Beating Heart versus Conventional Coronary Bypass Surgery: Our Experience

Background

Off-pump Coronary Artery Bypass (OPCAB) has become the standard surgical treatment of Coronary Artery Disease in most centres in India. It is clear from the current evidence that, in certain patients, OPCAB offers advantages over conventional Coronary Artery Bypass Grafting (CABG). Experience of this procedure in the Armed Forces is highlighted. Methods: Retrospective analysis of 200 nonrandomized consecutive patients taken up for OPCAB and 200 conventional CABG between Jan 2005 and Dec 2007 was done. The European system for cardiac operative risk evaluation (euroSCORE) was used in all patients. Perioperative morbidity and mortality was compared in the two groups.

Result

OPCAB was possible in 192 (96 %) out of 200 patients taken up for this procedure. Eight patients required cardiopulmonary bypass (CPB) to complete the revascularization. Incidence of reoperation for bleeding was 2.5% in OPCAB and 6% in CABG In the CABG group 2% patients developed severe bleeding complications, 3% required ventilation for more than 24 hour, 1% required renal replacement therapy, 1% had acute respiratory distress syndrome and 3.5% had neuro-psychiatric manifestations. Incidence of these complications in OPCAB patients was lower or NIL. Overall mortality in the OPCAB group was 1.5% and 2% in the CABG group. However only one patient out of 192 (0.5%) who underwent successful OPCAB died, while two patients out of eight who required conversion to CPB in this group died. Incidence of stroke, deep sternal infection and mortality was similar in both groups.

Conclusion

OPCAB is safe, effective and can be offered to more than 90% patients as the primary strategy for surgical myocardial revascularization. It has lower overall morbidity than conventional CABG Its main limitations are hemodynamic instability and inability to find a deeply embedded target vessel. Both these factors affect the outcome adversely making conventional CABG a better option in these situations.Key Words: Off-pump coronary artery bypass!, Coronary artery bypass     

To study the effects of gamma irradiation on single donor apheresis platelet units by measurement of cellular counts,functional indicators and a panel of biochemical parameters,in order to assess pre-transfusion platelet quantity and quality during the shelf life of the product

Background

The occurrence of transfusion associated graft versus host disease can be prevented by gamma irradiation of blood components. This study was undertaken to assess the effects of gamma irradiation on single donor platelet (SDP) concentrate units.

Method

SDPs were collected by a continuous flow apheresis technique (n = 400). The SDPs from each donor were divided into two parts, one gamma-irradiated with 25 Gy and the other used as a non-irradiated control. Swirling and morphological features, cellular counts, biochemical parameters including blood gas analysis, and platelet activation levels (CD62P: p-selectin) by flow cytometry were analyzed on Day 1 and on Day 5.

Results

Swirling and morphology were maintained in all products, in both the groups throughout the shelf life. No significant change was seen in both groups, on the first and fifth day, as far as pO₂, pCO₂, Na⁺, K⁺, HCO₃⁻ & Ca²⁺ were concerned. However, lactate increased and glucose decreased significantly in irradiated products over 5-day storage period. A small but significant decrease in pH and platelet count was found in the irradiated PCs after 5-day storage. The mean proportion of platelets expressing CD62P over 5-day storage increased significantly.

Conclusion

After an overall assessment of all our in vitro parameter results and observations, a few of which were significant, while most were not significant, we concluded that a well-preserved quality of gamma irradiated apheresis platelets is maintained throughout the entire 5-day shelf life of the platelet product, with minimal difference compared to non-irradiated platelets.     

Malaria in Pregnancy

Background

Malaria in pregnancy contributes to low birth weight and increased infant mortality.

Methods

The study included 416 pregnant women reporting with fever and the impact of malaria on pregnancy was assessed.

Result

The study revealed that the protozoal infection affects second trimester more commonly. It increases the chances of abortions, intrapartum foetal distress and meconium stained amniotic fluid.

Conclusion

Malaria is an important cause of feto-maternal morbidity during pregnancy.Key Words: Malaria in pregnancy, Plasmodium     

Neonatal Immune Thrombocytopenia

Background

Neonatal immune thrombocytopenia, a consequence of transplacental transfer of antiplatelet antibodies can result in serious bleeding with disastrous consequences in the otherwise healthy newborn.

Methods

Over 2 years at a service hospital, 5 mothers with chronic autoimmune thrombocytopenia and one with maternal alloimmunisation delivered, which comprised the study sample.

Results

Of these, two ladies suffered episodes of thrombocytopenia in the current pregnancy. They were provided platelet transfusions and intravenous immunoglobulins. All patients delivered vaginally. Cord blood platelet was normal in all cases. Three babies developed thrombocytopenia, two due to autoimmune and one alloimmune pathology. The nadir of thrombocytopenia occurred in 36-72 hours with recovery taking place in 10 days. The clinical manifestations were petechiae, ecchymosis, gastric bleed and oozing from vitamin K injection site. Two of the affected babies were provided intravenous immunoglobulins and one steroids. Only one of the two mothers who suffered thrombocytopenia during pregnancy and was provided intravenous immunoglobulins was associated with neonatal thrombocytopenia, an inconsistent relation. It was also observed that antenatally provided immunoglobulins raised effectively maternal rather than fetal platelet counts. However, postnatal immunoglobulins were efficacious in thrombocytopenic neonates.

Conclusion

Thus inspite of several therapeutic and preventive modalities being described, the optimum management strategy of immune mediated perinatal thrombocytopenia is yet in evolution.Key Words: Immunoglobulins, Immune thrombocytopenia, Neonate     

Platelet kinetics after slow versus standard transfusions: a pilot study

Background

Platelet transfusion is required in the acute phase of some thrombocytopenic disorders in order to prevent potentially dangerous hemorrhages.The purpose of this study was to assess the increase in platelet count following a slow platelet transfusion.

Methods

Patients suffering from thrombocytopenia due to various underlying diseases were enrolled in the prospective pilot feasibility trial and were randomly divided into two groups. Standard platelet transfusion was administered in one group, while slow transfusion was used in the other. The platelet count was examined at 1 hour, 24 hours, and 1 week following the transfusions.

Results

Although the platelet count was higher following 1 hour after transfusion via the standard method, the count tended to be higher 1 week after the transfusion in the slow transfusion group. This difference, however, only turned out to be statistically significant amongst females.

Conclusion

A therapy of slow platelet transfusion might be more effective for the prevention of platelet loss. Further studies will be required to strengthen this hypothesis.     

Whole blood coagulation and platelet activation in the athlete: A comparison of marathon,triathlon and long distance cycling

Introduction

Serious thrombembolic events occur in otherwise healthy marathon athletes during competition. We tested the hypothesis that during heavy endurance sports coagulation and platelets are activated depending on the type of endurance sport with respect to its running fraction.

Materials and Methods

68 healthy athletes participating in marathon (MAR, running 42 km, n = 24), triathlon (TRI, swimming 2.5 km + cycling 90 km + running 21 km, n = 22), and long distance cycling (CYC, 151 km, n = 22) were included in the study. Blood samples were taken before and immediately after completion of competition to perform rotational thrombelastometry. We assessed coagulation time (CT), maximum clot firmness (MCF) after intrinsically activation and fibrin polymerization (FIBTEM). Furthermore, platelet aggregation was tested after activation with ADP and thrombin activating peptide 6 (TRAP) by using multiple platelet function analyzer.

Results

Complete data sets were obtained in 58 athletes (MAR: n = 20, TRI: n = 19, CYC: n = 19). CT significantly decreased in all groups (MAR -9.9%, TRI -8.3%, CYC -7.4%) without differences between groups. In parallel, MCF (MAR +7.4%, TRI +6.1%, CYC +8.3%) and fibrin polymerization (MAR +14.7%, TRI +6.1%, CYC +8.3%) were significantly increased in all groups. However, platelets were only activated during MAR and TRI as indicated by increased AUC during TRAP-activation (MAR +15.8%) and increased AUC during ADP-activation in MAR (+50.3%) and TRI (+57.5%).

Discussion

While coagulation is activated during physical activity irrespective of type we observed significant platelet activation only during marathon and to a lesser extent during triathlon. We speculate that prolonged running may increase platelet activity, possibly, due to mechanical alteration. Thus, particularly prolonged running may increase the risk of thrombembolic incidents in running athletes.     

Long term clinical outcome and bleeding complications among hospital survivors with acute coronary syndromes

Objective

To examine the 21 month clinical outcome and bleeding complications in hospital survivors with non‐ST segment elevation acute coronary syndromes (NSTEACS) who were discharged with combined clopidogrel and aspirin anti‐thrombotic therapy, and compare with those having ST segment elevation myocardial infarction (STEMI) who were discharged with aspirin alone.

Design

Observational study.

Setting

A large university hospital.

Patients

224 patients were admitted to hospital with either NSTEACS or STEMI, and survived to discharge between 1 October 2001 and 31 December 2002.

Main outcome measures

Cardiovascular death, total death, new myocardial infarction, unstable angina requiring hospitalisation, stroke or transient ischaemic attack, coronary revascularisation; and fatal, life threatening, major and minor bleeding over 21 months after discharge.

Results

Despite having no or small infarct (median maximum creatine kinase 155 v 1295 u/l; p<0.001) and taking more antianginal drugs, patients with NSTEACS had similar rates of cardiovascular death (9.5% v 8.3%; p = NS), new myocardial infarction (9.5% v 6.5%; p = NS) or unstable angina requiring hospitalisation (15.5% v 10.2%; p = NS) when compared with STEMI. Fatal, life threatening or major bleeding were <1% in both groups (p = NS); and minor bleeding occurred in 4.3% NSTEACS and 2.8% STEMI patients respectively (p = NS).

Conclusions

Patients with NSTEACS had a similar and unfavourable long term outcome when compared with STEMI. There was no difference in serious bleeding complications between both groups.     

Seasonal variation of platelets in a cohort of Italian blood donors: a preliminary report

Background

Since available data are not univocal, the aim of this study was to explore the existence of a seasonal variation in platelet count.

Methods

The study was based on the database of the Italian Association of Blood Volunteers (AVIS), section of Ferrara, Italy, 2001–2010. Hematological data (170,238 exams referring to 16,422 donors) were categorized into seasonal and monthly intervals, and conventional and chronobiological analyses were applied.

Results

Platelets and plateletcrit were significantly higher in winter-autumn, with a main peak in December-February (average +3.4% and +4.6%, respectively, P <0.001 for both).

Conclusions

Although seasonal variations have been reported for several acute cardiovascular diseases, it is extremely unlikely that such a slight increase in platelet count in winter alone may be considered as a risk factor.     

Initial experience with lingual mucosal graft urethroplasty for anterior urethral strictures

Background

To present the feasibility of lingual mucosal graft urethroplasty in anterior urethral strictures and appraisal of donor site morbidity.

Methods

From November 2007 to December 2010, 14 patients underwent dorsal onlay lingual mucosal graft urethroplasty for anterior urethral strictures. Lingual mucosal graft was harvested from the lateral and undersurface of the tongue. Check micturating cystourethrograms were done 2 weeks after catheter removal and uroflowmetry after 3 months. Success was defined as normal uroflowmetry rates at 3 months in the absence of any postoperative instrumentation. Tongue was assessed for any residual pain, taste disturbances or restricted movement at 3 months.

Results

Four patients had submucosal fibrosis of the oral cavity and their buccal mucosa was unfit for grafting. Mean (range) stricture length was 5 (3–16) cm and the operation time 170 (140–210) min. Graft width averaged 1.6 cm. Average length of harvested graft was 6.5 cm. Mean duration of follow-up was 12.8 months. Two patients developed stricture at the proximal anastomotic site. There were no donor site complications.

Conclusions

Lingual mucosal graft harvesting is simple, gives graft lengths comparable to buccal mucosa and is associated with negligible donor site morbidity.     

External Validation of EPICON: A Grouping System for Estimating Morbidity Rates Using Electronic Medical Records

Objective

To externally validate EPICON, a computerized system for grouping diagnoses from EMRs in general practice into episodes of care. These episodes can be used for estimating morbidity rates.

Design

Comparative observational study.

Measurements

Morbidity rates from an independent dataset, based on episode-oriented EMRs, were used as the gold standard. The EMRs in this dataset contained diagnoses which were manually grouped by GPs. The authors ungrouped these diagnoses and regrouped them automatically into episodes using EPICON. The authors then used these episodes to estimate morbidity rates that were compared to the gold standard. The differences between the two sets of morbidity rates were calculated and the authors analyzed large as well as structural differences to establish possible causes.

Results

In general, the morbidity rates based on EPICON deviate only slightly from the gold standard. Out of 675 diagnoses, 36 (5%) were considered to be deviating diagnoses. The deviating diagnoses showed differences for two main reasons: “differences in rules between the two methods of episode construction” and “inadequate performance of EPICON.”

Conclusion

The EPICON system performs well for the large majority of the morbidity rates. We can therefore conclude that EPICON is useful for grouping episodes to estimate morbidity rates using EMRs from general practices. Morbidity rates of diseases with a broad range of symptoms should, however, be interpreted cautiously.     

Low birth weight and incidence of first malaria episode and adherence to malaria treatment protocols in infants in Chikwawa district,Malawi

Background

In Malawi, malaria is a leading cause of infant morbidity and mortality. Low birthweight and fetal anaemia are also a common occurrence. The relationship between birthweight and fetal anaemia and malaria morbidity in infancy is not known.

Objectives

To investigate the relationship between incidence of first malaria episode and birthweight and fetal anaemia and to investigate adherence of health workers to Integrated Management of Childhood Illnesses (IMCI) malaria treatment protocol.

Design

A stratified sample of 561 infants was selected based on low birth weight (LBW, <2.5Kgs), fetal anaemia (FA, Hbcord <12g/dl) and matched controls with normal birth weight (NBW) and no fetal anaemia (NFA). Cases were defined as LBW FA, LBW NFA, and NBW FA.

Results

Cumulative incidence to first malaria episode did not significantly differ between the study groups and the controls. Sulphadoxine-pyrimethamine (SP) was prescribed to the majority of malaria cases (89.3%).

Conclusion

There is no relationship between birthweight and fetal anaemia and first malaria episode. There is good adherence to IMCI guidelines for malaria treatment.     

Impact of platelet count on results obtained from multiple electrode platelet aggregometry (Multiplate™)

Objectives

Use of potent antiplatelet drugs requires evaluation of platelet function. While platelet function in elective cases is usually assessed in a central laboratory environment, there is also an urgent need for rapid perioperative point-of-care assessment. Recently, multiple electrode platelet aggregometry has been developed and assumed to measure platelet function independent from platelet count. We tested the hypothesis that results of multiple electrode platelet aggregometry are affected by platelet count, in particular if platelet count is below normal range.

Methods

Whole blood samples from 20 healthy volunteers were prepared containing platelet concentrations of 50,000, 100,000, 150,000, 200,000, and 250,000 μl^-1 while maintaining hematocrit. Platelet aggregation was induced by collagen, thrombin receptor activating peptide 6 (TRAP-6), adenosine-diphoshate (ADP), and arachidonic acid, respectively, and aggregation was measured by multiple electrode platelet aggregometry (Multiplate™).

Results

Results of multiple electrode platelet aggregometry significantly decreased in blood samples with platelet count below normal range. Compared to results measured in blood samples with platelet count within normal range, aggregometry results decreased by 18.4% (p < 0.001) and 37.2% (p < 0.001) in blood samples with a platelet count of 100.000 and 50.000 μl^-1, respectively. On the other hand, large interindividual variation has been observed and some blood samples showed normal results even with platelet counts of 50.000 μl^-1.

Conclusion

The results obtained with Multiplate™ Analyzer are influenced by platelet function as well as platelet count thus displaying the overall platelet aggregability within the blood sample rather than platelet function alone.     

Comparative Analysis of Laser Assisted Endoscopie and Conventional Endoscopie Dacryocystorhinostomy

Background

Dacryocystorhinostomy (DCR) is the standard surgical treatment for epiphora caused by obstructions distal to the common canaliculus. Endoscopic DCR (EDCR) and laser assisted DCR (LAEDCR) are becoming increasingly popular alternatives.

Method

69 cases of EDCR were compared with 18 cases of LAEDCR. The success rates were noted at 01 week, 01, 03 and 06 months. The operating time required, incidence of adjuvant procedures, complications and post operative morbidity were recorded.

Results

At the end of 06 months, 100% and 95% success was achieved with LAEDCR and EDCR respectively. Operating time, complication rates and the incidence of adjuvant procedures required were lesser in the LAEDCR group.

Conclusion

In our study both the procedures have comparable success rates, though LAEDCR has an edge over EDCR in terms of decreased duration of surgery, decreased post operative morbidity and lesser complications.Key Words: Epiphora, endoscopic dacryocystorhinostomy, laser assisted endoscopic dacryocystorhinostomy     

Elective orthopedic and cardiopulmonary bypass surgery causes a reduction in serum endostatin levels

Background

Endostatin is an endogenous inhibitor of angiogenesis that inhibits neovascularisation. The aim of the study was to evaluate the effect of elective surgery on endostatin levels.

Methods

Blood samples were collected prior to elective surgery and 4 and 30 days postoperatively in 2 patient groups: orthopedic surgery (n =27) and coronary bypass patients (n =21). Serum endostatin levels were measured by ELISA.

Results

Serum endostatin was significantly reduced 30 days after surgery in comparison with presurgical values in both the orthopedic (P =0.03) and cardiopulmonary surgery (P =0.04) group.

Conclusion

Serum endostatin is reduced 30 days after surgery. This reduction would favor angiogenesis and wound-healing.     

Medical and Surgical Management of Keratomycosis

Background

Fungal keratitis is a diagnostic and therapeutic challenge to the ophthalmologist. If not treated energetically it results in marked ocular morbidity and permanent visual loss.

Methods

Twenty five patients of fungal keratitis were studied for their response to management and final visual outcome.

Result

Males outnumbered females. Medical treatment was successful in 72% cases, while 28% required surgical intervention. Keratoplasty was done in five patients out of which graft was clear in four after one year of follow up. Three of these underwent optical keratoplasty since therapeutic grafts became opaque.

Conclusion

Early recognition of the disease and institution of prompt therapy is the key to successful management in fungal keratitis. Occasionally surgical management is required to preserve anatomical integrity of the globe and to salvage useful vision.Key Words: Fungal keratitis, Keratomycosis, Keratoplasty     

Amputation in Diabetic Patients

Background

Foot ulcers and their complications are an important cause of morbidity and mortality in diabetes. The present study examines the amputation risk criterion and the long term outcome in terms of amputations and mortality in patients with diabetic foot.

Methods

27 patients with diabetic foot lesions were studied. There were 15 patients with early lesions and 10 with advanced lesions. 15 patients were managed conservatively including local amputations and 12 with lower extremity amputations. 80% patients were males in 45-59 years of age group and all patients had more than 6 years of poorly controlled diabetes.

Results

Precipitating factors included walking barefoot, history of minor trauma, infection, callosities or burns in 86% of patients. Major lower limb amputations were common in irregularly treated, poorly controlled diabetics due to infection in a limb devitalized by angiopathy and desensitised by neuropathy.

Conclusion

Diabetic foot ulcers are associated with high morbidity and mortality. Mortality was higher in ischaemic ulcers than neuropathic ulcers.Key Words: Amputations, Diabetic foot, Aggressiveness     

Psychological Correlates of Outcome after Coronary Artery Bypass Graft

Background

Psychological effects of Coronary Artery Bypass graft (CABG) have been of interest all over the world but there is a paucity of Indian work.

Methods

30 patients undergoing CABG at a service hospital were included. All patients filled a specially designed proforma. Mini Mental Status Examination, Hospital anxiety and depression scale, Coronary scale, Seattle angina questionnaire and Euro-QOL 5D were performed before and seven days after CABG.

Results

43.3% had significant anxiety and 30% had significant depression before CABG. Following CABG, 36.67% of the patients had significant anxiety while 40% had significant depression. On the Seattle angina questionnaire, physical limitation reduced from 71.6 ± 7.9 to 53.1 ± 14.6. There was significant improvement in treatment satisfaction from 37.8 ± 6.1 to 59.4 ± 4.2 following CABG. On th euro quality of life scale (EQ5D) health status improved from 38.17 ± 9.51 before CABG to 68.5 ± 5.28 after CABG.

Conclusion

There is a significant incidence of anxiety and depression in patients undergoing CABG, both before and after surgery.Key Words: CABG, anxiety, depression     

Cardiovascular disease, hypertension, dyslipidaemia and obesity in patients with hypothalamic-pituitary disease

Objective

Adults with hypothalamic‐pituitary disease have increased morbidity and mortality from cardiovascular disease (CVD). Therefore, the prevalence of CVD and adequacy of treatment of cardiovascular risk factors (according to current treatment guidelines) was studied in a large group of patients with hypothalamic‐pituitary disease.

Study design

In 2005, 152 consecutive adult patients with hypothalamic‐pituitary disease attending our neuro‐endocrine centre were clinically examined and blood pressure (BP), lipid profile, type 2 diabetes mellitus, body composition and smoking status were assessed.

Results

Of the 152 patients, 36.8% had treated hypertension and 28.2% had treated dyslipidaemia. Many of these patients had inadequate BP control (BP >140/85 mm Hg, 44.6%) and undesirable lipid levels (total cholesterol >4.0 mmol/l, 69%). Also, many of the untreated patients had BP and lipid levels which should have been considered for treatment (26 patients (27%) and 83 patients (76%), respectively). Smoking was admitted in 18% of patients. Central adiposity was present in 86% and obesity (body mass index ⩾30) was present in 50%.

Conclusions

Cardiovascular risk factors are highly prevalent and often inadequately treated in adult patients with hypothalamic‐pituitary disease. Aggressive treatment of these factors is essential to reduce mortality and morbidity from CVD in these patients.     

Study of Single Donor Platelet (SDP) Preparation by Baxter CS 3000 plus and Haemonetics MCS plus

Background

In plateletpheresis blood is withdrawn from a donor in anticoagulant solution and separated into components. Platelets are retained and the remaining components are returned to the individual.

Methods

The present study was aimed to compare the platelet yield and collection efficiency of Baxter CS 3000 plus and Haemonetics MCS plus cell separators and to study adverse donor reactions. Donors were selected as per the set criteria for single donor platelet (SDP) preparation. Donors'' samples for pre donation and post donation platelet count were collected in EDTA and for product counts in the sample pouch attached with apheresis kits. The results were obtained by haematology analyzer. Platelet yield and collection efficiency were calculated.

Result

Results were tabulated for both the cell separators and analyzed. Platelet yield was marginally better with Baxter CS 3000 plus but collection efficiency was better with the Haemonetics MCS plus. Residual white cells were more in single donor platelet concentrate preparation by MCS plus. Adverse donor reactions were similar with both cell separators, in form of mild citrate toxicity and mild to moderate pain at phlebotomy site.

Conclusion

Findings of the present study along with other factors such as less priming time for kit, portability of cell separator, better patient comfort owing to single arm venous access and lesser cost suggest that Haemonetics MCS plus is a better choice as compared to Baxter CS 3000 plus cell separator.Key Words: Plateletpheresis, Single donor platelet (SDP)     

Psychiatric Morbidity Pattern in a Child Guidance Clinic

Background

There is a paucity of Indian studies on psychiatric morbidity in children. Present work was undertaken in a child guidance clinic in armed forces.

Methods

Retrospective analysis of 213 patients who attended a child guidance clinic was done.

Results

Majority (n=138) were boys. 55.9% were referred from paediatric outpatient department while medical officers in periphery referred 38.5%. The diagnoses was mental retardation in 30.97%, behavioral and emotional disorders in 23.06% and neurotic, stress related and somatoform disorders in 15.98% cases.Key Words: Child psychiatry, Attention-deficit hyperactivity disorder, Mental retardation