Severe acute malnutrition (SAM) is associated with multiple vitamin deficiencies, including vitamin B12. Vitamin B12 deficiency is commonly found in the Indian subcontinent, and has devastating clinical consequences. It leads to megaloblastic anaemia and several other complications. Dysphagia is an unusual symptom of the same. The present study was undertaken to evaluate the reversal of dysphagia with vitamin B12 supplements. A hospital-based retrospective case series was conducted at the B. J. Wadia Hospital for Children. Cases were collected from 19 November 2021, to 25 August 2022. Five children less than two years of age, who presented with complaint of dysphagia, presence of megaloblastic anaemia and concurrent nutritional compromise were evaluated for their clinical profiles, and the outcomes were analysed. We found that dysphagia was a reversible symptom with medical nutrition therapy and injectable B12 therapy in children with SAM who had severe megaloblastic anaemia. The present study has identified the prevalence of dysphagia in cases of SAM with megaloblastic anaemia. This dysphagia is reversible and curable with nutritional rehabilitation and injectable B12 therapy without any further invasive intervention.

Objective: "Subclavian coronary steal" refers to diversion of blood flow from coronary bed to subclavian artery. In patients receiving internal mammary grafts during coronary artery bypass grafting surgery (CABG), aorta and its proximal branches become part of coronary circulation. Atherosclerotic occlusion of subclavian artery can manifest as subclavian coronary steal syndrome and patients may present with angina, myocardial infarction and even sudden cardiac death. The objective of our case report is to identify and present important non-conventional causes of angina for better management of patients. Case presentation: A 50-year-old, hypertensive, male patient with a prior history of having undergone CABG, presented with CCS class III angina of one-month duration. He was found to have a completely occluded left subclavian artery from origin with retrograde flow of blood in left internal mammary artery from coronary to subclavian artery. Percutaneous transluminal angioplasty with stenting to subclavian artery was performed. Antegrade flow was established and coronary steal through left internal mammarian artery graft was thus abolished with subsequent resolution of symptoms. Conclusion:We have presented a case of refractory angina in post coronary artery bypass grafting patient who was eventually treated with percutaneous stent implantation to treat the subclavian stenosis; and had complete resolution of symptoms post intervention. Take home message: Patients undergoing CABG should be screened for a possible asymptomatic subclavian stenosis that may become symptomatic after CABG. Also, subclavian coronary steal syndrome should be suspected in patients presenting with refractory angina post CABG.

Objective: The advancement in percutaneous transluminal coronary angioplasty (PTCA) has led to it becoming the predominant mode of revascularization. Post PTCA adverse events in the form of stent thrombosis, recurrent ischemia, unplanned revascularization, recurrent hospitalization etc. result in morbidity as well as mortality. Biomarkers predicting such outcomes can be useful in initiating more aggressive medical therapy and greater modification of risk factors. This study was undertaken to study the predictive significance of periprocedural plasma fibrinogen levels for coronary stenting outcomes. Methods: 80 patients diagnosed as either chronic stable angina (CSA), unstable angina (UA), Non ST Elevation Myocardial Infarction (NSTEMI) or late presentation ST Elevation Myocardial Infarction (STEMI) undergoing planned PTCA were included in study. Patients were evaluated for clinical history, electrocardiogram (ECG), two dimensional echocardiography (2D-echo) and cardiac biomarkers (Creatinine Phorphokinase-MB isomer (CK-MB) and Troponin I). Serum fibrinogen level was measured 24 hours prior to PTCA along with routine pre-operative investigations; and also 24 hours after coronary stenting. Patients were followed for six months. Outcome measure was taken to be freedom from cardiac related adverse events, including rehospitalisation, unplanned repeat revascularization, definite stent thrombosis, transient ischemic attack, stroke and all-cause mortality. Results:  Fibrinogen level ≥393 mg/dL, 24 hours prior to percutaneous transluminal coronary angioplasty, was associated with higher major adverse cardiac and cerebrovascular events (MACCE) rates (60%) as compared to those with fibrinogen level <393 mg/dL (3.6%).  Fibrinogen level ≥427 mg/dL 24 hours after percutaneous transluminal coronary angioplasty, was associated with higher major adverse cardiac and cerebrovascular events rates (65%) as compared to those with fibrinogen level <427 mg/dL (6.7%). Conclusion: The current study demonstrates that higher baseline and post procedural fibrinogen, is an independent predictor of 6 months major adverse cardiac and cerebrovascular events after elective percutaneous coronary intervention. Key words:  Coronary stent outcomes, major adverse cardiac and cerebrovascular events, plasma fibrinogen, stent diameter

Background Percutaneous Balloon Mitral Valvuloplasty (PBMV) using an Accura balloon is an effective method for management of rheumatic mitral stenosis. Case Summary Herein, we present a case of a 43-year-old female, who had undergone a previous PBMV, who presented with very severe mitral re-stenosis with type Ia left atrial (LA) clot, in atrial fibrillation and New York Heart Association (NYHA) functional class-III. We used the modified septal puncture and over the wire technique, avoiding inadvertent manipulation of the LA clot for PBMV. The mitral valve was successfully dilated from 0.9 cm2 to 1.5 cm2 and patient had an uneventful post procedure recovery. Discussion The presence of LA clot and mitral restenosis in a previously intervened valve are considered unfavourable characteristics for a PBMV procedure, and patients are usually advised surgical intervention. These patients are also high risk candidates for surgery due to late presentation with advanced disease and poor functional capacity. Our patient underwent successful re-intervention with PBMV despite having suboptimal characteristics.

No abstract