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PurposeCoronary artery disease (CAD) is reported as one of the most common sources of death all over the world. The presence of stenosis (plaque) in the coronary arteries results in the restriction of blood supply, leading to myocardial infarction. The current study investigates the influence of multi stenosis on hemodynamic properties in a patient-specific left coronary artery.Design/methodology/approachA three-dimensional model of the patient-specific left coronary artery was reconstructed based on computed tomography (CT) scan images using MIMICS-20 software. The diseased model of the left coronary artery was investigated, having the narrowing of 90% and 70% of area stenosis (AS) at the left anterior descending (LAD) and left circumflex (LCX), respectively.FindingsThe results indicate that the upstream region of stenosis experiences very high pressure for 90% AS during the systolic period of the cardiac cycle. The pressure drops maximum as the flow travels into the stenotic zone, and the high flow velocities were observed across the 90% AS. The higher wall shear stresses occur at the stenosis region, and it increases with the increase in the flow rate. It is found that the maximum wall shear stress across 90% AS is at the highest risk for rupture. A recirculation region immediately after the stenosis results in the further development of stenosis.Originality/valueThe current study provides evidence that there is a strong effect of multi-stenosis on the blood flow in the left coronary artery.

Kaposiform hemangioendothelioma (KHE) is a rare and aggressive vascular tumor that can be associated with a consumptive coagulopathy and thrombocytopenia (Kasabach-Merritt phenomenon). Only one case of an intracardiac KHE has been reported which was treated with surgical excision and then expectant management.We present a patient with an intracardiac KHE which presented as a large mass surrounding the atria, pulmonary veins, superior vena cava, and infiltrating the atrial septum with moderate compression of the superior vena cava and mild compression of the pulmonary veins. This tumor clinically presented as persistent tachypnea and was unresponsive to conventional therapy with vincristine and steroids but responded dramatically to Sirolimus with almost complete regression on follow-up.None of the current treatments for KHE, alone or in combination therapy have been found to be effective in a uniform or reproducible manner. Well designed, preferably randomized trials are required for a better understanding of the appropriate dosage and duration as well as response to treatment and a consensus of first and second line therapies.

Bilomas are localized collections of bile which usually happen post-operatively from an injured cystic or bile duct and most of the biloma collections are in the sub hepatic space.

Background: In dengue, association of fever (most common presenting symptom) with hepatic involvement can be relatively more serious. Such patients may have raised serum aminotransferase levels as well as can be more prone to bleeding due to deranged liver functions. Thus, the present study was conducted with an objective to correlate these enzyme levels with the severity of dengue fever.Methods: This prospective, observational study was carried out for 1.5 years at a tertiary care teaching hospital in southern Rajasthan after ethics committee approval. Those patients diagnosed with dengue, admitted at this tertiary centre, aged 18 years and above and willing to give consent for participation, were included in the study. Patients were assessed for clinical features of dengue along with both laboratory and radiological investigations. Severity of dengue was correlated with aminotransferase levels. Data analysis was carried out using appropriate statistical tests.Results: Total 200 patients were analysed. Mean age was 36.92±14 years while male: female ratio was 1.23:1 in the study population. All patients (100%) had fever whereas shock and bleeding tendency were noted in 16 (8%) and 4 (2%) patients respectively. Majority 130 (65%) patients had moderate dengue. Raised aminotransferase levels were noted in approximately 65% study patients out of which nearly 40% patients had moderate dengue. Correlation of raised aminotransferase levels with thrombocytopenia, shock, bleeding tendency were not statistically significant. Conclusions: Serum aminotransferase levels were elevated in moderate dengue patients. However, there was no significant correlation of raised enzyme levels with thrombocytopenia, presence of shock and bleeding tendency or as the severity of dengue increases. Thus, it is quite subjective whether to predict severity of dengue from raised enzyme levels or not.

Background: Both dysnatremia at admission and that acquired in the intensive care unit (ICU) have been shown to have a direct influence on prognosis. The present was planned to study dysnatremia in adult patients admitting in medical intensive care unit (MICU).Methods: The present prospective observational study was conducted on patients admitted in medical ICU over a period of 1 year who developed dysnatremia during ICU stay. Patient’s age, sex, diagnosis at the time of diagnosis, comorbidities, serum sodium levels, risk factors, length of ICU stay, and survival status were noted.Results: Out of total 798 patients during the study period; 207 (25.94%) were found to have hypernatremia and 87 (10.9%) were hyponatremic. In hypernatremic group male/ female ratio was 125/82 and it was 50/37 in hyponatremic group. The mean ICU stay was significantly more in hypernatremic patients (4.76±3.57) compared to hyponatremic group (4.06±2.80). (p˂0.05) Mortality in both hypernatremic patients and hyponatremic patients was found significantly more in hypervolemic group which was 84.38% and 53.84% respectively. (p˂0.05)Conclusions: This study concluded that nowadays hypernatremia is more common with longer ICU stay. In both hypernatremia and hyponatremia mortality was found similar without any significant difference.

Background: Snakebite - a global public health problem can be a traumatic experience for patients. They may develop local pain and swelling at the site with or without systemic involvement (haematological and neurological) and at times complications depending upon nature of snake. The present study was planned to determine the epidemiological and clinical profile of snakebite patients at a tertiary care teaching hospital of southern Rajasthan, India.Methods: This retrospective observational study was carried out at a tertiary care teaching hospital only after approval from institutional ethics committee. The data of patients aged between 18-80 years of either gender that had presented with a history of snakebite and admitted to the intensive care unit (ICU) in past 3 years were included. Data related to epidemiological, clinical and investigational parameters was collected and analysed. Data was presented as number (percentage) or mean ± standard deviation.Results: Total 80 patients were analyzed. Male:female ratio was 1.67:1 and mean age of study population was 33.91±14.34 years. Maximum 71 (89%) patients belonged to rural region. Only 16 (20%) patients complained of local pain. Bleeding was noted in 5 (6.25%) patients whereas 36 (45%) patients had ptosis. Prolonged coagulation markers were reported in 35 (44%) patients. Only 2 (2.5%) patients had acute kidney injury. Altered liver and renal function tests were noted in 71 (89%) and 63 (79%) patients respectively. Mechanical ventilation was required in 27 (34%) patients.Conclusions: Young adult males and rural population were prone to snakebites. Local and systemic manifestations were noted in relatively lesser patients compared to the published data. Only fewer patients in I.C.U. required mechanical ventilation.

Background: Scrub typhus is an acute febrile infectious disease which is common in both male and female patients. This study was done to compare the laboratory tests of the scrub typhus patients with reference to sex. Methods: This retrospectively study was carried out in diagnosed scrub typhus patients who were admitted to intensive care unit of a tertiary care teaching hospital of Southern Rajasthan. Diagnosis was done by testing for specific IgM antibodies against Orientia tsutsugamushi using a commercial ELISA kit. Results: Out of total 72 undiagnosed acute febrile illness patients, 26 (36.11%) were diagnosed as scrub typhus. Mean age of the patients was 39.5±12.1. There were 12 (46.15%) males and 14 (53.5%) females. Out of all 26 patients, 3 (11.54%) patients died. All laboratory tests were having non-significant difference between male and female values except haemoglobin, platelets count, serum Na and alkaline phosphatase. Raised creatinine, SGOT, SGPT and decreased albumin was found in all patients. Thrombocytopenia was found in all 12 males (100%) and 11 females (78.57%). Raised bilirubin level was found more in males (10, 83.33%) as compared to females (5, 35.71%) which were statistically significant. Raised alkaline phosphatase level was found more in female (12, 85.71%) as compared to male (5, 50%) which was also significant. Conclusions: Scrub typhus should be considered in differential diagnosis for both male and female acute febrile illness patients due to its non-significant difference in their laboratory values.

Introduction: Between the two techniques of laparoscopic nephrectomy, retroperitoneoscopy has certain distinct advantages over transperitoneal access but may be a more difficult technique to learn. We present our experience of training novices in retroperitoneoscopic nephrectomy with a good outcome, making it a standard of care for nephrectomy at our institute. Methods: The aim of this study was to report the initial experience, learning curve, and outcome of retroperitoneoscopic nephrectomy by novices under a mentored approach. The series included four novice urologists. The data from the initial forty retroperitoneoscopic nephrectomies performed by each of them were reviewed. To assess the learning curve for retroperitoneoscopic nephrectomy, we studied changes in key operative parameters (operative time, blood loss, complications, nonprogression by novices, conversion rate) as a function of the case number. Results: Retroperitoneoscopic nephrectomies were successfully completed by novices in 88.1% (141/160) of the patients. Nine cases (5.6%) required the mentor's help because of nonprogression, and ten cases (6%) required conversion to open nephrectomy. The median operative time of all surgeons decreased with increased surgical experience. There was some intersurgeon variation in the learning curve ranging from 10 to 30 cases, but all surgeons showed a significant reduction in operative time across consecutive sets of ten cases. Seven cases required mentor help in the initial series (7/80) and only two in later half of cases (2/80). All minor complications were also significantly less in the later series. Conclusions: The present series represents the effectiveness of training in retroperitoneoscopic nephrectomy of novices by a responsible team and with the standard protocol and surgical steps. Through effective mentoring, the steep learning curve associated with retroperitoneoscopic nephrectomy has been overcome, making it standard of care for nephrectomy at our institute.

Hemoptysis in the children is a rare but serious diagnosis and is even more uncommon in infancy. Mortality is reported and depends on associated illnesses, underlying etiology, and amount of bleeding. A 4-month-old patient presented with significant hemoptysis. Flexible bronchoscopy with differential lavage confirmed the presence and site of origin of hemoptysis. She was managed with cardiac catheterization for embolization of an aorto-pulmonary collateral vessel with immediate complete resolution and no further recurrences. This highlights the importance of cardiac catheterization to detect collateral vessels as a cause for hemoptysis at this age and its successful resolution following embolization. Pediatr Pulmonol. 2016; 51:E31-E33. © 2016 Wiley Periodicals, Inc.

Pulmonary artery, and rarely aortic, calcifications have been reported in sporadic case reports in the recipient twin of twin-to-twin transfusion syndrome. This presentation is more likely to be secondary to the haemodynamic alterations in the recipient twin, but must be differentiated from idiopathic infantile arterial calcification as the clinical implications, treatment, and prognosis may be drastically different.