Modified Senning procedure in a patient with dextrocardia with left atrial isomerism and anomalous systemic venous drainage: a rare case report

The atrial switch procedure by Senning or Mustard technique primarily aims in correcting parallel systemic and pulmonary circulations at atrial level. This procedure may be used in late presenting D-transposition of great arteries with a deconditioned left ventricle, congenitally corrected transposition of great arteries and isolated ventricular inversion. We describe the case of a child with dextrocardia, left atrial isomerism with complex pulmonary and systemic venous drainage resulting in mixing at atrial level. She was successfully operated by modified Senning procedure performed through the left-sided atrium.

Total Aortic Arch and Neoaortic Root Replacement Following Stage III Palliation for Hypoplastic Left Heart Syndrome

Progressive dilatation of the neoaortic root and reconstructed aortic arch is a serious complication after the Norwood procedure. There are no clear guidelines on the management of this complex anatomy in the setting of single ventricle physiology, and the surgical treatment of such an entity remains anecdotal. We describe a successful surgical repair in a 15-year-old girl presenting with a severely dilated neoaortic root and aortic arch causing compression and narrowing of the left pulmonary artery after successful three-stage palliation for hypoplastic left heart syndrome.

Surgical management of a giant pulmonary artery aneurysm in a patient with ischaemic heart disease - a case report

Association of Pulmonary Artery Aneurysm with Ischemic Heart Disease is uncommon, and its surgical management has been rarely described in the literature. Surgical intervention should be individualised according to the coexisting diseases and comorbidities to achieve optimal outcome. We report a case of a 76-year-old man with background history of coronary artery stenting due to ischaemic heart disease. The patient presented with features of coronary compression due to giant pulmonary artery aneurysm. He was operated with replacement of aneurysmal pulmonary trunk with 25 mm Hancock conduit.

Microbial contamination in herbal medicines available in Bangladesh

Plants have long been used as herbal medicines in many countries. However, microbial contamination of these medicines may affect human health. Present study was performed to assess the pathogenic proliferation in the locally available commercial herbal oral medicines. The pathogenic load was compared with the microbiological standard given by the British Pharmacopoeia. Out of 85 oral liquid samples, 2 were found to be highly contaminated with a total aerobic bacterial load of 1.24 x 10(5) cfu/ml, 10 samples were contaminated with fungi (1.2 x 10(4)-6.3 x 10(4) cfu/ml). Tests for specific pathogens were carried out. One sample showed contamination by coliforms but none of the samples were contaminated by Salmonella spp. and Shigella spp. Among 40 semisolid samples, one showed to be contaminated with bacteria (1.93 x 10(5) cfu/g) and 5 samples consisted of fungal load ranging between 1.5 x 10(4)-2.2 x 10(4) cfu/g. The presence of bacteria and fungi in these samples thus suggest the fact that aseptic handling is necessary during processing of oral herbal medicines.

Don't neglect 'neglect'- an update on post stroke neglect

OBJECTIVES

Post-stroke neglect is common and an independent predictor of functional outcome. Assessment of neglect is very demanding, the treatment extremely difficult and the literature vast; we performed a literature search for all aspects of this difficult subject.

METHODS

We searched the PubMed, EMBASE databases and historical manuals for authoritative studies on post stroke neglect between 1951 and 2011.

FINDINGS

There is a great dearth of randomised controlled data on neglect because standardised assessment does not occur frequently. Eighty-eight manuscripts were identified in the literature, which were quite heterogeneous in their content and addressing diverse aspects of this clinical entity.

INTERPRETATION AND IMPLICATIONS

The most important historical papers were selected along with the most widely accepted and proven strategies for assessment and treatment. Standardised assessment of neglect does not always occur, but several useful strategies are available and are described in the following sections.

Advances in spontaneous intracerebral haemorrhage

OBJECTIVES

  To assess the evidence and available literature on the clinical, pathogenetic, prognostic and therapeutic aspects of intracerebral haemorrhage.

METHODS

  The most important manuscripts and reviews on the subject were considered. Information was collected from Medline, Embase & National Library of Medicine over the last 40 years up to Oct 2011. The bibliographies of relevant articles were searched for additional references. The most up to date and randomised trials were given preference. Clinical guidelines including AHA/ASA, Royal college of Physicians, NICE, Scottish Intercollegiate guidelines and several others were taken into consideration.

FINDINGS

  There are numerous advances in the understanding of the pathogenesis and management, but hardly any change in the overall mortality in the last few decades. There is a poor understanding of the results of surgical trials that has resulted in a large drop in surgical intervention since 2007. INTERPRETATIONS AND IMPLICATIONS:  Advances in neuroimaging and neurophysiology have improved our understanding of the mechanisms of neuronal injury and existence of perihaematomal 'tissue at risk'. Numerous new therapeutic targets have been identified. There is a lot of misunderstanding of the results of the newer surgical trials which need to be clarified. The importance of cerebral amyloid angiopathy and microbleeds in older patients is increasingly recognised. Control of hypertension is the most important public health measure. Stroke units provide the best outcomes for the patients.

Effect of biotin supplementation on hoof health and ceramide composition in dairy cattle

The effect of biotin supplementation on various foot lesions and hoof ceramide composition of toe (wall) and sole portions of hooves was studied in crossbred dairy cattle. Biotin supplementation was done for five months in 14 cattle at a farm and the other 14 animals kept as control. A significant decline was observed in heel erosions and sole avulsions along with total disappearance of white line fissures and double soles in the biotin supplemented cattle resulting in decrease in the overall disease score. Thin layer chromatographs of the hoof lipids revealed 11 types of ceramides in sole lipids and 6 types of ceramides in toe (wall) lipids. The ceramides were typed and identified according to their Rf values. A qualitative increase in the density of thin layer chromatographs of sole lipids was observed in biotin supplemented cattle whereas a non-significant difference in density of thin layer chromatographs of toe lipids was observed after supplementation of biotin.

Carotid and vertebral artery dissection syndromes

Cervicocerebral arterial dissections (CAD) are an important cause of strokes in younger patients accounting for nearly 20% of strokes in patients under the age of 45 years. Extracranial internal carotid artery dissections comprise 70%-80% and extracranial vertebral dissections account for about 15% of all CAD. Aetiopathogenesis of CAD is incompletely understood, though trauma, respiratory infections, and underlying arteriopathy are considered important. A typical picture of local pain, headache, and ipsilateral Horner's syndrome followed after several hours by cerebral or retinal ischaemia is rare. Doppler ultrasound, MRI/MRA, and CT angiography are useful non-invasive diagnostic tests. The treatment of extracranial CAD is mainly medical using anticoagulants or antiplatelet agents although controlled studies to show their effectiveness are lacking. The prognosis of extracranial CAD is generally much better than that of the intracranial CAD. Recurrences are rare in CAD.

Value of routine duodenal biopsy in diagnosing coeliac disease in patients with iron deficiency anaemia

BACKGROUND

Iron deficiency anaemia (IDA) is a recognised feature of coeliac disease in adults and can be its only presentation.

OBJECTIVE

To determine the yield of routine distal duodenal biopsies in diagnosing coeliac disease in adult and elderly patients with IDA whose endoscopy revealed no upper gastrointestinal cause of iron deficiency.

STUDY DESIGN

Prospective study in a teaching hospital endoscopy unit.

METHOD

Altogether 504 consecutive patients with IDA, aged 16-80 years, attending for endoscopy were included in this study. At least two distal duodenal biopsies were taken if endoscopy revealed no cause of iron deficiency.

RESULT

In nine (1.8%) patients duodenal biopsies revealed typical histological features of coeliac disease. Of these, five patients were above 65 years old.

CONCLUSION

In adult and elderly patients undergoing endoscopy for IDA, the endoscopist should take distal duodenal biopsies to exclude coeliac disease if no upper gastrointestinal cause of anaemia is found. Coeliac disease is not an uncommon cause of IDA in patients >65 years of age and a history of chronic diarrhoea increases diagnostic yield in this age group.

Neuropsychiatric non-motor aspects of Parkinson's disease

Parkinson's disease is often recognised as a motor disease characterised by rest tremor, rigidity, bradykinesia, and postural disturbances. However, there are several non-motor aspects of the disease that are of at least equal importance in the management of patients with Parkinson's disease. They include depression, cognitive impairment, anxiety, and psychosis among others. It is important to recognise them, as they are common and they contribute significantly to patients' morbidity, quality of life, and institutionalisation to long term care homes. In addition to the disease duration and severity, other factors including drugs may contribute to their occurrence. Pathogenesis of these aspects is not fully understood, though there has been a significant increase in the knowledge in recent years. Management of these aspects involves a multidisciplinary approach.

Acceptability of oesophagogastroduodenoscopy without intravenous sedation: patients' versus endoscopist's perception with special reference to older patients

BACKGROUND

Unsedated oesophagogastroduodenoscopy (OGD) is considered by most endoscopists to be a quick, safe, and well tolerated procedure. Older patients are said to tolerate it better than younger patients. However, patients' perception of the discomfort for the unsedated OGD has not been well studied.

OBJECTIVE

This study was undertaken to compare (1) patients' perception of discomfort with the endoscopist's perception of patients' discomfort for the unsedated OGD, (2) tolerability between older (> or =75 years) and younger (<75 years) patients.

DESIGN AND SUBJECTS

A total of 130 consecutive patients attending a day case endoscopy unit were recruited for the study. The patients and endoscopist recorded their assessment using a visual analogue scale (VAS). The results were analysed using non-parametric tests. Thirty patients were excluded from the study based on exclusion criteria. Sixty three (57%) patients were aged > or =75 years and 37 (43%) were <75 years.

RESULTS

A significant difference was noted between patients' perception of the discomfort and the endoscopist's assessment of the patient's discomfort as suggested by the overall higher VAS scores for patients (median 4.9, SD 2.6) than those of the endoscopist (median 2.2, SD 1.2), giving a significant difference in median VAS score of 3.4 (p<0.001). Older and younger patients had similar scores, with median (SD) VAS scores of 4.8 (2.5) for > or =75 years and 4.9 (2.8) for <75 years. The endoscopist's median scores for these two groups were 2.2 (1.2) and 2.1 (1.3), respectively.

CONCLUSIONS

Patients' discomfort during OGD performed without sedation was greatly underestimated by the endoscopist. There was no significant difference in acceptability between old and the young patients.

Recurrent autumnal psychosis

Acute confusional states in the older patient often have a remediable cause. Every effort should be made to ascertain the cause so that appropriate treatment can be given and future episodes prevented. A patient is described who presented with recurrent episodes of acute psychosis after ingestion of Atropa belladonna (deadly nightshade).

Arterial strokes associated with factor V Leiden mutation

A 41-year-old Caucasian woman was admitted with right hemiparesis and blurred vision. There was no history of hypertension, diabetes, ischaemic heart disease, previous stroke, oral contraceptive use or miscarriages nor any family history of stroke. She was a non-smoker. Clinical examination confirmed the presence of right-sided weakness. There were no carotid bruits and her fundi were normal. Computed tomography scan of the brain confirmed the presence of a large infarct in the right middle cerebral artery territory (Figure 1). Full blood count, urea, creatinine, glucose and cholesterol levels were normal. Autoimmune profile, including antinuclear antibody, antineutrophil cytoplasmic antibody and anticardiolipin antibody, were negative. Other thrombophilia tests, including lupus anticoagulant, antithrombin III, plasminogen and protein S levels, were normal. Her electrocardiogram, chest X-ray, echocardiogram and a carotid Doppler study were unremarkable. A thrombophilia screen revealed markedly decreased activated protein C activity at 1.32 (normal ratio 2.25—2.63) when tested with factor V deficient plasma suggestive of factor V Leiden mutation.

Outcome of renal replacement therapy in the very elderly

BACKGROUND

In a retrospective case-note and computer database analysis we assessed the outcome of very elderly patients (> or = 75 years old) with end-stage renal disease (ESRD) on renal replacement therapy (RRT).

METHODS

Fifty-eight individuals aged 75 or over (group 1) commenced RRT between 1 January 1991 and 31 December 1995. Comparisons were made with other patients commencing RRT who were divided into two groups: group 2 (201 individuals 65-74 years old) and group 3 (379 patients <65 years old). All subjects were followed up until the point of assessment (30 June 1998), the time of death, or withdrawal from dialysis. Survival rates in the three groups were compared using Kaplan-Meier method. The number of hospital admissions, length of in-patient stay, and complications rate on RRT were assessed for group 1.

RESULTS

One-year survival rates in groups 1, 2 and 3 were 53.5, 72.6, and 90.6% respectively and the 5-year survival rates were 2.4, 18.8, and 61.4% respectively. The very elderly spent 20% of their time in hospital, 46% had two co-morbid factors at the outset, and 26% developed multiple complications while on RRT. Withdrawal from dialysis remained the most common cause of death in this group of individuals (38%), followed by cardiovascular causes (24%) and infections (22%).

CONCLUSION

Very elderly ESRD patients on RRT have a very poor outcome and, since they are the largest growing group of RRT patients, this has important implications for future health policies.

Three-dimensional structure of physalis mottle virus: implications for the viral assembly

The structure of the T=3 single stranded RNA tymovirus, physalis mottle virus (PhMV), has been determined to 3.8 A resolution. PhMV crystals belong to the rhombohedral space group R 3, with one icosahedral particle in the unit cell leading to 20-fold non-crystallographic redundancy. Polyalanine coordinates of the related turnip yellow mosaic virus (TYMV) with which PhMV coat protein shares 32 % amino acid sequence identity were used for obtaining the initial phases. Extensive phase refinement by real space molecular replacement density averaging resulted in an electron density map that revealed density for most of the side-chains and for the 17 residues ordered in PhMV, but not seen in TYMV, at the N terminus of the A subunits. The core secondary and tertiary structures of the subunits have a topology consistent with the capsid proteins of other T=3 plant viruses. The N-terminal arms of the A subunits, which constitute 12 pentamers at the icosahedral 5-fold axes, have a conformation very different from the conformations observed in B and C subunits that constitute hexameric capsomers with near 6-fold symmetry at the icosahedral 3-fold axes. An analysis of the interfacial contacts between protein subunits indicates that the hexamers are held more strongly than pentamers and hexamer-hexamer contacts are more extensive than pentamer-hexamer contacts. These observations suggest a plausible mechanism for the formation of empty capsids, which might be initiated by a change in the conformation of the N-terminal arm of the A subunits. The structure also provides insights into immunological and mutagenesis results. Comparison of PhMV with the sobemovirus, sesbania mosaic virus reveals striking similarities in the overall tertiary fold of the coat protein although the capsid morphologies of these two viruses are very different.