Surgical correction of rare anomaly of scimitar syndrome with tetralogy of Fallot.

We present a 9-year-old male with a history of cyanosis diagnosed as scimitar syndrome with tetralogy of Fallot with left anterior descending coronary artery crossing right ventricle outflow tract. He underwent reimplantation of scimitar vein into right atrium baffled into left atrium along with intracardiac repair for tetralogy of Fallot. Postoperative recovery was uneventful and the patient was discharged on postoperative Day 8 and was asymptomatic at follow-up at 6 months.

Informed consent in psychiatry outpatients.

Background & objectives: Comprehension and process of consent are important for persons with mental illness as they may not be impaired in considering research participation. The American Psychiatric Association developed a detailed Cultural Formulation Interview (CFI). The present study was a part of field testing of CFI, aimed to standardize cultural information affecting the patients' management in India. This paper describes the process and conclusions from the consent-seeking process of this study. Methods: The purpose and procedures about field trial of the CFI were introduced and the patient and caregiver were requested for participation. Consent process was carried out step by step, by reading out the consent form to the first new patient of the day in the psychiatry outpatients department of a tertiary care hospital in north India, inviting questions followed by the 'comprehension' questions. The entire process was audiotaped without any personal identifiers. The process was repeated if not comprehended. Results: A total of 67 patients consented, 11 refused and majority were educated more than secondary school. Some concerns shown by the patients and caregivers included risk of participation, loss or benefits of participation, privacy, etc. All types of mentally ill patients participated in the study. Interpretation & conclusions: Translations of consent forms used simple words, consonant with understanding of the potential participants. Patients' belief that participating in this long process would improve their care, and serve humanity, influenced their decision to participate. Except for intoxication and severe psychosis, patients could understand and comprehend issues around consent. Main issues were confidentiality and culture. Our experience in the psychiatry OPD refutes the commonly held belief that mentally ill persons lack comprehension and ability to consent.

Unusual presentation and rupture of left sinus of Valsalva into mitral-aortic intervalvular fibrosa.

Ruptured sinus of Valsalva aneurysm from the left coronary sinus communicating through the mitral-aortic intervalvular fibrosa is rare. We report a 35-year-old patient who presented with only hemoptysis without any other cardiac complaint. The patient with this unusual diagnosis and presentation was managed successfully.

An alternative technique for intracardiac exposure during transatrial repair of tetralogy of fallot.

The commonly used technique to facilitate intracardiac exposure during transatrial repair of tetralogy of fallot involves considerable retraction of the tricuspid valve using retractors. We describe an alternative surgical technique in which it is possible to dispense away with the retractors. The advantages of such a technique are discussed.

An alternative technique for completion of the total cavopulmonary connection.

BACKGROUND: Total Cavopulmonary connection (Fontan) is the final palliation for patients with a functionally univentricular heart. This is commonly accomplished after a prior bidirectional Glenn on cardiopulmonary bypass (CPB) with separate cannulation of the aorta, superior vena cava (SVC), and inferior vena cava. We describe an alternative technique of Fontan completion that eliminates the need for cannulation and dissection of the SVC, and pulmonary artery dissection. METHODS: Between January and October 2018, 17 patients underwent completion Fontan using an alternate technique at our institute. All operations were conducted on CPB at normothermia without cannulating the SVC RESULTS: Mean CPB time was 60 ± 16.8 minutes (range, 39-102 minutes). There were no early deaths. Mean postoperative Fontan pressures were 15.6 ± 1.2 mm Hg with no gradient between the SVC and IVC pressures. Mean duration of hospital stay was 15.6 ± 3.6 days (range, 10-22 days). No patient developed phrenic nerve paresis or palsy. CONCLUSIONS: Completion without cannulating the SVC is simple, reproducible, and easy to teach. It avoids the disadvantages associated with routine techniques.

COVID Associated Invasive Aspergillosis.

To study the possible association between invasive fungal sinusitis (aspergillosis) and coronavirus disease. An observational study was conducted at a tertiary care centre over 6 months, involving all patients with aspergillosis of the paranasal sinuses suffering from or having a history of COVID-19 infection. 92 patients presented with aspergillosis, all had an association with COVID-19 disease. Maxillary sinus (100%) was the most common sinus affected. Intraorbital extension was seen in 34 cases, while intracranial extension was seen in 5 cases. Diabetes mellitus was present in 75 of 92 cases. All had a history of steroid use during their coronavirus treatment. New manifestations of COVID-19 are appearing over time. The association between coronavirus and aspergillosis of the paranasal sinuses must be given serious consideration. Uncontrolled diabetes and overzealous use of steroids are two main factors aggravating the illness, and both of these must be properly checked.

A reappraisal of the sinus venosus defect.

OBJECTIVES: The phenotypic features and morphogenesis of the 'sinus venosus defect' remain controversial. The phenotypic features are anomalous systemic connections of 1 or more pulmonary veins that retain their left atrial connection, usually associated with a biatrial connection of the superior caval vein. Cases with these features, however, have not always been described as sinus venosus defects. METHODS: We reviewed the findings documented in the literature from 11 patients with a biatrial connection of the superior caval vein, most reported following an autopsy examination. We compared these findings with the anatomical details of 50 patients undergoing surgical correction in our centre, paying particular attention to the override of the superior caval vein. RESULTS: In only two-thirds of those undergoing surgery did the superior caval vein override the rims of the oval fossa, with the degree of override >50% in only 2 individuals. It is only these latter 2 cases that are directly comparable to the reported cases of biatrial connection of the superior caval vein. CONCLUSIONS: Our comparisons provide new insights into the developmental background and phenotypic features of the superior sinus venosus defect. The defects exist because of the anomalous systemic connection of the pulmonary veins that retain their left atrial connections but not always in association with a biatrial connection of the superior caval vein. In extreme cases, nonetheless, they can underscore the connection of the caval vein to the morphologically left atrium, frequently described previously as a 'biatrial connection'. The sinus venosus defect is better considered a venovenous malformation than a septal defect.

COVID-19, Diabetes and Steroids: The Demonic Trident for Mucormycosis.

Coronavirus disease 2019 (COVID-19) has been found to be associated with mucormycosis in few parts of the world, especially India. It is important to look for reasons for this upsurge of cases so that other countries may take proper steps to prevent it. A prospective clinico-demographic study was conducted in SMS Medical College, Jaipur, India from April to May 2021. All patients (235) with COVID associated mucormycosis (CAM) were studied in detail with reference to their diabetic status and steroid intake during treatment of COVID-19. Steroid usage was in 84.3% of patients with methylprednisolone being the most commonly used steroid (66.8%). Majority of the patients had taken steroids for 7-14 days. Diabetes was found in 204 patients and 42.1% of patients were newly diagnosed during/after COVID-19 treatment. The HbA1c levels of diabetic patients ranged from 6.0% to 16.3%. This is perhaps the biggest study in the world shows that the triad of COVID-19, diabetes and steroid usage is a major contributing factor towards mucormycosis. Proper steps should be taken to prevent CAM.

Total Pericardiectomy Using a Modified Left Anterolateral Thoracotomy Without Cardiopulmonary Bypass.

BACKGROUND: We sought to ascertain the short- and long-term results of total pericardiectomy for chronic constrictive pericarditis using a modified left anterolateral thoracotomy without cardiopulmonary bypass on postoperative low cardiac output, normalization of intracardiac pressures, survival, and reoperations. METHODS: Between January 2005 and December 2019 a series of 127 consecutive patients (91 male patients) between ages 4 and 72 years (median, 25 years; interquartile range, 18-38) underwent radical total pericardiectomy using a modified left anterolateral thoracotomy without cardiopulmonary bypass. RESULTS: Operative and late mortalities were 3.1% and 1.6%, respectively. Thirty-one patients (24.4%) had postoperative low cardiac output, and none required reoperations. At a median follow-up of 99 months (interquartile range, 56-141) the actuarial survival was 97.6% ± 0.01% months (95% confidence interval, 92.8-99.2). At their last follow-up 113 (93.4%) and 8 (6.6%) survivors were in New York Heart Association class I and II, respectively. CONCLUSIONS: Total pericardiectomy is associated with lower perioperative and late mortality and decreased low cardiac output syndrome and confers significant long-term advantage of superior hemodynamics.

Long-Term Outcomes of the Double-Barrel Technique for Superior Sinus Venosus Defect With Partially Anomalous Pulmonary Venous Connection.

BACKGROUND: Repair of superior sinus venosus defect with high partially anomalous pulmonary venous connection (PAPVC) using an intracardiac baffle may be complicated by systemic or pulmonary venous pathway obstruction and sinus nodal dysfunction (SND). Our surgical strategy for repair of all types of superior sinus venosus defect has evolved chiefly to avoid the abovementioned complications and preserving the growth potential of the superior cavoatrial junction. METHODS: Between 2007 and 2019, fifty consecutive patients aged 2 to 60 (mean, 17.6±16.7) years underwent repair of superior sinus venosus defect using the double-barrel technique as described. The anomalous pulmonary veins drained into the superior cavoatrial junction in 17 patients and more than 2 cm above the cavoatrial junction in 33 patients. RESULTS: There were no early or late deaths and no reoperations. At a mean follow-up of 103.9 (±50.2) months, all survived the operation, and actuarial freedom from SND was 97.9% (±standard error, 0.02%; 95% CI: 0.86-0.99). No patient had systemic or pulmonary venous pathway obstruction. A permanent pacemaker was required in one (2%) patient for sick sinus syndrome. CONCLUSIONS: The double-barrel method is an expedient, safe, and effective technique in superior sinus venosus defect. It provides dual drainage of superior vena cava preserving the superior cavoatrial junction without causing systemic or pulmonary venous pathway obstruction and can be utilized in all cases including those with high PAPVC. Preservation of the cavoatrial junction and use of autogenous atrial tissue for systemic venous pathway avoids SND and preserves growth potential.

Glyceryl trinitrate spray in the management of painful diabetic neuropathy: a randomized double blind placebo controlled cross-over study.

OBJECTIVES: Various drugs are effective in the management of painful diabetic neuropathy, but none is completely satisfactory. The objective of this study is to test the effectiveness and safety aspect of glyceryl trinitrate (GTN) in the management of painful diabetic neuropathy as a nitric oxide (NO) donor with local vasodilating properties in spray form. DESIGN: Randomized double blind placebo controlled cross-over study. METHODS: Fifty patients with painful diabetic neuropathy (type 2) were screened consecutively, out of which two were excluded (1 with HbA(1)c>11 and one withdrew his consent). The remaining 48 were given either drug (group A) or placebo (group B) in the first phase. After thorough clinical assessment in the first phase, quantitative assessment of pain was done by McGill Pain Questionnaire, Visual Analogue Score, Present Pain Intensity and 11 point Lickerts Scale, at the beginning and after 4 weeks, followed by 2 weeks wash out period and thereafter receiving 4 weeks of cross-over regimen. Adverse drug effects were assessed periodically. RESULTS: Of the 48 patients, five dropped out, two in group A and three in group B. Both groups A and B experienced significant improvement in pain score in their drug phase of trial, when compared to placebo phase of other group (p<0.001). After crossing over the treatment arm, patients of group B observed significant improvement in all pain scores compared to group A (p<0.001). The numbers needed to treat (NNT) calculated on VAS as pain parameters came out to be 4. The drug was well tolerated by all the patients except palpitation and headache for some days in five patients. CONCLUSION: GTN spray, a well tolerated drug, provides significant improvement in painful diabetic neuropathy. These data provide a basis for future trials for longer duration in a larger group of patients.

Neurological soft signs and cognitive functions: Amongst euthymic bipolar I disorder cases, non-affected first degree relatives and healthy controls.

Both neurological soft signs (NSS) and cognitive deficits are present among euthymic bipolar patients. NSS could be related to neurocognitive performance, but this is not explored thoroughly. Healthy relatives of patients may also suffer from similar deficits. This study compared NSS and cognitive functions in euthymic Bipolar I Disorder (BPI) cases to their non-affected first degree relatives and healthy controls. We also investigated the association between NSS and cognitive functions in these three groups. NSS were assessed in three groups using Neurological Evaluation Scale-revised (NES-r). Eight cognitive domains were assessed in 31 euthymic BPI cases, their 30 non-affected first degree relatives and 30 healthy controls using Computerized Neurocognitive Battery (CNB). Euthymic BPI patients had significantly more NSS than non-affected first degree relatives on 5/7 tests (p-value ranges from 0.042 to p=0.0001) and healthy controls on all tests (p-value from 0.042 to <0.0001). Non-affected first degree relatives and controls did not have any significant difference. BPI participants performed worse than their non-affected first degree relatives on one neurocognitive domain of CNB (spatial memory accuracy, p=0.03) and healthy controls on four domains (spatial memory accuracy (p=0.04), abstraction and mental flexibility efficiency (p=0.04), spatial memory efficiency (p=0.04), and emotion efficiency (p=0.04). Non-affected relatives and healthy controls were similar on neurocognitive domains. Accuracy and efficiency indices of some specific cognitive domains were negatively associated with AV rating and tap copying NSS ratings.

A study of predictors of anxiety and depression among stroke patient-caregivers.

CONTEXT: Caregivers play an important role in supporting people with illness either acute or chronic. It is important to explore caregiver's emotional turmoil as it helps in exploring their burden which can have impact on the patient's illness and functioning apart from their own. AIMS: The current study aimed at assessing the predictors of anxiety and depression among caregivers of patients with stroke. SETTINGS AND DESIGN: Seventy-five consecutive patient-caregiver dyads were recruited in the study. MATERIALS AND METHODS: Patients and caregivers were assessed using a semi-structured proforma for the sociodemographic details. Subsequently these dyads were assessed for anxiety and depression levels using the Hospital Anxiety and Depression Scale. STATISTICAL ANALYSIS USED: Chi-square tests (for categorical variables) were used to find difference between the patients and the caregivers on different variables. Additionally Cramer's V-test and phi test were used for 2*4 contingency tables. Linear regression model was used. RESULTS: Linear regression revealed that anxiety level in caregivers was predicted by the sex of care giver. CONCLUSIONS: Caring for the patients with stroke presents increased burden to the care givers which manifests as increased rate of anxiety and depression among them. It is important to assess the care givers along with the patients for emergence of these negative affective states. One needs to be extra cautious if the patient happens to be the primary earning member of the family.