On pump harvesting of Left Internal Mammary Artery (LIMA) in unstable patients undergoing coronary artery bypass grafting (CABG) is a safe operative strategy: A pilot study.

OBJECTIVE: To evaluate the clinical safety of left internal mammary artery (LIMA) harvesting in hemodynamically unstable patients after establishing cardiopulmonary bypass (CPB) in isolated coronary artery bypass graft (CABG) surgery. METHODS: The prospective observational study was conducted at Chaudhry Pervaiz Elahi Institute of Cardiology, Multan, Pakistan, from December 2016 to August 2018. All patients undergoing isolated CABG surgery in which LIMA conduit was harvested after establishing cardiopulmonary bypass because of hemodynamic instability at induction of anaesthesia or during surgery were included in the study. Preoperative, operative and postoperative characteristics of the patients were recorded. Data was analyzed using SPSS 19. RESULTS: In Forty nine patients including 39 male and 10 female, early CPB had to be established because of hemodynamic instability and afterwards LIMA was harvested. Out of 49, 30 patients presented with CCS class III angina. 37 (75.5%) patients were scheduled on elective coronary surgery waiting list. There were 39 (79.59%) patients who weaned off bypass on mild inotropic support and 4 (8.16%) patients needed IABP support. All patients had multi-vessel coronary artery disease. Mean number of grafts were 3.428±0.577, CPB time was 110.59±25.594 and hospital stay was 5.367±1.424. CONCLUSIONS: The study showed that LIMA can be safely harvested in unstable patients after establishing extracorporeal circulation and by using this operative strategy in patients who need urgent or emergent surgical coronary revascularization LIMA can be safely used as a conduit.

Upper gastrointestinal tract symptoms are predictors of postoperative large pericardial effusion in cardiac surgery.

In this prospective observational study we evaluated the clinical symptoms in patients who presented with early or late significant pericardial effusion after cardiac surgery and underwent its open drainage in our institution. It was a series of 35 patients where the clinical symptoms and lab investigations were recorded. There were 21 male and 14 female (3:2). Majority of patients presented with postoperative large pericardial effusion within 2 -3 weeks of cardiac surgery. Eighteen (51.4%) patients presented with predominantly nonspecific upper gastrointestinal tract (GIT) symptoms like nausea, vomiting, loss of appetite and epigastric discomfort, 29 (82.85%) patients with postoperative large pericardial effusion had undergone mechanical valve replacement surgery. Majority of patients were on anticoagulation therapy and had prolonged INR. This study showed that non- specific upper gastrointestinal tract (GIT) symptoms like nausea, vomiting, loss of appetite are very frequent in patients with post-operative pericardial effusion. If a patient presents with these non-specific GI symptoms along with raised INR and low haemoglobin in postoperative follow up, significant pericardial effusion should be excluded.

Effect of nasal continuous positive airway pressure on the pharyngeal swallow in neonates.

OBJECTIVE: Feeding neonates orally while on nasal continuous positive airway pressure (nCPAP) is a common practice. We hypothesize that pressurized airflow provided by nCPAP will alter the swallowing mechanism in neonates, increasing the risk of aspiration during oral feeding. STUDY DESIGN: Infants receiving nCPAP with a RAM cannula and tolerating at least 50% of their feeding orally were included in the study (one term; six preterm infants). Each participant underwent a videofluoroscopic swallow study while on nCPAP and off nCPAP. A non-parametric signed-rank test was used for paired data. RESULT: The incidence of deep penetration (P=0.03) and aspiration (P=0.01) decreased significantly off-nCPAP compared with on-nCPAP. However, the incidence of mild penetration (P=0.65) and nasopharyngeal reflux (P=0.87) remained the same under both conditions. CONCLUSION: Oral feeding while on-nCPAP significantly increases the risk of laryngeal penetration and tracheal aspiration events. We recommend caution when initiating oral feedings on nCPAP.

Myocardial Protection with multiport antegrade cold blood cardioplegia and continuous controlled warm shot through vein grafts during proximal ends anastomosis in conventional coronary artery bypass graft.

OBJECTIVE: To evaluate the benefits of simultaneous aortic root and vein graft cold blood cardioplegia and continuous controlled warm blood perfusion through vein grafts during proximal aortocoronary anastomosis in conventional coronary artery bypass graft surgery in patients with multi-vessel coronary artery disease. METHODS: The prospective randomised study was conducted at Chaudary Pervaiz Elahi Institute of Cardiology, Multan, Pakistan, from April 2013 to June 2014, and comprised patients of isolated conventional coronary artery bypass graft surgery. The patients were randomised into 2 groups; Group I had patients in whom multiperfusion set was used for cardioplegia and continuous warm blood perfusion through vein grafts during proximal ends anastomosis, and Group II had patients in whom routine aortic root antegrade cardioplegia was used with no warm blood perfusion during proximal anastomosis of vein grafts. Data was analysed using SPSS 20. RESULTS: There were 434 patients in the study, with Group 1 having 215(49.5%) being the study group, and Group II having 219(50.5%)being the Control group. The groups showed no significant difference in the number of grafts, and aortic cross-clamp time (p>0.05 each). Total bypass time was significantly prolonged in the Control Group (p=0.001). Incidence of intra-operative arrhythmias, peri-operative myocardial infarction, need for inotropic support and intra-aortic balloon counter-pulsation and operative mortality were significantly higher in the Control group (p<0.05 each). CONCLUSIONS: Simultaneous aortic root and vein graft cold blood cardioplegia and continuous controlled warm blood perfusion was beneficial for myocardial protection and early patient outcome.

Early outcome of Coronary Artery Bypass Graft Surgery in patients with significant Left Main Stem stenosis at a tertiary cardiac care center.

OBJECTIVE: Primary objective of this study was to evaluate the impact of significant left main stem (LMS) stenosis on the early outcome of coronary artery bypass graft (CABG) surgery. METHODS: A Retrospective non-randomized analytical study was conducted in Cardiac surgery department, Chaudhary Pervaiz Elahi Institute of Cardiology (CPEIC) Multan, Pakistan. The data of patients who underwent isolated CABG at our institution from February 2008 to March 2014 were analyzed. Two thousand six hundred two (2602) patients of isolated CABG were divided into 2 groups according to the LMS disease. Group I (n=2088): without significant LMS disease and Group II (n=514): with LMS disease. Data was analyzed using SPSS V16. The groups were compared using Student's t-test for numeric variables. Chi-square test and Fishers Exact test were used for categorical variables. P-value ≤ 0.05 was considered as significant difference. RESULTS: Out of two thousand six hundred two, 2088 patients were in Non.LMS group (Control Group) and five hundred fourteen were in LMS Group (Study Group). Patients with LMS disease were older. In both groups there was no statistically significant difference regarding gender distribution, risk factors of IHD, pre-operative renal function and preoperative CKMB levels. Significant number 50 (9.7%) of patients were unstable in LMS group and they needed urgent surgery (p-value <0.0001). Need and duration for inotropic support and intra-aortic balloon counter-pulsation support were significantly high in LMS group (p-value <0.0001, 0.002, 0.003 respectively). Similarly Mechanical ventilation time and hospital stay were higher in LMS group. Incidence of pulmonary complications and operative mortality were significantly higher in LMS group (p-value 0.005 and 0.001 respectively). Mortality of CABG patients with significant left main coronary stenosis was 13 out of five hundred fourteen (2.5%) as compared to just 17 out of two thousand eighty eight (0.8%) in control group. CONCLUSION: This study showed that significant LMS disease is an independent risk factor for early cardiopulmonary morbidity and mortality after CABG surgery.

Clinical outcomes of intermittent antegrade warm versus cold blood cardioplegia.

OBJECTIVE: To compare clinical outcome in patients undergoing conventional coronary artery bypass graft surgery who received intermittent antegrade warm blood cardioplegia or intermittent antegrade cold blood cardioplegia for myocardial protection. METHODS: The observational, prospective non-randomised analytical comparative study was conducted at the Punjab Institute of Cardiology, Lahore, and Chaudhry Pervaiz Elahi Institute of Cardiology, Multan, from September 2012 to October 2013, and comprised patients undergoing coronary artery bypass graft surgery. They were divided into two groups, with Group I having those who received intermittent antegrade warm blood cardioplegia, and Group II having those who received intermittent antegrade cold blood cardioplegia. SPSS 16 was used for statistical analysis. RESULTS: Of the 215 patients, 94(44%) were in Group I, and 121(56%) in Group II. Total surgical time in Group II was 119.26±22.24 minutes compared to 105.73±31.34 in Group I (p >0.0001). Spontaneous resumption of sinus rhythm and peri-operative myocardial infarction was statistically insignificant (p>0.05). There were 21(17.4%) patients in Group II to whom peri-operative myocardial infarction occurred compared to 9(9.6%) in Group I (p=0.10). CONCLUSIONS: Intermittent antegrade warm blood cardioplegia showed better myocardial protection in early postoperative period compared to intermittent antegrade cold blood cardioplegia.

Mandibular block success rate in relation to needle insertion and position: a self-report survey.

AIM: To evaluate possible associations between successful mandibular block injection and location of penetrating the oral mucosa, location of injection on the ramus and the needle insertion length. STUDY DESIGN: The study consisted of 101 dentists, of whom, 33 were oral surgeons, 33 certified paediatric dentists and 35 general dental practitioners. The dentists were asked to estimate their rate of success in mandibular block injections, defined as the proportion of their patients for whom only a single carpule was necessary, and to indicate the needle insertion length and the location of the injection on a photograph of a ramus and on a photograph of the oral mucosa. RESULTS: Injecting a single carpule for achieving full anaesthesia in 90% or more of their patients was reported by 79.3 and 57.8% of the dentists treating children and adults, respectively. Of practitioners treating children, experienced dentists (>5 years in occupation) reported higher success rates than did inexperienced ones (p = 0.05). A positive correlation was found between failure rate reported in children, shorter length of the inserted needle (R = 0.356, p = 0.001) and injecting at the central (superior inferior dimension) most anterior quarters of the ramus (p = 0.006; odd ratio = 3.9375). Routine waiting period of more than 5 min after the injection and before operative treatment was associated with higher rates of failure (p = 0.042, χ(2) = 6.335). No correlation was found between the success rates of mandibular block injection and the location of penetrating the oral mucosa in children (p = 0.94), adults (p = 0.57), or between success rates and the target location on the ramus in adults (p = 0.42). STATISTICS: χ(2) test was used to determine the significance of differences among proportions and t test for continuous variables. Pearson's correlation analysis was used to analyse the correlation between the length of the needle inserted in children and adults by the same dentist. CONCLUSIONS: Shorter needle insertion lengths and targeting the injecting to the most anterior quarters of the ramus were positively correlated with failure of anaesthesia in children, according to dentists' reports. A routine waiting period of over 5 min did not increase the success rates of mandibular block injection.

Is there any benefit of preoperative oral trimetazidine in coronary artery bypass graft?

OBJECTIVE: To evaluate the impact of preoperative oral trimetazidine on myocardial protection in coronary bypass surgery. METHODS: We conducted a prospective double blind randomized study in the Department of Cardiac Surgery, Chaudhry Pervaiz Elahi (CPE) Institute of Cardiology, Multan, Pakistan. One hundred and seventy (170) patients of isolated CABG were included in the study. All operations were done by conventional technique of CABG using cardiopulmonary bypass, moderate systemic hypothermia and cold antegrade blood cardioplegia. The patients were randomized into 2 groups i.e. Group 1 (n = 85), who received and Group 2 (n = 85), who did not receive Trimetazidine. Trimetazidine (20 mg) was given orally, at 10:00 pm the night before operation and also at 7.00 am on the day of surgery. The CPK and CK-MB levels were determined before operation, immediately after shifting to the ICU, 12 hours and 36 hours after the operation. The comparison of CPK and CK-MB levels was carried out using analysis of variance with repeated measures. The peri-operative clinical and laboratory data were compared using Student's t-test for numeric variables and Chi-square test for categoric varaibles. The difference was considered statistically significant if the p-value was < 0.05. RESULTS: The pre-operative variables i.e. age, gender, Canadian Cardiovascular Society (CCS) class, ejection fraction, diabetes, history of smoking, haemoglobin level, serum creatinine etc had no differences in both group. Both groups showed no significant difference in Cardiopulmonary Bypass time (BPT), Aortic cross Clamp Time (CxT), prevalence of intra-operative arrhythmia and need for inotropic support. The analysis did not show any within group or between groups differences in the CPK and CKMB levels. CONCLUSION: This study showed that oral Trimetazidine given before coronary bypass grafting did not provide any benefit in myocardial protection.

Identification of residues important both for primary receptor binding and specificity in fibroblast growth factor-7.

Fibroblast growth factors (FGFs) mediate a multitude of physiological and pathological processes by activating a family of tyrosine kinase receptors (FGFRs). Each FGFR binds to a unique subset of FGFs and ligand binding specificity is essential in regulating FGF activity. FGF-7 recognizes one FGFR isoform known as the FGFR2 IIIb isoform or keratinocyte growth factor receptor (KGFR), whereas FGF-2 binds well to FGFR1, FGFR2, and FGFR4 but interacts poorly with KGFR. Previously, mutations in FGF-2 identified a set of residues that are important for high affinity receptor binding, known as the primary receptor-binding site. FGF-7 contains this primary site as well as a region that restricts interaction with FGFR1. The sequences that confer on FGF-7 its specific binding to KGFR have not been identified. By utilizing domain swapping and site-directed mutagenesis we have found that the loop connecting the beta4-beta5 strands of FGF-7 contributes to high affinity receptor binding and is critical for KGFR recognition. Replacement of this loop with the homologous loop from FGF-2 dramatically reduced both the affinity of FGF-7 for KGFR and its biological potency but did not result in the ability to bind FGFR1. Point mutations in residues comprising this loop of FGF-7 reduced both binding affinity and biological potency. The reciprocal loop replacement mutant (FGF2-L4/7) retained FGF-2 like affinity for FGFR1 and for KGFR. Our results show that topologically similar regions in these two FGFs have different roles in regulating receptor binding specificity and suggest that specificity may require the concerted action of distinct regions of an FGF.

Mutations uncouple human fibroblast growth factor (FGF)-7 biological activity and receptor binding and support broad specificity in the secondary receptor binding site of FGFs.

The fibroblast growth factor (FGF) family plays a key role in a multitude of physiological and pathological processes. The activities of FGFs are mediated by a family of tyrosine kinase receptors, designated FGFRs. The mechanism by which FGFs induce receptor activation is controversial. Despite their structural similarity, FGFs display distinct receptor binding characteristics and cell type specificity. Previous studies with FGF-2 identified a low affinity receptor binding site that is located within a loop connecting its 9th and 10th beta-strands. The corresponding residues in the other family members are highly variable, and it was proposed that the variability might confer on FGFs unique receptor binding characteristics. We studied the role of this loop in FGF-7 by both site-directed mutagenesis and loop replacement. Unlike the other members of the FGF family, FGF-7 recognizes only one FGFR isoform and is, therefore, ideal for studies of how the specificity in the FGF-FGFR interaction is conferred at the structural level. Point mutations in the loop of FGF-7 did not change receptor binding affinity but resulted in reduced mitogenic potency and reduced ability to induce receptor-mediated phosphorylation events. These results suggest that the loop of FGF-7 fulfills the role of low affinity binding site required for receptor activation. The observation that it is possible to uncouple FGF-7 receptor binding and biological activity favors a bivalent model for FGFR dimerization, and it may be clinically relevant to the design of FGF-7 antagonists. Reciprocal loop replacement between FGF-7 and FGF-2 had no effect on their known receptor binding affinities nor did it alter their known specificity in eliciting a mitogenic response. In conclusion, these results suggest that, despite the diversity in the loop structure of FGF-2 and FGF-7, the loop has a similar function in both growth factors.

Specialized extended hospital treatment for borderline patients.

The intensive psychoanalytically oriented hospital treatment described by the authors was developed specifically for borderline patients. This unique treatment, an integrated multimodal approach, is based on the theory that the disturbed behaviors and relationships of borderline patients are manifestations of intrapsychic impairment. The authors use a detailed case report to illustrate how the theory is transformed into technical precepts and applied to all aspects of the treatment.

Long-term hospital treatment of borderline patients: a descriptive outcome study.

The authors report a prospective 2-year outcome study of 40 inpatients with severe personality disorders who were treated on a specialized long-term unit for patients with "borderline conditions." Treatment goals included improving interpersonal relationships and facilitating a lasting discharge from the hospital. Data were collected at admission, discharge, and 1 and 2 years after discharge. The data reflect change from admission to follow-up in impulsivity, psychotherapy, and social adjustment. Mediating effects of length of stay on outcome are discussed.

Strauss and Carpenter outcome criteria--revised.

Poor inter-rater reliability of the Strauss and Carpenter Outcome Criteria in hospital outcome study was attributed to lack of operational definition. A revision aimed at remedying this problem was used to rate a portion of the original sample of subjects. The revised form proved superior in interrater reliability for seven of the nine categories, suggesting that this more explicitly behavioral version may improve hospital outcome research.