Childhood leprosy in an endemic area

A study was done on 794 new cases of leprosy among children (aged 0-14 years) detected and treated with MDT during 1990-1995 in Gudiyatham Taluk, South India. Incidence rates of leprosy and proportion of multibacillary cases increased with age, while bacillary + tuberculoid was most common. Over 80% had a single patch and most children were detected through surveys. Nearly 30% had history of household contacts with leprosy, mostly parents or grandparents. Reactions and relapses were not uncommon. The findings emphasize the need for more careful surveys for case detection and better follow-up in case management.

Follow-up results of transvenous occlusion of patent ductus arteriosus with the buttoned device

OBJECTIVES

The purpose of this presentation is to document results of buttoned device (BD) occlusion of patent ductus arteriosus (PDA) in a large number of patients with particular emphasis on long-term follow-up in an attempt to provide evidence for feasibility, safety and effectiveness of this method of PDA closure.

BACKGROUND

Immediate and short-term results of BD occlusion of PDA have been documented in a limited number of children.

METHODS

During a six-year period ending August 1996, transcatheter BD closure of PDA was attempted in 284 patients, ages 0.3 to 92 years (median 7) under a protocol approved by the local institutional review boards and FDA with an investigational device exemption in U.S. cases.

RESULTS

The PDAs measured 1 to 15 mm (median 4) at the narrowest diameter; 20 were larger than 8 mm and 10 larger than 10 mm. They were occluded with devices measuring from 15 to 35 mm delivered via 7F (N = 140) or 8F (N = 144) sheaths. Successful implantation of the device was accomplished in 278 (98%) of 284 patients. The Qp:Qs decreased from 1.8+/-0.6 (mean+/-SD) to 1.09+/-0.19 (p < 0.001). Effective occlusion defined as no (N = 167 [60%]) or trivial (N = 79 [28%]) residual shunt was achieved in 246 (88%) patients. All types of PDAs, irrespective of the shape (conical, tubular or short), size (small or large) or length (short or long) of the PDA and previously implanted Rashkind devices, could be occluded. Follow-up data, 1 to 60 months (median 24) after device implantation, were available in 234 (84%) patients. Seven (3%) patients required reintervention to treat residual shunt with (N = 2) or without (N = 5) hemolysis. Actuarial reintervention-free rates were 95% at 1 and 5 years. There was gradual reduction of actuarial residual shunts and were 40%, 28%, 21%, 14%, 11%, 10%, 6% and 0% respectively at 1 day, 1, 6, 12, 24, 36, 48 and 60 months after device implantation. Incorporation of folding plug over the button loop in 10 additional patients produced immediate and complete occlusion of PDA.

CONCLUSIONS

This large multiinstitutional experience confirms the feasibility, safety and effectiveness of buttoned device closure of PDAs. All types of PDAs irrespective of the shape, length and diameter can be effectively occluded. Incorporation of folding plug over the button loop produces complete PDA occlusion at the time of device implantation.

Impact of leprosy on the quality of life

Leprosy is considered by many as not merely a medical condition, but as a condition encompassing psychological, socioeconomic and spiritual dimensions that dehabilitate an individual progressively, unless properly cared for. The present study was undertaken to document the nature and extent of decreases in the quality of life (QOL) of an affected person. The World Health Organization questionnaire on quality of life was given to a representative random sample of 50 leprosy-affected persons and 50 unaffected individuals in the Bommasamudram Taluk of Chittoor District, Andhra Pradesh, India. This questionnaire explores the following six domains; physical; psychological; level of independence; social relationships; spiritual; and environmental. The mean QOL score of the cases was significantly lower than that of the controls with the exception of the spiritual domain. The mean total score for women was higher than that of males in each domain and age group. Males with deformities had a significantly lower score than those with no visible deformities. Although the scores for females with deformities were also lower than those without deformities, the differences were not statistically significant. Analyses of economic status versus the QOL scores clearly showed that they were positively correlated. The study revealed that quality of life decreased progressively in leprosy-affected persons. Women had a better QOL score than men in almost every domain. Given the secondary role of women in Indian rural society, this may simply imply an acceptance of their situation. The findings are discussed in comparison with other diseases and in the context of a poor socioeconomic environment. With modern amenities, better education and higher expectations, the perception of an individual regarding his or her own quality of life is bound to change. The need for frequent assessments and further studies along these lines is emphasized.

Salmonella typhi VI antigen co-agglutination test for the rapid diagnosis of typhoid fever

A slide Co-agglutination test for the detection of Salmonella typhi Vi antigen in blood was evaluated for its efficiency in rapid diagnosis of Typhoid fever. The results were compared with conventional methods like Blood culture and Widal test. The test showed a sensitivity of 86.67% and specificity of 88.83% when compared with blood culture positivity or Widal titre above 160. This is a useful rapid diagnostic test for the early diagnosis of Typhoid fever.

Incidence of nerve damage in leprosy patients treated with MDT

The incidence rates of sensory and motor impairments during and after multidrug therapy (MDT) are reported for a prospective cohort of patients who had no nerve damage at registration (N = 1621). Sensory and motor loss increased with age and both were high among multibacillary patients as compared with paucibacillary patients. The lateral popliteal (common peroneal) and posterior tibial nerves seem to be most affected for sensory loss; whereas the posterior tibial and ulnar nerves are mainly responsible for motor loss. No significant difference by gender was found. Implications for prevention of disability (POD) activities are discussed and suitable recommendations made.

Results of three to 10 year follow up of balloon dilatation of the pulmonary valve

BACKGROUND

The results of immediate and short term follow up of balloon dilatation of the pulmonary valve have been well documented, but there is limited information on long term follow up.

OBJECTIVE

To evaluate the results of three to 10 year follow up of balloon dilatation of the pulmonary valve in children and adolescents.

SETTING

Tertiary care centre/university hospital.

DESIGN

Retrospective study.

METHODS AND RESULTS

85 patients (aged between 1 day and 20 years, mean (SD) 7.0 (6.4) years) underwent balloon dilatation of the pulmonary valve during an 11 year period ending August 1994. There was a resultant reduction in the peak to peak gradient from 87 (38) to 26 (22) mm Hg. Immediate surgical intervention was not required. Residual gradients of 29 (17) mm Hg were measured by catheterisation (n = 47) and echo Doppler (n = 82) at intermediate term follow up (two years). When individual results were scrutinised, nine of 82 patients had restenosis, defined as a peak gradient of 50 mm Hg or more. Seven of these patients underwent repeat balloon dilatation of the pulmonary valve: peak gradients were reduced from 89 (40) to 38 (20) mm Hg. Clinical evaluation and echo Doppler data of 80 patients showed that residual peak instantaneous Doppler gradients were 17 (15) mm Hg at long term follow up (three to 10 years, median seven), with evidence for late restenosis in one patient (1.3%). Surgical intervention was necessary to relieve fixed infundibular stenosis in three patients and supravalvar pulmonary stenosis in one. Repeat balloon dilatation was performed to relieve restenosis in two patients. Actuarial reintervention free rates at one, two, five, and 10 years were 94%, 89%, 88%, and 84%, respectively. Pulmonary valve regurgitation was noted in 70 of 80 patients at late follow up, but neither right ventricular dilatation nor paradoxical interventricular septal motion developed.

CONCLUSIONS

The results of late follow up of balloon dilatation of the pulmonary valve are excellent. Repeat balloon dilatation was performed in 11% of patients and surgical intervention for subvalvlar or supravalvar stenosis in 5%. Most patients had mild residual pulmonary regurgitation but right ventricular volume overload was not required. Balloon dilatation is the treatment of choice in the management of moderate to severe stenosis of the pulmonary valve. Further follow up studies should be undertaken to evaluate the significance of residual pulmonary regurgitation.

Transumbilical venous, anterograde, snare-assisted balloon aortic valvuloplasty in a neonate with critical aortic stenosis

Balloon aortic valvuloplasty is an acceptable alternative to surgery in the treatment of critical aortic stenosis in the neonate. In this report, we describe a 1-day-old infant with critical aortic stenosis who was successfully treated with an anterograde, transumbilical venous, snare-assisted balloon aortic valvuloplasty. Based on this experience, it is suggested that the anterograde transumbilical venous approach is a feasible and effective alternative to retrograde femoral, carotid, or umbilical arterial and transfemoral venous anterograde routes for performing balloon aortic valvuloplasty in the neonate.

Munchiwarin, a prenylated chalcone from crotalaria trifoliastrum

Munchiwarin, a chalcone with the first 2,2, 6-tri-isoprenyl-cyclohex-5-ene-1,3-dione skeleton, was isolated from Crotalaria trifoliastrum and structurally identified by various NMR techniques in combination with X-ray crystallography.

Comparison of darkground microscopy with serological tests in the diagnosis of leptospirosis with hepatorenal involvement--A preliminary study

Darkground Microscopy (DGM) was initially done on Plasma in the Department of Microbiology, Kasturba Medical College, Manipal for 44 cases of suspected Leptospiral hepatorenal involvement. A total of 60 sera were collected from these patients and stored at -70 degrees C. Passiive haemagglutination test (PHA) was performed on 25 sera and latex agglutination test on 35 sera (Leptospira antigen Seiken) Leptospira was detected by Darkground Microscopy in 12 patients (27.27%). Serology was positive in 16 samples (36.36%) of which 7 (15.90%) by PHA and 9 by Latex agglutination (20.45%). Serological tests confirmed the findings of Darkground Microscopy. DGM was found to be simple and rapid and could be performed on all suspected patients.

Results of transvenous buttoned device occlusion of patent ductus arteriosus in adults. International Buttoned Device Trial Group

Examination of the immediate and follow-up results of transvenous buttoned device occlusion of patent ductus arteriosus suggests that the method is feasible, safe, and effective irrespective of the size and shape of the ductus. Although residual shunts are present, they tend to disappear during follow-up, and complete occlusion at the time of implantation may be achieved by incorporation of a folding plug over the button loop of the device.

A revised structure for crotaramosmin from crotolaria ramosissima

The structure of crotaramosmin has been reassigned to 1-(5-hydroxy-2, 2-dimethyl-2H-chromen-6-yl)-3-(4-hydroxyphenyl)-propanone (1) as determined by extensive NMR investigation.

Colchicine antimitosis abolishes resiliency of postnatally developing rats to chlordecone-amplified carbon tetrachloride hepatotoxicity and lethality

We have previously reported that rats are resilient to the hepatotoxic and lethal combination of chlordecone (CD) and carbon tetrachloride (CCl4) during early postnatal development. The overall findings pointed to stimulated cell division and tissue repair mechanisms as the underlying cause of resistance. The objective of the current study was to investigate if the antimitotic effect of colchicine (CLC) abolishes this resiliency to CD + CCl4 by inhibiting ongoing and stimulated cell division. We used 45-day-old rats in this study because this age group exhibited partial sensitivity to CD + CCl4 in our previous studies. Male Sprague-Dawley rats were treated with a single low intraperitoneal dose of CCl4 (100 microl/kg) or corn oil after exposure to either 10 ppm CD in the diet or a normal diet (ND) for 15 days. CLC (1 mg/kg) was administered 6 or 30 hr after CCl4 to ND or CD rats, respectively. Administration of CLC resulted in increased CCl4-induced mortality from 25% to 85% in rats pretreated with CD, in contrast to 100% survival in ND rats. Liver injury was assessed by plasma alanine transaminase (ALT) and sorbitol dehydrogenase (SDH) elevations as well as by histopathology. Hepatocellular regeneration was assessed by 3H-thymidine (3H-T) incorporation into hepatonuclear DNA and proliferating cell nuclear antigen (PCNA) studies during 0-96 hr after CCl4. Administration of CLC to ND + CCl4 rats resulted in a slight delay in cell division and tissue repair, as indicated by 3H-T incorporation and PCNA, thereby leading to prolonged liver injury as revealed by elevations in plasma ALT, SDH, and histopathological lesions. In contrast, CLC administration to CD + CCl4-treated rats further delayed and diminished cell division by 80%, which led to unrestrained progression of CCl4-induced liver injury, resulting in 85% mortality. These findings underscore the importance of ongoing and toxicant-stimulated cell division and tissue repair mechanisms in hepatotoxicity, and the need for the inclusion of age factors in risk assessment of exposure to environmental and other chemicals.

Endotoxin-induced atrial natriuretic factor release: in vivo and in vitro studies

OBJECTIVE

We evaluated the effects of coliform endotoxin on the circulating levels of atrial natriuretic factor and renal function. To understand the direct effects of endotoxin in the release of atrial natriuretic factor by cardiac tissue, studies in isolated rat atria were performed.

STUDY DESIGN

In vivo studies were used. Anesthetized dogs were studied, with one group receiving isotonic saline solution (n = 6) and the other group receiving 50 microg/kg of coliform endotoxin (n = 7) as a continuous infusion over a 4-hour period. Cardiovascular parameters, renal function, and circulating levels of atrial natriuretic factor were measured at specified time intervals. In another set of experiments with in vitro studies left atria from Sprague-Dawley rats were isolated and perfused. In the control group (n = 9) the standard Krebs perfusate was used. In the endotoxin group (n = 9) coliform endotoxin was added at a concentration of 250 microg/mL to the standard perfusate. Atrial pressure was used as an index of stretch, and atrial natriuretic factor was measured from the perfusate.

RESULTS

Administration of endotoxin resulted in decreased blood pressure (P < .05) with a concomitant increase in heart rate. Renal artery flow, however, showed an increase (P < .05) initially followed by a return to its baseline value, with a sustained increase occurring in the saline solution control group. A significant (P < .05) and sustained increase in the circulating levels of atrial natriuretic factor after endotoxin infusion did not prevent the decrease in fractional sodium excretion (P < .05) and creatinine clearance despite an increase in the urinary output. Serum sodium, serum potassium, and osmolalities, however, remained relatively stable. The study pertaining to isolated atria showed that in the presence of low atrial pressures, addition of endotoxin had no significant effect on the release of atrial natriuretic factor. With the increase in atrial pressure atrial natriuretic factor release was significantly higher in the group directly exposed to endotoxin compared with the control group.

CONCLUSIONS

These studies demonstrate that the slow infusion of coliform endotoxin results in increased circulating levels of atrial natriuretic factor. This increase is in part due to the direct effect of endotoxin on the heart as indicated by studies in isolated atria. Our data suggest that atrial natriuretic factor in endotoxemia acts in an integrative manner with other hormones on a variety of target organs to modulate cardiovascular function and fluid balance.

Epidemiological significance of first skin lesion in leprosy

The epidemiological significance of monolesions in leprosy and the possible inferences on the mode of entry by Mycobacterium leprae into the body are presented based on data from the clinical records of the Leprosy Control Programme of Gudiyatham Taluk in India; 660 children with monolesions (335 males, 305 females) younger than 15 years of age and detected during the period 1990-1995 were included in the study. Detailed investigations on the location of monolesions were carried out and compared with a random sample of 669 normal rural children matched for age and sex. A large majority of the leprosy monolesions were in the uncovered parts of the body, with special predilection for the posterior aspects of the upper extremities and the anterior aspects of the lower extremities. Based on observation of normal children, these happen to be precisely the sites vulnerable for trauma since they are exposed to the environment where M. Leprae could enter through abraded skin and manifest as a patch. The need for further studies is emphasized.

Morphometric assessment of the innominate vein in the prediction of persistent left superior vena cava

This study sought to develop a simple echocardiographic predictor of persistent left (L) superior vena cava (SVC) in subjects with bilateral SVC. Two groups of children were studied: one with known LSVC (n = 19) and the other, a control group, without LSVC (n = 15). Both groups were of similar age (3.5 +/- 3.0, mean +/- SD vs 3.8 +/- 3.1 years; p = 0.8) and weight (14.6 +/- 7.1 vs 15 +/- 8 kg; p = 0.9). The left innominate vein was either absent (n = 11) or hypoplastic (n = 8) in the LSVC group. The ratio of the innominate vein to the innominate artery was found to be independent of age or body surface area but was significantly smaller in the LSVC group than in the control group (0.33 +/- 0.1 vs 0.97 +/- 0.1; p < 0.001). A cutoff value of 0.47 or less discriminated the LSVC group from the control subjects. Interobserver and intraobserver variations, although important, did not influence the discriminating value of the ratio in the diagnosis of LSVC. Validation of the proposed ratio in 30 consecutive prospectively studied patients with LSVC proved to be 100% sensitive in predicting LSVC. No false-positive diagnosis of LSVC was made when this principle was applied. Absent or hypoplastic left innominate vein measuring 0.47 or less of the innominate artery is an easily recognizable and reliable echocardiographic predictor of LSVC.

Relation of biophysical response of coarcted aortic segment to balloon dilatation with development of recoarctation following balloon angioplasty of native coarctation

OBJECTIVE

To evaluate the role of biophysical response of the coarcted segment to balloon dilatation in the causation of aortic recoarctation.

SETTING

Tertiary care centre/university hospital.

DESIGN

Retrospective case series.

METHODS

Records of 67 consecutive infants and children undergoing balloon angioplasty of native aortic coarctations were examined for an 8.7 year period ending September 1993. At 12 months (median) follow up catheterisation, 15 (25%) of 59 children developed recoarctation, defined as a gradient > 20 mm Hg. Stretch (balloon circumference--preballoon coarcted segment circumference/preballoon coarcted segment circumference), gain (postballoon coarcted segment circumference--preballoon coarcted segment circumference), and recoil (balloon circumference--postballoon coarcted segment circumference) were calculated from measurements obtained from cineangiograms performed before and immediately after balloon dilatation.

RESULTS

The stretch in 44 children without recoarctation (2.18 (1.23)) was similar (p > 0.1) to that in 15 children with recoarctation (1.90 (0.65)), implying that similar balloon dilating stretch was applied in both groups. Greater gain (p < 0.05) was observed in the group without recoarctation (8.8 (8.0) mm) than in the recoarctation group (5.7 (2.7) mm) but this was not substantiated in the infant population. However, the recoil was greater (p < 0.001) in the group without recoarctation (5.1 (4.3) mm) than in the recoarctation group (2.1 (1.1) mm); this was also true in the infant group.

CONCLUSIONS

Greater recoil in the patients without recoarctation implies preservation of intact elastic tissue in the coarcted segment. In the recoarctation group, with less recoil, the elastic properties may not have been preserved, thereby causing recoarctation. There might be a more severe degree of cystic medial necrosis in the recoarctation group than in the no recoarctation group. This needs confirmation in future studies.

Expression of human prostatic acid phosphatase correlates with androgen-stimulated cell proliferation in prostate cancer cell lines

Androgen plays a critical role in regulating the growth and differentiation of normal prostate epithelia, as well as the initial growth of prostate cancer cells. Nevertheless, prostate carcinomas eventually become androgen-unresponsive, and the cancer is refractory to hormonal therapy. To gain insight into the mechanism involved in this hormone-refractory phenomenon, we have examined the potential role of the androgen receptor (AR) in that process. We have investigated the expression of AR and two prostate-specific androgen-responsive antigens, prostatic acid phosphatase (PAcP) and prostate-specific antigen (PSA), for the functional activity of AR in LNCaP and PC-3 human prostate carcinoma cells. Our results are as follows. (i) Clone 33 LNCaP cells express AR, PAcP, and PSA, and cell growth is stimulated by 5alpha-dihydrotestosterone (DHT). Stimulation of cell growth correlates with decreased cellular PAcP activity. (ii) In clone 81 LNCaP cells, the expression of PAcP decreases with a concurrent decrease in the degree of androgen stimulation of cell growth, whereas the expression of PSA mRNA level is up-regulated by DHT, as in clone 33 cells. Conversely, in PAcP cDNA-transfected clone 81 cells, an additional expression of cellular PAcP correlates with an increased stimulation by androgen, higher than the corresponding control cells. (iii) PC-3 cells express a low level of functional AR with no detectable PAcP or PSA, and the growth of PC-3 cells is not affected by DHT treatment. Nevertheless, in two PAcP cDNA-transfected PC-3 sublines, the expression of exogenous cellular PAcP correlates with androgen stimulation. This androgen stimulation of cell growth concurs with an increased tyrosine phosphorylation of a phosphoprotein of 185 kDa. In summary, the data indicate that the expression of AR alone is not sufficient for androgen stimulation of cell growth. Furthermore, in AR-expressing prostate cancer cells, the expression of cellular PAcP correlates with androgen stimulation of cell proliferation.

Elective coronary artery stenting--immediate and follow up results

Elective coronary artery stenting was performed in 242 consecutive patients in our centre for complex lesions (Type B, C), proximal lesions, restenotic lesions, total occlusion and venous grafts. The procedural success rate was 94.21%. Three patients (1.23%) required emergency coronary artery bypass surgery. Acute and sub-acute thrombosis rate was 1.26% and 4.13%, respectively. There was one in-hospital death (0.41%). 164 patients were followed up clinically for a mean period of 11 +/- 6 months (range 1 month to 30 months). Angiographic follow up was done in 68 patients with a restenosis rate of 16.17%.

Congenital coronary artery abnormalities

Congenital coronary artery abnormalities are rare and account for approximately 0.1 to 2% of congenital heart defects. They may pose significant risk of mortality or morbidity to the patient. The pediatrician and the pediatric cardiologist should be aware of their subtle but very serious presentations and diagnostic steps to be undertaken to pinpoint the diagnosis. Prevention of serious complications from these abnormalities can be achieved by making the appropriate diagnosis and performing timely surgical intervention. This review will discuss the most common congenital coronary artery abnormalities and their management.

Intermediate-term results of Phase I Food and Drug Administration Trials of buttoned device occlusion of secundum atrial septal defects

OBJECTIVES

This study was conducted to evaluate the intermediate-term results of the multi-institutional U.S. trial of the buttoned device for transcatheter closure of atrial septal defects (ASDs).

BACKGROUND

The trial was conducted in three centers (University of Arizona, University of Michigan and University of Wisconsin) under a Food and Drug Administration (FDA)-approved clinical trial with investigational device exemption. Only short-term follow-up is known.

METHODS

All 46 patients who had successful implantation of the device were prospectively followed up. Patients were evaluated at 1, 6 and 12 months after device occlusion and yearly thereafter.

RESULTS

This cohort was followed up from 51 to 68 months (mean 60.8, median 62). Patient ages ranged from 1 to 62 years (median 4); weights ranged from 10 to 105 kg (median 18); and stretched ASD sizes were 14 +/- 4 mm (left to right shunts) and 10 +/- 3 mm (right to left shunts). Of the 46 patients, 45 (98%) had effective occlusion of their ASD, and 34 (74%) had complete ASD closure. The incidence of residual shunts decreased from 65% (30 of 46 patients) at 1 month after device placement to 27% (12 of 45 patients) at last follow-up. All residual shunts were quantitated as trivial. Only two patients (4%) required reintervention for significant residual defects. There were no cases of endocarditis or thromboembolism in 224 patient-years of follow-up.

CONCLUSIONS

In up to 5.5 years of follow-up, the buttoned device provided effective closure in 98% of patients in whom the device was successfully implanted. The incidence of residual shunts decreased during follow-up, and no instances of endocarditis or thromboembolism were observed.

Successful transcatheter closure with the buttoned device of aortopulmonary window in an adult

This case report describes a technique to close an intermediate aortopulmonary window with the use of the buttoned device in an adult.

Long-term follow-up results of balloon angioplasty of postoperative aortic recoarctation

Immediate- and short-term follow-up results of balloon dilatation of aortic recoarctation following surgery have been well documented, but there is sparse data on long-term follow-up. During a 10-year period ending in August 1995, 33 children, aged 2 months to 14 years old, underwent balloon angioplasty of aortic recoarctation. Prior surgery included resection and end-to-end anastomosis (n = 9), subclavian flap (n = 16) or prosthetic (Dacron or Gore-Tex) patch (n = 5) angioplasty, and repair of an interrupted aortic arch (n = 3). Recoarctation developed 1 month to 14 years (mean +/- SD 29 +/- 44 months) after surgery. The indications for angioplasty were peak-to-peak systolic gradients > 20 mm Hg and systemic hypertension and/or congestive heart failure. After balloon angioplasty, the peak-to-peak systolic pressure gradient across the coarctation decreased from 48 +/- 22 to 13 +/- 15 mm Hg (p <0.01), and the size of the coarcted segment increased from 3.3 +/- 1.4 to 6.5 +/- 2.3 mm (p <0.01). Follow-up angiography and/or magnetic resonance imaging were performed in 20 children 17 +/- 12 months after angioplasty. No aneurysms were observed and improvement in the diameter of the coarcted aortic segment (9 +/- 3 mm) persisted. One- to 10-year (median 5) clinical follow-up was available in 32 children. During follow-up, 2 children required surgery to repair a long tubular isthmic narrowing. The residual gradients, determined by arm-leg systolic blood pressure difference, were 5 +/- 8 mm Hg. No patient was symptomatic and only 1 patient (3%) was hypertensive, controlled with antihypertensive medications. We conclude that balloon angioplasty of aortic recoarctation following all types of surgical repair is feasible, safe, and effective with good long-term results. We recommend balloon angioplasty as the procedure of choice in the management of postsurgical recoarctation with hypertension and/or congestive heart failure.

Balloon mitral valvuloplasty with bifoil catheter: immediate and long-term follow-up results

This report documents clinical and hemodynamic benefits of balloon mitral valvuloplasty (BMV) using a bifoil balloon catheter from a single center in 415 consecutive cases of rheumatic mitral stenosis (MS). The procedure was successful in 396 (95.2%) patients, with an increase in mitral valve area (MVA) from 0.82+/-0.35 cm2 to 2.21+/-0.24 cm2 (P < 0.001). There were 2 (0.48%) in-hospital deaths, and 6 (1.44%) patients developed acute mitral regurgitation. The procedural and fluroscopy time was reduced significantly from 52+/-11 and 38+/-6 min to 33+/-7 and 19+/-5 min, respectively, after modifications of technique in our last 326 cases. The bifoil balloon catheter technique is safe and effective, and provides excellent hemodynamic benefits which are sustained at long-term follow-up. This technique should be considered as an addition to the existing armamentarium of interventional cardiologists performing mitral balloon valvuloplasty.

Chest pain in children

Chronic chest pain is a complaint that frequently prompts referral to pediatric cardiology clinics although very few pediatric patients with this symptom will be found to have cardiac disease. This review will discuss the common non-cardiac and cardiac causes of chest pain. Guidelines on the office management of this group of patients will be presented as well as the indications for referring patients for evaluation and treatment by the subspecialist.

Interventional pediatric cardiology: state of the art and future directions

Although the interventional pediatric cardiology began in the early 1950s, it was not until the mid-1980s that a full spectrum of transcatheter interventions in children could be undertaken including balloon atrial septostomy which has been in usage since 1966. Enormous developments have occurred even from the mid-1980s to date. In this review, current state-of-the-art for each broad area of therapeutic catheterization is presented. A large variety of lesions could be opened-up or closed, as the case may be and the results of these interventions were either similar to or better than those reported for the alternative surgical therapy. Indeed, therapeutic catheterization techniques have replaced the conventional surgery for many lesions and are threatening to do so for others. However, long-term follow-up results are scanty and are needed. Further miniaturization of catheters/sheaths used in interventional pediatric cardiology and development of new technology for the lesions which are not amenable to currently available transcatheter methods are awaited. The future seems to be bright for interventional pediatric cardiology.

Effectiveness of five-loop coils to occlude patent ductus arteriosus

Coil occlusion of patent ductus arteriosus with 5-loop coils was undertaken in 10 patients without coil embolizations, and with 90% immediate occlusion and 100% occlusion at follow-up. We conclude that 5-loop coil occlusion of patent ductus arteriosus is safe and effective.

Transcatheter management of neonates with pulmonary atresia and intact ventricular septum

This report describes a 1 day-old infant with valvar pulmonary atresia with intact ventricular septum in whom we were successful in performing transcatheter guidewire perforation and balloon pulmonary valvuloplasty to establish right ventricle-to-pulmonary artery continuity and flow. Also described is implantation of a 4 mm coronary stent into ductus arteriosus in lieu of surgical aortopulmonary shunt to treat pulmonary oligemia and systemic arterial hypoxemia. Details of transcatheter guidewire perforation are presented and it is suggested that this method be used as an alternative to Laser/radio frequency wires, especially in the absence of approval of the latter wires by the regulatory agencies. Stenting of the ductus may be considered an alternative to surgical aortopulmonary shunt. Role of transcatheter technology in the management of selected patients with pulmonary atresia and intact ventricular septum is discussed.

Induction of somatic embryogenesis and plantlets in tendrils of Vitis vinifera L

Somatic embryogenesis was observed in callus initiated from tendril explants of Vitis vinifera L. cvs. Thompson, Sonaka and Tas-e-Ganesh on Emershad and Ramming medium supplemented with 1 µM 6-benzylaminopurine. Low-frequency conversion to shoots was obtained in the third and fourth subculture on the same medium. Emerging shoots subsequently formed complete plantlets on liquid rooting medium containing 1 µM indole-3-acetic acid. The possible use of tendrils as a novel explant for somatic embryogenesis in grape is discussed.

Redox potential measurements of plasma in patients undergoing coronary artery bypass graft and its clinical significance

The apparent redox potentials (Em) of plasma as a marker of oxidant injury during coronary artery bypass graft (CABG) is determined, and their clinical significance is discussed. We measured plasma Em of normal volunteers (n = 20) and samples drawn at different time points from patients undergoing elective CABG (n = 60) directly and by adding 5 microl (20 mM) oxidants or reductants with known redox potential to plasma (95 microl), using a micro Pt/AgCl combination redox electrode. The Em value stays elevated up to 30 min during the surgery, after the administration of protamine it came down toward a more reduced state. Similar changes are seen with the lactate pyruvate ratio. Smaller changes of Em than normal are observed in plasma samples from patients treated with Aprotinin (antiprotease), Carmeda (heparin-coated) circuit and aspirin reflecting their protective effect. Redox potential (Em) measurements appear to be effective and useful in monitoring redox shifts wherever oxidative stress needs to be monitored.

Evaluation of routine postoperative chest X-rays in the management of the cardiac surgical patient

OBJECTIVES

To evaluate the role of routine chest X-rays in the management of patients post cardiac surgery.

METHODS

340 adult patients undergoing cardiac surgery were studied in three consecutive groups (A, B, C) of 100 patients each. Forty patients were excluded due to the intensive care stay greater than 36 h (n = 35), or early mortality within 36 h (n = 5). Routine chest X-rays were performed according to different protocols in Groups A and B. In group C there were no routine chest X-rays during the entire postoperative period [corrected]. In all three groups chest X-rays were performed where clinically indicated. Group A had three routine chest X-rays post-operation. Group B had one routine chest X-ray on day 4 post-operation. Group C had chest X-rays only when indicated. The X-rays were evaluated in terms of their assistance value and the resultant number of interventions.

RESULTS

The three groups were similar preoperatively for age, sex, preoperative left ventricular function, presence of chronic obstructive airway disease and type of operation performed. The total number of chest X-rays in groups A, B and C were 304, 133 and 36, respectively. The number of chest X-rays leading to interventions were five, four and four in groups A, B and C, respectively. Chest X-rays that helped in management were 36, 28, and 28, respectively, in the same groups. There was no mortality or morbidity attributable to non-performance of routine chest X-ray.

CONCLUSIONS

Routine chest X-rays post-cardiac surgery are of very little value and patients are adequately managed by performing chest X-rays only when clinically indicated. There was no increased mortality or morbidity attributed to lack of routine chest X-rays in any of these groups. We recommend performing chest X-rays only when clinically indicated in satisfactorily recovering adult cardiac surgical patients.

Inhibition of tumor angiogenesis using a soluble receptor establishes a role for Tie2 in pathologic vascular growth

Tie2 is a novel receptor tyrosine kinase that is expressed almost exclusively by vascular endothelium. Disruption of Tie2 function in transgenic mice resulted in embryonic lethality secondary to characteristic vascular defects; similar defects occurred after disruption of the Tie2 ligand. These findings indicate that the Tie2/Tie2 ligand pathway plays important roles during development of the embryonic vasculature. To determine whether the Tie2 pathway was involved in pathologic angiogenesis in adult tissues, a soluble form of the extracellular domain of murine Tie2 (ExTek.6His) was developed and used as a Tie2 inhibitor. After a single application of the ExTek.6His protein into a rat cutaneous window chamber, growth of a mammary tumor inside the chamber was reduced by > 75% (P < 0.005), and tumor vascular length density was reduced by 40% when compared with control-treated tumors (P < 0.01). In the rat cornea, ExTek.6His blocked angiogenesis stimulated by tumor cell conditioned media. ExTek.6His protein did not affect the viability of cultured tumor cells, indicating that the antitumor effect of ExTek.6His was due to the inhibition of tumor angiogenesis. These data demonstrate a role for the Tie2 pathway in pathologic angiogenesis, suggesting that targeting this pathway may yield effective antiangiogenic agents for treatment of cancer and other angiogenic diseases.

Role of inverted buttoned device in transcatheter occlusion of atrial septal defects or patent foramen ovale with right-to-left shunting associated with previously operated complex congenital cardiac anomalies

Feasibility, safety, and effectiveness of transcatheter occlusion of atrial septal defect (ASD) with the buttoned device has been demonstrated. Despite its effectiveness in occluding secundum ASD with left-to-right shunt and patent foramina ovalia, presumably responsible for paradoxic embolism, it has limitations in effectively occluding ASD with evident right-to-left shunts. Therefore, the device was modified so that the square-shaped occluder component of the device is on the right atrial side, the inverted buttoned device. This study determines the feasibility, safety, and effectiveness of inverted buttoned device occlusion of atrial defects with right-to-left shunts. During a 17-month period ending August 1996, 12 patients, aged 1.6 to 39.0 years, underwent occlusion of residual ASD after repair of pulmonary atresia/stenosis with intact ventricular septum (n = 5), modified or fenestrated Fontan for tricuspid or pulmonary atresia (n = 5), and double-inlet left ventricle (n = 2). The systemic arterial oxygen saturation increased (p <0.001) from 82 +/- 7% (range 72% to 90%) to 94 +/- 3% (range 88% to 98%). There was no change in heart rate or cardiac index measured by Fick. Right atrial pressure increased by 1 to 4 mm in 5 of 12 patients (42%). There was trivial (n = 5) or no (n = 7) residual shunt by color Doppler study. Six- to 18-month (median 12) follow-up in all 12 patients revealed stable oxygen saturations (92 +/- 3%) by pulse oximetry. Color Doppler studies revealed small (n = 1), trivial (n = 1), or no (n = 10) residual shunt at follow-up. Based on these data, it is concluded that transcatheter occlusion of ASD with right-to-left shunts with inverted buttoned device is feasible in relieving arterial hypoxemia. Further clinical trials in a larger number of patients and careful evaluation of follow-up results are indicated to examine its safety and longer term effectiveness.

Data utilization and analytical skills among NLEP managers. National Leprosy Elimination Programme

Mid-level managers of the National Leprosy Elimination Programme, India were assessed regarding their ability to turn routine data received from primary units into tools for management, analysis and decision making. Sixty-two managers (25 District leprosy officers, 37 Medical officers) were administered a questionnaire containing 20 questions on calculations of rates, ratios, proportions, percentages as well as construction and interpretation of graphs. It was found that 11% of the study subjects scored very poor, 48% scored poor, 35% scored good and only 5% of the managers scored very good. Among the district leprosy officers, 8%, 40%, 48% and 4% were rated as performing very poor, poor, good and very good, respectively. Among the medical officers, the corresponding figures were 14%, 54%, 27% and 5%.

Follow-up results of balloon aortic valvuloplasty in children with special reference to causes of late aortic insufficiency

The purpose of this study was to report on 3- to 9-year follow-up data after balloon aortic valvuloplasty in children and to investigate causes of aortic insufficiency at late follow-up. Although the immediate and short-term results of balloon aortic valvuloplasty have been well documented, little information is available on long-term follow-up results. During a 7.3-year period ending December 1992, 26 young patients, aged 6 weeks to 20 years, underwent balloon aortic valvuloplasty with resultant reduction of peak-to-peak aortic valvar gradient from 71 +/- 20 (mean +/- SD) to 25 +/- 12 mm Hg (p < 0.001). None required immediate surgical intervention. At intermediate-term follow-up, 6 (23%) of 26 had restenosis develop and underwent surgical (4 patients) or repeat balloon valvuloplasty (2 patients). Clinical and echo-Doppler data 3 to 9 years (median 6 years) after balloon valvuloplasty revealed residual peak instantaneous Doppler gradients of 26 +/- 13 mm Hg (p < 0.001), without restenosis beyond what was observed at intermediate-term follow-up. Aortic insufficiency progressed in seven patients. However, none required intervention. Actuarial intervention-free rates at 1, 2, 5, and 9 years were 80%, 76%, 76%, and 76%, respectively. Logistic regression analysis suggested that the degree of Doppler-quantitated aortic insufficiency 1 day after valvuloplasty predicts persistent aortic insufficiency at late follow-up. These data indicate that immediately successful balloon aortic valvuloplasty in children yields a residual gradient of < or = 36 mm Hg at a median of 6 years of follow-up in most patients and an intervention-free rate at 9 years of 76%. Restenosis occurs but can be treated with a repeat intervention with good results. Aortic insufficiency remains stable and does not appear to require intervention, at least during the first decade after balloon dilatation.

Tissue injury and repair as parallel and opposing responses to CCl4 hepatotoxicity: a novel dose-response

Recent studies indicate that the rate and extent of tissue repair, elicited as an endogenous response to toxic insult, are critical determinants in the ultimate outcome of hepatic injury. Therefore, the objective of this study was to develop a dose-response relationship for CCl4 measuring liver injury and tissue repair as two simultaneous but opposing responses. Male Sprague-Dawley rats were injected with a 40-fold dose range of CCl4 (0.1-4 ml/kg i.p.) in corn oil vehicle. Liver injury was assessed by serum enzyme elevations and histopathology, and tissue repair was measured by [3H]thymidine incorporation into hepatonuclear DNA and proliferating cell nuclear antigen immunohistochemistry over a time course of 0 to 96 h. Stimulation of cell division, evident even after a subtoxic dose of CCl4, increased in a dose-dependent manner until a threshold (2 ml/kg) was reached. Doses above this threshold yielded no further increase in tissue repair. Instead, tissue repair response was significantly delayed and diminished. Injury was markedly accelerated above the threshold indicating an unrestrained progression of injury. Although 4 ml CCl4/kg consistently caused 80% lethality by 48 h, tissue repair response in the 20% surviving rats was increased by about 5-fold, aptly demonstrating the critical role of tissue repair in overcoming injury and enabling these animals to survive. This study suggests that, in addition to the extent of tissue repair, the time of onset of tissue repair also determines the extent of hepatic injury and inter-individual differences in the magnitude of tissue repair may contribute significantly to inter-individual differences in susceptibility to toxic chemicals. Thus, while dose-related and prompt stimulation of tissue regeneration leads to recovery, delayed and attenuated repair response, occurring at higher doses, leads to progression of injury and animal mortality. Such dose-response relationships may lead to a better understanding of the underlying cellular mechanisms of injury inflicted by chemical toxicants and aid in fine-tuning risk assessment.

A case-control analysis of risk factors in HIV transmission in South India

A case-control study was done among patients attending our clinic for sexually transmitted diseases in South India to assess risk factors for human immunodeficiency virus (HIV) infection. Of 5,876 patients tested, 105 (1.79%) were HIV antibody positive (87 men, 18 women) by enzyme-linked immunosorbent assay and Western blot. They were compared with an equal number of age- and sex-matched patients without HIV antibody. Risk factors significant in the crude odds ratio analysis were occupation (truck drivers and truck cleaners), age at first exposure, and sexual contact with commercial sex workers. In the logistic regression analysis, only a history of past genital ulcer was a significant risk factor. Other important findings of this study were that (a) the spread of HIV to women is mostly from their infected husbands and (b) regular condom use was reported by less than 8% of patients and controls. Obviously, the current methods of education of the population are far from adequate.