Posttraumatic osteonecrosis and nonunion of distal pole of scaphoid

Posttraumatic osteonecrosis of distal pole of scaphoid is an extremely rare with only two reported cases so far. We present a case of a 30-year-old male with a 2-year-old posttraumatic osteonecrosis and nonunion of distal pole of scaphoid left wrist. He presented with complaints of pain and restriction of movements. There was no evidence of radiocarpal arthritis. He was managed with open reduction and internal fixation with k-wires, supplemented by a pronator quadratus based muscle pedicle bone graft. The fracture union was achieved at 6 months. After 2 years, he had almost complete range of wrist motion and had returned to his preinjury level of functional activity. His MRI (magnetic resonance imaging) scans showed evidence of revascularization suggesting successful incorporation of bone graft.     

Utility of Sonoclot analysis and tranexamic acid in tetralogy of Fallot patients undergoing intracardiac repair

Sonoclot analysis is a point of care test to monitor the coagulation process, presenting a comprehensive evaluation of the clot formation and retraction as well as platelet function. This randomized double-blinded study was designed to investigate the utility of Sonoclot analysis in monitoring the coagulation profile as also the antifibrinolytic effects of tranexamic acid administered in patients with tetralogy of Fallot undergoing intracardiac repair. Eighty of a total 94 patients were randomly divided into two groups of 40 each. In the study group, TA was administered thrice at a dosage of 10 mg/kg, i.e. before CPB, on CPB and after CPB, whereas in the control group, placebo was administered at the same time intervals. Sonoclot analysis and D-dimer measurement were performed at baseline and following heparin neutralisation. An additional variable, DR?? (diminishing rate of clot strength at 15 min postmaximal clot strength), was calculated from the Sonoclot graph and was compared with d-dimer levels as a measure of fibrinolysis. The three Sonoclot variables, i.e. activated clotting time, clot rate and platelet function, were deranged at baseline in all the patients. Post-CPB, the change in these variables was not significant. ACT, clot rate and platelet function showed no significant (P > 0.05) difference in both the groups at both the time intervals. DR?? and d-dimer values were comparable at baseline in both the groups. However, a significant (P < 0.05) difference was seen in these variables in the control group as compared with the TA group following heparin neutralisation. To conclude, Sonoclot analysis is a useful, point of care method for the monitoring of coagulation and fibrinolysis in patients with tetralogy of Fallot undergoing intracardiac repair.     

Role of Heart Rate as a Marker and Mediator of Poor Outcome for Patients with Heart Failure

Tachycardia has been associated with worse outcomes for patients with heart failure and is also thought to have a direct adverse impact on the myocardium. This report highlights the current evidence for heart rate as both a risk factor and mediator for poor outcome for patients with heart failure. We summarize the large number of studies evaluating heart rate in patients with systolic dysfunction and newer studies that examine patients with preserved systolic function. The effect on outcomes in heart failure of medications known to slow the heart rate such as β-blockers and the more recently developed drug ivabradine are discussed. The data clearly show that a high heart rate is a marker of increased mortality. There is also a strong suggestion that a higher heart rate directly worsens outcome and that this can be mitigated by heart rate–reducing medications.