Coronary artery anomalies overview: The normal and the abnormal

The aim of this review is to give a comprehensive and concise overview of coronary embryology and normal coronary anatomy, describe common variants of normal and summarize typical patterns of anomalous coronary artery anatomy. Extensive iconography supports the text, with particular attention to images obtained in vivo using non-invasive imaging. We have divided this article into three groups, according to their frequency in the general population: Normal, normal variant and anomaly. Although congenital coronary artery anomalies are relatively uncommon, they are the second most common cause of sudden cardiac death among young athletes and therefore warrant detailed review. Based on the functional relevance of each abnormality, coronary artery anomalies can be classified as anomalies with obligatory ischemia, without ischemia or with exceptional ischemia. The clinical symptoms may include chest pain, dyspnea, palpitations, syncope, cardiomyopathy, arrhythmia, myocardial infarction and sudden cardiac death. Moreover, it is important to also identify variants and anomalies without clinical relevance in their own right as complications during surgery or angioplasty can occur.     

What is the best treatment for a child with an acute tear of the anterior cruciate ligament?

With the heightened popularity of childhood sporting activity, the number of paediatric anterior cruciate ligament (ACL) ruptures has increased. Management of these injuries presents a particular challenge due to the open femoral and tibial growth plates. Physeal damage has the potential to cause angular deformity or length discrepancy. This review was conducted to determine the best way to treat this injury. A primary search of Ovid MEDLINE (1 October 2017) used the terms: (ACL or anterior cruciate ligament) and (young or child or children or pediatric or immature or pre‐pubescent). Titles/Abstracts of 369 articles were screened for relevance. A total of 217 were excluded, leaving 152 articles for full‐paper retrieval. Of these, 9 articles remained with one further article identified during cross‐referencing; 10 papers (1 level 2 and 9 level 3) were included for analysis. Comparative studies investigating surgical (140 knees) versus conservative (110 knees) treatment provide evidence in favour of the former, in reducing instability and meniscal tears and improving return to previous activity. Of the papers analysed (163 reconstructions), there was only one case of growth arrest (0.6%) and no cases of length discrepancy. In those studies investigating early (218 patients) versus delayed (140 patients) reconstruction, medial meniscal tears and chondral injuries occurred more frequently in the delayed group. To conclude, for children, there is level 2/3 evidence that early operative ACL reconstruction offers the best chance of a return to pre‐injury sporting activity and minimises the risks of further structural damage. Iatrogenic growth disturbance remains a rare but worrying complication.     

Frequency and predictors of post-stroke delirium in PRospective Observational POLIsh Study (PROPOLIS)

Delirium is the most common and serious neurobehavioral complication in acute hospital admissions. Some patients develop signs of delirium but do not meet all diagnostic criteria. Stroke is a major risk factor for delirium. The aim of this prospective study was to build a predictive model for delirium and subsyndromal post-stroke delirium. Patients with stroke were screened for delirium during the first 7 days after admission. Delirium was diagnosed according to DSM-V criteria. Baseline demographic, biochemical, stroke-related data, medications used, neurological deficit, and premorbid cognitive and functional impairment were assessed. 750 consecutive stroke patients (71.75 ± 13.13 years) were recruited; 203 (27.07%) had delirium. In predictive model for delirium MoCA score and white blood count on admission, neglect, vision deficits, physical impairment, and higher comorbidity prior to stroke had the highest predictive value. Subsyndromal delirium was diagnosed in 60 patients. MoCA score and potassium level on admission, and urinary tract infection during hospitalization had the highest predictive value for its development. Delirium occurs in one-fourth of admissions due to stroke; subsyndromal delirium is less prevalent and affects less than one per ten patients. The hyperactive form is the most rare type of delirium. The factors best predicting delirium are easily assessed in everyday practice and their co-occurrence in patients with stroke should alert the treating physician of high risk of delirium.     

Bi-spectral index guided closed-loop anaesthesia delivery system (CLADS™) in pheochromocytoma

Objectives. Anaesthetic management of pheochromocytoma is far from satisfactory even though various techniques are available. Feasibility as well as safety of Bi-spectral Index (BIS™)-guided closed-loop control of anaesthesia has been shown in various clinical settings. We evaluated the performance of BIS-guided closed-loop-anaesthesia-delivery system (CLADS) in patients undergoing resection of pheochromocytoma. Methods. Thirteen patients (7 males and 6 females, 15–65 years) who underwent adrenalectomy for pheochromocytoma in the past 4 years operated by a single surgeon were included in the study. Closed-loop-control of propofol-anaesthesia was induced and maintained with target BIS value =50. Results. Median performance error and median absolute performance error of target BIS control were 2 (2–7) [median (IQR)] and 10 (8–10), respectively. BIS was maintained within 50 ± 10 for 87 ± 8.6% (mean ± SD) of the valid CLAD time. Heart rate (HR) and mean arterial pressure (MAP) were maintained within ±25% of the baseline value for 90.3 ± 12.1% and 76.3 ± 13.2% of the time duration, respectively. BIS increased significantly following intubation, incision and tumor handling (P = 0.001, 0.001 and 0.03 respectively). There was a significant fall in both HR and MAP following induction of anaesthesia (P = 0.001), and MAP following tumor excision (P = 0.045) as compared to the baseline. Though maximum HR within 5 min post-intubation, post-incision and during tumor handling were significantly higher (P = 0.001, 0.014 and 0.037) compared to just before the respective event, they were not statistically different from the baseline. Though maximum MAP within 5 min post-intubation, post-incision and during tumor handling were significantly higher compared to MAP just before the respective event (P = 0.001, 0.021 and 0.001), they were not significantly different compared to the baseline value except maximum MAP during tumor handling (P = 0.001). Conclusion. CLADS performed well in patients undergoing pheochromocytoma surgeries which represent one of the few clinically extreme situations. Hegde HV, Puri GD, Kumar B, Behera A. Bi-spectral index guided closed-loop anaesthesia delivery system (CLADS™) in pheochromocytoma.