Hydrocephalus is one of the commonest complications of tuberculous meningitis (TBM). It can be purely obstructive, purely communicating, or due to combinations of obstruction in addition to defective absorption of cerebrospinal fluid (CSF). Endoscopic third ventriculostomy (ETV) as an alternative to shunt procedures is an established treatment for obstructive hydrocephalus in TBM. ETV in TBM hydrocephalus can be technically very difficult, especially in acute stage of disease due to inflamed, thick, and opaque third ventricle floor. Water jet dissection can be helpful in thick and opaque ventricular floor patients, while simple blunt perforation is possible in thin and transparent floor. Lumbar peritoneal shunt is a better option for communicating hydrocephalus as compared to VP shunt or ETV. Intraoperative Doppler or neuronavigation can help in proper planning of the perforation to prevent neurovascular complications. Choroid plexus coagulation with ETV can improve success rate in infants. Results of ETV are better in good grade patients. Poor results are observed in cisternal exudates, thick and opaque third ventricle floor, acute phase, malnourished patients as compared to patients without cisternal exudates, thin and transparent third ventricle floor, chronic phase, well-nourished patients. Some of the patients, especially in poor grade, can show delayed recovery. Failure to improve after ETV can be due to blocked stoma, complex hydrocephalus, or vascular compromise. Repeated lumbar puncture can help faster normalization of the raised intracranial pressure after ETV in patients with temporary defect in CSF absorption, whereas lumbar peritoneal shunt is required in permanent defect. Repeat ETV is recommended if the stoma is blocked. ETV should be considered as treatment of choice in chronic phase of the disease in obstructive hydrocephalus.

Background Endovascular repair of abdominal aortic aneurysm (AAA) has recently been made a class I indication in the treatment of AAA. In comparison to the conventional open surgical treatment, endovascular AAA repair (EVAR) is associated with equivalent long‐term morbidity and mortality rates. Vascular surgeons perform majority of EVAR. There are no reports for the long‐term results of this intervention performed by interventional cardiologists. We present one of the first reports of periprocedural and long‐term outcomes of EVAR performed by interventional cardiologists. Methods Retrospective chart review on patients with attempted EVAR between September 2005 and January 2011 was performed. Included cases were all consecutive patients who had attempted EVAR by interventional cardiologists. Results During the study period EVAR was attempted in 170 patients, with 27% being women. The mean age was 74 years (range 52–93). The endovascular graft placement was successful in 96% (163/170) of patients. Procedure failures were more common in women (6 of 46 vs 1 of 124, P = 0.003). The 30‐day mortality was 1.8 % (3 of 170). In patients with successful EVAR the mean follow‐up was 30 months and mean length of hospital stay was 3.5 ± 3.2 days. Major periprocedural complications were noted in 9% patients (15 of 167). During follow‐up, six patients (3.5%) required re‐intervention and additional 16 patients died with no aneurysm related deaths. Conclusion EVAR primarily performed by interventional cardiologists demonstrates high periprocedural and long‐term success rates. A higher EVAR failure rate has been observed in women. © 2014 Wiley Periodicals, Inc.

Providing effective discharge instructions, appropriate dose uptitration, education regarding heart failure (HF) monitoring, and strict follow-up have all been shown to decrease readmissions for HF but are all underutilized. The authors developed and evaluated the impact of a quality-improvement HF checklist as a tool to remind physicians to improve quality of care in HF patients. The checklist was used in randomly selected patients admitted with a primary diagnosis of acute decompensated HF. It included documentation regarding medications and dose uptitration, relevant counseling, and follow-up instructions at discharge. The checklist was used in 48 patients, and this checklist group was compared with 48 patients as a randomly selected control group. Higher proportions of patients were taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in the checklist group compared with the control group (40 of 48 vs 23 of 48, P<.001). Compared with the controls, the rate of dose uptitration for β-blockers and/or ACE inhibitors/ARBs was more common in the checklist group (4 of 48 vs 21 of 48, P<.001). Both 30-day (19% to 6%) and 6-month (42% to 23%) readmissions were lower in the checklist group. The use of an HF checklist was associated with better quality of care and decreased readmission rates for patients admitted with HF.

Background: Approximately 33% to 40% of older adults with heart failure are re-hospitalized within three months of discharge. The 6 month readmission rate is as high as 50%. Studies have shown that upward titration of ACE I, ARB and beta-blockers after discharge resulted in reduced hospital re-admission rates, improved functional capacity and quality of life. In our quality improvement project two groups of patients admitted with primary diagnoses of CHF were studied. A discharge checklist was developed for the second group and its effect on dose titration and readmissions was studied. Methods: For the first group, all patients readmitted within 3 months for CHF from April 1, 2007 to December 31, 2007 were identified. The primary end point was the difference in dosage of ACE I/ARB and B- blockers between discharge and readmission. For the second group a CHF discharge checklist was used randomly in patients admitted with primary diagnoses of CHF from August 2008 to October 2009. Checklist included documentation regarding dose titration, relevant counselling, education and follow up instructions. Results: The first group had 127 readmissions for CHF within 3 months of discharge. The second had 48 patients in which CHF discharge checklist was used. The characteristics of two populations is shown in the Table. Second group readmissions for CHF were decreased after using the checklist from 68% (15/22) to 36% (8/22, p = 0.3). Compared to prior to using the checklist, the total number of readmissions within 6 months of discharge were reduced significantly from 25 to 9 (p = 0.04). Up titration of diuretics in the hospital was associated with decreased readmissions (p=0.07, 4/14 vs 0/8). Conclusion: The use of CHF discharge checklist significantly improves dose titration of heart failure medications and decreases the total number of readmissions due to CHF. Furthermore among drug dose titration, up titration of diuretics tend to decrease CHF readmissions. Baseline characteristics of the two study groups and effect of discharge checklist on dose titration Baseline characteristic Study group 1 Study group 2 (discharge checklist) p - value Age (mean +/− SD) in years 75.94 +/− 13.1 75.97 +/− 13.1 CHF readmissions 180 of 318 25 of 48 0.8 Women 70 of 127 21 of 48 0.47 Dose titration of beta blocker 16 of 127 17 of 48 0.008 Dose titration of ACE I/ARB 7 of 127 7 of 48 0.07 Dose titration of diuretic 16 of 127 11 of 48 0.17 Dose titration in beta blocker + ACE I/ARB 19 of 127 21 of 48 0.004 Dose titration in beta blocker + ACE I/ARB + diuretic 31 of 127 27 of 48 0.009

PURPOSE: There are various risk factors for coronary heart disease (CHD) and ST elevation myocardial infarction (STEMI), out of which the prevalence of obesity is increasing in epidemic proportions. Literature is sparse and there are few reports for the association of obesity and myocardial infarction in the young population. We present our hospital experience demonstrating the prevalence of various risk factors including obesity in young patients with STEMI.

PURPOSE: The 6-month readmission rate for congestive heart failure (CHF) is as high as 50%. Studies have shown that upward titration of ACE inhibitor (ACE I) or angiotensin receptor blocker (ARB) and beta-blockers after discharge resulted in reduced hospital re-admission rates, improved functional capacity and quality of life. Despite compelling scientific evidence and readily accessible national guidelines, life-prolonging agents remain underused. We present our community based randomized controlled trial to show the effect of quality improvement discharge tool in CHF.

INTRODUCTION:Endovascular repair of abdominal aortic aneurysm (AAA) is a relatively recent technology. In comparison to the conventional open surgical treatment for AAA, endovascular AAA repair (EVAR) combines a less-invasive approach with lower morbidity and mortality. There have been few studies regarding the performance of this procedure in a community-based setting. We report our experience of EVAR performed primarily by interventional cardiologists in a community hospital.METHODS:In our community hospital setting, between September 2005 and November 2007, we included all patients who underwent EVAR by interventional cardiologists, with available on-site vascular surgical support. Clinical and serial computed angiographic imaging outcomes were followed by a retrospective chart review. Data collection tools included demographic and clinical characteristics, anatomical aneurysm features, length of stay, peri- and postprocedural complications, and mortality.RESULTS:A total of 71 consecutive patients had EVAR attempted. The endovascular stent placement was successful in 67 (93%) patients. Thirty-day mortality in this study was 1 of 71 (1.4%). All four procedural failures and the single periprocedural mortality occurred in women. Mean follow-up was 12 months. There were a total of six mortalities and among these four were women (P ≤ 0.001); however, multivariate analysis revealed loss of significant difference in mortality (P = 0.16). Major complications following EVAR were noted in 10 of 71 (14%) patients.CONCLUSION:EVAR can be successfully performed by experienced interventional cardiologists with vascular surgical support in a community-based setting. In our experience, there is acceptable rate of complications and mortality in a carefully selected patient population.

The treatment options for symptomatic arachnoid cysts are shunting, open craniotomy, and endoscopic fenestration. Endoscopic fenestration of large arachnoid cyst is safe and effective. Postoperative subdural hematoma and intraparenchymal hemorrhage can be avoided by endoscopic fenestration. This technique has the additional advantage of identifying and treating ventricular abnormalities, such as foramen of Monro stenosis and cerebral aqueduct occlusion. This report describes endoscopic dual fenestration in a child with large multicompartmental intraventricular arachnoid cyst extending from foramen magnum to foramen of Monro. The child presented with difficulty to hold the neck in upright position, irritability, vomiting, and large head. Follow-up postoperative magnetic resonance imaging at 3 months showed a significant reduction in size of the cyst. Clinically, the patient showed a gradual improvement at 10 months follow-up. Probably this is the first report of this nature.