Coronary-pulmonary fistula with common sac: An uncommon variant

A 68-year-old male patient presented with chief complaints of chest pain and dyspnea on exertion. On physical examination, his pulse was regular at 82 bpm and blood pressure was 140/80 mmHg. Resting electrocardiography (ECG) was within normal limit and chest X-ray also did not reveal any significant abnormality. Routine blood investigations were unremarkable; transthoracic echocardiography also did not show any significant abnormality. Catheter coronary angiography revealed severe triple vessel disease and showed possibility of coronary artery fistula. Computed tomography (CT) coronary angiography showed three aberrant branches arising from right and left coronary arteries forming a sac which subsequently opened into the main pulmonary artery.

Management of joint dislocations of the lower limb in Larsen syndrome: practical approach

INTRODUCTION Larsen syndrome is an autosomal-dominant osteochondrodysplasia characterised by large joint dislocations and craniofacial anomalies. CASE HISTORY We present a rare case of Larsen syndrome with bilateral dislocated hips and knees and severe clubfeet at 7-year follow-up. We undertook bilateral open reduction of both hips at age 8 months. This procedure was preceded by open reduction and left-knee V-Y quadricepsplasty at age 4 months following a failed trial of closed reduction of the left knee. Both feet had a severe deformity (Pirani score of 5.5 and 6.0) and were treated using the Ponseti method, but the left foot relapsed at 24 months and required posteromedial release. CONCLUSIONS We tried to address the difficult questions on the timing and sequence of surgical interventions by treating clubfeet and dislocated knees early using Ponseti casts which included the knees. Open reduction of hips was done later, and further interventions were guided by functional needs.

The effect of a dedicated Ponseti service on the outcome of idiopathic clubfoot treatment

We report the effect of introducing a dedicated Ponseti service on the five-year treatment outcomes of children with idiopathic clubfoot. Between 2002 and 2004, 100 feet (66 children; 50 boys and 16 girls) were treated in a general paediatric orthopaedic clinic. Of these, 96 feet (96%) responded to initial casting, 85 requiring a tenotomy of the tendo-Achillis. Recurrent deformity occurred in 38 feet and was successfully treated in 22 by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior, The remaining 16 required an extensive surgical release. Between 2005 and 2006, 72 feet (53 children; 33 boys and 20 girls) were treated in a dedicated multidisciplinary Ponseti clinic. All responded to initial casting: 60 feet (83.3%) required a tenotomy of the tendo-Achillis. Recurrent deformity developed in 14, 11 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The other three required an extensive surgical release. Statistical analysis showed that children treated in the dedicated Ponseti clinic had a lower rate of recurrence (p = 0.068) and a lower rate of surgical release (p = 0.01) than those treated in the general clinic. This study shows that a dedicated Ponseti clinic, run by a well-trained multidisciplinary team, can improve the outcome of idiopathic clubfoot deformity.

Assessing the impact of irrigation treatments on thiram residual trends: correspondence with numerical modelling and field-scale experiments

The present study was undertaken to study the trends of transport of thiram, a dithiocarbamate pesticide, at different time and depth in the fields under real field conditions for wheat crop. Numerical simulations were carried out by solving the coupled soil-water content movement and mass transport equations using HYDRUS- 1D. The supplementary data used for paramaterization of HYDRUS-1D comprise of irrigation treatments, climatic conditions, and soil characteristics. Results focus on the effects and influence of irrigation treatments on pesticide persistence and mobility. Modelling results were in good agreement with the experimentally determined thiram concentrations. Application of the model to measured field data of thiram movement indicates that the modelling approach can provide reliable and useful estimates of the mass flux of water and non-volatile pesticide in vadose zone. For policy-makers and planners, some regulation strategies are suggested for controlling inappropriate pesticide application under deficit irrigation or rain-fed conditions.

The association between clubfoot and developmental dysplasia of the hip

The association between idiopathic congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip is uncertain. We present an observational cohort study spanning 6.5 years of selective ultrasound screening of hips in clubfoot. From 119 babies with CTEV there were nine cases of hip dysplasia, in seven individuals. This suggests that 1 in 17 babies with CTEV will have underlying hip dysplasia. This study supports selective ultrasound screening of hips in infants with CTEV.

Soluble endothelial cell adhesion molecules and their relationship to disease activity in Takayasu's arteritis

OBJECTIVE

To investigate soluble (s) E-selectin, vascular cell adhesion molecule-1 (VCAM-1), and intercellular cell adhesion molecule-1 (ICAM-1), and their relationship to disease activity in Takayasu's arteritis (TA).

METHODS

Levels of adhesion molecules were measured by enzyme immunoassay in the sera of 35 patients with TA, 17 healthy controls, and 15 patients with 12 months followup.

RESULTS

Compared to controls, patients had elevated levels of sE-selectin (54.5 +/- 35.0 vs 36.4 +/- 13.0 ng/ml, p < 0.05), sVCAM-1 (280.9 +/- 267.6 vs 141.2 +/- 76.1 ng/ml, p < 0.05), and sICAM-1 (261.3 +/- 168.1 vs 198.3 +/- 74.3 ng/ml, p < 0.05). Compared to controls, patients with inactive TA also had elevated levels of sE-selectin (67.4 +/- 45.9 vs 36.4 +/- 13.0 ng/ml, p < 0.02), sVCAM-1 (327.6 +/- 327.8 vs 141.2 +/- 76.1 ng/ml, p < 0.02), and sICAM-1 (321.9 +/- 179.5 vs 198.3 +/- 74.3 ng/ml, p < 0.02). There was no difference between active TA and controls. sE-selectin had a trend towards increased levels in inactive versus active TA (67.4 +/- 45.9 vs 44.9 +/- 20.3 ng/ml p = 0.059), but there was no difference in sVCAM-1 and sICAM-1 levels between the groups. No adhesion molecule levels showed a change among followup patients.

CONCLUSION

Patients with inactive TA have elevated levels of sE-selectin, sVCAM-1, and sICAM-1 that might indicate persistent vasculopathy in clinically inactive disease.

Treatment of idiopathic club foot using the Ponseti method. Initial experience

We report our initial experience of using the Ponseti method for the treatment of congenital idiopathic club foot. Between November 2002 and November 2004 we treated 100 feet in 66 children by this method. The standard protocol described by Ponseti was used except that, when necessary, percutaneous tenotomy of tendo Achillis were performed under general anaesthesia in the operating theatre and not under local anaesthesia in the out-patient department. The Pirani score was used for assessment and the mean follow-up time was 18 months (6 to 30). The results were also assessed in terms of the number of casts applied, the need for tenotomy of tendo Achillis and recurrence of the deformity. Tenotomy was required in 85 of the 100 feet. There was a failure to respond to the initial regimen in four feet which then required extensive soft-tissue release. Of the 96 feet which responded to initial casting, 31 (32%) had a recurrence, 16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The remaining 15 required extensive soft-tissue release. Poor compliance with the foot-abduction orthoses (Denis Browne splint) was thought to be the main cause of failure in these patients.

Is secondary radiological follow-up of infants with a family history of developmental dysplasia of the hip necessary?

The practice of regular radiological follow-up of infants with a positive family history of developmental dysplasia of the hip is based on the widespread belief that primary acetabular dysplasia is a genetic disorder which can occur in the absence of frank subluxation or dislocation. We reviewed all infants who were involved in our screening programme for developmental dysplasia of the hip, between November 2002 and January 2004, and who had a normal clinical and ultrasound examination of the hip at six to eight weeks of age, but who, because of a family history of developmental dysplasia of the hip, had undergone further radiography after an interval of 6 to 12 months. The radiographs of 89 infants were analysed for signs of late dysplasia of the hip and assessed independently by three observers to allow for variability of measurement. There were 11 infants (11%) lost to follow-up. All the patients had normal radiographs at the final follow-up and none required any intervention. We therefore question the need for routine radiological follow-up of infants with a positive family history of developmental dysplasia of the hip, but who are normal on clinical examination and assessment by ultrasound screening when six to eight weeks old.

Elastic stable intramedullary nail fixation for severely displaced fractures of the neck of the radius in children

Several techniques are available for the treatment of displaced fractures of the neck of the radius in children. We report our experience in 14 children treated by indirect reduction and fixation using an elastic stable intramedullary nail. The patients were followed up for a mean of 28 months. One developed asymptomatic avascular necrosis. The rest had excellent results. One had a neuropraxia of the posterior interosseous nerve, which recovered within six weeks. We advocate elastic stable intramedullary nailing for the closed reduction and fixation of these fractures in children.

Pulmonary thromboembolism in Klippel–Trenaunay–Weber syndrome – should all cases be anticoagulated?

Klippel–Trenaunay–Weber syndrome (KTWS) is a congenital disorder characterized by a triad of varicose veins and venous malformation involving one or more extremities, cutaneous haemangioma, and hypertrophy of soft tissue and bone. The syndrome is rare and it usually presents as varicose veins or cutaneous naevi. We report a patient with KTWS who developed superficial thrombophlebitis in her varicose veins and died from a pulmonary embolism. To optimize management it is important to recognize the syndrome, and the patient should ideally be referred for multidisciplinary vascular care and all such patients should be anticoagulated in the long term.

Intermittent electromechanical dissociation due to mechanical prosthetic valve dysfunction

We describe a patient who developed the rare hemodynamic phenomenon of intermittent electromechanical dissociation during normal sinus rhythm at about four months after mitral valve replacement with a Medtronic Hall prosthesis, along with resuspension of the papillary muscles using Gore-Tex sutures. Echocardiographic examination confirmed the presence of a filamentous structure that could be either suture material, tissue tag or thrombus, and was entangling intermittently in the prosthesis. The patient recovered spontaneously after a three-week symptomatic period, with no subsequent evidence of either electromechanical dissociation or the filamentous structure; normal prosthetic valve function was restored. During a subsequent three-month follow up period, the patient was asymptomatic, with normal prosthetic valve function. The diagnostic and hemodynamic aspects of this case are discussed.

Percutaneous Ethibloc injection in aneurysmal bone cysts

OBJECTIVE

To investigate whether the injection of Ethibloc into aneurysmal bone cysts can be an effective treatment modality.

DESIGN AND PATIENTS

Ethibloc is an alcoholic solution of zein (corn protein) which has thrombogenic and fibrogenic properties. Ten patients with aneurysmal bone cysts were treated with CT-guided percutaneous injection of Ethibloc into the cyst cavity. Ethibloc injection was the primary treatment in five patients. Four patients had recurrence following previous curettage and bone grafting and one patient had not responded to injection into the lesion of autologous iliac crest bone marrow aspirate. Three patients needed a second injection. The median follow-up was 27 (6-60) months.

RESULTS AND CONCLUSION

Symptoms were relieved in all patients. At imaging, seven patients had resolution of the lesion and three had partial response at the most recent follow-up. Complications consisted of a local transitory inflammatory reaction in two patients and an aseptic abscess in one patient. This relatively simple, minimally invasive procedure makes an operation unnecessary by stopping the expansion of the cyst and inducing endosteal new bone formation. This technique may be used as the primary management of aneurysmal bone cysts excluding spinal lesions.

Picroliv protects against alcohol-induced chronic hepatotoxicity in rats

Daily administration of ethyl alcohol (3.76 g/kg, p.o.) for 45 days resulted in significant changes in several biochemical parameters of the liver and serum of albino rats. After exposure to alcohol for 30 days when Picroliv (12 mg/kg, p.o.), an iridoid glycoside fraction of Picrorhiza kurroa, was administered for 15 days along with alcohol, the degree of change in most of the parameters was reduced.

Percutaneous autogenous bone marrow grafting in 20 cases of ununited fracture

We grafted autogenous bone marrow percutaneously to stimulate healing in 20 ununited long bone fractures. 15-20 mL of bone marrow was injected twice, with an interval of 3 weeks. All cases were immobilized in a plaster cast. 17 cases united in 5 (3-7) months.

Perfusion with picroliv reverses biochemical changes induced in livers of rats toxicated with galactosamine or thioacetamide

Perfusion of liver of rats toxicated with galactosamine or thioacetamide with a 0.02% solution of picroliv (glycoside fraction of Picrorhiza kurroa) for 30 min (1 ml/min; 6 mg/rat), significantly reversed toxicant-induced changes in the activities of several enzymes. Galactosamine induced increases in the activities of alkaline phosphatase, gamma-glutamyl transpeptidase, acid ribonuclease, acid phosphatase, succinate dehydrogenase and decreases in the activities of Na(+)-K(+)-adenosine triphosphatase (ATPase) and glucose-6-phosphatase (reversed by 40-87%). Similarly, thioacetamide-induced inhibitions of the activities of Na(+)-K(+)-ATPase, Ca(++)-ATPase, Mg(++)-ATPase, succinate dehydrogenase and elevations in the activities of alkaline phosphatase, gamma-glutamyl transpeptidase, and acid ribonuclease were also significantly reversed. A significant reversal of the toxicants-induced decrease in [14C]-leucine incorporation was also observed. These results indicate that picroliv can also reverse D-galactosamine- or thioacetamide-induced hepatic damage in rats.

Picroliv protects against aflatoxin B1 acute hepatotoxicity in rats

The hepatoprotective activity of Picroliv, a standardized iridoid glycoside fraction of Picrorhiza kurroa, has been investigated by studying the protection of biochemical and histological changes induced in livers of rats given single oral doses (7 mg/kg) of aflatoxin B1. Administration of aflatoxin B1 resulted in a significant increase in 5'-nucleotidase, r-glutamyl transpeptidase, acid ribonuclease, total lipids, cholesterol and lipid peroxides in liver and transaminases, alkaline phosphatase and bilirubin in serum. However, the activity of glucose 6-phosphatase and levels of cytochrome P450, cytochrome b5, DNA, RNA, proteins and glycogen in liver and total proteins in serum decreased. The liver histology showed ballooned hepatocytes, degeneration, microvesicular fat, focal necrosis, bile duct hyperplasia and proliferation of oval and spindle cells in portal tracts. When Picroliv (25 mg/kg x 7 days) was given to aflatoxin B1 toxicated rats, the majority of the biochemical and histological changes were significantly protected. The findings indicate a hepatoprotective activity of Picroliv against aflatoxin B1 toxicity in rats.

Picroliv and its components kutkoside and picroside I protect liver against galactosamine-induced damage in rats

D-Galactosamine (800 mg/kg, intraperitoneally) caused significant decrease in the activities of 5'-nucleotidase, glucose-6-phosphatase and cytochrome P450 and increase in activities of gamma-glutamyl transpeptidase, succinate dehydrogenase, acid phosphatase and acid ribonuclease in liver after 24 hr. The levels of RNA, protein and glycogen decreased while total lipids, phospholipids, cholesterol and lipid peroxides increased. It also increased the serum levels of transaminases, alkaline phosphatase and bilirubin while protein concentration decreased significantly. Oral administration of Picroliv (12 mg/kg/day for 7 days), a standardised iridoid glycoside fraction of Picrorhiza kurroa, significantly prevented the biochemical changes in liver and serum of galactosamine-toxicated rats. Kutkoside (12 mg/kg/day for 7 days) also protected against changes in most of the hepatic and serum constituents studied. Another iridoid glycoside from Picroliv, Picroside I, at the same dose level could only prevent toxicant-induced changes in acid phosphatase, phospholipids and lipid peroxides in liver and alkaline phosphatase in serum. Mixture of Picroside I and Kutkoside in the ratio of 1:1.5 at 12 mg/kg dose elicited lesser response than Picroliv.

Effects of picroliv, the active principle of Picrorhiza kurroa, on biochemical changes in rat liver poisoned by Amanita phalloides

The efficacy of Picroliv, a standardized iridoid glycoside fraction of Picrorhiza kurroa, was studied against the Amanita phalloides-induced biochemical changes in rat liver. A phalloides (50 mg.kg-1) caused significant increases in the activities of hepatic 5'-nucleotidase, gamma-glutamyl transpeptidase, acid ribonuclease, and succinate dehydrogenase, but a decrease in glucose-6-phosphatase. The level of cytochrome P-450 in microsomal fraction and content of glycogen in liver showed significant depletions. Picroliv (25 mg.kg-1.d-1 x 10 d) provided significant restorations of all the biochemical changes poisoned by A phalloides except cytochrome P-450 and glycogen. These results demonstrated the protective effect of Picroliv against A phalloides-induced hepatotoxicity in rats.

Percutaneous bone-marrow grafting of osteotomies and bony defects in rabbits

The effects of percutaneous bone-marrow grafting done on the fifth day after osteotomies and induced defects of the shaft of the radius were studied in 41 adult rabbits. At 2 and 3 weeks, the callus volume was larger in the grafted radii than in the controls. Serial radiographs and gross and histologic findings confirmed that percutaneous bone-marrow grafting improved healing of osteotomies and defects at 4 weeks.

Picroliv protects against monocrotaline-induced hepatic damage in rats

Monocrotaline, a pyrrolizidine alkaloid, caused changes in most of the biochemical parameters in rats 12 days after a single dose of 120 mg/kg. These included significantly increased activities of hepatic succinate dehydrogenase, acid ribonuclease, acid phosphatase, gammaglutamyl transpeptidase and 5'-nucleotidase and decreased in the activities of glucose-6-phosphatase and cytochrome P450. The levels of DNA, RNA and glycogen in liver and albumin and protein in serum decreased while serum bilirubin increased. The histopathological changes in liver were characterized by diffused hepatocyte alterations in the form of ballooning, granular cytoplasm, indistinct cell outlines, nuclear changes, focal necrosis, and vascular damage. When picroliv, a standardized iridoid glycoside fraction of Picrorhiza kurroa, was administered orally in a dose of 25 mg/kg simultaneously with monocrotaline, alterations in most of the biochemical parameters along with the histopathological changes in liver caused by monocrotaline were prevented.

Hepatoprotective activity of picroliv against carbon tetrachloride-induced liver damage in rats

Administration of carbon tetrachloride to normal rats increased activities of hepatic 5(1)-nucleotidase, acid phosphatase, acid ribonuclease while the activities of succinate dehydrogenase, glucose 6-phosphatase, superoxide dismutase and cytochrome P450 were decreased. Levels of lipid peroxides, total lipids and cholesterol of liver were also increased. The activities of serum glutamate oxaloacetate transaminase, glutamate pyruvate transaminase and alkaline phosphatase were increased. Other serum parameters showing changes after carbon tetrachloride were: bilirubin, proteins, cholesterol, triglycerides and lipoprotein-X. Picroliv (from the plant Picrorhiza kurroa) in doses of 6 and 12 mg/kg provided a significant protection against most of the biochemical alterations produced by carbon tetrachloride. The degree of protection afforded by picroliv, when administered simultaneously or as a pretreatment was almost equal.

Evaluation of hepatoprotective activity of picroliv (from Picrorhiza kurroa) in Mastomys natalensis infected with Plasmodium berghei

Administration of picroliv, a standardized fraction of alcoholic extent of Picrorhiza kurroa (3-12 mg/kg/day for two weeks) simultaneously with P. berghei infection showed significant protection against hepatic damage in Mastomys natalensis. The increased levels of serum glutamate oxaloacetate transaminase (GOT), glutamate pyruvate transaminase (GPT), alkaline phosphatase, lipoprotein-X (LP-X) and bilirubin in the infected animals were marked reduced by different doses of picroliv. In the liver, picroliv decreased the levels of lipid peroxides and hydroperoxides and facilitated the recovery of superoxide dismutase and glycogen. Picroliv had no effect on the degree of parasitaemia.

Sterols of Acanthamoeba culbertsoni strain A-1

Two new sterols, stigmasta-5,7,22,25-tetraene-3 beta -ol (1) and stigmasta-5,7,14,22,25-pentaene-3 beta -ol (2), have been characterized along with ergosterol and 7-dehydrostigmasterol in the nonsaponifiable fraction of the total lipids extracted from trophozoites of Acanthamoeba culbertsoni strain A-1 (virulent strain). However, these sterols were found to be absent in the nonpathogenic strain C-7 of A. culbertsoni.

Changes in the lipid composition and activities of isocitrate dehydrogenase and isocitrate lyase during encystation of Acanthamoeba culbertsoni strain A-1

The contents of total lipids, total sterols, total and individual phospholipids: lysophosphatidyl choline, lysophosphatidyl ethanolamine, phosphatidyl choline, phosphatidyl ethanolamine and alkali-stable phospholipids I and II, were significantly lower in mature cysts of Acanthamoeba culbertsoni strain A-1 than in trophozoites. The major constituent sterols of trophozoites, viz. ergosterol, 7-dehydrostigmasterol and 7,22,25-tridehydrostigmasterol which resolved as a single spot on thin-layer chromatography, disappeared in the cysts. When trophozoites grown in the presence of [14C]acetate were transferred to encystation medium, there was a steady decrease in the radioactivity in the lipids and acid-soluble fraction (glycogen) of the encysting cells while the radioactivity increased in the akali-insoluble fraction (cellulose). The activity of isocitrate lyase in the encysting cells steadily increased up to 24 h of encystation, followed by a slight decrease during 24-32 h, but the activity of isocitrate dehydrogenase steadily decreased up to 32 h of encystation, beyond which time no enzyme activity was detected. Inhibitors of isocitrate lyase, glycolate and maleate at 8.5 to 34 mM concentration inhibited encystation by 18-67%.

Effect of alloxan diabetes on some aspects of lipid metabolism in albino rats

Administration of alloxan (40 mg/kg i.v.) caused a marked decrease in the lipolytic and esterolytic activities of rat aorta. This effect was completely reversed when the diabetic rats were treated with low doses of insulin (2-3 U/die) for 3 days. The insulin-dependence of esterolysis and lipolysis in rat aorta and the role of hydrolases in atherogenesis in experimental diabetes have been discussed.