Aortopulmonary window with patent ductus arteriosus and interrupted aortic arch: A case report

Indian Journal of Thoracic and Cardiovascular Surgery -     

Superovulation in the cow: comparison of oestradiol-17 beta and progesterone patterns in plasma and milk of cows induced to superovulate; relationships with ovarian responses

Free oestradiol-17 beta, free + conjugated oestradiol-17 beta (total oestradiol-17 beta) and progesterone in milk, and free oestradiol-17 beta and progesterone in plasma were measured in 16 cyclic cows injected with FSH to induce superovulation during the treatment and periovulatory periods. The patterns of steroid secretion were the same in milk as in plasma but at different concentrations. Among oestrogens, the highest concentrations were measured for total oestradiol-17 beta in milk, followed by free oestradiol in plasma and free oestradiol in milk. Progesterone concentrations in milk were higher than in plasma. The peak concentrations of oestrogens were related to ovulation rate: Spearman Rank Correlation coefficient (r.s.) = 0.87 (P less than 0.001), 0.78 (P less than 0.001) and 0.69 (P less than 0.001) for total oestradiol, free oestradiol in milk and free oestradiol in plasma respectively. The increase in progesterone concentrations in milk between the beginning of treatment and prostaglandin injection was negatively correlated with the percentage of viable embryos among those recovered (r.s. = -0.68; P less than 0.001). This was not observed for progesterone in plasma. These results therefore show that the steroid pattern in milk gives a better indication as to the ovarian response to a superovulatory treatment than does the steroid pattern in plasma. In addition the fact that milk samples are easier to obtain and handle than blood plasma have led us to conclude that, to follow the effect of gonadotrophin stimulation, it would be more informative to assay oestradiol-17 beta and progesterone in milk rather than in plasma.     

Late recovery of atrioventricular conduction after pacemaker implantation for complete heart block associated with surgery for congenital heart disease

OBJECTIVES: Pacemaker implantation is a standard recommendation for patients with persistent complete heart block following surgery for congenital heart disease. This study was performed to determine the incidence and clinical significance of late recovery of atrioventricular conduction following pacemaker implantation. METHODS: Between 1990 and 2001, 5662 open cardiac procedures for congenital heart defects were performed at our institution. The postoperative course of all patients with complete heart block in whom a permanent pacemaker was implanted was followed on a monthly basis, by either clinical or transtelephonic follow-up. RESULTS: A total of 72 patients with persistent postoperative complete heart block underwent pacemaker implantation. After insertion of the pacemaker, recovery of atrioventricular conduction was recognized in 7 of 72 patients (9.6%) at a median of 41 days (18-113 days) after the initial cardiac operation. These included 3 patients with ventricular septal defect, 2 with ventricular inversion or single ventricle, and 1 each with left ventricular outflow tract obstruction and atrioventricular septal defect. During a mean follow-up of 4.4 +/- 2.6 years, there was no late recurrence of heart block. Three patients had residual right bundle branch block and 1 had first-degree atrioventricular block. CONCLUSIONS: Atrioventricular conduction may return in a small but significant percentage of patients following pacemaker implantation for complete heart block associated with congenital heart surgery. When recovery of atrioventricular conduction occurs within the first months after surgery it appears reliable, which suggests that lifelong cardiac pacing may not be necessary in these individuals.     

Brachial plexus block with midazolam and bupivacaine improves analgesia

PURPOSE: Adjuncts to local anesthetics for brachial plexus block may enhance the quality and duration of analgesia. Midazolam, a water-soluble benzodiazepine, is known to produce antinociception and enhance the effect of local anesthetics when given epidurally or intrathecally. The purpose of this study was to assess the effect of midazolam added to brachial plexus anesthesia. METHODS: A prospective, randomized, double blind study was conducted on 40 ASA I or II adult patients undergoing upper limb surgeries under supraclavicular brachial plexus block. Patients were randomly divided into two groups. Patients in Group B (n = 20) were administered 30 mL of 0.5% bupivacaine and Group BM (n = 20) were given 30 mL of 0.5% bupivacaine with midazolam 50 microg x kg(-1). Hemodynamic variables (i.e., heart rate, noninvasive blood pressure), pain scores and rescue analgesic requirements were recorded for 24 hr postoperatively. RESULTS: The onset of sensory and motor block was significantly faster in Group BM compared to Group B (P < 0.05). Pain scores were significantly higher in Group B compared to Group BM from two hours to 24 hr postoperatively (P < 0.05). Rescue analgesic requirements were significantly less in Group BM compared to Group B (P < 0.05). Hemodynamics and sedation scores did not differ between groups in the post-operative period. CONCLUSION: Midazolam (50 microg x kg(-1)) in combination with 30 mL of bupivacaine (0.5%) hastened onset of sensory and motor block, and improved postoperative analgesia when used in brachial plexus block, without producing any adverse events.     

Reconstruction of Complex Abdominal Wall Defects

Introduction

Reconstruction of large abdominal wall defects not amenable to primary closure remains a challenging problem. These defects result from trauma, previous surgery, infection and tumour resection. The primary objectives of abdominal wall reconstructions are to protect abdominal contents and provide functional support. The abdominal wall reconstruction aims at providing basic component parts, i.e. skin, soft tissue and fascia. For large soft tissue defects, pedicled or free flap closure can be used. In clean wounds, fascial replacement is accomplished with synthetic mesh provided there is adequate soft tissue coverage.

Methods

We treated a total of 20 consecutive patients with complex abdominal wall defects utilizing various reconstructive procedures. There were 15 males (75%) and 5 females (25%). The aetiology included dehiscence of laparotomy wounds in eight (40%), following ablative surgery for malignant tumours in seven (35%), trauma in three (15%) and congenital defects in two (10%) cases. The reconstructive procedures consisted of onlay prolene mesh in seven (35%), Gore-Tex (PTFE) dual mesh both as inlay and onlay in five (25%), facial partition release technique in three (15%), inlay prolene mesh covered with omentum and split skin graft in two (10%), inlay prolene mesh covered with expanded skin in two (10%), and Gore-Tex dual mesh covered with latissimus dorsi myocutaneous flap in one (5%) case. Postoperatively none developed mesh infection or extrusion. Three patients with malignant aetiology received postoperative radiotherapy. During follow up, one patient developed ventral hernia cephalad to the repair and one died due to recurrence of abdominal wall malignancy.

Conclusion

The reconstruction of an abdominal wall defect requires a comprehensive plan of preoperative and post operative care of the patient and aims toward restoration of abdominal structural integrity by a variety of procedures. The use of new biomaterials and tissue expanders provides reliable and durable abdominal wall closure along with good aesthetic results.Key Words: Abdominal wall defect, Mesh repair, Abdominal wall reconstruction     

Nifedipine attenuates the intraocular pressure response to intubation following succinylcholine

Forty patients without eye disease, undergoing elective nonophthalmic surgery, were studied to evaluate the efficacy of sublingual nifedipine in attenuating the intraocular pressure response to succinylcholine administration, laryngoscopy and intubation. The patients were randomly given either nifedipine 10 mg or placebo sublingually 20 minutes before induction of anaesthesia. Intraocular pressure (IOP) and systolic blood pressure (SBP) were recorded before and after induction of anaesthesia. The IOP response to succinylcholine administration, laryngoscopy and intubation was significantly less in patients receiving nifedipine (P > 0.01). The mean maximum rise in IOP above basal level at one minute postintubation was 7.82 mmHg in the control group compared with 0.15 mmHg in the nifedipine pretreated group. These results suggest that sublingual nifedipine is effective in attenuating the IOP response after succinylcholine administration, laryngoscopy and intubation.