Outcomes With Intermediate Left Main Disease: Analysis From the ISCHEMIA Trial

BACKGROUND

Patients with significant (≥50%) left main disease (LMD) have a high risk of cardiovascular events, and guidelines recommend revascularization to improve survival. However, the impact of intermediate LMD (stenosis, 25%-49%) on outcomes is unclear.

METHODS

Randomized ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) participants who underwent coronary computed tomography angiography at baseline were categorized into those with (25%-49%) and without (<25%) intermediate LMD. The primary outcome was a composite of cardiovascular mortality, myocardial infarction (MI), or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. The primary quality of life outcome was the Seattle Angina Questionnaire summary score.

RESULTS

Among the 3699 participants who satisfied the inclusion criteria, 962 (26%) had intermediate LMD. Among invasive strategy participants with intermediate LMD on coronary computed tomography angiography, 49 (7.0%) had significant (≥50% stenosis) left main stenosis on invasive angiography. Patients with intermediate LMD had a higher risk of cardiovascular events in the unadjusted but not in the fully adjusted model compared with those without intermediate LMD. An invasive strategy increased procedural MI and decreased nonprocedural MI with no significant difference for other outcomes including the primary end point. There was no meaningful heterogeneity of treatment effect based on intermediate LMD status except for nonprocedural MI for which there was a greater absolute reduction with invasive management in the intermediate LMD group (-6.4% versus -2.0%; Pinteraction=0.049). The invasive strategy improved angina-related quality of life and the benefit was durable throughout follow-up without significant heterogeneity based on intermediate LMD status.

CONCLUSIONS

In the ISCHEMIA trial, there was no meaningful heterogeneity of treatment benefit from an invasive strategy regardless of intermediate LMD status except for a greater absolute risk reduction in nonprocedural MI with invasive management in those with intermediate LMD. An invasive strategy increased procedural MI, reduced nonprocedural MI, and improved angina-related quality of life.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT01471522.

Target Vessel Versus Complete Revascularization in Non-ST Elevation Myocardial Infarction Without Cardiogenic Shock

Introduction

The role of complete revascularization (CR) vs target vessel revascularization (TVR) in non-ST-elevation myocardial infarction (NSTEMI) in patients without cardiogenic shock is still not established. In this study, we compared outcomes at one and six months among patients with NSTEMI with multivessel disease (MVD) undergoing CR vs TVR.

Methods

It was a prospective, observational study carried out among 60 NSTEMI patients with MVD (30 undergoing TVR and 30 CR) from October 2018 to November 2019. They were assessed at one and six months for primary and secondary outcomes.

Results

The mean age of the patients was 56.13 ± 9.23 years and both the groups were well matched with respect to age, gender, risk factors, and comorbidities. In the majority of patients, the target vessel was left anterior descending (LAD) followed by right coronary artery (RCA) and left circumflex (LCX) in both groups. The primary outcomes of death from any cause, non-fatal myocardial infarction, and the need for revascularization of the ischemia-driven vessel showed no significant difference at one and six months follow-up between the CR and TVR groups. However, the secondary outcomes of heart failure hospitalizations and angina episodes were significantly more in the TVR group than CR group at one month (6 vs 1, P=0.044), (8 vs 2, P=0.038) and six months (8 vs 2, P=0.038), (9 vs 2, P=0.02), respectively.

Conclusion

CR was associated with no difference in death from all-cause or future revascularization but significantly lesser secondary outcomes of heart failure hospitalizations and angina episodes as compared to TVR in NSTEMI without cardiogenic shock.

Lead one ratio: A new electrocardiogram marker for cardiac resynchronization therapy response

BACKGROUND

Wider QRS duration and presence of left bundle branch block (LBBB) predict better cardiac resynchronization therapy (CRT) response. Despite strict patient selection, one-third of patients have a sub-optimal response. We aim to evaluate the impact of lead one ratio (LOR) on CRT response.

METHODS

We enrolled 93 patients receiving CRT from August 2016 to August 2019. Pre-implant 12-lead electrocardiogram (ECG) was recorded, and LOR was derived by dividing the maximum positive deflection of QRS complex in ECG lead I by the maximum negative deflection in lead I; cut-off value of 12 was used to divide the cohort into two groups. Patients were followed for 6 months, and outcomes were compared for CRT response, New York Heart Association (NYHA) class improvement, all-cause mortality, and heart failure (HF) hospitalization events.

RESULTS

At the end of 6-month follow-up, LOR ≥ 12 was associated with significantly better CRT response (75.76% vs. 51.85% in LOR < 12, P = 0.02), lower mortality per 100 patient-years (9.09 vs. 14.81 in LOR < 12, P = 0.012), and more improvement in HF symptoms (NYHA improvement) (78.79% vs. 55.56% in LOR < 12, P = 0.02). Patients with LOR < 12 had more HF hospitalization events (2.04 vs. 1.81 episodes in LOR ≥ 12, P = 0.029) and less QRS narrowing (∆5.74 ± 2.09 vs. ∆7.10 ± 3.97 ms in LOR ≥ 12, P = 0.01). QRS duration and LBBB morphology were predictors of response in both groups of patients.

CONCLUSION

LOR ≥ 12 was associated with better response to CRT, less HF hospitalization, and more relief in HF symptoms. This ratio helps to identify possible sub-optimal response among patients with an indication for CRT.

Comparing the Modified Frailty Index with conventional scores for prediction of cardiac resynchronization therapy response in patients with heart failure

Objective:

The aim of the study was to compare, Modified Frailty Index (mFI), EAARN (LVEF <22%, Atrial Fibrillation, Age ≥70 years, Renal function (eGFR <60 mL/min/1.73m²), NYHA class IV), and ScREEN (female Sex, Renal function (eGFR ≥60 mL/min/1.73m²), LVEF ≥25%, ECG (QRS duration ≥150 ms) and NYHA class ≤III) score for predicting cardiac resynchronization therapy (CRT) response and all-cause mortality.

Methods:

In this prospective, non-randomized, single-center, observational study we enrolled 93 patients receiving CRT from August 2016 to August 2019. Pre-implant scores were calculated, and patients were followed for six months. Performance of each score for prediction of CRT response (defined as ≥15% reduction in left ventricular end-systolic volume [LVESV]) and all-cause mortality was compared.

Results:

Optimal CRT response was seen in seventy patients with nine deaths. All the three scores exhibited modest performance for prediction of CRT response and all-cause mortality with AUC ranging from 0.608 to 0.701. mFI has an additional benefit for prediction of prolonged post-procedure stay and 30-day rehospitalization events.

Conclusion:

mFI, ScREEN and EAARN score can be used reliably for predicting all-cause mortality and response to CRT.

Cardiovascular outcomes of antidiabetic drugs

Type 2 Diabetes Mellitus (T2DM) is associated with a high risk of atherosclerotic cardiovascular disease (ASCVD). Intensive blood glucose reduction with antidiabetic drugs significantly reduce microvascular complications but there is no strong evidence of reduction in cardiovascular (CV) events. In 2008, the US Food and Drug Administration (FDA) issued guidance to demonstrate cardiovascular safety of newer antidiabetic drugs in addition to reduction in blood glucose level. After which a number of CVOTs were conducted involving newer antidiabetic drugs. The newer drugs (e.g. GLP-1 RAs, SGLT2 inhibitors and DPP 4 inhibitors) might have potential effects on body weight, lipid parameters and blood pressure, as well as endothelial dysfunctions, inflammatory markers and oxidative stress. The current review summarizes the results of the main trials focused on the cardiovascular outcomes of traditional as well as newer antidiabetic drugs.

Six months clinical outcome comparison between quadripolar and bipolar left ventricular leads in cardiac resynchronization therapy: A prospective, non-randomized, single-centre observational study

Background and objectives

Quadripolar left ventricular (LV) leads in cardiac resynchronization therapy (CRT) offer multi-vector pacing with different pacing configurations and hence enabling LV pacing at most suitable site with better lead stability. We aim to compare the outcomes between quadripolar and bipolar LV lead in patients receiving CRT.

Methods

In this prospective, non-randomized, single-center observational study, we enrolled 93 patients receiving CRT with bipolar (BiP) (n = 31) and quadripolar (Quad) (n = 62) LV lead between August 2016 to August 2019. Patients were followed for six months, and outcomes were compared with respect to CRT response (defined as ≥5% absolute increase in left ventricle ejection fraction), electrocardiographic, echocardiographic parameters, NYHA functional class improvement, and incidence of LV lead-related complication.

Results

At the end of six months follow up, CRT with quadripolar lead was associated with better response rate as compared to bipolar pacing (85.48% vs 64.51%; p = 0.03), lesser heart failure (HF) hospitalization events (1.5 vs 2; p = 0.04) and better improvement in HF symptoms (patients with ≥1 NYHA improvement 87.09% vs 67.74%; p = 0.04). There were fewer deaths per 100 patient-year (6.45 vs 9.37; p = 0.04) and more narrowing of QRS duration (Δ12.56 ± 3.11 ms vs Δ7.29 ± 1.87 ms; p = 0.04) with quadripolar lead use. Lead related complications were significantly more with the use of bipolar lead (74.19% vs 41.94%; p = 0.02).

Conclusions

Our prospective, non-randomized, single-center observational study reveals that patients receiving CRT with quadripolar leads have a better response to therapy, lesser heart failure hospitalizations, lower all-cause mortality, and fewer lead-related complications, proving its superiority over the bipolar lead.

Percutaneous management of Stuck Rotational Atherectomy Burr: Experience at a tertiary care centre

Background: The incidence of stuck rotational atherectomy (RA) burr is extremely low, and its description has been sporadic in the literature about the systemic management of this complication. Aims and Objective: The current study was designed to present the experience of our center and propose an algorithm for the retrieval of stuck RA burr. Materials and Methods: We retrospectively evaluated cases of RA between August 2018 to August 2020 at our center. An entrapped RA burr was defined as an inability to move the burr backward without any additional maneuvers during or after the rotablation of a coronary lesion. Angiographic and procedural details were reviewed in the identified cases of entrapped rotablator burr, details of maneuvers used to retract the burr was documented. We further analyzed the literature using PubMed search using the keywords “entrapment of rotablator burr”, “stuck rotablator” and “rotablation complications”. All the articles with entrapped rotablation burr were identified and scrutinized for the techniques used for percutaneous retrieval. Results: Out of the total 5780 Percutaneous coronary intervention (PCI) procedures, RA was performed in 75 patients and RA burr entrapment was confirmed in two cases. Both the cases were seen in patients with angulated and heavily calcified lesions. The cases were managed percutaneously by endovascular maneuvers. A total of 8 techniques were identified by analysis of available literature for burr retrieval with surgery being the favored one. Using the experience of our center and available literature we propose a simplified working algorithm towards systematic management of this complication. Conclusion: RA burr entrapment is rare, but a life-threatening complication, and the operator should be prepared with strategies for successful retrieval of stuck burr. Percutaneous retraction maneuvers should be used as the first-line management for retrieval of stuck burr followed by surgical referral. Using the proposed algorithm this rare complication can be managed systematically and effectively.

Transpedal Approach in Failed Antegrade Attempt of Lower Limb Peripheral Arterial Disease-A Review with Different Treatment Strategies

Transpedal access is an evolving technique primarily used in patients after failed femoral antegrade approach to revascularize complex tibiopedal lesions. In patients who are at high risk for surgery the transpedal access may be the only option in failed antegrade femoral access to avoid amputation of the limbs. In recent years transpedal access is used routinely to revascularize supra-popliteal lesions due to more success and less complications over femoral artery approach. Retrograde approach parse will not give success in all cases and importantly success depends on techniques used. There are different techniques that need to be used depending on lesion characteristics, comorbidities, and hardware available to improve success with less complications. This review provides different strategies for successful treatment of iliac and femoral artery lesions by transpedal approach after failed antegrade femoral attempt.

Role of strain imaging for assessment of myocardial viability in symptomatic myocardial infarction with single vessel disease: An observational study

PURPOSE

To study and evaluate the predictive value of strain imaging parameters in patients undergoing viability assessment postmyocardial infarction (MI) in comparison with Dobutamine stress echocardiography (DSE) alone.

METHODS

This was a prospective observational study (October, 2016-March, 2018), which recruited 100 symptomatic patients with MI, and angiographically proven single vessel disease, LV dysfunction with severe hypokinesia/akinesia on 2D echocardiography and viability proven by baseline DSE. Patients undergoing primary PCI were excluded. Patients were recruited in two groups: DSE alone (first group) and strain imaging with DSE (second group). Revascularization was done in all patients. Patients were assessed at 3 months for functional recovery by 2D echocardiography.

RESULTS

On 3 month follow-up after revascularization, 37 patients (74%) in first group and 33 patients (66.67%) in second group had functional recovery. Dobutamine-stimulated strain parameters such as circumferential strain (CS; P = .005), radial velocity (RV; P < .001), longitudinal strain (LS; P < .001), and longitudinal strain rate (LSR; P < .001) were found to be a significant predictor of viability. The greatest area under the curve (AUC) for the ROC curves was obtained for low dose dobutamine RV (AUC = 0.92), low dose dobutamine LS (AUC = 0.94), and low dose dobutamine LSR (AUC = 0.88). Positive predictive value of the combination of low dose DSE with strain parameters (RV-97.2%, LS-97.4%, and LSR-87.5%) for myocardial viability was significantly higher than low dose DSE positive/low dose strain parameters negative patients as well as low dose DSE group alone.

CONCLUSION

Evaluation of strain parameters with low dose DSE is clinically feasible for the detection of myocardial viability and adds incremental value to the subjective and semiquantitative wall-motion scoring. LS at low dose DSE with WMSI was found to have the highest positive predictive value.

Baseline Predictors of Low-Density Lipoprotein Cholesterol and Systolic Blood Pressure Goal Attainment After 1 Year in the ISCHEMIA Trial

BACKGROUND

Risk factor control is the cornerstone of managing stable ischemic heart disease but is often not achieved. Predictors of risk factor control in a randomized clinical trial have not been described.

METHODS AND RESULTS

The ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) randomized individuals with at least moderate inducible ischemia and obstructive coronary artery disease to an initial invasive or conservative strategy in addition to optimal medical therapy. The primary aim of this analysis was to determine predictors of meeting trial goals for LDL-C (low-density lipoprotein cholesterol, goal <70 mg/dL) or systolic blood pressure (SBP, goal <140 mm Hg) at 1 year post-randomization. We included all randomized participants in the ISCHEMIA trial with baseline and 1-year LDL-C and SBP values by January 28, 2019. Among the 3984 ISCHEMIA participants (78% of 5179 randomized) with available data, 35% were at goal for LDL-C, and 65% were at goal for SBP at baseline. At 1 year, the percent at goal increased to 52% for LDL-C and 75% for SBP. Adjusted odds of 1-year LDL-C goal attainment were greater with older age (odds ratio [OR], 1.11 [95% CI, 1.03-1.20] per 10 years), lower baseline LDL-C (OR, 1.19 [95% CI, 1.17-1.22] per 10 mg/dL), high-intensity statin use (OR, 1.30 [95% CI, 1.12-1.51]), nonwhite race (OR, 1.32 [95% CI, 1.07-1.63]), and North American enrollment compared with other regions (OR, 1.32 [95% CI, 1.06-1.66]). Women were less likely than men to achieve 1-year LDL-C goal (OR, 0.68 [95% CI, 0.58-0.80]). Adjusted odds of 1-year SBP goal attainment were greater with lower baseline SBP (OR, 1.27 [95% CI, 1.22-1.33] per 10 mm Hg) and with North American enrollment (OR, 1.35 [95% CI, 1.04-1.76]).

CONCLUSIONS

In ISCHEMIA, older age, male sex, high-intensity statin use, lower baseline LDL-C, and North American location predicted 1-year LDL-C goal attainment, whereas lower baseline SBP and North American location predicted 1-year SBP goal attainment. Future studies should examine the effects of sex disparities, international practice patterns, and provider behavior on risk factor control.

Embolized Guidewire into Central Aorta: A Nightmare in the Pediatric Intensive Care Unit

A 4-month-old preterm, critically ill infant weighing 3.8 kg was admitted to our pediatric intensive care unit with congestive cardiac failure due to a large ventricular septal defect and its sequelae. During an attempt to insert a central line into the right subclavian vein at bedside, the guidewire inadvertently entered the subclavian artery and embolized distally. After multiple failed retrieval attempts, including surgical femoral cut-down to retrieve the wire, it was removed finally by fluoroscopic-guided percutaneous catheterization with the help of a cardiac bioptome and a gooseneck snare utilizing a novel maneuver.

Acute effect of primary PCI on diastolic dysfunction recovery in anterior wall STEMI - A non-invasive evaluation by echocardiography

BACKGROUND

It is well established fact that acute coronary occlusion leads to diastolic dysfunction, followed by systolic dysfunction when myonecrosis occur. It is also proven that primary percutaneous coronary intervention (PPCI) is an excellent therapy for ST elevation myocardial infarction (STEMI) to improve outcomes. However there is a paucity of information on efficacy of PPCI in improving diastolic function. Evaluation of the role of PPCI in improving diastolic dysfunction is required.

METHODS

61 patients with first anterior wall STEMI who underwent PPCI to left anterior descending artery were included. Echocardiographic evaluation was performed within 24 h of PPCI and then on day 15, 3 months and 6 months after PPCI. We evaluated the prevalence of diastolic dysfunction after PPCI and its recovery during 6 months along with effect of duration of chest pain on diastolic function.

RESULTS

54.1% of patients had diastolic dysfunction after PPCI whereas it was only 21.3% after 6 months (p value < 0.001). Diastolic function indices like deceleration time, isovolumic relaxation time, E wave, A wave, E/A ratio, left atrial volume and index improved statistically from baseline to 6 months except mitral E/e' ratio. As time required to achieve reperfusion increases (chest pain duration and D to B time) the incidence of residual diastolic dysfunction also increases (p value < 0.001). Patients with TIMI flow < III had more diastolic dysfunction (p value < 0.001).

CONCLUSIONS

Primary PCI improves diastolic dysfunction in patients with anterior wall STEMI over a period of 6 months. Time to achieve reperfusion and effectiveness of reperfusion have significant effect on diastolic dysfunction.

"Double Ball Valve Mechanism Obstructing Both Right Ventricular Inflow and Outflow": Atypical Presentation of Right Atrial Myxoma Presenting as Right Ventricular Mass

Large intracavitary masses such as those occupying most of a cardiac chamber and obstructing blood flow are not routinely encountered in clinical practice. The differential diagnosis includes neoplastic as well as nonneoplastic causes. Primary cardiac tumors by themselves are uncommon. We hereby report a rare case of a middle-aged female presenting with New York Heart Association Class III symptoms, whose transthoracic echocardiogram revealed a huge mass in right-sided chambers with a novel double ball valve type movement. She successfully underwent urgent surgical resection of the mass with histopathological confirmation of diagnosis.

Large pectoral haematoma post-transradial catheterisation: an unusual but avoidable complication

Large pectoral haematoma is an extremely rare complication of transradial catheterisation. Branch or main vessel injury due to luminal passage of guidewires and catheters may lead to bleeding and haematoma formation at adjacent sites along the vessel track. We present a 53-year-old post-transradial catheterisation patient, who complained of chest pain due to right axillary artery branch perforation causing haematoma, which was emergently managed by embolisation with autologous coagulated blood.

An unconventional valvuloplasty: severe pulmonary stenosis with 'candy cane' inferior vena cava

Femoral vein is the usual approach to balloon pulmonary valvuloplasty (BPV). However, alternative access may be mandated in some peculiar situations. We hereby report a 10-year-old patient with symptomatic severe valvular pulmonary stenosis with interrupted inferior vena cava which was successfully treated with transjugular BPV. Technical considerations for this approach as well as other possible options for such patients are discussed.

Asymptomatic late embolization of Amplatzer septal occluder device

Atrial septal defects of Ostium Secundum type with suitable anatomy and margins are commonly closed with septal occluder devices. With the increasing number of catheterization laboratories and increasing availability of different devices, the device closure procedure is very commonly performed in different institutes. Embolization of the septal occluder is one of the most dreaded complications of this procedure, which usually occurs in the early hours or days after the procedure. We report a case of silent embolization of the Amplatzer septal occluder, detected seven months after its use to close an Ostium Secundum atrial septal defect, which was detected during pre-anaesthetic evaluation and echocardiography for non-cardiac surgery. The patient denied having any symptom in-between. The device was retrieved and the defect was closed surgically.

Ruptured submitral aneurysm

Submitral aneurysm is a rare entity, with around few hundred cases reported till date. Presentation can be varied. We describe here a case of submitral aneurysm in a young male with rupture into the left atrium cavity.

A case of sinus venosus atrial septal defect misdiagnosed as primary pulmonary hypertension

We present a case of sinus venosus atrial septal defect in a patient who was previously diagnosed as having primary pulmonary hypertension in a tertiary care center. Our findings are based on 2-dimensional trans-thoracic echocardiography, chest X-ray and surface electrocardiogram. A 26-year-old man, previously diagnosed as a case of primary pulmonary hypertension, presented to the emergency department (ED) with chest pain and breathlessness on exertion. Cardiac biomarkers were within their normal ranges. Surface electrocardiogram showed right atrial and ventricular overload with right axis deviation. Chest imaging noted enlarged central pulmonary vascularity with bilateral plethoric lung fields. Trans-thoracic echocardiography showed a dilated right atria and ventricle with severe tricuspid regurgitation and severe pulmonary artery hypertension with an intact atrial septum. Surprisingly, the transoesophageal echocardiogram revealed the presence of a sinus venous superior vena cava-type atrial septal defect with the right pulmonary vein draining into the right atria. In this full-text version, we present a more detailed discussion of sinus-venous atrial septal defect associated with partial anomalous pulmonary venous return that was wrongly diagnosed as a case of primary pulmonary hypertension in a tertiary care center.

Successful percutaneous management of Lutembacher syndrome

BACKGROUND

The surgical management of Lutembacher syndrome is straight forward but percutaneous management, though technically demanding, is always desirable.

METHODS

A 17 year old unmarried female presented with severe Mitral stenosis and a 19 mm almost circular Ostium secundum ASD with moderate pulmonary artery hypertension and dilated right sided chambers. She was managed in a staged manner. Percutaneous trans mitral commissurotomy (PTMC) was done first, using a 26 mm Inoue balloon catheter set, and after 48 h, ASD was closed with a 20 mm Cocoon Septal Occluder.

RESULTS

The mitral valve area increased after PTMC from 0.8 cm2 to 2.1 cm2 and QP/QS decreased from 4.9 to 2. ASD was successfully closed under echocardiographic and fluoroscopic guidance.

CONCLUSION

Percutaneous management of the Lutembacher syndrome (PTMC and ASD device closure) is an effective and low risk procedure and avoids considerable morbidity and mental trauma for the patients.

Image quality associated with the use of an MR-compatible incubator in neonatal neuroimaging

OBJECTIVES

MRI in the neonate poses significant challenges associated with patient transport and monitoring, and the potential for diminished image quality owing to patient motion. The objective of this study was to evaluate the usefulness of a dedicated MR-compatible incubator with integrated radiofrequency coils in improving image quality of MRI studies of the brain acquired in term and preterm neonates using standard MRI equipment.

METHODS

Subjective and objective analyses of image quality of neonatal brain MR examinations were performed before and after the introduction of an MR-compatible incubator. For all studies, the signal-to-noise ratio (SNR) was calculated, image quality was graded (1-3) and each was assessed for image artefact (e.g. motion). Student's t-test and the Mann-Whitney U-test were used to compare mean SNR values.

RESULTS

39 patients were included [mean gestational age 39 weeks (range 30-42 weeks); mean postnatal age 13 days (range 1-56 days); mean weight 3.5 kg (range 1.4-4.5 kg)]. Following the introduction of the MR-compatible incubator, diagnostic quality scans increased from 50 to 89% and motion artefact decreased from 73 to 44% of studies. SNR did not increase initially, but, when using MR sequences and parameters specifically tailored for neonatal brain imaging, SNR increased from 70 to 213 (p=0.001).

CONCLUSION

Use of an MR-compatible incubator in neonatal neuroimaging provides a safe environment for MRI of the neonate and also facilitates patient monitoring and transport. When specifically tailored MR protocols are used, this results in improved image quality.

A two-centre collaborative study on clinico-epidemiological profile of a recent outbreak of epidemic dropsy in New Delhi (India) with special emphasis on its cardiac manifestations in pediatric patients

A hundred and six clinically diagnosed cases of epidemic dropsy, admitted in June to August 1998 to the P-III unit of RML Hospital and the Department of Pediatrics, Safdarjang Hospital, were studied. All of them consumed mustard oil contaminated with Argemona mexicana, confirmed by ferric chloride and nitric acid tests. No specific sex predilection was seen. No child was affected below the age of 3 years. Pedal edema and reddish hyperpigmentation were the most consistent findings (100 per cent). Frank cardiac failure was seen in only 24 (22.64 per cent), yet persistent tachycardia was alarmingly high (104/106, i.e. 98.4 per cent). Notably ECG showed prolonged Q-T interval in 24 children (22.64 per cent), unrelated to serum Ca2+ level in patients with congestive cardiac failure (CCF). Color Doppler echocardiography showed biventricular dilatation in all the 24 patients with CCF. Wide pulse pressure was recorded in two patients only. Mortality occurred in only two patients (1.89 per cent). Eye involvement was a late finding. All those who survived (i.e. 104/106) recovered completely, except two patients who were left with sarcoid-like changes of skin telangiectasia.

Eosinophilic cholecystitis as a possible late manifestation of the eosinophilia-myalgia syndrome

We describe a case of acute acalculous cholecystitis occurring in a 43-year-old woman with a history of the eosinophilia-myalgia syndrome, associated with the ingestion of 1-tryptophan. The patient underwent a laparoscopic cholecystectomy and subsequent histological examination of the gallbladder revealed an infiltrate predominantly of eosinophils, suggesting a possible relationship to the underlying condition. This may represent a late complication of the eosinophilia-myalgia syndrome--such an association has not previously been reported in the literature. The gastrointestinal and hepatic complications of this syndrome are discussed.

Experimental investigation and mathematical modeling of Pluronic F127 gel dissolution: drug release in stirred systems

We have examined the dissolution of Pluronic F127 gels in a USP dissolution apparatus under stirred conditions, and simultaneously monitored the release of model drugs from these gels. The drugs selected were propranolol HCl, metronidazole and cephalexin. Our results show that drug release is zero-order and is controlled by the dissolution of the gel for all the drugs, under various conditions of temperature, F127 concentration, drug concentration, and for stirring speeds between 20 and 80 rpm. The addition of inorganic salts has no significant effect on dissolution rate or drug release. Increasing F127 concentration in the gel decreases gel dissolution and drug release rates. We have developed a predictive mathematical model based on the assumption that uptake of water into the gel and subsequent disentanglement of F127 micelles control gel dissolution. There is good agreement between experimental results and model predictions for stirring speeds above 20 rpm. As stirring speed is decreased to 20 rpm and below, there are discrepancies between actual and predicted values, presumably due to a significant diffusion component that contributes to drug release.

Non-specific inflammatory gingival enlargement--a case report

An unusual case of unilateral idiopathic gingival hyperplasia in a 6 year old child is reported and its management discussed.

Effect of Salts on the Micellization, Clouding, and Solubilization Behavior of Pluronic F127 Solutions

We have examined the effect of NaCl, Na(2)SO(4), Na(3)PO(4), and NaSCN on F127 solutions; properties examined were critical micellization temperature (cmt), cloud point, and solubilization of a model hydrophobic drug, propyl paraben. Static light scattering showed that the first three salts lower the cmt of F127 in the order Na(3)PO(4)>Na(2)SO(4)>NaCl. The extent of lowering depends on the salt concentration and can be ascribed to the water structure-making properties of these salts. NaSCN, a water structure breaker, was found to increase cmt. Pyrene fluorescence was used to study the changes in micellar interior in the presence of salts. We found that the micellar micropolarity is not significantly changed by salts, evidenced by a constant I(1)/I(3) ratio of pyrene. However, the I(e)/I(3) ratio changes significantly with salts, being lower for NaCl, Na(2)SO(4), and Na(3)PO(4) and higher for NaSCN. This is consistent with an increase in the total hydrophobic micellar domain, in micellar microviscosity, or both. Solubilization of propylparaben increases in the presence of Na(3)PO(4), consistent with a larger hydrophobic domain for solubilization. The thermodynamics of micellization continue to be entropically driven in the presence of salts, evidenced by a positive entropy overcoming an unfavorable enthalpy. Copyright 2000 Academic Press.

A Study of the Temperature-Dependent Micellization of Pluronic F127

We have examined the temperature-dependent micellization of the pharmaceutically important PEO-PPO-PEO copolymer, Pluronic F127, using static light scattering and various aspects of the pyrene fluorescence spectrum (monomer intensity, excimer formation and the I1/I3 ratio). All techniques gave essentially the same value for the critical micellization temperatures (cmt) of various F127 solutions, and our results agreed with those reported in the literature. Cmt values decrease with increasing F127 concentration. We observed significant solubilization of pyrene in F127 solutions below the cmt, which was also reflected in the measured I1/I3 ratios. The thermodynamics of the micellization process were studied and gave different results at low and high F127 concentrations. In the low F127 concentration range (up to approximately 50 mg/mL), we obtain DeltaH = 312 kJ mol-1 and DeltaS = 1.14 kJ mol-1 K-1. Above 50 mg/mL we obtain DeltaH = 136 kJ mol-1 and a DeltaS = 0.54 kJ mol-1 K-1. This discontinuity in thermodynamic behavior can be due to a change in aggregation number with temperature and/or a change in the micellization process at higher concentrations. Copyright 1999 Academic Press.

Conjunctival impression cytology for detection of early vitamin A deficiency in children

Children presenting with recurrent infections have a high risk of developing vitamin A deficiency. Conjunctival impression cytology (CIC) was used in the present study in such children to detect subclinical deficiency and to monitor the outcome after therapy. Seventy children with history of recurrent infections, and 10 healthy children in the age group of six months to five years were included in the study. CIC was performed using millipore filter paper and stained with PAS stain. A three tier grading system was used consisting of normal, borderline abnormal and abnormal for interpretation. Vitamin A supplementation was given in children in the latter two categories. Repeat cytology showed reversal to normal in these children. Hence in children with high risk of developing vitamin A deficiency, it is suggested to do CIC for detection and monitoring it.

The 'mouse face' appearance of the vertebrae in Paget's disease

Paget's disease is occasionally found as an incidental finding on bone scans performed for the evaluation of metastatic disease, which causes a diagnostic and a subsequent therapeutic dilemma. We have previously described the "Mouse Face" appearance of vertebrae on bone scans (increased uptake in the vertebral body, posterior elements, and the spinous process), which was fairly specific for Paget's disease in a small series. This retrospective study was undertaken to determine if this observation holds true in a larger series. Bone scans performed in 2,881 patients were randomly selected, and were reviewed by 2 physicians. Thirty-nine cases with a "Mouse Face" appearance were identified. Diagnosis was established in 30 of the 39 patients by correlative radiographic studies and/or clinical follow-up. Twenty patients were referred for the evaluation of possible metastases, and 7 were found to have metastases at the sites of "Mouse Face". The other 13 had Paget's disease. However, 6 of the 7 patients with metastases had extravertebral findings compatible with multiple metastases, and the remaining patient had a "Mouse Face" lesion only, with a question of metastases. Ten patients were evaluated for Paget's disease or others, and none of them had metastases at the site of the "Mouse Face". The "Mouse Face" appearance is more suggestive of Paget's disease than metastases even in patients with cancer. These patients should be assumed unlikely to have vertebral metastases, unless proven by another correlative radiologic study.

Brain perfusion imaging during preoperative temporary balloon occlusion of the internal carotid artery

The main objective of this study was to assess whether 99mTc-HMPAO brain SPECT imaging can identify patients at high risk of developing an infarct following permanent carotid occlusion in the course of brain surgery.

METHODS

Test balloon occlusion of the internal carotid artery was performed in 44 patients with a variety of head and neck tumors or aneurysms. Technetium-99m-HMPAO was injected intravenously while the balloon was initiated and a SPECT study was obtained 30 min later. Follow-up CT scans were obtained routinely for all patients at 2 wk and 1 mo following surgery, or earlier when necessary. Thirty patients and five normal volunteers had semiquantitative analysis of cerebral perfusion.

RESULTS

Twenty-six patients demonstrated ipsilateral perfusion abnormalities during trial occlusion. Eight patients in this group underwent bypass grafting prior to sacrifice of the artery: two resulting in infarcts. Eighteen patients had symmetric cerebral perfusion during occlusion and four of these patients underwent permanent therapeutic carotid occlusion; three patients had subsequent infarcts and the fourth patient had an impending stroke.

CONCLUSION

Patients with symmetric cerebral perfusion measured by 99mTc-HMPAO SPECT may still have a high long-term complication rate following carotid sacrifice. The scan findings in these patients were not predictive of the outcome. Patients with asymmetric cerebral perfusion had alternative therapeutic approach to carotid sacrifice and most of them had good surgical outcomes.

Reversible cerebral perfusion abnormalities associated with cyclosporine therapy in orthotopic liver transplantation

A 60-yr-old woman experienced several episodes of generalized seizures following 2 wk of immunosuppressive therapy with cyclosporine for orthotopic liver transplantation. CT showed low density in the white matter of the parieto-occipital lobes. A 99mTc-HMPAO brain SPECT showed diminished perfusion in the parieto-occipital cortex bilaterally. Although the cyclosporine was discontinued, the patient's neurologic status initially worsened and then improved over the next several days. Repeat perfusion brain SPECT showed resolution of most of the perfusion abnormalities, while repeat CT showed persistent white matter changes in the parieto-occipital lobes. We report the presence of reversible cortical perfusion abnormalities in conjunction with cyclosporine therapy. The findings suggest that perfusion brain SPECT may be a sensitive monitor of cyclosporine-induced neurotoxicity.