Post-infarction ventricular septal defect: percutaneous or surgical management in the UK national registry

AIMS

Post-infarction ventricular septal defect (PIVSD) is a mechanical complication of acute myocardial infarction (AMI) with a poor prognosis. Surgical repair is the mainstay of treatment, although percutaneous closure is increasingly undertaken.

METHODS AND RESUTS

Patients treated with surgical or percutaneous repair of PIVSD (2010-2021) were identified at 16 UK centres. Case note review was undertaken. The primary outcome was long-term mortality. Patient groups were allocated based upon initial management (percutaneous or surgical). Three-hundred sixty-two patients received 416 procedures (131 percutaneous, 231 surgery). 16.1% of percutaneous patients subsequently had surgery. 7.8% of surgical patients subsequently had percutaneous treatment. Times from AMI to treatment were similar [percutaneous 9 (6-14) vs. surgical 9 (4-22) days, P = 0.18]. Surgical patients were more likely to have cardiogenic shock (62.8% vs. 51.9%, P = 0.044). Percutaneous patients were substantially older [72 (64-77) vs. 67 (61-73) years, P < 0.001] and more likely to be discussed in a heart team setting. There was no difference in long-term mortality between patients (61.1% vs. 53.7%, P = 0.17). In-hospital mortality was lower in the surgical group (55.0% vs. 44.2%, P = 0.048) with no difference in mortality after hospital discharge (P = 0.65). Cardiogenic shock [adjusted hazard ratio (aHR) 1.97 (95% confidence interval 1.37-2.84), P < 0.001), percutaneous approach [aHR 1.44 (1.01-2.05), P = 0.042], and number of vessels with coronary artery disease [aHR 1.22 (1.01-1.47), P = 0.043] were independently associated with long-term mortality.

CONCLUSION

Surgical and percutaneous repair are viable options for management of PIVSD. There was no difference in post-discharge long-term mortality between patients, although in-hospital mortality was lower for surgery.

Primary percutaneous coronary intervention in nonagenarians: is it worthwhile?

Background

Previous studies have demonstrated the feasibility of primary percutaneous coronary intervention (PPCI) in carefully selected nonagenarians. Although current guidelines recommend immediate revascularization in patients with ST elevation myocardial infarction (STEMI) it remains unclear whether PPCI reduces mortality in nonagenarians. The objective of this study is to compare mortality in nonagenarians presenting via the PPCI pathway who undergo coronary intervention, versus those who are managed medically.

Methods and results

A total of 111 consecutive nonagenarians who presented to our tertiary center via the PPCI pathway between July 2013 and December 2018 with myocardial infarction were included. Clinical and angiographic details were collected alongside data on all-cause mortality. The final diagnosis was STEMI in 98 (88.3%) and NSTEMI in 13 (11.7%). PPCI was performed in 42 (37.8%), while 69 (62.2%) were medically managed. A significant number of the medically managed cohort had atrial fibrillation (23.2% vs 2.4% p = 0.003) and presented with a completed infarct (43.5% vs 4.8% p = 0.001). Other baseline and clinical variables were well matched in both groups. There was a trend towards increased 30-day mortality in the medically managed group (40.6% vs 23.8% p = 0.07). Kaplan Meier survival analysis demonstrated a significant difference in survival by 3 years (48.1% vs 21.7% p = 0.01). This was the case even when those with completed infarcts were excluded (44.3% vs 14.6%, p = 0.01).

Conclusion

In this series of selected nonagenarians presenting with acute myocardial infarction, those undergoing PPCI appeared to have a lower mortality compared to those managed medically.

Radial versus femoral vascular access in ST-elevation myocardial infarction: Are the results of femoral operators unfairly represented in observational research?

BACKGROUND

Recent randomized controlled trials comparing femoral and radial access in primary percutaneous coronary intervention (PPCI) have shown conflicting results regarding the incidence of major adverse cardiovascular events (MACE) and major bleeding.

METHODS

Using data from the HEAT-PPCI trial, we compared the primary efficacy (all-cause mortality, stroke, new myocardial infarction or unplanned repeat revascularization) and safety (major bleeding BARC 3-5) outcomes at 28 days, by final access site used (radial or femoral) and by default operator type. We then assessed outcomes in femoral cases performed by both operator types.

RESULTS

Radial access (RA) was associated with fewer MACE (91/1472 = 6.2% vs. 36/332 = 10.8% P = .003) and major bleeding events (38/1472 = 2.6% vs 22/332 = 6.6% P = .001) when compared to femoral access (FA). When analyzing outcomes by default operator type, there was a similar incidence of MACE (111/1575 = 7% vs 16/229 = 7% P = .97) and major bleeding events (49/1575 = 3.1% vs 11/229 = 4.8% P = .18). In cases where FA was performed by default radial operators, there was a higher rate of MACE (22/122 = 18% vs 14/210 = 6.7% P = .003) and major bleeding events (11/122 = 9% vs 11/210 = 5.2% P < .001), potentially explained by a higher risk profile in these cases.

CONCLUSION

Default femoral operators achieved comparable outcomes when compared to default radial operators. The less favorable outcomes observed in FA cases may result from its selective use by radial operators in high risk cases.

Efficacy and safety of carfilzomib regimens in multiple myeloma patients relapsing after autologous stem cell transplant: ASPIRE and ENDEAVOR outcomes

Autologous stem cell transplantation (ASCT) is a standard treatment for eligible multiple myeloma (MM) patients, but many patients will relapse after ASCT and require subsequent therapy. The proteasome inhibitor carfilzomib is approved for relapsed or refractory MM (RRMM). In phase 3 trials, carfilzomib-based regimens (ASPIRE, carfilzomib-lenalidomide-dexamethasone; ENDEAVOR, carfilzomib-dexamethasone) demonstrated superior progression-free survival (PFS) compared with standard therapies for RRMM (ASPIRE: lenalidomide-dexamethasone; ENDEAVOR, bortezomib-dexamethasone). This subgroup analysis of ASPIRE and ENDEAVOR evaluated outcomes according to prior ASCT status. In total, 446 patients in ASPIRE and 538 in ENDEAVOR had prior ASCT. Median PFS was longer for carfilzomib-based regimens vs non-carfilzomib-based regimens for patients with prior ASCT (ASPIRE: 26.3 vs 17.8 months (hazard ratio (HR)=0.68); ENDEAVOR: not estimable vs 10.2 months (HR=0.61)), those with one prior line of therapy that included ASCT (ASPIRE: 29.7 vs 17.8 months (HR=0.70); ENDEAVOR: not estimable vs 11.2 months (HR=0.46)), and those without prior ASCT (ASPIRE: 26.4 vs 16.6 months (HR=0.76); ENDEAVOR: 17.7 vs 8.5 months (HR=0.43)). Overall response rates also favored the carfilzomib-based regimens. No new safety signals were detected. This analysis suggests that carfilzomib-based treatment may lead to improvement in PFS and response rates regardless of prior transplant status. Further evaluation is warranted.

Balloon-Expandable Transcatheter Aortic Valves Can Be Successfully and Safely Implanted Transfemorally Without Balloon Valvuloplasty

OBJECTIVES

To assess the necessity for balloon aortic valvuloplasty (BAV) during transfemoral transcatheter aortic valve implantation (TAVI) when using balloon-expandable valves.

BACKGROUND

BAV is a usual part of TAVI procedures, prior to valve implantation. However, the benefits and necessity of this are unknown and recent evidence in self-expanding valves suggests it may not be necessary.

METHODS

Retrospective single-center study of 154 patients undergoing first-time, transfemoral TAVI for native aortic valve stenosis, with (N = 76), and without (N = 78), BAV as part of the procedure. Data collected included demographic, procedural, and outcome data.

RESULTS

BAV did not alter VARC-2 defined procedural success or early safety compared to not performing a BAV, including mortality, degree of aortic regurgitation, or need for post-TAVI balloon dilatation, although there was a strong trend to reduced stroke when not performing a BAV. There was a significantly reduced procedural time (P = 0.01) and fluoroscopic time (P < 0.001) without performing a BAV. There were no differences in cerebral embolization (solid, gaseous, or total emboli) noted between the 2 groups, as measured on transcranial doppler (TCD).

CONCLUSIONS

TAVI can be effectively and safely performed without a BAV and this results in reduced procedural and fluoroscopic times, although embolization to the brain is not reduced. There is a trend toward reduced stroke risk. (J Interven Cardiol 2016;29:319-324).

Percutaneous Device Closure of Paravalvular Leak: Combined Experience From the United Kingdom and Ireland

BACKGROUND

Paravalvular leak (PVL) occurs in 5% to 17% of patients following surgical valve replacement. Percutaneous device closure represents an alternative to repeat surgery.

METHODS

All UK and Ireland centers undertaking percutaneous PVL closure submitted data to the UK PVL Registry. Data were analyzed for association with death and major adverse cardiovascular events (MACE) at follow-up.

RESULTS

Three hundred eight PVL closure procedures were attempted in 259 patients in 20 centers (2004-2015). Patient age was 67±13 years; 28% were female. The main indications for closure were heart failure (80%) and hemolysis (16%). Devices were successfully implanted in 91% of patients, via radial (7%), femoral arterial (52%), femoral venous (33%), and apical (7%) approaches. Nineteen percent of patients required repeat procedures. The target valve was mitral (44%), aortic (48%), both (2%), pulmonic (0.4%), or transcatheter aortic valve replacement (5%). Preprocedural leak was severe (61%), moderate (34%), or mild (5.7%) and was multiple in 37%. PVL improved postprocedure (P<0.001) and was none (33.3%), mild (41.4%), moderate (18.6%), or severe (6.7%) at last follow-up. Mean New York Heart Association class improved from 2.7±0.8 preprocedure to 1.6±0.8 (P<0.001) after a median follow-up of 110 (7-452) days. Hospital mortality was 2.9% (elective), 6.8% (in-hospital urgent), and 50% (emergency) (P<0.001). MACE during follow-up included death (16%), valve surgery (6%), late device embolization (0.4%), and new hemolysis requiring transfusion (1.6%). Mitral PVL was associated with higher MACE (hazard ratio [HR], 1.83; P=0.011). Factors independently associated with death were the degree of persisting leak (HR, 2.87; P=0.037), New York Heart Association class (HR, 2.00; P=0.015) at follow-up and baseline creatinine (HR, 8.19; P=0.001). The only factor independently associated with MACE was the degree of persisting leak at follow-up (HR, 3.01; P=0.002).

CONCLUSION

Percutaneous closure of PVL is an effective procedure that improves PVL severity and symptoms. Severity of persisting leak at follow-up is independently associated with both MACE and death. Percutaneous closure should be considered as an alternative to repeat surgery.

Use of cannabinoids in cancer care: palliative care

All too often neglected, maximal quality improvement in the setting of life-limiting illness and noxious symptomatology is a worthy medical, public health, and humanitarian goal [...]

Closure of Long-Tunnel PFOs With the Coherex Flatstent EF - A Tailored Approach

AIMS

Despite rapid progress in device technologies for patent foramen ovale (PFO) closure over the past decade, long-tunnel anatomies still constitute a challenge. The present study investigated the performance of a novel in-tunnel device (Flatstent EF; Coherex Medical) in long-tunnel PFOs.

METHODS AND RESULTS

Three different umbrella devices (n = 61) and the Coherex Flatstent (n = 27) were used for PFO closure. The Flatstent was the preferred device in long-tunnel anatomies. Seven patients with long PFO tunnels underwent "detunnelization" by stepwise inflation of a low-pressure balloon followed by implantation of an umbrella device. Complete occlusion or trivial residual shunting ("clinical" occlusion) was achieved in 93% of the Flatstent and 92% of the umbrella device procedures (P=.92). Device performance in long-tunnel anatomies was in favor of the Flatstent (n = 24) compared with conventional occluders (n = 7), with "clinical" occlusion of 96% vs 86% (P=.24) and procedure time of 44 ± 16 minutes vs 59 ± 21 minutes (P=.04). Furthermore, postprocedural arrhythmias were significantly less frequent after Flatstent implantations (0.0% vs 9.1%; P=.03).

CONCLUSION

In long-tunnel PFOs, the Flatstent device was quicker to deploy, was at least as equally efficacious as umbrella devices, and reduced the incidence of symptomatic arrhythmias following PFO closure.

Chemically selective polymer substrate based direct isotope dilution alpha spectrometry of Pu

Quantification of actinides in the complex environmental, biological, process and waste streams samples requires multiple steps like selective preconcentration and matrix elimination, solid source preparations generally by evaporation or electrodeposition, and finally alpha spectrometry. To minimize the sample manipulation steps, a membrane based isotope dilution alpha spectrometry method was developed for the determination of plutonium concentrations in the complex aqueous solutions. The advantages of this method are that it is Pu(IV) selective at 3M HNO3, high preconcentration factor can be achieved, and obviates the need of solid source preparation. For this, a thin phosphate-sulfate bifunctional polymer layer was anchored on the surface of microporous poly(ethersulfone) membrane by UV induced surface grafting. The thickness of the bifunctional layer on one surface of the poly(ethersulfone) membrane was optimized. The thickness, physical and chemical structures of the bifunctional layer were studied by secondary ionization mass spectrometry (SIMS), scanning electron microscopy (SEM) and SEM-EDS (energy-dispersive spectroscopy). The optimized membrane was used for preconcentration of Pu(IV) from aqueous solutions having 3-4M HNO3, followed by direct quantification of the preconcentrated Pu(IV) by isotope dilution alpha spectrometry using (238)Pu spike. The chemical recovery efficiency of Pu(IV) was found to be 86±3% below Pu(IV) loading capacity (1.08 μg in 2×1 cm(2)) of the membrane sample. The experiments with single representative actinides indicated that Am(III) did not sorb to significant extent (7%) but U(VI) sorbed with 78±3% efficiency from the solutions having 3M HNO3 concentration. However, Pu(IV) chemical recovery in the membrane remained unaffected from the solution containing 1:1000 wt. proportion of Pu(IV) to U(VI). Pu concentrations in the (U, Pu)C samples and in the irradiated fuel dissolver solutions were determined. The results thus obtained were found to be in good agreement with those obtained by conventional alpha spectrometry, biamperometry and thermal ionization mass spectrometry.

Implementation of NICE Clinical Guideline 95 for assessment of stable chest pain in a rapid access chest pain clinic reduces the mean number of investigations and cost per patient

Objective

In 2010, the National Institute for Health and Care Excellence (NICE) in the UK published Clinical Guideline 95 (CG95) advocating risk stratification of patients using ‘CADScore’ to guide appropriate cardiac investigations for chest pain of recent onset. Implementation of the guideline in the University College London Hospitals NHS Foundation Trust was evaluated to see if it led to a reduction in the average cost of the diagnostic journey per patient and fewer investigations per patient in order to confirm a diagnosis.

Methods

This was a single centre study at a Tertiary Centre in Central London. The investigative journey for each patient presenting to the Rapid Access Chest Pain Clinic (RACPC) at University College London Hospitals NHS Foundation Trust was recorded. Retrospective analysis on this data was performed.

Results

Data for 4968 patients presenting to the RACPC from 2004 to 2012 was analysed and a size-matched cohort of 1503 patients preimplementation and postimplementation of the guidelines was compared. The mean cost of investigations postimplementation was £291.83 as compared to £319.54 preimplementation of the guidelines despite higher costs associated with some of the recommended initial investigations. The mean number of tests per patient postguidelines was 0.78 compared to 0.97 for preguidelines. An approximate twofold increase in patients not requiring tests was seen post-CG95 implementation (245 pre-CG95 vs 476 post-CG95).

Conclusions

The implementation of the NICE guidelines in our trust has reduced the average cost of the investigative journey and the number of investigations required per patient.

Isotopic correlation for 242Pu composition prediction: Multivariate regresssion approach

Multivariate regression calibration using multiple linear regression (MLR), principle component regression (PCR) and partial least squares regression (PLSR) algorithm was performed on ²³⁸Pu, ²³⁹Pu, ²⁴⁰Pu and ²⁴¹Pu atom% abundances to predict ²⁴²Pu isotopic abundance. The MLR algorithm was found to be the best among these three algorithms. The effect of ²³⁸Pu composition on the ²⁴²Pu abundance prediction was found to be small but significant especially for achieving high accuracy of <0.5%. PCR and PLSR generated nearly identical results and were inferior to the MLR results. A comparison of MLR results with those obtained by employing seven previously reported empirical methods revealed far superior prediction capability of MLR model. Among the seven empirical models, the best prediction capability was found for Bignan correlation containing ²³⁸Pu isotopic data. The study clearly demonstrates that the production of ²³⁸Pu and ²⁴²Pu has some small correlation and the use of ²³⁸Pu in isotopic correlation for ²⁴²Pu prediction is important to get accurate results.

Post-procedural arterial hypertension: implications for clinical outcome after transcatheter aortic valve implantation

BACKGROUND AND AIM OF THE STUDY

Persistent arterial hypertension (HT) has been associated with increased morbidity and mortality after surgical aortic valve replacement (AVR). The impact of increased blood pressure (BP) after transcatheter aortic valve implantation (TAVI) has not yet been fully elucidated.

METHODS

The mean systolic and diastolic BP after TAVI were calculated from the last 10 non-invasive recordings performed before discharge in 176 patients. The primary end-point was symptomatic improvement after 6-12 months according to BP control at the time of discharge.

RESULTS

In patients with controlled BP (<140/90 mmHg), the symptomatic response after TAVI was significantly better compared to patients with uncontrolled BP (> or =140/90 mmHg), as reflected by NYHA functional class (+1.4 +/- 0.8 versus +0.8 +/- 1.0, p = 0.002) and six-minute walk test (6-MWT) distance improvement (+100 +/- 71 m versus +30 +/- 64 m, p < 0.001) at 6-12 months' follow up. A 10 mmHg decrease in systolic BP was associated with an 18 m increase in 6-MWT distance (p = 0.001). In addition, reverse left ventricular (LV) remodeling was significantly impaired in uncontrolled BP individuals, as reflected by regression of LV mass (-15 +/- 61 g versus -37 +/- 54 g, p = 0.041) and relative wall thickness (-0.02 +/- 0.09 versus -0.07 +/- 0.1, p = 0.01). Cumulative all-cause and cardiovascular mortality were significantly lower in patients with controlled BP compared to those with uncontrolled BP (6.5% versus 16%, p = 0.04; cardiovascular 3.7% versus 11.6%, p = 0.035).

CONCLUSION

Uncontrolled HT after TAVI may contribute to diminished symptomatic improvement.

Immature teratoma of the nose and paranasal sinuses masquerading as bilateral nasal polyposis: a unique presentation

Teratomas are tumors of multipotent cells derived from all three germ cell layers and recapitulate normal organogenesis. Teratomas are hypothesized to arise by misplacement of multipotent germ cells. Teratoma is usually developmental and sometimes congenital neoplasm which displays both solid and cystic components with gross and microscopic differentiation into a wide variety of tissues representative of all three germ layers--ectoderm, mesoderm and endoderm. We are describing a case which was initially diagnosed as bilateral nasal polyposis clinically but histopathology report came out to be immature teratoma. This case is being reported to make aware all ENT surgeons of such unique presentation of sinonasal teratomas as such presentation of these tumors has not been reported in literature previously, and hence teratomas should be considered in the differential diagnosis of nasal polyposis in future.

Oxidised LDL, HDL cholesterol, LDL cholesterol levels in patients of coronary artery disease

Coronary artery disease is a major cause of morbidity and has various risk factors. Lipid profile i.e. low HDL-cholesterol, high LDL cholesterol, high total cholesterol, high triglycerides playing important role in its causation. Recently interest has been shown in the oxidized fraction of LDL as one of the risk factors. In the present study 60 age and sex matched normal healthy individuals were taken as controls and 60 patients of CAD were taken. Cholesterol was measured by enzymatic method, HDL cholesterol by phosphotungstate precipitation method. Serum levels of LDL fraction of cholesterol was measured by a new and simpler method of precipitation. Result was expressed as mol/L of diene conjugates. It was observed that LDL cholesterol, VLDL cholesterol, total cholesterol, total cholesterol: HDL cholesterol, LDL cholesterol: HDL cholesterol were significantly raised and HDL cholesterol was significantly low in patients. (p<0.001). Though HDL cholesterol was significantly raised in females as compared to males in both the groups (p<0.001). Serum level of total cholesterol, oxidized LDL:HDL cholesterol were also raised significantly (p<0.05). The level of oxidized LDL showed an increasing trend in patients.

Antioxidant vitamins and chemoprevention

Free radicals play an important role in human carcinogenesis and the mechanism of their counteraction by antioxidant vitamins has been reviewed. It seems more likely that these vitamins work in concert rather than acting singly. Currently available data are compatible with the notion that these vitamins act as chemopreventives against some important cancers, e.g. carotenoids for lung cancer, ascorbic acid for salivary gland cancer, tocopherols for head and neck cancers etc. Thus, a greater consumption of fruits and vegetables should be encouraged as they are the natural sources of these chemopreventive, antioxidants along with other protective factors packaged by nature. However, much work still remains to be done to establish the role of antioxidant vitamins in carcinogenesis.

Hyperhomocysteinemia and cardiovascular disease: The nutritional perspectives

Several members of the vitamin B-complex family are known to participate in the normal metabolism of homocysteine (Hcy). Leaving aside the genetic determinants of hyperhomocysteinemia (HHC), the deficiencies of these vitamins can also result in HHC. The situation of sustained and long standing HHC is likely to be prevalent in population groups with low/average socio-economic status, geriatric population and alcohol abusers. If not corrected by supplementation, these population groups certainly are more vulnerable to develop atherosclerosis (AS) and subsequently, cardiovascular disease (CVD). Hyperhomocysteinemia per se and/or HHC-induced oxidative stress result(s) in chronic chemical endothelial injury/dysfunction, smooth muscle proliferation, prothrombotic state and oxidation of low density lipoproteins (LDL) leading to diverse cardiovascular complications. In the first decade of the new millennium, major research efforts would be directed towards understanding the basic mechanism of HHC-induced oxidative stress and the pathophysiology of HHC-induced CVD, culminating in the evolution of hitherto unknown therapeutic strategies such as nutriceuticals and oxidant-antidotes.

Megacystis, microcolon, intestinal hypoperistalsis syndrome and bilateral streak gonads

Megacystis, microcolon, intestinal hypoperistalsis is an uncommon condition presenting in neonatal age with features of intestinal obstruction and bladder evacuation abnormalities. We present here an infant girl with the diagnosis consistent with this entity.

Outbreak of Meningococcal Infection amongst Soldiers Deployed in Operations

BACKGROUND

Meningococcal infection may lead to life threatening meningitis and fulminant meningococcal sepsis. Sporadic cases of meningococcal infection have been reported in soldiers but no outbreak in soldiers has been reported earlier from India. This outbreak in soldiers serving in counter insurgency role under field setting was effectively controlled without compromising their operational commitment.

METHODS

This is an epidemiological investigation and control of an outbreak of meningococcal infection, bringing out the predisposing factors and highlighting the role of early diagnosis and management of cases. Mass chemoprophylaxis in contacts was used as an effective control measure in the absence of vaccine in this institution based outbreak.

RESULT

Out of a total of 17 cases reported, 14 presented as meningitis and three as meningococcemia. Two cases of meningococcemia ended fatally. Serogroup A of Neisseria meningitidis was responsible for this outbreak. Gross over- crowding was the predisposing factor.

CONCLUSION

An outbreak of meningococcal infection in soldiers deployed in counter- insurgency role was effectively contained using mass chemoprophylaxis in the absence of meningococcal vaccine.

Renal tuberculosis in infancy

We report a case of congenital renal tuberculosis in a 34-day-old child presenting as severe hematuria. Adequate antitubercular treatment may provide protection to fetus in subsequent pregnancies.

Meconium peritonitis presenting as abdominal calcification: three cases with different pathology

Intra-abdominal calcification is uncommon in newborns and has several causes of which meconium peritonitis is the most frequent. Three neonates with intra-abdominal calcification as a complication of meconium peritonitis are presented. The types of meconium peritonitis were cystic, meconium pseudocyst and meconium ascites. Two required surgical intervention. Meconium peritonitis should be considered in newborns with intra-abdominal calcification.

Blood glutathione levels in head and neck malignancies

Blood glutathione was estimated in fifty patients of head and neck cancer in the age group of 18-76 years and the results were compared with a group of normal healthy controls. Mean blood glutathione level was found to be significantly lowered in patients than the controls. Irrespective of the site, TNM classification, histopathology, and character of lesion, fall in blood glutathione was nearly same in all the patients. The mean level was significantly increased after radiotherapy when compared with the levels before radiotherapy. The decreased levels of GSH in-patients with head and neck cancer, observed in the present study, may be due to its increased utilization by the cells. The results suggest that patients with head and neck cancer have increased oxidative stress.

Laser-induced breakdown spectroscopy for simultaneous determination of Sm, Eu and Gd in aqueous solution

This paper reports studies on the determination of trace levels of samarium, europium and gadolinium in aqueous samples by laser-induced breakdown spectroscopy (LIBS). In this work, a membrane-based filter paper was used as a sample support for the liquid samples. The laser-induced plasma was produced in air at atmospheric pressure, using a pulsed Nd:YAG laser. Calibration standards and synthetic mixtures of these lanthanides were prepared using solutions prepared from respective high purity oxides. Linear calibration was obtained for Sm, Eu and Gd by normalizing the intensities of lanthanides emission lines with respective to C(I) 193.029 nm emission line. The concentrations of Sm, Eu and Gd were then determined in a solution containing a mixture of these lanthanides. The concentrations of individual lanthanides were obtained within 5% of the expected values. Limits of detection were found to be 1.3 ppmw (Sm), 1.9 ppmw (Eu) and 2.3 ppmw (Gd).

Giant single left coronary artery with right ventricular fistula diagnosed in early childhood

We present an unusual case of an 18-month-old boy, who presented with dyspnea and recurrent respiratory tract infections. Echocardiography and subsequent angiography were suggestive of a fistula from a coronary artery to the right ventricle. Finally, only on table could the actual diagnosis of a single left coronary artery with right ventricular fistula be made. Surgical treatment was successfully performed with off-pump ligation and the patient was well with no residual fistula on echocardiogram when seen at 3 month follow-up.

Ruptured sinus of valsalva: unexpected finding in a patient diagnosed with ventricular septal defect with aortic regurgitation

Ruptured sinus of Valsalva aneurysm is an uncommon condition which has a good prognosis if surgically corrected. However, sometimes making the diagnosis on echocardiography and even cardiac catheterization can be difficult. We describe a case which was diagnosed as ventricular septal defect with aortic regurgitation but, on the table, was found to be a ruptured sinus of Valsalva aneurysm.

Use of faecal excretion function for quick estimation of initial and existing lung burden for occupational exposure control due to 239Pu for S-class of intake

Two functions namely initial lung deposition and lung retention per unit faecal excretion rate are constructed primarily based on the excretion pattern of four subjects exposed to (239)Pu. In the absence of initial clear knowledge about the class of compound inhaled, faecal to urine excretion ratio was used to infer the type of inhaled class. Trends in the urine and faecal data had suggested that the intake was due to mixed class of plutonium compound for each case. With the assumption of 1:1 mixture of plutonium M&S class inhaled compound, faecal excretion rates for only S-class intake were worked out. Uptake inferred based on their urinary data had suggested it to be of similar level within 40% of uncertainty for 5 microm particle size distribution. Data, all the four cases, were pooled for analysis citing the similar level of intake, particle size distribution, nature and pattern of work. The function obtained was tested for S-class lung retention and faecal excretion rate value. These functions are handy tool for estimating initial lung burden and lung retention value for low level of S-class plutonium intake based on subject faecal analysis data.

Derivation and validation of a urinary excretion function for plutonium based on occupational exposure

Formation of a three-component urinary excretion function using the data of occupational exposure cases is described. Measurement results of plutonium inhalation from two subjects over 6000 and 2500 d are used in the derivation of this function. The three-component excretion function obtained is U(t) = 0.0008e(-0.0566(t)) + 0.00009e(-0.0042(t)) + 0.00004e(-0.00008(t)). The function is therefore proposed as a reliable basis to make an uptake assessment for operational control for mixed class of plutonium dominated by M-class chronic exposure.

Snake venom for acute myocardial infarction: Natural serendipity or an obstruction to treatment?

A 55-year-old man developed an acute myocardial infarction and was bitten by a snake with haemotoxic venom prior to any treatment being given. We discuss our treatment of myocardial infarction in a patient who had been unintentionally anticoagulated.

Determination of 243Am by pulse shape discrimination liquid scintillation spectrometry

Alpha specific activity of 243Am was determined using pulse shape discrimination in liquid scintillation spectrometry. 238Pu, 36Cl and 239Np (purified from 243Am) were used for obtaining the spillover of alpha/beta particles into the beta/alpha channels, respectively. Synthetic mixtures of 241Am/243Am were prepared. Using the alpha-specific activity, weights of the stock solutions used and the half-life of 241Am and 243Am isotopes, the expected 241Am/243Am atom ratios in the mixtures were determined and compared with those obtained by thermal ionization mass spectrometry (TIMS). An agreement of about 1% was obtained between the 241Am/243Am atom ratios determined by the two methods. This shows that liquid scintillation counting with pulse shape discrimination can be used for 243Am determination with an accuracy better than 1%.

Lipid peroxide levels and antioxidant status in alcoholic liver disease

The present study was conducted to evaluate some of the components of antioxidant defense system and oxidative damage in 20 male patients of alcoholic liver disease (ALD). The results were compared with 20 healthy male smokers and 20 healthy male non-smokers volunteers. Patients were subjected to detailed clinical examination and laboratory investigations. Blood samples were collected for estimating reduced glutathione (GSH), total thiols (T-SH) malondialdehyde (MDA), transaminases (AST, ALT), glutathione-S-transferease (GST) and gammaglutamyl transferase (GGT). Serum aspartate amino transferase (AST)/alanine amino transferase (ALT) ratio was significantly (p<0.01) reduced in ALD patients as compared to the controls. However, the core of utility of MDA and GST was found to be significantly (p<0.01) increased in ALD patients compared to controls. There was a significant negative correlation of MDA with both GSH and TSH. Plasma GGT levels were significantly (p<0.01) increased in alcoholics and the enzyme showed a significant positive correlation with MDA. These results give enough evidence of increased oxidative stress and compromised antioxidant defense system in patients with ALD.

Benign rheumatoid nodules

Rheumatoid nodules occur usually in advanced seropositive rheumatoid arthritis, signifying poor prognosis. However rarely rheumatoid nodules can be encountered in patients with no antecedent evidence of arthritis. Herein a case of an arthritic benign rheumatoid nodules is described.

Role of supravital staining of urine sediment and bright field microscopy in diagnosis of acute renal failure in bedside medicine

BACKGROUND

An early accurate etiological categorization of acute renal failure (ARF) into acute glomerulonephritis (AGN), acute tubular necrosis (ATN) and acute interstitial nephritis (AIN) is very important in clinical medicine.

METHODS

To evaluate the efficacy of a simple, cheap supravital staining method developed in our laboratory, we examined urine of 32 cases of ARF at their initial presentation in oliguric phase, which were later biopsied. The stain consisted of 1% crystal violet and 0.5% safranin in normal saline. The coverslip preparations of coded and stained urine sediments were examined under ordinary bright field microscope (BFM) by two independent observers.

RESULTS

The renal biopsy showed 12 cases of AGN, 12 ATN and 8 AIN. The diagnosis could be predicted by supravital staining method in 75% cases with 95% uniformity among two observers with a sensitivity of 85.7% for AGN followed by AIN (80%) and ATN (75%).

CONCLUSION

Thus this simple supravital staining technique can be used with ordinary BFM for accurate urine sediment analysis in cases of ARF in bedside medicine.

Immune system activation by CDDP and "poly-plat"

Murine peritoneal macrophages, human fibroblasts and human ovarian teratocarcinoma cells were treated with CDDP (10 micrograms/ml) and "poly-plat" (10 micrograms/ml) for 2 h and cultured for 2-96 h. After "poly-plat" treatment macrophages developed cytoplasmic extensions much faster and secreted higher levels of interleukin-2 (IL-2), compared to CDDP. "Poly-plat" treated human fibroblasts demonstrated a significant release of IL-2 (138 pg/ml), compared to CDDP (64 pg/ml) or the untreated normal cells (31 pg/ml) after 8 h. Correspondingly there was a 53% increase in cells after "poly-plat" treatment compared to only 37% after CDDP. However, human ovarian teratocarcinoma cells didn't show any significant increase in IL-2 levels after "poly-plat" treatment and there was instead a decrease of 15% in cell numbers at 8 h. Based on our studies, we propose that "poly-plat" is more effective in activation of the macrophages and human fibroblasts in terms of IL-2, but not so with human ovarian teratocarcinoma cells.

Synergistic immunosuppression by candida in HIV infection: a cytokine based analysis

Candida is a common opportunistic pathogen in HIV infection and is regarded a signal infection for progression to AIDS. Cytokine imbalances between Th1/Th2 groups have been described in both candida and HIV infections. A study was undertaken to assess the role of candida in furthering immunosuppression in HIV infection based on cytokine levels and CD4 cell counts. 30 Indian subjects were enrolled; 10 HIV positive patients with and 10 without mucosal candidiasis and 10 age matched controls. Th1 cytokines; interleukin (IL) 2, IL 12 and interferon (IFN) gamma, Th2 cytokines; IL 4, IL 6, IL 10 and tumor necrosis factor (TNF) alpha with CD 4 cell counts were estimated using ELISA in all subjects. CD4 cell counts were reduced in both patient groups as compared to controls; significantly more in patients with both HIV and candida infections. There was a decrease in Th1 cytokine levels in all patients; lower levels of Th1 cytokines were seen in patients with both infections. Among the Th2 cytokines, there was a significant increase in the levels of IL 6, IL 10 and TNF alpha in both patient groups; IL 10 and TNF alpha values were significantly raised in patients with dual HIV and candida infections as compared to the other patients. There was no difference in IL 4 values across the subject groups. A positive correlation between CD4 cell counts and Th1 cytokine levels and a negative correlation with Th2 cytokines were noted; these were stronger in patients with both HIV and candidiasis. Thus, there was a Th1/Th2 cytokine imbalance with CD4 cell count reduction in all HIV infected patients, which was more pronounced in patients with both infections. It can be concluded that, owing to the depressed CD4 cell count and Th1 response and increased Th2 cytokines in patients with both candidiasis and HIV as compared to patients with only HIV candidiasis may have a synergistic immunosuppressive effect with HIV in patients with dual infections.

Immunocytochemical and in situ hybridization studies of gastrin after cisplatin treatment

Cisplatin treatment (9 mg/kg) causes bloating of the stomach, an increase in gastric acid, and ulceration in rats. Gastrin, a gut peptide, plays an important role in regulating gastric acid production. To study the role of gastrin in this increased gastric acid production after cisplatin treatment, male Wistar rats (100-150 g) were treated with cisplatin (9 mg/kg) in five divided doses over 5 consecutive days. The rats were sacrificed 1, 6, 10, or 15 days after the last treatment. As measured by immunocytochemistry, in situ hybridization, Northern blot, and dot-blot techniques, gastrin was found to be below detectable limits just 1 day after cisplatin treatment. However, 10-15 days after the last injection, the levels for both gastrin and its mRNA gradually recovered to normal. Northern blot studies showed that decreased somatostatin mRNA parallels the changes of gastrin and its mRNA. These results suggest that after cisplatin treatment the increased gastric acid production in rat stomach is independent of gastrin. This decrease of gastrin production is not under the influence of somatostatin, which also decreased after cisplatin treatment.