Closed mitral commissurotomy for mitral stenosis with dextrocardia—case series

Rheumatic valvular affection is not an uncommon disease especially in the developing nations, but its association with dextrocardia is relatively rare. In the present day scenario, where mitral valve replacements far exceed the number of closed commissurotomies, a sound understanding of the anatomy, approach, and technique is vital vis-à-vis surgical management of these patients who do not have the finances for replacement of a severely stenotic valve or patients who may present in extremis. We present a case series of three such patients who underwent successful closed commissurotomies.     

Role of bromocriptine in multi-spectral manifestations of traumatic brain injury

Purpose: Despite the prevalence and cost of traumatic brain injury related disabilities, there is paucity in the literature on modern approaches to pharmacotherapy. Medications may promote recovery by enhancing some neurological functions without impacting others. Herein we discussed the role of bromocriptine in neurorehabilitation for patients with traumatic brain injury. Methods: A cohort comprising of 36 selective nonsurgical cases of traumatic brain injury in minimally conscious state were enrolled in the study. After hemodynamic stability, bromocriptine was given at paediatric dose of 3.75 mg/d and adult dose of 7.5 mg/d. It was administered through a naso-gastric (NG) feeding tube in the patients with minimally conscious state, then changed to oral route after proper swallowing and good gag reflex were ensured in the patient. The drug was slowly reduced over three weeks after neurological improvement in the patients. Positive result was determined by improvd GCS score of 2 and motor power by at least 1 British Medical Council (BMC) motor score. Improvement of deficits was evaluated in terms of fluency of speech for aphasia, task switching, digit span double tasking and trail-making test for cognition and attention, and functional independence measure score for motor functioning and self-independence. Results: Accelerated arousal was seen in 47.0% of cases (8/17) in 4e40 days. In 41.2% of cases (7/17), Glasgow outcome score (GOS) was improved to 4/5 in 90 days. Improvement in hemiparesis by at least 1 BMC score was seen in 55.6% of cases (5/9) in 40 days. Aphasia was improved in 80% of cases (4/5) in 7-30 days. Moderate improvement in cognitive impairment was seen in 66.7% of cases (2/3) in 14e20 days. Improvement in memory was observed in 50% of cases (1/2) in over 30 days. No cases were withdrawn from the study because of adverse reactions of the drug. There was no mortality in the study group. Conclusion: Bromocriptine improves neurological sequelae of traumatic brain injury as well as the overall outcome in the patients. If medication is given to promote recovery and treat its associated disabilities, clinicians should thoroughly outline the goals and closely monitor adverse effects.     

Complications of Psychotropic and Pain Medications in an Ultrarapid Metabolizer Patient at the Upper 1% of Cytochrome P450 (CYP450) Function Quantified by Combinatorial CYP450 Genotyping

A 44-year-old Caucasian woman presented with a history of empirical treatment with 20 pain and psychotropic medications, as well as dual comorbidity of intractable pain and depression. A multiple gain-of-function profile in the CYP450 family of cytochrome P450 (CYP450) drug metabolism isoenzymes was discovered. The patient was a homozygote of suprafunctional alleles for both CYP2D6 (^*35/^*35) and CYP2C19 (^*17/^*17) genes and functional alleles for CYP2C9 (^*1/^*1), which account for aggregate drug metabolism function at the upper 1% of the population. The patient improved clinically with discontinuation of psychotropics and pain medications that were substrates of CYP2D6 and/or CYP2C19, suggesting that much of her symptomatology was drug induced. Combinatorial genotyping of CYP450 genes is diagnostically useful in individuals with histories of multiple side effects or drug resistance, which could be avoided by genetically informed therapeutics in behavioral health.     

Non small cell lung cancer (NSCLC): current status and future prospects

The incidence of lung cancer is rising dramatically and it is now the commonest cause of mortality and morbidity not only in the industrialised countries, but in developing nations like India as well. Tobacco smoking has consistently been demonstrated to be an important aetiological factor, though lung cancer occurs in non-smokers also. In spite of great advances in radiological and molecular diagnostic techniques, the ideal screening marker for early detection of lung cancer has still not been found. Histological diagnosis and staging is essential for selecting the mode of therapy in patients with lung cancer. Stages I and II are amenable to surgery. However, advanced stage III and IV need an individualised combination of surgery, chemotherapy and radiotherapy. With a better understanding of the cellular mechanisms operating in carcinogenesis, newer target specific modalities are being developed and tested in order to stem this disease, which threatens to assume epidemic proportions.     

The effects of preexisting depression on cerebrovascular health outcomes in geriatric continuing care

BACKGROUND: Previous studies have investigated depression as the cause and outcome of vascular deficit in elderly persons. METHODS: The authors wanted to determine whether baseline depression is predictive of subsequent cardiovascular events in very elderly persons residing in a continuing care retirement community (n = 181). RESULTS: Controlling for demographic factors, both depression and the number of cardiovascular risk factors (CVRFs) at baseline were strongly predictive of stroke, whereas only CVRFs strongly predicted myocardial infarctions. Depression accounted for 12% of the variance in stroke incidence, beyond the contribution of CVRFs. Path analysis indicated that depression was also a partial moderator of the effect of CVRFs. CONCLUSIONS: In support of the vascular depression hypothesis, the study findings indicate that, for the oldest old, depression may be a strong predictor of future stroke. The presence of depression in elderly patients should alert physicians to carefully investigate other stroke risk factors and to integrate depression into an overall intervention regimen for reducing patients' risks for stroke.     

Oxidative damage of erythrocytes infected with Plasmodium falciparum

Summary The extent of reduced glutathione, activity of glutathione peroxidase, amount of membrane lipid peroxidation products, and the extent of hemoglobin release from host erythrocytes during in vitroPlasmodium falciparum growth was studied. Highly synchronized parasite cultures were studied to examine the alterations caused by different growth stages of the parasite. There was a moderate increase in the reduced glutathione content as the parasite matured, which was significant only in schizontrich erythrocyte lysates (p<0.05) whereas the activity of glutathione peroxidase was significantly low in all the parasitized red blood cells (ring-infected RBC,p<0.005; trophozoite- and schizont-infected RBC,p<0.001). The lipid peroxidation product, malonyldialdehyde, of the host red cells increased gradually to more than fourfold in schizont-rich cells as compared with normal erythrocytes (p<0.001). The hemoglobin release from cultured cells was significantly higher in all parasitized red cell cultures as well as in uninfected cells kept in in vitro, as compared with normal erythrocytes. The consequence of such changes induced by the malarial parasites in the host red cells in the pathogenesis of erythrocyte destruction and anemia ofP. falciparum malaria is discussed.     

Extra corporeal carbon dioxide removal: A reliable modality in refractory hypercapnia to prevent invasive ventilation

Extracorporeal carbon dioxide removal (ECCO2R) is a valid alternative to consider in hypercapnic respiratory failure in chronic obstructive pulmonary disease (COPD) patients to avoid invasive ventilation when noninvasive ventilation fails. Here we report a similar case, after obtaining informed consent, where a patient suffering from severe hypercapnic respiratory failure due to COPD, was selected for ECCO2R and improved remarkably.