Trans-radial Angioplasty of Anomalous Origin of Right Coronary Artery: A Single-Centre Experience.

Successful percutaneous coronary intervention (PCI) to anomalous coronary arteries is technically challenging, particularly through transradial route. The application of appropriate techniques and devices may help overcome these challenges. The objective of this study is to explore the technical and procedural challenges in percutaneous coronary intervention (PCI) of anomalous origin of right coronary artery (AORCA) through the trans-radial route. This prospective study consisted of 25 consecutive patients who underwent PCI for an angiographically significant stenosis in AORCA from November 2017 to May 2019 at Ibrahim Cardiac Hospital & Research Institute (ICHRI). Demographic details and procedural data including numbers of catheters used, access, hardware, techniques, duration of procedure, volume of contrast and complications were recorded and statistically analyzed. The origin of AORCA was 48.0% each from the right and left coronary sinus, with 4.0% arising from the ascending aorta. Among those of right coronary sinus origin, superior take off was 83.3% and inferior take-off was 8.3%, with a further 8.3% originating from the left main, with a common origin with the left anterior descending (LAD) artery, from right coronary sinus. The mean age was 55.8±7.5 years. Diabetics were 84.0%, hypertensive 88.0%, dyslipidemic 68.0% and 20.0% had a history of smoking. Percutaneous coronary intervention (PCI) was performed successfully in 100.0% cases. Transradial access was the default route for coronary angiography in all cases. Angioplasty was performed trans-radially in 92.0% and trans-femoral in 8.0%, for two cases requiring switch over from radial to femoral route. The average number of guide catheters used was (2.0±1.0), (range: 1-4). The guide catheter hooked the coronary ostium selectively in 32.0%, off ostium in 56.0% and deep intubation was done in 12.0% cases. Anchoring wire to enhance guide support was used in 12.0%. 6 Fr guide extension catheter Guidezilla was used in 8.0% cases. The average duration of the procedure was 39.4 (range; 15-90) minutes, the average volume of contrast used was 67.0 (range: 30-150) ml. Average stent length was 28.6 (range; 12-43) mm. For PCI, Judkin's left (JL) and Judkin's Right (JR) were most commonly used guides (36.0% and 28.0% respectively), followed by multipurpose angled (MPA) guide (12.0%). The majority of the lesions stented were of ACC/AHA classification of type B (48.0%) followed by type A (36.0%) and type C (16.0%). Thrombus extraction was performed in a single case. One case was complicated by coronary artery dissection. PCI of AORCA through transradial route is technically challenging but feasible with a reasonable amount of contrast and radiation, and appropriate use of guides and techniques. Proper localization of ostium and selection of suitable guide is the key to success, aided by additional devices in the armamentarium of interventional cardiology such as guide extension catheter and anchoring wires.

Predictors of In-hospital Mortality in Patients Presenting with Acute Coronary Syndromes in a Tertiary Cardiac Center in Dhaka, Bangladesh.

The outcomes of acute coronary syndromes (ACS) vary internationally, given regional differences in patient co-morbidities, access to health care, interventional procedures and adherence to guideline-based management practices. This study aimed to identify the predictors of mortality from a large ACS registry of patients admitted to a tertiary care cardiac centre in Dhaka, Bangladesh. This was a hospital record based retrospective cross sectional observational study that included all patients presenting with ACS to Ibrahim Cardiac Hospital and Research Institute, Dhaka, Bangladesh from January 2013 to December 2013. Data were collected from cardiac catheterization laboratory database and hospital discharge records. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 16.0. A p value <0.05 was considered statistically significant. Ethical approval was obtained by Institutional Review Board of the hospital. A total of 1914 ACS patients were studied: 39.8% presented with ST-elevation myocardial infarction (STEMI), 39.7% with non-ST-elevation myocardial infarction (NSTEMI) and 20.5% with unstable angina (UA). There were 146 in-hospital deaths (7.6%). Mortality was highest among STEMI patients (10.5%), followed by NSTEMI (8.1%) and UA (1.03%). The mean age of expired patients was significantly higher than that of those who survived (64.82±12.14 years vs. 57.32±11.99 years; p<0.001). Male patients were 71.4%, with no significant gender differences observed between expired and surviving groups. Age >50 years {odds ratio (OR) 2.56, p=0.005}, chronic kidney disease (CKD) (OR 2.1, p<0.001), shock (OR 16.82, p<0.001), left ventricular failure (LVF) (OR 2.43, p<0.001) and STEMI (OR 1.92, p=0.002) were independent predictors of mortality among ACS patients. Although diabetes per se was not associated with mortality (OR 1.3; 95% CI=0.89-1.91; p=0.169), uncontrolled diabetes defined as HbA1c levels ≥7.5% had significant risk of mortality (OR 51.4, p<0.001). ACS patients who did not undergo angiography (OR 16.4; p<0.001) or PCI (OR 18.9; p<0.001) had greater risk of mortality. ACS patients complicated with shock, LVF, uncontrolled diabetes and CKD had increased risk of in-hospital mortality. Improved outcomes may be likely with prompt angiography and PCI during index admission. This study is a preliminary initiative, and prospective multi-centre registries with nation-wide involvement are warranted.

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.

Etiological Evaluation of Patients with Lymphadenopathy by Clinical, Histopathological and Microbiological Assessment.

Lymph node enlargement is a common presenting complaint in outpatient and inpatient department. The present observational cross sectional study was conducted in department of Internal Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh during the period from December 2014 to May 2016 to evaluate etiologies of significant lymphadenopathy by clinical, histopathological and microbiological assessment. Biopsy/FNA materials of 177 patients of 18-75 years age range with significant lymphadenopathy were sent for histopathology/cytology, Gram stain & culture, AFB stain & culture and Gene Xpert. Among them, 102(57.62%) were granulomatous lymphadenitis, 52(29.38%) were lymphoma, 12(6.78%) reactive lymphadenitis, 7(3.95%) metastatic malignancy, 2(1.13%) atypical lymphoid hyperplasia, 1(0.57%) myeloid sarcoma and 1(0.57%) chronic sialadenitis. Growth of MTB was on 23(22.55%) cases; among 102 granulomatous lymphadenitis and Gene Xpert was positive in 73(71.56%) cases with 100% Rif. sensitive. Gene Xpert is an important tool for diagnosis of tuberculous lymphadenitis. Time of symptoms to diagnosis of most of the TBL patients was within 2-8 months.

Late lead Perforation Following Permanent Pace Maker Implantation--A Case report.

Ventricular lead perforation is an infrequent but it's a critical complication of pacemaker implantation. Perforation was usually associated with the use of small-caliber active fixation leads, and can occur beyond the first few days (sub acute) or even more than a month after implantation (late). We report the case of right ventricular perforation by a ventricular fixation lead in 61 years old man detected more than two months after implantation. Radiology and echocardiography can confirm the perforation by revealing progression of the lead beyond the cardiac silhouette or indirectly visualizing the presence of pericardial effusion. However, its pathophysiology and optimal management are currently unclear.

Comparison of P2Y12 receptor inhibition by clopidogrel and prasugrel in patients undergoing percutaneous coronary intervention.

Dual antiplatelet treatment (DAPT) with aspirin and clopidogrel is vital after percutaneous coronary intervention (PCI). Clopidogrel and prasugrel act on P2Y12 platelet surface receptors. Both these P2Y12 inhibitors are pro-drugs and depend on cytochrome system of the liver for their conversion to active metabolite. There is growing concern regarding suboptimal response in platelet inhibition by clopidogrel. Verify Now system got approval by Federal Drug Administration, USA, for assessing platelet function as its result is almost comparable to gold standard Light Transmission Aggregometry (LTA). There are no data on the prevalence of clopidogrel resistance in Bangladeshi population. Prasugrel, as an antiplatelet drug, is a newer introduction in this country. This study will show light on the efficacy of these drugs on our population especially in patients who undergo PCI where DAPT is mandatory. A total 120 (60 diabetics) patients with Acute Coronary Syndrome (ACS), were alternatively given 600 mg clopidogrel loading dose (LD) followed by 75 mg maintenance dose (MD) daily or 60 mg LD of prasugrel followed by 10 mg MD daily. Five samples of blood were taken at different time intervals over a period of 2 weeks. Measurement of percent inhibition of P2Y12 was done by VerifyNow. Patients who showed less than 20% inhibition (clopidogrel resistant) at any stage were switched to prasugrel. The outcomes of clopidogrel, prasugrel and clopidogrel switched to prasugrel groups were then compared. Nearly half (46.7%) of the patients in the clopidogrel group was found resistant to the drug as opposed to none in the prasugrel group. No difference was found between diabetic and non-diabetic subjects with respect to drug resistance. Intracoronary blood samples showed high degree of platelet inhibition with prasugrel. There was a gradual decline of platelet inhibition over two weeks with prasugrel. Almost fifty percent of the population is clopidogrel resistant in our study. Prasugrel is a much more potent antiplatelet drug and should be preferred in patients undergoing PCI. Prasugrel may also show resistance over time.

Structured data system for a breast cancer medical record.

We have developed software for an Electronic Medical Record (EMR) to be used by oncologists and researchers. It has rapid, structured data entry, visualization of clinical information and a searchable data base. Interactive, rules-based forms were designed for structured data entry. The web-based forms have been customized for the clinical staff who enter the data. The forms have been tested by oncologists and their office assistants. Modules have been added to upload images and add legends, metadata, and code classifications such as ICD and CPT. Other features include a search interface and a permission system that controls user access. Oncologists enter detailed information during a patient's visit to the clinic. The electronic forms capture diagnoses, stage and history, which includes social, family, and medical history. A time map provides a graphical summary of a patient's record. Visualization of complex clinical information with intuitive navigation increases clarity while retaining the detail necessary for clinical information. Customized data entry forms and automatic coding speed the workflow. The system can potentially interface with multi-institutional data-sharing systems such as Cancer Bioinformatics Grid (CaBig).

Injuries at school: a review.

Injuries are the leading cause of morbidity and mortality in children older than 1 year, with a significant proportion occurring in the school. This article reviews the past 10 years of literature on school-related injuries. The incidence, types, anatomic locations, sites, and activities related to injuries on school premises are presented. Comprehensive studies in a population where injuries occur in a supervised environment are needed. The role that cooperative programs involving schools, parents, and other agencies can play in developing school safety policies is discussed. Because injuries are common in the daily lives of thousands of school children, a proactive attitude coupled with intensive research on the causes, prevention, and better on-site management would impact immensely or the health status of school-going Texans.

Medical genetics and the Human Genome Project: a historical review.

The $3 billion, 15-year international project to map out the nucleotide sequence of the entire human genome could revolutionize medical care in the 21st century. The location, makeup, and function of the 50,000 to 100,000 human genes could lead to tailor-made therapies not only for treating diseases but for preventing them. There may be a major role for the genetic engineer in the practice of medicine. On the other hand, the technology could identify people with undesirable genetic profiles who may be subject to discrimination by insurance companies, employers, and others. Physicians who fail to perform genetic screening may face malpractice suits for wrongful births. This article traces the historical evolution of our knowledge regarding medical genetics from the Talmud to the present day.

Mechanism of tumor growth and metastasis; an alternate hypothesis.

The author proposes that malignant tumors increase in size not only by cell division, but also by transforming neighboring normal cells into malignant ones. Further, tumor metastasis may occur by humoral mechanisms, in addition to, physical migration of malignant cells.

Fibrosis of extrahepatic biliary system after continuous hepatic artery infusion of floxuridine through an implantable pump (Infusaid pump).

A case of severe fibrosis of the extrahepatic biliary system after hepatic artery infusion of floxuridine is described. The clinical and pathologic features are presented, and its pathogenesis discussed. The authors suggest investigation of an alternate drug schedule and/or dosage of floxuridine to eliminate or minimize this serious complication.

Doxorubicin-induced congestive heart failure in adults.

The prognosis of doxorubicin-induced congestive heart failure (CHF) is reported to be poor. To define the clinical course of doxorubicin-induced CHF, the authors reviewed their experience with 43 patients with this diagnosis. The median age of the total group was 55 years (range, 23-69); the median cumulative dose of doxorubicin was 450 mg/m2 (range, 200 mg/m2-1150 mg/m2). A majority of the patients had a diagnosis of breast cancer. The median survival of the whole group estimated by means of a Kaplan-Meier plot was 112 weeks. Twelve of 43 patients (28%) died of CHF, 7 of them (16%) because of fulminant failure in less than 8 weeks and the remaining 5 because of a more protracted course with recurrent episodes of cardiac decompensation. Twenty-five of the 43 patients (58%) achieved complete control of CHF. In the remaining 6 patients (14%), CHF had improved but was not completely controlled at the time of death, which was secondary to progressive tumor. Treatment consisted of standard therapy with digitalis and diuretics. Survival was significantly shorter in patients who presented with class IV dyspnea and in those who developed CHF less than 4 weeks after administration of the last dose of doxorubicin. The authors conclude that in a majority of patients, doxorubicin-induced CHF is easily treatable and frequently controlled with digitalis and diuretics.

Temporary effects of AMSA (4'-(9-acridinylamino) methanesulfon-m-anisidide) chemotherapy on spermatogenesis.

Spermatogenesis in a melanoma patient treated with 12 courses of acridinyl anisidide (AMSA) (20 mg/m2/course) was studied by monitoring sperm concentration, motility, and morphology at various phases of treatment. Chemotherapy was interrupted for 20 weeks between the ninth and tenth course. Sperm concentration and motility began to decline after the second course. At the third course, the percentage of morphologic abnormalities had increased to 86.5% from a pretreatment value of 57.8% (P less than 0.001). Azoospermia was observed at the sixth course and persisted until 12 weeks after the ninth course, when semen levels returned to pretreatment levels: 20 million/ml; 70% motility; 60.1% abnormal forms. Three weeks after the 12th course, the sperm count was reduced to 250,000/ml, motility to 5%, and abnormalities increased to 84.0%. The rapid recovery of normal spermatogenesis observed during the chemotherapy interruption indicates that AMSA has only a temporary, reversible effect on differentiating germinal cells with no toxicity to stem cells.

Hepatotoxicity of hycanthone in patients with metastatic breast cancer.

Hycanthone is an antischistosomal drug with promising antitumor activity against experimental animal tumors. In phase I clinical trials, hepatitis weas the dose-limiting toxic effect and a dose of 60-70 mg/m2/day for 5 days was reported as the maximum-tolerated dose. In a phase II study of hycanthone in patients with breast cancer we have recently observed severe hepatotoxicity, even at lower doses, which resulted in two drug-related deaths. From this study and the previously available data, we conclude that this drug is too toxic for human trials at the currently recommended doses. Its radiosensitizing effect may be worth exploring at a lower dose level.

Cytotoxic chemotherapy in adrenal cortical carcinoma.

Adrenal cortical carcinoma is a rare tumor with a poor prognosis. Experience with chemotherapy in this tumor besides mitotane is practically nonexistent. We are reporting the results of 27 trials of various chemotherapeutic regimens among 12 patients with metastatic disease. Most patients (nine of 12) had a trial of mitotane before cytotoxic drugs were instituted. Three patients achieved a partial remission, one achieved a minor regression, and three had stable disease. All of the responses were of short duration. Alkylating agents and doxorubicin appear to have some antitumor activity. Multi-institutional cooperative studies are needed to detect active drugs and drug combinations against this neoplasm.