the SARS-CoV-2 virus and has been declared a pandemic by the World Health Organization (WHO). There are currently no particular treatments, however, nebulized heparin has been offered as a viable therapy. The purpose of this systematic review is to assess the efficacy of nebulized heparin in COVID-19 patients with respiratory symptoms. Methods: Relevant studies were identified through a systematic search of the PubMed, Medline, Embase, Cochrane Library and Web of Science, and Scopus databases. The search terms included "nebulized heparin," "COVID-19," and "SARS-CoV-2." Studies that evaluated the use of nebulized heparin in COVID-19 patients with respiratory symptoms were included. The rest of the studies along with those that were not published in English were excluded. The systematic review was registered under PROSPERO-CRD42023413927. Observations: Five studies have been included in this systematic review. Case reports, case series, observational studies, and randomized controlled trial (RCT) comprised the studies. The patient sample sizes ranged from 2 to 98. The studies assessed the efficacy of nebulized heparin in COVID-19 patients with variable disease severity. The evaluated outcomes included mortality, hospital stay duration, oxygen requirements, and laboratory parameters. Conclusion: Based on the clinical studies included in this systematic review, nebulized heparin may be useful in the management of COVID-19. Oxygen saturation was greater, inflammatory indicators were lower, and hospital stays were shorter in these patients. However, the studies had limitations, including inconsistent sample sizes, varying dosages of nebulized heparin, and no control groups. Nebulized heparin in patients with COVID-19 needs to be studied further to determine its safety and effectiveness. How to cite this article: Gupta B, Ahluwalia P, Gupta N, Gupta A. Role of Nebulized Heparin in Clinical Outcome of COVID-19 Patients with Respiratory Symptoms: A Systematic Review. Indian J Crit Care Med 2023;27(8):572-579.

A Comparison of Proliferative Capacity of Reticular and Erosive Variants of Oral Lichen Planus by Argyrophilic Nucleolar Organizer Regions Method.

Background: Oral lichen planus (OLP), an immune mediated disorder, has been recognized since 1869 and is presented as any one of the six variants. Reticular and erosive are the most frequently encountered. Its proliferative capacity can give some information regarding its progression. We adopted the argyrophilic nucleolar organizer regions (AgNORs) method because of its simplicity to use and dependable results. We evaluated AgNORs in basal, suprabasal, and squamous cell layers. We also compared these three layers within two variants, reticular, and erosive. Materials and Methods: Thirty clinically diagnosed patients of OLP were included in the study. Reticular and erosive variants were included in our study. This was followed by hematoxylin and eosin staining and later by the AgNOR method. The mean number of AgNORs per nucleus was calculated. Results: Thirteen males and 17 females were the gender distribution. Twenty-three (76.67%) had reticular pattern and seven (23.33%) had erosive pattern. The basal cell layer had the highest mean AgNOR compared to suprabasal and squamous layers. Even among, erosive and reticular variants, the former had higher mean AgNOR counts. Discussion: Our results suggest that the inflammatory infiltrate close to the epithelial cells can alter the proliferation index for the pattern of protein synthesis of these cells. Moreover, the high proliferative index in OLP can be related to a specific immunologic response. Conclusion: We conclude that AgNOR can be used as a proliferative marker in earlier lesions to detect the severity.

Palladium-catalyzed intramolecular oxypalladation-initiated cascade: solvent-dependent chemodivergent approach to functionalized benzazepines and tetrahydroquinolines.

Palladium-catalyzed, solvent-dependent intramolecular oxypalladation-triggered domino sequences of internal alkynes bearing tethered nucleophilic carboxylic ester and electrophilic enone functionalities were developed for the chemodivergent synthesis of two completely distinct biologically significant complex molecules including isochromenone-fused benzazepines and isobenzofuranone-fused tetrahydroquinolines/chromanes in a single synthetic operation.

Lifestyle Optimization Leads to Superior Liver Regeneration in Live Liver Donors and Decreases Early Allograft Dysfunction in Recipients: A Randomized Control Trial.

INTRODUCTION: The aim of the current randomized control trial was to assess the efficacy of donor lifestyle optimization on liver regeneration and outcome following live donor liver transplantation. METHODS: Live liver donors (LLDs) who were fit with no or minimal steatosis were randomized to receive either a customized low-calorie diet with calorie intake equalling their basal requirement along with exercise for 2 weeks before surgery versus to continue their normal routine lifestyle. Primary objectives were the difference in the day of normalization of serum bilirubin and PT-International normalized ratio and the percentage growth of the liver at postoperative day 7 and 14. Secondary objectives were differences in intraoperative liver biopsy, liver-regeneration markers, blood loss, hospital stay, the complication rate in LLDs, and rates of early graft dysfunction (EGD) in recipients. RESULTS: Sixty-two consecutive LLDs were randomized (28 in intervention vs. 34 in control). Baseline parameters and graft parameters were similar in both groups. LLDs in the intervention arm had significantly decreased calorie intake ( P <0.005), abdominal girth ( P <0.005), BMI ( P =0.05), and weight ( P <0.0005). The mean blood loss ( P =0.038), day of normalization of bilirubin ( P =0.005) and International normalized ratio ( P =0.061), postoperative peak aspartate transaminase ( P =0.003), Alanine transaminase ( P =0.025), and steatosis ( P <0.005) were significantly less in the intervention group. There was significantly higher volume regeneration ( P =0.03) in donors in the intervention arm. The levels of TNF-α, IL-6, and IL-10 levels were significantly higher, while the TGF-ß level was lower in donors in the intervention group. The rate of EGD was significantly higher in recipients in the control group ( P =0.043). CONCLUSION: Lifestyle optimization of LLD is simple to comply with, improves liver regeneration in LLDs, and decreases EGD in recipients, thus can enhance donor safety and outcomes in live donor liver transplantation.

A microwave-assisted intramolecular aminopalladation-triggered domino sequence: an atom economical route to 5,10-dihydroindeno[1,2-b]indoles.

A microwave-assisted, palladium(II)-catalyzed cascade reaction of 2-alkynylanilines tethered with an α,ß-unsaturated carbonyl moiety was established to access 5,10-dihydroindeno[1,2-b]indoles in high yields (up to 84%) in a short reaction time. This operationally simple cascade process shows 100% atom economy and allows the construction of two new five-membered rings and two new (1 C-C and 1 C-N) bonds in a single synthetic attempt. The mechanistic pathway of this reaction is visualized involving intramolecular aminopalladation (5-endo-dig) followed by carbopalladation (olefin insertion) and protonolysis steps. A systematic comparison between microwave irradiation and conventional heating methods was also performed to demonstrate the supremacy of the microwave-assisted approach. This domino reaction requires no protecting groups for the amino group and the palladium catalyst needs no ligands. To the best of our knowledge, this is the first report on microwave-assisted nucleopalladation-initiated cascade transformation.

Infracardiac obstructive total anomalous pulmonary venous return with ventricular septal defect: a rare anomaly.

The infracardiac variant of total anomalous pulmonary venous return occurs only rarely and is frequently obstructive in nature, thereby presenting in the early days of life [1]. An atrial septal defect is present in most cases and is necessary for survival, but a ventricular septal defect is extremely rare; only a few cases have been reported. Surgery is the only treatment option but carries a high risk of morbidity and mortality.

Utility of VExUS score in the peri-operative care unit, intensive care unit, and emergency setting - A systematic review.

Background and Aims: The venous excess ultrasound (VExUS) score presents a prospect of valuable clinical utility. The study aimed to systematically review the effectiveness of the VExUS score in detecting venous congestion across emergency, critical care, and peri-operative contexts; assessing its utility in improved patient outcomes; and exploring its relationship with established parameters. Methods: This systematic review was registered in the International Prospective Register of Systematic Reviews (CRD42023421034). A comprehensive literature search, employing pre-defined search terms related to the VExUS score in diverse clinical contexts, was conducted on articles published between 2000 and 15 May 2023 across databases- PubMed, PubMed Central, Cochrane, Scopus, Elsevier Clinical Key, and Google Scholar. Bias risk assessment was carried out using the Risk of Bias in Non-Randomised Studies tool. Given the significant heterogeneity across studies concerning participants, interventions, outcomes, and study designs, data pooling for a meaningful meta-analysis was not feasible. Results: The review included 15 articles comprising observational studies, case series, and case reports. Most patients exhibited moderate-to-severe venous congestion based on their baseline VExUS scores. Higher VExUS scores correlated with a greater risk of acute kidney injury (AKI) in post-operative patients. The VExUS score strongly correlated with central venous pressure; specific components, such as the intra-renal monophasic pattern, portal-pulsatility, and inferior vena cava diameter, exhibited robust predictive value for venous congestion. Conclusion: VExUS score is valuable in assessing and predicting venous congestion, especially regarding AKI prediction risk and guiding interventions. However, its utility in predicting outcomes in acute heart failure patients appears less certain.

EXPRESSION OF ALPHA-SMOOTH MUSCLE ACTIN IN ODONTOGENIC CYSTS AND TUMORS.

BACKGROUND: Odontogenic cysts and tumors exhibit different degrees of aggressiveness in their biological behavior. There has been evidence that the presence of myofibroblasts (MFs) at the invasion front promotes tumor invasion. Our study is based on the fact that MFs are important in the biological behavior of odontogenic cysts and tumors. AIM: To assess immunohistochemically expression of alpha-smooth muscle actin (α-SMA) of MFs in odontogenic cysts and tumors and correlate this expression to their biological behavior. MATERIALS AND METHODS: The archival tissues collected for 1.5 years were obtained from the Department of Oral Pathology & Microbiology, People's Dental Academy, Bhopal (India). A total of 40 cases consisting of 10 cases each of odontogenic keratocysts, radicular cysts, dentigerous cysts and ameloblastomas formed the study group. An immunohistochemical analysis of α-SMA expression and localization was carried out. RESULTS: Mean MF counts were the highest in odontogenic keratocysts which was followed by ameloblastomas, entigerous cysts and radicular cysts. Weak α-SMA-expression was found in 50% of cases, moderate in 22.5% of cases, and intense - in 10% cases. MFs were arranged in the spindle, focal, or network patterns in 35; 27.5 and 20% of cases, respectively. CONCLUSION: The analysis revealed that the MFs were distinctly heterogeneous in distribution and pattern of arrangement. This provided persuasive evidence that stroma of these lesions harbor MFs as reflected by α-SMA immunopositive cells.

Role of high dose vitamin C in management of hospitalised COVID-19 patients: A minireview.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as one of the most dreadful viruses the mankind has witnessed. It has caused world-wide havoc and wrecked human life. In our quest to find therapeutic options to counter this threat, several drugs have been tried, with varying success. Certain agents like corticosteroids, some anti-virals and immunosuppressive drugs have been found useful in improving clinical outcomes. Vitamin C, a water-soluble vitamin with good safety profile, has been tried to reduce progression and im-prove outcomes of patients with coronavirus disease 2019 (COVID-19). Because of its anti-oxidant and immunomodulatory properties, the role of vitamin C has expanded well beyond the management of scurvy and it is increasingly been employed in the treatment of critically ill patients with sepsis, septic shock, acute pancreatitis and even cancer. However, in spite of many case series, observational studies and even randomised control trials, the role of vitamin C remains ambiguous. In this review, we will be discussing the scientific rationale and the current clinical evidence for using high dose vitamin C in the management of COVID-19 patients.

An unusual case report of basal cell ameloblastoma and a detailed review of literature.

Ameloblastoma is an odontogenic tumour derived from the remnants of odontogenic epithelium. Ameloblastoma shows versatile clinical and histological variants. Basal cell ameloblastoma is a rare variant among all histopathological variants of ameloblastoma. We present a case of a 25-year-old male patient with painless swelling on the lower left side of the face for 1 year, which had gradually increased in size and histologically showed features of basal cell ameloblastoma. The aim of the present paper is to understand this rare variant of ameloblastoma and review the literature.

Regulation of Calcium Homeostasis in Acute Kidney Injury: A Prospective Observational Study.

Background: Maintaining homeostasis is an integral part of all physiological processes both in health and disease including critically ill patients and may impact clinical outcomes. The present study was designed to assess prevalence of serum calcium, phosphate, vitamin-D3, FGF-23, and PTH levels abnormalities in AKI. Patients and methods: Single-center, prospective, observational study in a tertiary care hospital. Patients meeting KDIGO criteria for AKI were included. Paired blood samples were drawn from eligible patients-first sample within 24 hours of AKI diagnosis and second after 5 days or at time of hospital discharge, whichever was earlier for measuring serum calcium (albumin corrected), phosphate, PTH, 25(OH)Vit-D, and FGF-23 levels. Clinical outcomes analyzed included survival status, utilization of RRT, and hospital stay. Results: Of the 50 patients with AKI, about three-fourths were males. Mean age of the participants was 57.32 ± 11.47 years. Around half of patients had hypocalcemia and four-fifths had low serum phosphate. Nearly 82% had low 25(OH)Vit-D and 52% cases had high PTH level. Patients who underwent RRT had numerically higher but not significant serum calcium and PTH levels. FGF-23 levels (pg/mL) were significantly higher in patients on RRT (81.70 ± 17.30 vs non-RRT, 72.43 ± 20.27, p = 0.049), nonsurvivors (87.96 ± 18.82 vs survivors 57.11 ± 15.19, p = 0.045), and those hospitalized for time of stay above median (109.67 ± 26.97 vs below median 70.27 ± 20.43, p = 0.046). Among all the bone and mineral parameters analyzed high FGF23 levels were consistently linked with poor clinical outcomes in AKI. Conclusion: The present study found high prevalence of calcium and phosphate disorders in AKI with dysregulated phosphate homeostasis as evidenced from elevated FGF-23 levels linked with morbidity and mortality in AKI. How to cite this article: Singh NP, Panwar V, Aggarwal NP, Chhabra SK, Gupta AK, Ganguli A. Regulation of Calcium Homeostasis in Acute Kidney Injury: A Prospective Observational Study. Indian J Crit Care Med 2022;26(3):302-306.

Evaluation of immunohistochemical expression of E-cadherin in pleomorphic adenoma and adenoid cystic carcinoma.

Background: Pleomorphic adenoma (PA) and adenoid cystic carcinoma (ADCC) are benign and malignant salivary gland tumors, respectively, with distinct behavior. They have similar origins and cell components. E-cadherins are the main homophilic cell adhesion molecules, which play a central role in maintaining epithelial integrity, functioning in intercellular adhesion and differentiation. Hence, changes in E-cadherin function are reflected in the morphologic events associated with the cellular arrangement, movement and wound healing. Aim: To study and compare the expression of E-cadherin immunostaining in PA and ADCC. Materials and Methods: Fifteen cases of each PA and ADCC were immunohistochemically stained with E-cadherin. Five cases of normal salivary gland tissues were taken as the positive control.Mann-Whitney U-test was used for statistical analysis. Results: About 86.6% of PA cases showed homogeneous staining. 66.6% of cases of ADCC showed heterogeneous staining. PA, cribriform and tubular patterns of ADCC predominantly showed moderate immune-staining and solid patterns of ADCC exhibited predominantly mild immunostaining. Depending on the intensity of staining, we found a significant P value between PA and the solid variant of ADCC. Conclusion: E-cadherin proved to be a better marker for epithelial phenotypes in PAs. In ADCC difference in staining intensity between different histological subtypes suggests that further studies should be done to assess the usefulness of an immuno-marker to know the aggressive behavior of ADCC.