Shifting the Paradigm: How Stress Hyperglycemia Alters the Landscape of Heart Failure Management.

Background Acute decompensated heart failure (ADHF) significantly contributes to global morbidity. Stress hyperglycemia (SHGL), although commonly observed in non-diabetic ADHF patients, remains underexplored. This study investigates the predictive value of SHGL for major adverse cardiac events (MACEs) and its impact on coronary intervention outcomes. Methods In this prospective observational study at a tertiary care center, 650 non-diabetic ADHF patients admitted for coronary intervention between April 2021 and April 2022 were assessed. SHGL was defined by random blood sugar levels >140 mg/dl. We monitored the incidence of MACEs, including cardiac death, non-fatal myocardial infarction, and heart failure rehospitalization, alongside the success rates of coronary revascularizations over 12 months. Results SHGL was present in 54% of patients (n=352) and was significantly associated with increased MACEs (p<0.001), higher rehospitalization rates (p<0.01), and lower success in revascularization (p<0.05). Using logistic regression, SHGL, age >65, and prior heart failure hospitalization were identified as independent predictors of MACEs. Statistical analyses were performed using two-tailed Mann-Whitney U tests, with significance levels set at p<0.05 for noteworthy findings and p<0.01 or p<0.001 for highly significant findings. Conclusions SHGL significantly impacts coronary intervention outcomes and the future prognosis of heart failure in non-diabetic ADHF patients, identifying it as a critical, modifiable risk factor. These findings advocate integrating SHGL management into ADHF care, emphasizing the need for further research to develop standardized treatment protocols. Proper management of SHGL could potentially improve patient outcomes, highlighting the importance of metabolic control in heart failure management.

The Impact of Age, Comorbidities, and Discharge Timing on Clinical Outcomes Following Elective Percutaneous Coronary Intervention.

Background The adoption of same-day discharge (SDD) in elective percutaneous coronary intervention (PCI) procedures offers potential benefits in terms of patient satisfaction and reduced healthcare costs. Despite these advantages, the safety and efficacy of SDD, especially among patients with diverse health profiles, are not fully understood. This study investigates the effects of patient-specific factors, including age, comorbidities, and discharge timing, on the clinical outcomes of elective PCI, focusing on the viability of SDD. Methods A prospective study was carried out at Lady Reading Hospital, Peshawar, Pakistan, involving 220 patients undergoing elective PCI from January to June 2023. This research compared the clinical outcomes of patients discharged on the same day with those who had extended hospital stays, examining the impact of age, comorbidities, and PCI success. Main outcome measures included post-procedure complications and hospital readmissions within 30 days. Results The study enrolled participants with an average age of 62 years, the majority (88%, n=194/220) of whom had comorbidities. Interestingly, 16% (n=35/220) of the participants were discharged on the same day, while the rest stayed longer in the hospital. Notably, those in the SDD group experienced significantly more complications and readmissions, with 95.14% (n=33/36) compared to only 16.22% (n=30/184) in their counterparts. Factors such as age, comorbidities, success of PCI, timing of discharge, and patient satisfaction emerged as significant predictors of the observed outcomes. Conclusion This study highlights the essential role of personalized care in discharge planning following elective PCI, advocating for a cautious approach towards SDD, especially for older patients and those with multiple health issues.

Evaluating the Differential Risk of Contrast-Induced Nephropathy Among Diabetic and Non-diabetic Patients Following Percutaneous Coronary Intervention.

Background Contrast-induced nephropathy (CIN) significantly complicates percutaneous coronary intervention (PCI), with a higher prevalence in diabetic patients. This study compares the incidence of CIN in diabetic and non-diabetic patients undergoing PCI. Material and methods Conducted at Lady Reading Hospital, Peshawar, PAK, from January to December 2023, this observational study involved 450 adult patients with coronary artery disease (CAD) undergoing PCI. The cohort was categorized based on diabetes status, excluding patients with chronic kidney disease and those on renal replacement therapy. Baseline characteristics documented included age, gender, blood pressure, creatinine levels, and the presence of acute coronary syndrome (ACS). CIN was defined as a ≥25% increase in serum creatinine from baseline within 48-72 hours post-PCI. Data analysis was performed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 25.0, Armonk, NY), incorporating descriptive statistics, Chi-square tests, and independent t-tests, with a significance level of p<0.05. Results The median age of the study population was 55 years. The cohort comprised 52% male (n=234) and 48% female (n=216). Notably, 33% (n=149) had ACS. Diabetic patients exhibited a significantly higher incidence of CIN post-PCI compared to non-diabetics. The highest incidence of CIN (17%, n=77) occurred in the 70+ age group. The findings highlight the criticality of renal function monitoring and procedural adjustments for diabetic patients. Conclusion Diabetic patients demonstrate an increased risk of CIN following PCI. This necessitates the development of tailored prevention strategies for this high-risk subgroup.

One Year Outcomes After Percutaneous Coronary Intervention in Diabetics With Stable Ischemic Heart Disease: A Single-Center Comparative Study.

Introduction Coronary artery disease is the leading cause of death not only in Pakistan but also worldwide. Coronary artery disease is prevalent in diabetes and is the major cause of morbidity and mortality. This study aims at comparing the long-term outcomes of patients with and without diabetes undergoing percutaneous coronary interventions (PCI) in in a tertiary care hospital. Methods This is a prospective study including 200 patients undergoing PCI for stable ischemic heart disease. All the patients were followed up over three, six months, and then over one year for major outcomes, including death, nonfatal myocardial infarction, and revascularization, including target vessel revascularization (TVR), and target lesion revascularization (TLR), as well as the outcome of a major adverse cardiovascular event (MACE). Results The mean age (standard deviation) of the non-diabetic with stable ischemic heart disease (SIHD) patients was higher (57.4±8.9 years) than diabetes mellitus (DM) patients. All baseline characteristics were not statistically significant between the two groups. Triple vessel disease prevalence was more in DM than in the non-DM patients with SIHD, although it was not statistically significant. The number of stents implanted per patient (2.8±0.7 vs 1.9±0.8) was more in DM patients than in non-DM patients with SIHD. In-hospital adverse outcomes, including death due to cardiovascular causes, periprocedural myocardial infarction, hyperacute stent thrombosis, and bleeding complications, were insignificant between the two groups. Contrast-induced nephropathy was more prevalent in diabetics with SIHD. Although one-year major adverse cardiovascular outcomes were common in the diabetic group, these were statistically insignificant. Conclusion PCI for complex lesions in stable ischemic heart disease, both with and without diabetes, is associated with favorable in-hospital and long-term outcomes with regards to MACE and ischemia-driven revascularization.

Teleoncology: improving patient outcome through coordinated care.

INTRODUCTION: There are few specialized oncology centers in Pakistan. Teleoncology was introduced for weekly tumor case meetings between the surgery departments of Holy Family Hospital and NORI Hospital using videoconferencing. The team of surgeons, radiologists, and histopathologists of Holy Family Hospital and the oncologists from NORI Hospital are now conducting joint regular multidisciplinary meetings weekly for the well-being of patients of the area. The purpose of this study is to describe the infrastructure, consultative process, technical aspects, and initial evaluation of these meetings. MATERIALS AND METHODS: The surgical oncology patients are discussed every Friday morning since November 2009. A standardized format was adopted for case discussion in these multidisciplinary meetings. The postgraduate trainee presents the case from either side followed by management plan discussion. The oncologists may request a discussion to plan an intervention at Holy Family Hospital, or the surgeons at Holy Family Hospital may present a case that would benefit from multidisciplinary skills. RESULTS: In total, 264 patients were discussed. The mean age of the patients was 51±16.2 years. In 43% of the patients, the joint treatment strategy was refined from the initial proposed treatment. Breast and gastrointestinal tract malignancies were the most common cases, followed by endocrine and skin and soft tissue tumors. CONCLUSIONS: Teleoncology services can be extended easily with little addition to existing infrastructure but significantly reduce the stress for families as they deal with this challenging disease. Moreover, they improve the clinical evaluation and management strategies.

Metastatic involvement of the spleen by endometrial adenocarcioma; a rare asylum for a common malignancy: a case report.

BACKGROUND: Metastatic involvement of the spleen by solid tumors is a rare clinical entity; those coming from endometrial adenocarcinomas are exceptionally rare. Spleen is an uncommon site for metastatic deposits due to its specific anatomy and microenvironment. Typically, splenic metastasis from endometrial carcinomas present months to years after curative surgery, chemotherapy or radiotherapy. The most common complaint in symptomatic patients is abdominal pain localized to the left hypochondrium. Most however, are asymptomatic only to be picked up on vigilant routine ultrasonography or computerized tomography during follow up. We report the case of a 54-year-old woman who presented to us after 50 months of total abdominal hysterectomy and bilateral salpingo-oophorectomy for an endometrial adenocarcinoma. She had severe abdominal pain localized to the left hypochondrium as the presenting complaint. To the best of our knowledge, this is the 1st case to be reported from Pakistan with 14 cases reported prior to our report. All past cases report the endometroid variant of endometrial adenocarcinoma as the primary tumor and our patient was a victim to the same variant. CASE PRESENTATION: A 54-year-old, nulliparous widowed woman presented with severe abdominal pain in the left hypochondrium for the last 4 months. The pain radiated to the left shoulder and was exacerbated with deep breathing. She had a history of total abdominal hysterectomy with bilateral salpingo-oophorectomy done 50 months back for stage 1a endometroid endometrial adenocarcinoma. Clinical examination revealed tenderness in the left hypochondrium but no visceromeglay was appreciable. Ultrasonography and computerized tomography revealed a space-occupying lesion within the spleen with associated splenomegaly. Computed tomography further suggested a large splenic abscess however the patient did not have fever, vomiting or leukocytosis which are the hallmarks of a splenic abscess. A splenectomy was performed for her complaints. On histopathology a metastatic adenocarcinoma was identified consistent with the primary tumor. The tumor was CK7, CA-125 and epithelial membrane antigen positive (EMA). The patient was then referred for further chemotherapy. CONCLUSION: From this case we conclude, that although very rare, the spleen is a potential site for metastasis in endometroid endometrial adenocarcinoma. Since most patients are asymptomatic, routine examinations and imaging can identify its presence and avoid complications. If the practice is employed with vigilance, we may expect the clinical event to be diagnosed more frequently. The standard treatment is a classic splenectomy followed by chemotherapy.

Direct access midwifery booking for prenatal care and its role in Down syndrome screening.

OBJECTIVE: To compare the uptake of Down syndrome screening by women following referral by direct access and general practitioner (GP) modes. METHODS: The method of referral by either GP or direct access, for women who booked into prenatal care in Hull and East Yorkshire in 2010, was analysed using data collected from the Protos database at the Women and Children's Hospital, Hull. Subsequently, the uptake of first and second trimester screening for Down syndrome was reviewed by combining the Protos database to the screening data collected by the Clinical Biochemistry Laboratory at Hull Royal Infirmary, Hull. RESULTS: Women booked into prenatal care significantly earlier when referred by GP in comparison to direct access with a significant difference in screening uptake of 49.5 and 42.7%, respectively. The ratio of uptake between first and second trimester screening was not significantly different. CONCLUSIONS: Further research on the new direct access method of referral is required, as it may have a role in the uptake of prenatal screening for Down syndrome. More time is needed to show a definitive effect.

Introduction of first trimester combined test increases uptake of Down's syndrome screening.

OBJECTIVE: To describe any trends in the uptake of antenatal screening for Down's syndrome since the addition of the earlier first trimester combined test. STUDY DESIGN: All antenatal screening tests for Down's syndrome were carried out and their results were recorded by the Clinical Biochemistry Department at the Hull Royal Infirmary (HRI) and reviewed against the antenatal booking data held at the Women and Children's Hospital at HRI. The uptake of antenatal Down's syndrome screening for 5 different age groups of women across a four-year-period from 2007 to 2010 was analysed. RESULTS: There was a significant increase in uptake of antenatal screening for Down's syndrome from 43.9% to 56.5% after the introduction of the combined test in 2010. This increase was apparent in all age groups. There was no change in the proportion of women opting for an invasive test following a positive screening test. CONCLUSION: Addition of the earlier first trimester combined test has increased uptake of antenatal screening for Down's syndrome in women of all ages. This is most likely due to the advantages this test gives women such as earlier decision making, earlier further invasive diagnostic testing and earlier termination, if necessary.

Assessment of left ventricular systolic and diastolic function by tissue Doppler imaging after acute myocardial infarction.

OBJECTIVE: To evaluate left ventricular systolic and diastolic function by Tissue Doppler imaging after acute myocardial infarction. METHODS: It was a hospital based, prospective descriptive study, from 1st July 2010 to 31st Dec. 2010. Total of 200 patients having acute myocardial infarction underwent detailed tissue Doppler imaging (TDI) echocardiographic examination for evaluation of left ventricular systolic and diastolic function on day 3, in echocardiographic section of Govt. Lady Reading Hospital, Peshawar. Peak systolic (Sm), peak early diastolic (Em) and peak late diastolic (Am) velocities were recorded at 4 different sites of the mitral annulus. The ejection fraction and pulse wave TDI diastolic parameters were also recorded. Using SPSS version 16 data was analysed, frequencies and Mean +/- SD were determined for categorical and numerical variables, respectively. A p-value < or = 0.05 was considered significant. RESULTS: Total study sample was 200 patients having acute myocardial infarction (MI). The sample was divided into 4 groups, i.e., anterior MI, inferior MI, septal MI, and lateral MI. There were 122 men and 78 women and the mean age was 42 +/- 5 SD. There was a marked reduction in Sm velocity at mitral annulus, especially at the infarction sites. The mean peak systolic velocity from 4 mitral annulus sites was well correlated with ejection fraction (p = 0.0001). Similar to systolic velocities, Em velocity was also reduced, especially at the infarction sites. The mean peak early diastolic velocity from 4 mitral annulus sites was well correlated with ejection fraction (p = 0.0001). The mean Em velocity was correlated well with isovolumic relaxation time (IVRT). There was no correlation between mean Em velocity and deceleration time (DT). CONCLUSION: Tissue Doppler Imaging is a reliable, accurate and easily reproducible modality of echocardiography. The reduced peak systolic velocity and reduced peak early diastolic velocity seems to be an expression of regionally reduced systolic and diastolic functions, respectively. While the reduced mean systolic velocity and reduced mean early diastolic velocity from 4 mitral annulus sites are expressions of globally reduced systolic and diastolic functions, respectively and were correlated well with the ejection fraction.

Frequency of pericardial effusion in patients with first myocardial infarction and its effects on in-hospital morbidity and mortality.

BACKGROUND: Pericardial effusion (PE) is not an uncommon finding in serial echocardiographic evaluation of patients with AMI, especially when infarction is anterior and extensive. The objective of this study was to determine the frequency of pericardial effusion after first myocardial infarction and its effects on in-hospital morbidity and mortality. METHODS: This descriptive study was performed in the Department of Cardiology, PGMI, LRH Peshawar, from July 2007 to December 2007. Main outcome measure was frequency of pericardial effusion. RESULTS: Out of 200 patients with first acute myocardial infarction (AMI), mean age was 56 +/- 18 (28-90 years). Majority of patients (31.5%) were in the age range of 51-60 years. Males were 65.5% and 34.5% were females. Pericardial effusion was found in 4.5% patients on day 0, in 12.5% patients on day 2 and in 15% patients on day 4. Left ventricular failure was documented in 19 (9.5%) patients without and 42 (21%) patients with pericardial effusion (p<0.05%). Cardiogenic shock was reported in 5 (2.5%) patients without and 16 (8%) in patients with pericardial effusion and mitral regurgitation was found in 3 (1.5%) patients in each group. Death was recorded in 1 (0.5%) patient without pericardial effusion and was 1.5% (n=3) in patients with pericardial effusion. CONCLUSIONS: Pericardial effusion was seen in one third of the patients with first acute myocardial infarction. In acute phase of myocardial infarction, the chances of development of pericardial effusion increases as the time passes. Left ventricular failure was the commonest in-hospital morbidity followed by cardiogenic shock and mitral regurgitation. In-hospital mortality was more in patients with pericardial effusion.