Need for enrichment of lutetium isotope and design of a laser based separator module.

Lutetium-177 radio-pharmaceutical has become an important theranostic candidate in cancer treatment. Its availability from bench-to-bed requires strategic implementation of isotope-enrichment, neutron-irradiation and radio-chemical techniques. In this paper, the need for enrichment of lutetium-176 is emphasized by estimating specific activity of lutetium-177 as a function of enrichment percentage for typical neutron flux available at Dhruva reactor, India. A novel Atomic Vapour Laser Isotope Separation (AVLIS) module for lutetium-176 enrichment is designed to meet the above requirement. The paper documents its characteristics and production estimates. The design is carried out after critical assessment and evaluation of available AVLIS-infrastructure in the country. Outline of lutetium-177 enrichment, capable of producing non-carrier-added lutetium is also provided. This work concludes that India has taken a step forward towards self-reliance (Atmanirbhar Bharat) in securing the supply chain of lutetium-177.

Prediction of Coronary Artery Disease Severity by Using CHA2DS2-VASC-HSF Score in Patients with ST-Elevation Myocardial Infarction.

CHADS2 and CHA2DS2-VASc scores are widely used in clinical practice and include similar risk factors for the development of coronary artery disease (CAD). It is known that the factors comprising the newly defined CHA2DS2-VASC-HSF score promote atherosclerosis and associated with severity of CAD. Objective of the study was to find out the association of the CHA2DS2-VASC-HSF score with the severity of CAD in patients with ST elevation myocardial infarction (STEMI). One hundred (100) patients with STEMI were enrolled in this study after considering inclusion and exclusion criteria over a one year period from October, 2017 to September, 2018 in the Department of Cardiology, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh. Coronary angiogram was done within index hospitalization and coronary artery disease severity was assessed by SYNTAX score system. Patients were divided into two groups on the basis of SYNTAX score. Patients with SYNTAX score ≥23 assigned as Group I and SYNTAX score <23 assigned as Group II. The CHA2DS2-VASC-HSF score was calculated. Cut-off value of high CHA2DS2-VASC-HSF score was ≥4.0. In this study mean age of study population was 51.8±9.8, male patients were predominant (79.0%). Among the studied patients, highest percentage had history of smoking followed by hypertension, diabetes mellitus and family history of CAD in Group I patients. It was found that DM and family history of CAD and history of stroke/TIA were significantly higher in Group I than Group II. An increasing trend of SYNTAX score was observed according to the CHA2DS2-VASc-HSF score. SYNTAX score was significantly higher in CHA2DS2-VASc-HSF score ≥4 than CHA2DS2-VASc-HSF score <4 (26.3±6.3 vs. 12.1±7.7, p<0.001). Patients with CHA2DS2-VASC-HSF score ≥4 had severe coronary artery disease than CHA2DS2-VASC-HSF score <4 assessed by SYNTAX score with 84.4% sensitivity and 81.9% specificity (AUC:0.83, 95% CI: 0.746-0.915, p<0.001). CHA2DS2-VASc-HSF score was positively correlated with the severity of CAD. This score could be considered as a predictor of coronary artery disease severity.

Association of Aortic Valve Sclerosis with Angiographic Severity of Coronary Artery Disease in Patients with Acute Coronary Syndrome, Aged ≤65 Years.

Aortic valve sclerosis (AVS) represents a degenerative process that progresses with advancing age. The study was intended to find out the association between aortic valve sclerosis and the severity of CAD in patient's age ≤65 years with acute coronary syndrome. This cross-sectional analytical study was carried out in the department of cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh during a period of October 2017 to September 2018. A total of 140 Acute coronary syndrome (ACS) patients undergoing coronary angiogram during index hospitalization were included in the study. Study patients were divided into two groups on the basis of echocardiographic presence or absence of Aortic valve sclerosis (AVS), with 70 patients in each group. Group I was patients with aortic valve sclerosis and Group II was patients without aortic valve sclerosis. All patients underwent transthoracic echocardiography before they underwent coronary angiography on different days. Severity of CAD was determined by Gensini score and Vessel score. Association of traditional risk factors (smoking habit, hypertension, diabetes mellitus, dyslipidaemia and family history of CAD) with severity of CAD was investigated. Coronary angiography showed that AVS group had a higher positive rate of CAD (82.9% vs. 54.3%, p<0.001) and incidence rate of triple vessel CAD (40% vs. 14.3%, p<0.001) than non-AVS group. Gensini score had higher in AVS group than non AVS group (37.9±27.8 vs. 12.5±14.2; p<0.001). Multivariate analysis showed that AVS (p=0.01) and age (p=0.04) were independent predictors of the presence of significant coronary artery disease. The study concluded that echocardiographically detected AVS is an independent predictor of coronary artery disease severity. There is positive correlation between severity of AVS and severity of CAD in patient's age ≤65 years with ACS.

Association of Echocardiographic Epicardial Fat Thickness with the Angiographic Severity of Coronary Artery Disease in Patients with Acute Coronary Syndrome.

Estimation of visceral adipose tissue is important as it carries high cardiometabolic risk and several methods are available as its surrogate. Epicardial fat thickness (EFT) is a direct measure of visceral fat rather than anthropometric measurements. EFT can be accurately measured by two-dimensional (2D) echocardiography. It tends to be higher in patients with Acute Coronary Syndrome (ACS). The present study was intended to find out the association between echocardiographic EFT and severity of Coronary Artery Disease (CAD) in patients with ACS. This cross-sectional observational study was carried out in the department of cardiology, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh from October 2017 to September 2018. Sampling technique was purposive sampling. Comparison between groups was done by unpaired-t test & dichotomous variables were compared by chi-square test. A total of 164 patients was enrolled in the study, prospectively examined EFT on echocardiography and patients were divided into 2 groups, Group I patients with EFT >4.65mm and Group II patients with EFT ≤4.65mm. Coronary angiograms were analyzed for the extent and severity of CAD using Gensini score. The mean EFT (mm) was found 6.1±1.0 in Group I and 3.5±0.7 in Group II (p<0.001). Patients with a higher EFT were associated with a high Gensini score (Group I vs. Group II, 50.3±24.1 vs. 21.9±20.0; p<0.001). Multivariate analysis showed that EFT (OR 6.07, p<0.001) and smoking (OR 2.66, p=0.03) were independent factors affecting significant coronary artery stenosis. By ROC curve analysis, EFT >4.65mm predicated the presence of significant coronary stenosis by 76.1% sensitivity and 69.9% specificity. EFT measured using Transthoracic echocardiography (TTE) significantly correlates with the severity of CAD. It is sensitive, easily available, and cost-effective and assists in the risk stratification and may be an additional marker on classical risk factors for CAD.

Randomized control trial evaluating the use of a shared decision-making aid for older ventral hernia patients in the Geriatric Assessment and Medical Preoperative Screening (GrAMPS) Program.

PURPOSE: Shared decision making (SDM) is ideally suited to abdominal wall surgery in older adults given the breadth of decision making required by the hernia surgeon and the impact on quality of life (QOL) by various treatment options. Given the paucity of literature surrounding SDM in hernia patients, the feasibility of a novel, formalized SDM aid/tool was evaluated in a pilot randomized trial. METHODS: Patients 60 years or older with a diagnosed ventral hernia were prospectively randomized at an academic hernia center. In the experimental arm, a novel SDM tool, based on the SHARE Approach, guided the consultation. Previously validated SDM assessments and patient's hernia knowledge retention was measured. RESULTS: Eighteen (18) patients were randomized (9 control and 9 experimental). Cohorts were well matched in age (p = 0.51), comorbidities (Charlson Comorbidity Score: p = 0.43) and frailty (mFI-11: p = 0.19; Risk Analysis Index: p = 0.33). Consultation time was 11 min longer in the experimental cohort (p < 0.01). There was a trend towards better Decisional Conflict Scores in the experimental group (p = 0.25) and the experimental cohort had improved post-visit retained hernia knowledge (p < 0.01). All patients in the experimental arm (100%) enjoyed working through the SDM aid/tool and felt it was a worthwhile exercise. CONCLUSION: Incorporating a formalized SDM tool into a busy hernia surgical practice is feasible and well received by patients. In addition, early results suggest it improves retention of basic hernia knowledge and may reduce patient's decisional conflict. Next steps include condensing the SDM tool to enhance efficiency within the clinic and beginning a large, randomized control trial.

Phenomenological Constraints on the Transport Properties of QCD Matter with Data-Driven Model Averaging.

Using combined data from the Relativistic Heavy Ion and Large Hadron Colliders, we constrain the shear and bulk viscosities of quark-gluon plasma (QGP) at temperatures of ∼150-350 MeV. We use Bayesian inference to translate experimental and theoretical uncertainties into probabilistic constraints for the viscosities. With Bayesian model averaging we propagate an estimate of the model uncertainty generated by the transition from hydrodynamics to hadron transport in the plasma's final evolution stage, providing the most reliable phenomenological constraints to date on the QGP viscosities.

Recurrent aplastic anemia with donor-type aplasia: A rare occurrence in the Indian subcontinent.

Donor-type aplasia (DTA) is a condition where an individual continues to be aplastic even after a successful engraftment of a hematopoeitic stem cell transplant with a majority of donor type cells in the bone marrow. This entity has been seen with varying frequency around the world, especially in Southeast Asia. However, its incidence in the Indian subcontinent remains fairly low. Here is a case of a 17-year-old child with DTA who had a 89% population of donor cells after a successful transplant and presented with recurrent severe aplastic anemia later. The patient eventually succumbed to his condition before a second transplant could be performed. The awareness about the seriousness of this relatively rare condition, therefore, needs to be emphasized.

National Clinical Guidance for the Management of Cardiovascular Intervention in the COVID-19 Pandemic: From Bangladesh Society of Cardiovascular Interventions (BSCI).

Since the first recorded case of SARS-CoV-2 in Bangladesh on 8th March 2020, COVID-19 has spread widely through different regions of the country, resulting in a necessity to re-evaluate the delivery of cardiovascular services, particularly procedures pertaining to interventional cardiology in resource-limited settings. Given its robust capacity for human-to-human transmission and potential of being a nosocomial source of infection, the disease has specific implications on healthcare systems and health care professionals faced with performing essential cardiac procedures in patients with a suspected or confirmed diagnosis of COVID-19. The limited resources in terms of cardiac catheterization laboratories that can be designated to treat only COVID positive patients are further compounded by the additional challenges of unavailability of widespread rapid testing on-site at tertiary cardiac hospitals in Bangladesh. This document prepared for our nation by the Bangladesh Society of Cardiovascular Interventions (BSCI) is intended to serve as a clinical practice guideline for cardiovascular health care professionals, with a focus on modifying standard practice of care during the COVID-19 pandemic, in order to ensure continuation of adequate and timely treatment of cardiovascular emergencies avoiding hospital-based transmission of SARS-COV-2 among healthcare professionals and the patients. This is an evolving document based on currently available global data and is tailored to healthcare systems in Bangladesh with particular focus on, but not limited to, invasive cardiology facilities (cardiac catheterization, electrophysiology & pacing labs). This guideline is limited to the provision of cardiovascular care, and it is expected that specific targeted pharmaco-therapeutics against SARS-CoV-2 be prescribed as stipulated by the National Guidelines on Clinical Management of Corona virus Disease 2019 (COVID-19) published by the Director General of Health Services, Ministry of Health and Family Welfare of Bangladesh.

Assessment of myofascial medialization following posterior component separation via transversus abdominis muscle release in a cadaveric model.

PURPOSE: Posterior component separation (PCS) via the transversus abdominis release (TAR) procedure continues to gain popularity. However, neither the physiologic basis nor the extent of myofascial medialization after TAR is established. We aimed to assess both anterior and posterior rectus fascia (AF and PF) medialization following each step of the TAR procedure. METHODS: Ten fresh cadavers underwent PCS via TAR. Steps included midline laparotomy (MLL), retrorectus dissection (RRD), incision of the posterior rectus sheath (IPL), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Medial advancement of AF and PF was measured following application of 2.5, 5.0 lb, and maximal tension to the fascial edge. Values are represented as mean advancement past midline in centimeters. RESULTS: MLL allowed advancement of 2.5, 3.7, and 4.9 cm. RRD provided advancement of 4.1, 5.9, and 7.6 cm for AF and 4.4, 6.2, and 7.5 cm for PF. IPL provided advancement of 4.2, 6.1, and 8.0 cm for AF and 4.6, 6.6, and 8.3 cm for PF. TAD provided advancement of 4.5, 6.6, and 8.6 cm for AF and 5.3, 7.5, and 9.5 cm for PF. RMD provided advancement of 5.5, 7.9, and 9.9 cm for AF and 6.9, 9.6, and 11.2 cm for PF. Overall, the complete TAR procedure provided AF advancement of 102% and PF advancement of 129%, over baseline. CONCLUSIONS: The TAR procedure provides for substantial medial advancement of both anterior and posterior myofascial components of the abdominal wall. Retromuscular dissection deep to the divided transversus abdominis muscle appears to be the key step of the procedure, allowing for effective reconstruction of very wide (≈ 20 cm) defects.

Outcomes of utilizing absorbable mesh as an adjunct to posterior sheath closure during complex posterior component separation.

BACKGROUND: A minority of patients undergoing posterior component separation (PCS) have abdominal wall defects that preclude complete reconstruction of the visceral sac with native tissue. The use of absorbable mesh bridges (AMB) to span such defects has not been established. We hypothesized that AMB use during posterior sheath closure of PCS is safe and provides favorable outcomes. METHODS: We performed a retrospective review of consecutive patients undergoing PCS with AMB at two hernia centers. Main outcome measures included demographics, comorbidities, and post-operative complications. RESULTS: 36 patients were identified. Post-operative wound complications included five surgical site infections. At a median of 27 months, there were five recurrent hernias (13.9%), 2 of which were parastomal, but no episodes of intestinal obstruction/fistula. CONCLUSIONS: Utilization of AMB for large posterior layer deficits results in acceptable rates of perioperative wound morbidity, effective PCS repairs, and does not increase intestinal morbidity or fistula formation.

The use of Vicryl mesh in a porcine model to assess its safety as an adjunct to posterior fascial closure during retromuscular mesh placement.

BACKGROUND: Posterior component separation has become a common approach to complex abdominal wall reconstructions. This technique includes creation of an extraperitoneal retromuscular space for subsequent large synthetic mesh reinforcement. In certain cases, when complete restoration of "posterior" layer is precluded by significant tissue loss/damage, one proposed strategy is to replace the posterior fascia with an absorbable synthetic polyglactin (Vicryl) mesh. However, the safety of this strategy to prevent mesh-related visceral complication is unknown. Herein, we aimed to characterize mesh-viscera adhesion profiles and host tissue response of synthetic mesh either exposed directly to the viscera, or protected with Vicryl mesh. METHODS: Using adult Yorkshire pigs, 5 × 5 cm pieces of mesh were secured to the intact peritoneum in each of the four quadrants (n = 6 pigs, 24 mesh samples). The study groups were Vicryl (V), Marlex (M), Softmesh (S), Marlex + Vicryl construct (MV), Softmesh + Vicryl construct (SV). The self-made composite meshes were then implanted with the Vicryl side facing the exposed viscera. The pigs were survived for 60 days. At necropsy, grossly, the extent and tenacity of visceral adhesions were evaluated using established scales. Histologically, all specimens for fibrous encapsulation on the visceral surface of the mesh were reviewed by an experienced pathologist blind to meshes used. RESULTS: At necropsy, all Vicryl meshes were completely resorbed. The mean adhesion and tenacity scores for M and MV were 1.8 and 1.1 (P > 0.05), 2.0 and 1.5 (P > 0.05), respectively; while the mean adhesion extent scores and tenacity scores for S and SV were 2.0 and 1.2 (P > 0.05), 2.0 and 1.7 (P > 0.05). No significant difference in adhesion extent and tenacity was observed between Synthetic and Vicryl composite mesh groups. Histologically, Marlex + Vicryl mesh and Softmesh + Vicryl mesh constructs had thicker fibrous capsules than the corresponding unprotected Marlex and Soft mesh implants. Furthermore, visceral adhesions in the composite groups were noted to be to the fibrous capsule and not synthetic mesh itself. CONCLUSION: Utilization of the absorbable polyglactin (Vicryl) mesh as a separating layer between a synthetic mesh and intestines, did not reduce adhesions across various mesh types and composites. Histologically, however, a thick fibrous capsule replaced the Vicryl mesh and may be an important layer to prevent intestinal erosion into retromuscular synthetic meshes.

Rheumatic fever and rheumatic heart disease in Bangladesh: A review.

Rheumatic fever (RF) and rheumatic heart disease (RHD) are the most-common cardiovascular disease in young people aged <25 years, globally. They are important contributors to cardiovascular morbidity and mortality in Bangladesh. Classical risk factors, i.e. poverty, overcrowding, ignorance, and insufficient health care services were responsible for the high incidence and prevalence of these diseases over the last century. In concert with the progresses in socioeconomic indicators, advances in health sectors, improved public awareness, and antibiotic prophylaxis, acute RF came into control. However, chronic RHD continues to be prevalent, and the actual disease burden may be much higher. RHD predominantly affects the young adults, seriously incapacitates them, follows a protracted course, gets complicated because of delayed diagnosis and is sometimes maltreated. The treatment is often palliative and expensive. Large-scale epidemiological and clinical researches are needed to formulate evidence-based national policy to tackle this important public health issue in future.

Immediate Clinical and Echocardiographic Outcome of Percutaneous Transvenous Mitral Commissurotomy for Patients of Mitral Stenosis with Atrial Fibrillation.

Rheumatic fever and rheumatic heart disease continue to be the major health problem in all developing countries including Bangladesh. Rheumatic mitral stenosis is a very common problem in our population having an incidence of 54 percent among rheumatic heart disease with a female preponderance of 2:1. Percutaneous balloon mitral commissurotomy is appealing because the mechanism of valve dilation closely parallels the mechanism of surgical mitral commissurotomy. The technique of balloon mitral commissurotomy has evolved rapidly, with improvements in balloons, guide wires, and the application of double-balloon techniques. There is controversy that whether the presence of AF has a direct negative effect on the immediate or long-term outcome after PTMC in mitral stenosis patients. The purpose of this study was to see the effect of atrial fibrillation (AF) on the immediate clinical and echocardiographic outcome of patients undergoing Percutaneous Transvenous Mitral Commissurotomy (PTMC). The immediate procedural and in-hospital clinical outcome after PTMC of 264 patients with AF were prospectively collected and compared with those of 288 patients in normal sinus rhythm (NSR) with mitral stenosis admitted in National Institute of Cardiovascular Diseases, Dhaka and Al-Helal Heart Institute, Mirpur, Dhaka, Bangladesh. Patients with AF were older than patients with normal sinus rhythm (53 ± 11 vs. 33 ± 12 years; p<0.0001) and presented more frequently with New York Heart Association (NYHA) class III-IV (78.3% vs. 58.5%; p<0.0001), echocardiographic score >8 (38.9% vs. 22.7%; p<0.0001), calcified valves under fluoroscopy (22.2% vs.12.4%, p<0.0001) and with history of previous surgical commissurotomy (21.7% vs. 10.5%; p<0.0001). In patients with AF, PTMC resulted in worse outcomes, as reflected in a smaller post-PTMC mitral valve area (1.6±0.4 vs. 2.1 ± 0.8 cm²; p<0.0001). Patients with atrial fibrillation have a worse immediate clinical and echocardiographic outcome after PTMC.

Repair of massive ventral hernias with "quilted" mesh.

INTRODUCTION: Prosthetic reinforcement is a critical component of hernia repair. For massive defects, mesh overlap is often limited by the dimensions of commercially available implants. In scenarios where larger mesh prosthetics are required for adequate reinforcement, it may be necessary to join several pieces of mesh together using non-absorbable suture. Here, we report our outcomes for abdominal wall reconstructions in which "quilted" mesh was utilized for fascial reinforcement. METHODS: Patients undergoing open incisional hernia repair utilizing posterior component separation and transversus abdominis muscle release, with use of quilted synthetic mesh placed in the retromuscular position, were reviewed. Main outcome measures included patient, hernia, and operative characteristics and post-operative outcomes, including surgical site occurrence (SSO), surgical site infection (SSI), and recurrence. RESULTS: Thirty-two patients (mean age 55.7 ± 9.3, BMI 38.3 ± 5.8 kg/m(2)) underwent open ventral hernia repair with "quilted" mesh placed in the retromuscular position. The mean defect area was 760.1 ± 311.0 cm(2) with a mean width of 24.7 ± 6.4 cm. Quilted meshes consisted of two-piece (69 %), three-piece (19 %) and four-piece (12 %) configurations. Wound morbidity consisted of eight (25 %) SSOs, including four (13 %) SSIs, all of which resolved without mesh excision. With mean follow-up of 9.0 ± 13.6 months, there were two (6.3 %) lateral recurrences, both unassociated with mesh-to-mesh suture line failure. CONCLUSIONS: Massive ventral hernias that require giant mesh prosthetics, currently not commercially available, may be successfully repaired using multiple mesh pieces sewn together in a quilt-like fashion. Such retromuscular repairs are durable, without added morbidity due to the mesh-to-mesh suture line. However, additional operative time is required for quilting the mesh together, prompting strong calls for manufacturing of larger mesh prosthetics.