This is Dr Kiran helloing everyone. I had a good response for the previous anecdote written by a friend. I am presenting the present one written by another friend. Thanks for the infectious zeal! This will be followed by our regular features: Interesting learning scenarios in Pediatric cardiology and the popular “pediatric cardiology pearls”. First - the anecdote: any resemblance to anyone living or dead is purely coincidental!!

Mrs Ana was enjoying her new dress in the mirror. Her husband, Mr Mike had done the payment after much reluctance. “You must dress your age and profession. You work amongst the public; these are too loud” was his argument, but she would not listen.

Mrs Ana started combing her hair, but the image in the mirror did not! She was surprised. She started waving her hand frantically, but the mirror image stood still. She got afraid and wanted to scream, but the voice did not erupt off her throat.

“Cool down”, the mirror image told her. The reflection in the mirror seemed having its own movements. Mrs Ana had no choice but to listen.

“How are your days going?” the reflection asked her.

Mrs Ana hesitated, but told “Fine”. Surprisingly, the voice had become normal.

“You are spending pretty much time with me nowadays!” said the mirror image.

“Well, you see, I am senior in the office now. My husband has come back from his posting. I have some spare time and I am trying to catch up.”

The reflection did not appear impressed. “How about your colleagues and seniors in the office? Do they have equal spare time?”

“They don’t. They still work like mad. In fact the work has increased. I pressurized the boss to hire few juniors. I clearly told him I cannot work more.”

“How is your typical day?” the mirror still did not look impressed.

“I go at around 10 am. By then, my seniors would have done the apprentices’ training session. I hang around for an hour. Then I go to the office gym. Stay there for an hour and a half. Come back and work for an hour and I go to lunch. After an hour of lunch break, I tell the others that I have to go to bank. Spend another hour hanging around at various places. I come back to the workstation by 3.45PM. By 4, I tell them that I have to attend to my family and leave for the day.”

“Very interesting” said the image sordidly. “How about your seniors?”

“As I told you, they work like mad. They start at around 8.30 AM, train the apprentices, start the work, go on till 2 PM. After the lunch, they continue till 5 or 5.30 PM. Few go on till 7 PM also.”

“How do you escape so easily then?”

“You know my previous boss. She was from my own community. My husband was working outside and my kid was young. So, out of sympathy of being a single mother, she gave lot of relaxations to me. She also paid me extra money as my husband was not earning. Both of us together made one of my colleagues a jackass and made him do all my extra work. We kept telling him that I am taking a pay-cut and he gets relatively more money than me. That idiot believed us and did all my work!! Stupid fellow.”

The image started getting blurred and came back. “You know, legally single mother is the term used for divorced or husband-dead ladies with children, unless they are unmarried and have adopted a child.”

“I do, but my stupid colleague did not” giggled Mrs Ana

“Do you justify what you did was correct? What would you have done if someone else had duped you like this?”

Mrs Ana was stern. “First, what I did was entirely wrong. Second, I would have kicked any person who would have done the same to me. After all this, I think I can still get away because I think I have killed my conscience. But the surprise is, why am I telling all the truth to you that I had hidden inside me all these while?”

The mirror image smiled. “Your first assumption is wrong. I AM your conscience. Second one is right. You can cheat the entire world but you cannot lie to your own conscience. The decision to make me reappear guilt-free or to make me vanish forever is left to you.”

The mirror image faded away leaving an awestruck Mrs Ana.

The above anecdote refers to all the black sheep who wish to outsmart their peers with the help of superiors who misplace the priorities. Work culture and ethics are relatively new terms in the western work-front, but are age-old in the Indian systems. There are numerous anecdotes in our epics and history on how an individual should work holding on to ethics and not cheating the final witness: the one’s own conscience. It is secondary whether such people get punished or get their due for wrong deeds in the outer world. It is probably more important to keep our own conscience free of guilt. The problem is in dealing with such people. They become a blemish and bane on the system. Such liabilities bring down the overall morale and work efficiency. When such characters go unpunished, they either simply spread the infection of indiscipline to others or make the honest workers rebel against the system. Once a critical number of such people are reached, the system collapses. It is for the people at power to decide whether such black sheep should be allowed to exist or perish in the system. Let us know how you deal with the “black-sheep” of your firm.

With this, let us get back to our regular feature: Interesting learning scenarios

A BANDED QUESTION

It is maintained that the best time for PA band in any infant with PAH for future single ventricle pathway is by 1 month. Although many surgeons would like to wait for some more time, the general opinion is for 1 month of age. Are there any studies which support this? What is the natural history of infants who were banded for future SV physiology between 1 month and 6 months of age? We often come across such children. One observation is the disparity in the mean PA pressure and ventricular EDP in such children. We generally get a bit liberal with mean PA pressures and plan a BD Glenn for them with the idea that the pressures may come down with the Glenn shunt. Few advocate tightening of PA further. What is the general consensus on this? Please send in your institution policies.

TAKAYASU DI(E)LEMMAS

It was a learning experience. We saw a 12-year-old girl about 3 months back. She had MVP with mild MR and trivial AR. The LV was disproportionately dilated. We did a detailed clinical examination and did not find any structural anomaly. The anemia was evident. Blood investigations showed anemia with dimorphic blood picture. We advised hematenics and follow up after 3 months to see the response. When she came for follow up, we could clearly see the clinical evidence of Takayasu arteritis. The disease process probably had shown some evidence of its presence, but we could not pick up at the inception. By the time we could pick up, the disease had shown its effects. Is there any way we could have diagnosed the problem at the beginning? Please let me know if you have found any methods.

SPINE Vs CEREBRUM

Continuing with the same issue, how effective are the interventions done in patients with Takayasu arteritis with activity in end stage? Although my seniors are optimistic, I am yet to come across any single kid with end stage Takayasu arteritis intervened and made it to another year. It is true that the morbidity comes down for few months, but the mortality factor does not seem to change much. Considering that isolated balloon dilatation is of limited value and cost of stents is usually not bearable by the poor family, it is largely an ethical question. One junior colleague of mine probably had a better expression: “We spend only spinal cord for managing any medical problem of a patient because we would have burned up our cerebral cortex for thinking the financial and social implications of the problem for the family!” Should there be a consensus for the limited finance set-ups for managing the problems whose outcomes are questionable? No one probably has enough time to think of how the family suffered to arrange the finances to treat a fatal condition with negligible outcome. The family would not have understood either the problem or the treatment, forget the chances of success. In a very high-volume centre, where is the time for one-to-one interaction? Such might be the problems of the third-world, but these are the issues which maintain us in the third-world!

BANDING THE HOMOGRAFT!

This one was a real test. We had a 7-year-old who underwent VSD closure with RV to PA homograft about 2 years back outside. Few small additional muscular VSDs were documented and were probably hoped to get spontaneously closed over time. The child was lost for follow up and presented to us one day with failure. The muscular VSDs appeared sizable. On cath, there was a significant step-up. However, the lesion was typically swiss cheesed and there was no single sizable lesion. Together, the hemodynamic effect was significant. How to handle such scenarios? The VSDs were so small that they could not be closed individually. Since it was a homograft, the option of PA band also did not exist. How to deal with such a scenario? Please let me know your options on this.

TERMINOLOGY

How would you classify tricuspid atresia in the setting of cTGA as per Kuhne’s?! The left sided TV would be atretic and the great arteries would be L malposed. Should we call it type 1 or type 3? Although many classifications are accepted for tricuspid atresia, the most used classification does not involve this scenario. Please let me know your take on it.

PEDIATRIC CARDIOLOGY PEARLS

56. In neonatal IE most cases occur in structurally normal hearts. Although relatively uncommon, increasing numbers of cases of neonatal IE have been reported since the 1970s. This reflects the increased use of prosthetic intravascular devices and more frequent insertion of long-term indwelling central venous catheters. (Ferrieri P, Gewitz MH et al: Unique features of infective endocarditis in childhood. Circulation 2002 page 2115)

57. Genetics in CHD have curious angle of research. Investigators from the Baltimore-Washington Infant Study analyzed the rate of precurrence – which is the number of currently affected relatives at the time of birth. These studies demonstrate substantial rates of familial disease and suggest that CHDs may not be as sporadic as once thought. (Boughman JA, Berg KA, Astemborski JA, et al. Familial risks of congenital heart defect assessed in a population-based epidemiologic study. Am J Med Genet 1987 page 839)

58. Although currently an unproven hypothesis, the potential neurodevelopmental advantage to be derived by the affected neonate who avoids acidemia may, in the long run, prove to be the most important long-term salutary effect of prenatal cardiac diagnosis. (Lavrijsen SW, et al. Severe umbilical cord acidemia and neurological outcome in preterm and full-term neonates. Biol Neonate 2005 page 27)

59. Two kinds of atrial receptors have been described. Type A receptors fire during atrial contraction and respond to changes in atrial pressure, and type B receptors fire during ventricular systole and respond to changes in atrial volume. Type A receptors stimulate and type B receptors inhibit sympathetic activity. These stretch receptors provide feedback to the hypothalamus and inhibit secretion of antidiuretic hormone called vasopressin (Little RC, Little WC. The output of the heart and its control. In: Physiology of the Heart and Circulation. Chicago: Year Book Medical, 1989 page 165)

60. The first reported case of autopsy-proven myocardial contusion was in 1764; it described a boy struck in the chest by a plate! (Akenside M. Account of blow upon heart and its effects. Philos Trans R Soc Lond Biol 1764 page 353)

With that, we come to the end of another post. Please let me know your opinions. Send in your comments and contributions to drkiranvs@gmail.com


Regards

Kiran