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A 65-year-old immunocompetent male presented with symmetric polyarthritis of 12 weeks and paresthesias in the distribution of the left median nerve distribution of 4 weeks duration. He had tender joint count of 20 and swollen joint count of 12. He was positive for rheumatoid factor and his erythrocyte sedimentation rate was 52 mm. Nerve conduction study demonstrated polyneuropathy. Radiographs showed severe juxta articular osteopenia at the wrist and the metacarpophalangeal joints. He received methotrexate of 10 mg/week and prednisolone of 0.15 mg/kg/day along with nonsteroidal antiinflammatory drugs (NSAIDs) with a diagnosis of seropositive rheumatoid arthritis (RA). Thirteen weeks after therapy, he presented to the outpatient clinic with disseminated vesicular eruptions all over his body with erythematous base and pneumonia involving the left upper lobe. Tzanck smear from the lesions and serology (IgG) for varicella-virus infection were positive. A diagnosis of acute disseminated varicella zoster with pneumonia was made. The patient improved on parenteral acyclovir and broad-spectrum antibiotics. With the improvement in rash and pneumonia after 2 weeks, the patient noticed a marked improvement in the joint symptoms. Arthritis remained in remission without the need for any disease-modifying drug or NSAID for next the 24 months and continued to be so until the last follow-up. Our case presents a unique phenomenon of RA remission after disseminated varicella-zoster infection in an immunocompetent individual.

Objective: Cyanotic congenital heart diseases (CCHD) with secondary polycythemia and hyperviscosity state are associated with a reduction in blood flow, stagnation of blood, and thrombosis. Sufficient hemodilution in cyanotic children results in higher blood flow and significant reductions in perioperative blood loss. The aim of this study was to investigate similar beneficial effects of hemodilution in preventing shunt thrombosis and decreasing postoperative blood loss after modified Blalock-Taussig (BT) shunt operations in children with CCHD., Design: Prospective, randomized, controlled study., Setting: Cardiac center of a tertiary care, referral hospital., Participants: Fifty children with CCHD undergoing modified BT shunt operations., Interventions: Patients were randomized into 2 groups. The study group (n = 25) received a calculated amount of 6% hydroxyethyl starch (200/0.5) solution to bring down the hematocrit to 45%, whereas the control group (n = 25) received 5% dextrose solution intraoperatively as per the authors' normal protocol., Measurements and Main Results: Effects of hemodilution on shunt patency, postoperative blood loss at 24 hours, blood and blood component usage, and re-exploration rates were recorded. The shunt patency rate was significantly higher in the study group than the control group (100% and 84%, respectively, p < 0.05). Postoperative blood loss at 24 hours was significantly higher in the control group than in the study group (14.4 +/- 11.8 mL/kg and 9.9 +/- 8 mL/kg, respectively, p < 0.05). The number of recipients and the amount of blood and blood components administered were higher in the control group, but they were not statistically significant. The re-exploration rate (for excessive postoperative chest-tube drainage) was significantly higher in the control group than the study group (12% and 0%, respectively, p < 0.05)., Conclusion: Hemodilution in CCHD patients undergoing modified BT shunt surgery has beneficial effects including improved shunt patency because of higher blood flow through the graft and less postoperative blood loss, which may be attributed to the lower viscosity produced by hemodilution.

Objective: The aim of this study was to review short- and long-term outcomes following total correction in patients with tetralogy of Fallot that presented during adulthood., Methods: It was a retrospective analysis of 284 patients (aged 14-50 years, mean 19.4 +/- 2.5 years) with tetralogy of Fallot who underwent total correction at our institution between January 1991 and December 2001. Thirty patients were subjected to postoperative first-pass radionuclide angiocardiography scans. A Hindi version of the standard World Health Organization quality of life proforma was mailed to 120 patients operated on during the first half of the study period., Results: Altogether, 45 (15.8%) patients had palliative shunts, and 32 (11%) had preoperative coil embolization. The transatrial/transpulmonary artery approach was used in 62 (22%) patients, the transventricular approach in 86 (30%) patients, and a combined approach in 136 (48%) patients. A transannular pericardial patch was used in 200 (70%) patients. A total of 61 (21%) patients had nonfatal complications. There were 28 hospital deaths. Follow-up ranged from 1 month to 10 years (mean 4.6 +/- 2.3 years). There were 7 (2.5%) late deaths and 6 (2.1%) reoperations. Altogether, 94% of patients were in New Yk Heart Association (NYHA) class I. Radionuclide angiocardiography showed normal right ventricular and left ventricular function in 18 (60%) and 22 (73%) patients, respectively. All of the 66 respondents perceived an improved quality of life. The actuarial survival and freedom from reoperation at 10 years were 82.88% +/- 3.80% and 92.82% +/- 3.40%, respectively., Conclusion: Total correction in this subset of patients offers the best option for long-term symptom-free survival.

Background & Objectives: Report from the west suggest an association of infections and inflammation with atherosclerotic coronary artery disease (CAD). Entire microbial burden from several simultaneous chronic infections could be more important than a single infection in promoting atherosclerosis. No study has been done in Indian population, investigating the association of various chronic infections with CAD. We therefore evaluated the presence of markers of chronic infections in CAD patients having no conventional risk factors and healthy individuals in a tertiary care hospital in north India., Methods: Seropositivity to IgG antibodies was investigated for Chlamydia pneumoniae, Mycoplasma pneumoniae, and Helicobacter pylori in 30 CAD patients with no conventional risk factors scheduled for coronary artery bypass surgery and in healthy blood donors. Periodontal pathogens were isolated by aerobic and anaerobic culture., Results: All patients except one were < 55 yr of age and six were younger than 40 yr. Seropositivity to C. pneumoniae was significantly higher in CAD patients than healthy controls (63.3 vs. 23.3%, P<0.01). Combined seropositivity to both C. pneumoniae and M. pneumoniae was significantly higher in CAD patients with myocardial infarction (MI) than those without MI (61.5 vs. 11.8%, P<0.05). Aerobic and anaerobic cultures for the isolation of periodontal pathogens were positive in seven patients and five healthy blood donors., Interpretation & Conclusion: C. pneumoniae seropositivity was significantly higher (P<0.001) in CAD patients without any of the conventional risk factors for CAD. Combined seropositivity to C. pneumoniae and M. pneumoniae was significantly higher (P<0.05) in CAD patients with MI than in those without MI. Possibly CAD in young is not (or less) governed by conventional risk factors, and infectious agents can be potential risk factors for the development of atherosclerosis and CAD in this subset of patients.

Context: Isolated pancreaticobiliary involvement with tuberculosis is extremely unusual. Clinical manifestations include abdominal discomfort, weight loss, obstructive jaundice or pancreatitis. Mass/cystic lesions are seen on imaging studies and are often mistaken for pancreatic malignancy. Diagnosis is by demonstration of caseation necrosis or the presence of acid-fast bacilli on Ziehl Neelson staining in the aspirated or biopsied specimen., Case Report: A 35-year-old man presented with pain in the upper abdomen of two-month duration associated with significant weight loss. Investigation showed elevated alkaline phosphatase. Imaging studies revealed a mass in the region of the head of the pancreas with dilated intra-hepatic biliary radicles. The diagnosis of pancreaticobiliary tuberculosis was confirmed by cytology from biliary brushing. Biliary brushings taken during endoscopic retrograde cholangiopancreatography have never previously confirmed the diagnosis of pancreaticobiliary tuberculosis., Conclusions: To the best of our knowledge, this is the first case report where the diagnosis was made on the basis of biliary brushings.

This prospective study uses heart-type fatty-acid-binding protein (hFABP) and creatine kinase-MB (CK-MB) release to compare myocardial injury in on-pump versus off-pump coronary artery bypass grafting (CABG). Fifty patients were randomly assigned to on-pump or off-pump CABG. The hFABP and CK-MB concentrations were measured in serial venous blood samples drawn before heparinization in both groups and after aortic unclamping at 1, 2, 4, 8, 24, 48, and 72 hours in the on-pump group. In the off-pump group, samples were taken after the last distal anastomosis at the same time intervals as in the on-pump group. The total amount of hFABP and CK-MB released was significantly higher in the on-pump than in the off-pump group (hFABP = 100.43 +/- 77.63 vs 3.94 +/- 0.36 ng/mL, P < 0.0001; CK-MB = 33.33 +/- 3.81 vs 28.65 +/- 3.91 log units, P < 0.001). In all patients, hFABP levels peaked as early as 1 hour after declamping (on-pump group) or 2 hours after the last distal anastomosis (off-pump group), whereas CK-MB peaked only at 4 hours after declamping (on-pump group) or 24 hours after the last distal anastomosis (off-pump group). The lower release of hFABP and CK-MB in the off-pump CABG group indicates that on-pump CABG with cardioplegic arrest causes more myocardial damage than does off-pump CABG. Heart-type fatty-acid-binding protein is a more rapid marker of perioperative myocardial damage, peaks earlier than CK-MB, and may predict the requirement for intensive monitoring for postoperative myocardial infarction.

The objective of this study was to assess the difference in muscular relaxation, produced by administration of the prebypass relaxant dose to the patient or in the bypass circuit. This prospective study was conducted on 100 patients scheduled to undergo elective coronary artery bypass grafting. All patients received 2 mg of vecuronium as prebypass relaxant, with neuromuscular junction monitoring using an accelograph. The patients in Group A (n=50) received the prebypass relaxant dose directly through the central venous cannula during heparinisation while group B patients (n=50) received it into the bypass circuit after initiation of bypass. Further doses of the relaxant were administered, if the train of four ratio was more than 10% at anytime after 5 min of bypass. The train of four ratio before heparinisation was similar in both groups, 12+/-6% in Group A and 13+/-5% in Group B, but after the prebypass relaxant dose, it was 1+/-2% in Group A and 15+/-3% in Group B (P<0.05). On bypass, in Group A it was 3+/-2%, 5+/-2%, 6+/-3% and 6+/-3% at 1, 5, 10 and 15 min at normothermia, while in Group B it was 29+/-6%, (P<0.01) at 1 min, 19+/-7%, (P<0.05) at 5 min, 13+/-6% at 10 min and 3+/-2% at 15 min. Additional doses of relaxant on bypass were required in 48 patients in Group B and none in Group A (P<0.01). It is concluded that the degree of muscle relaxation is significantly more profound when the prebypass relaxant dose is given to the patient directly before initiating the bypass, than when it is added to the bypass circuit after initiating the bypass. Time taken is longer and dose needed is larger, to produce the same effect.

Objective: This study compared the efficacy of aminocaproic acid and tranexamic acid in reducing postoperative blood loss, as well as blood and blood product requirements in children with cyanotic congenital heart disease., Design: A prospective randomized study., Setting: Cardiac center of a tertiary care, referral hospital., Participants: One hundred fifty children in the age group of 2 months to 14.5 years with cyanotic congenital heart disease undergoing corrective surgery on cardiopulmonary bypass (CPB)., Interventions: Patients were randomized into 3 groups. Group A was given aminocaproic acid in a dose of 100 mg/kg after anesthetic induction, 100 mg/kg on CPB and 100 mg/kg after protamine. Group T was given tranexamic acid, 10 mg/kg, after anesthetic induction, 10 mg/kg on CPB, and 10 mg/kg after protamine. Group C was the control group., Main Result: Control group had the longest sternal closure time, maximum blood loss at 24 hours, and maximum requirements of blood and blood products. Among the 2 groups given antifibrinolytics, there was no significant difference in postoperative blood loss, blood and product requirement, and reexploration rates., Conclusion: Aminocaproic acid and tranexamic acid are equally effective in reducing postoperative blood loss, as well as blood and blood product requirements in children with cyanotic heart disease undergoing corrective surgery as compared with the control group.

Background & Objectives: Antifibrinolytic agents are used commonly in adult cardiac surgery to reduce postoperative blood loss. Paucity of literature on the use of a newer antifibrinolytic agent tranexamic acid (TA) in children undergoing cardiac surgery promoted us to conduct this study in children with cyanotic heart disease., Methods: One hundred and twenty consecutive children with cyanotic heart disease were randomised into two groups. Control (group A) (n=24) given no drug while the study (group B, n=96) group was given tranexamic acid 10 mg/kg each after anaesthetic induction, on bypass and after protamine at the end of bypass. Postoperatively, total mediastinal chest tube drainage and blood and blood product usage at 24 h were recorded. Tests of coagulation including activated clotting time, fibrinogen, fibrin degradation products and platelet count were performed at 6 h postoperatively., Results: The two groups were comparable in terms of demographic characteristics such as age, sex, weight, operations performed, and preoperative haematocrit. Postoperatively, group B, had a significantly (P<0.05) lower blood loss, blood and blood product usage, re-exploration rate compared to the control group. There was preservation of fibrinogen and lower levels of fibrin degradation products in group B., Interpretation & Conclusion: Tranexamine acid was highly effective in reducing post-operative blood loss, blood and blood product usage in children with congenital cyanotic heart disease undergoing corrective surgery.