Insertable cardiac monitoring devices versus external cardiac monitoring for detecting atrial fibrillation and preventing the recurrence of stroke: A systematic review and meta-analysis.

BACKGROUND: Atrial Fibrillation (AF) is a major risk factor for stroke, which is the second leading cause of death worldwide. It remains uncertain whether insertable cardiac monitors (ICMs) enhance the ability to recognize AF over external cardiac monitoring in patients who have experienced a stroke. AIM: We conducted a systematic review and meta-analysis to determine whether ICM devices are more effective than external cardiac monitoring for the detection of AF in stroke patients. METHODS: We included studies that reported an AF detection rate in stroke patients with a follow-up of at least 12 months. We analyzed the data of 1233 patients from 3 randomized control trials (RCTs). RESULTS: When compared to external cardiac monitoring, ICM devices (Medtronic Reveal LINQ and Reveal XT) showed a significantly higher detection rate of AF (RR = 5.04, 95% CI = 2.93-8.68; p < 0.05; ARR = 10.47%, NNT = 10). The ICM arm had significantly higher usage of oral anticoagulants (OAC) as compared to the control arm. (RR = 2.76, 95% CI = 1.89-4.02, p < 0.05). Additionally, ICM usage was associated with a higher incidence of mild to moderate adverse events (RR = 10.52, 95% CI =1.35-82.14; p = 0.02) and a higher number of severe adverse events as compared to the control arm (RR = 7.61, 95% CI = 1.36-42.51; p = 0.02). CONCLUSION: ICM devices are associated with better detection rates of AF and higher usage of OAC as compared to external cardiac monitoring in post-stroke patients. However, ICM insertion is associated with a higher incidence of mild/moderate and severe adverse effects.

Knowledge, attitude, and practice regarding treatment of group a beta haemolytic tonsillo pharyngitis and prevention of rheumatic fever among doctors in Karachi, Pakistan: A perspective study.

OBJECTIVE: To assess knowledge and practices associated with rheumatic fever among medical practitioners in an urban setting. METHODS: The cross-sectional study was conducted at five major hospitals in Karachi from August to November 2019, and comprised house officers, postgraduate trainees, and general physicians of either gender. The subjects were given a questionnaire assessing their knowledge and perception regarding acute rheumatic fever as well as prophylaxis. Data was analysed using SPSS 25. RESULTS: Of the 247 respondents, 173(70%) were house officers, 31(13%) were postgraduate trainees and 43(17%) were general physicians. Overall, 202(82%) subjects were associated with some teaching hospital. Significantly more postgraduate trainees and general physicians answered correctly when asked to identify clinical and laboratory findings suggestive of Group A streptococcal throat infection than house officers (p<0.001). Among the house officers 49(28.3%), and among the postgraduate trainees 11(35.4%) knew the correct way to prescribe penicillin to prevent rheumatic fever. Among the general physicians, 20(46.5%) had accurate knowledge regarding the prescription. CONCLUSIONS: Knowledge and practices of medical practitioners regarding rheumatic fever were less than ideal and may play a part in misdiagnoses of Group A streptococcal infections and, hence, prophylaxis.

Exploring the impact of the COVID-19 pandemic on provision of cardiology services: a scoping review.

The coronavirus disease-19 (COVID-19) pandemic has forced hospitals to prioritize COVID-19 patients, restrict resources, and cancel all non-urgent elective cardiac procedures. Clinical visits have only been facilitated for emergency purposes. Fewer patients have been admitted to the hospital for both ST-segment elevation myocardial infarctions (STEMI) and non-ST segment elevation myocardial infarctions (NSTEMI) and a profound decrease in heart failure services has been reported. A similar reduction in the patient presentation is seen for ischemic heart disease, decompensated heart failure, and endocarditis. Cardiovascular services, including catheterization, primary percutaneous coronary intervention (PPCI), cardiac investigations such as electrocardiograms (ECGs), exercise tolerance test (ETT), dobutamine stress test, computed tomography (CT) angiography, transesophageal echocardiography (TOE) have been reported to have declined and performed on a priority basis. The long-term implications of this decline have been discussed with major concerns of severe cardiac complications and vulnerabilities in cardiac patients. The pandemic has also had psychological impacts on patients causing them to avoid seeking medical help. This review discusses the effects of the COVID-19 pandemic on the provision of various cardiology services and aims to provide strategies to restore cardiovascular services including structural changes in the hospital to make up for the reduced staff personnel, the use of personal protective equipment in healthcare workers, and provides alternatives for high-risk cardiac imaging, cardiac interventions, and procedures. Implementation of the triage system, risk assessment scores, and telemedicine services in patients and their adaptation to the cardiovascular department have been discussed.

Role of C- reactive proteins and liver function tests in assessing the severity of dengue fever.

OBJECTIVE: To determine whether C-reactive protein and liver function tests can serve as severity markers for dengue fever. METHODS: The cross-sectional study was conducted in 2015-16 in Karachi and comprised patients with dengue fever visiting a tertiary care hospital. World Health Organisation classifications 1997 and 2009 were used to categorise patients according to clinical signs and symptoms. Receiver Operating Characteristics curve was used to determine discriminative ability and optimum cut-off value of biochemical markers. Comparisons were done through one-way analysis of variance using SPSS 17. RESULTS: Of the 218 patients, 133(61%) were males and 85(39%) were females. The overall mean age was 35.07±15.96 years. Levels of C-reactive protein and total bilirubin were significantly higher for dengue haemorrhagic fever compared to dengue fever; dengue shock syndrome compared to dengue fever; dengue shock syndrome compared to dengue haemorrhagic fever; and dengue shock syndrome compared to dengue fever / dengue haemorrhagic fever (p<0.05 each). Levels of alanine aminotransferase, aspartate aminotransferase and alkaline phosphatase were significantly higher for dengue shock syndrome compared to dengue fever; dengue shock syndrome compared to dengue haemorrhagic fever; and dengue shock syndrome compared to dengue fever / dengue haemorrhagic fever (p<0.05 each). Levels of C-reactive protein, total bilirubin, alanine aminotransferase and alkaline phosphatise in patients with severe dengue were significantly higher compared to non-severe dengue. CONCLUSIONS: C-reactive protein and liver function tests were found to be effective biochemical markers in assessing dengue fever severity.

Perception and practices regarding cannabis consumption in Karachi, Pakistan: A cross-sectional study.

Several studies have been carried out regarding the awareness and usage of cannabis around the world, especially in developed countries. Pakistan ranks amongst the top nations in regards to cannabis consumption. However, the amount of literature shedding light on people's perception, knowledge and practices are scarce. Therefore, the authors sought to establish a baseline study to ignite the discussion on the possibility of cannabis' induction in the medical field in Pakistan, and additionally provide a foundation for further research. The purpose of this study was to investigate the level of understanding and consumption practices in Karachi with respondents from different socio-economic backgrounds, age groups and gender regarding cannabis use and assessing the awareness of the general population. The null hypothesis is that the usage of cannabis does not have a significant correlation with age, gender, or socio-economic status of a population. We conducted a cross-sectional study in November 2018 using convenience sampling and interviewed 518 individuals for their gender, age, and socio-economic status, to determine their knowledge, attitudes, and practices regarding cannabis usage. The participants were questioned about their knowledge and its source. Attitudes were judged using three and five-point Likert scales while questions regarding practices centered upon the past and current usage of cannabis. One-way analysis of variance and chi-square tests were used as the primary statistical tests. Out of the 518 people who responded, more than half of the respondents were males (n = 340, 65.6%). The majority was familiar with the use of cannabis (n = 514, 99.2%), and the different ways in which it is consumed (n = 435, 84%). About one-third of the participants happened to consume cannabis (n = 168, 32.4%), and a quarter mentioned recreational use/curiosity as the principal reason (n = 134, 25.9%). Majority of the respondents agreed upon the harmful effects of consuming cannabis (n = 364, 70.3%), while when compared to other inimical drugs, half of them believed it to be less harmful (n = 259, 50%). Besides, an overwhelming majority stated, that if they were to consume cannabis, they would not consider taking permission from their parents/guardians (n = 441, 85.2%). Concerning legality, three-fifths of the participants chose cannabis to remain illegal in Pakistan (n = 307, 59.3%) and, for not consuming/quitting cannabis, the primary reason chosen was its harmful consequences (n = 210, 40.5%). Our study revealed that knowledge about usage of cannabis still requires a great deal of attention. Only individuals from higher socio-economic backgrounds have a positive attitude towards cannabis usage and are aware of it. There is an urgent need for awareness programs that especially reach out to the lower socio-economic status population, who otherwise do not have access to essential information resources. We also found that males were more likely to be consumers and to have more knowledge about cannabis, therefore, it is equally important to educate females about this topic so that an informed discussion about cannabis use and its medical benefits can be generated in Pakistan.

Contribution of individual components to composite end points in contemporary cardiovascular randomized controlled trials.

Cardiovascular randomized controlled trials (RCTs) typically set composite end points as the primary outcome to enhance statistical power. However, influence of individual component end points on overall composite outcomes remains understudied. METHODS: We searched MEDLINE for RCTs published in 6 high-impact journals (The Lancet, the New England Journal of Medicine, Journal of the American Medical Association, Circulation, Journal of the American College of Cardiology and the European Heart Journal) from 2011 to 2017. Two-armed, parallel-design cardiovascular RCTs which reported composite outcomes were included. All-cause or cardiovascular mortality, myocardial infarction, heart failure, and stroke were deemed "hard" end points, whereas hospitalization, angina, and revascularization were identified as "soft" end points. Type of outcome (primary or secondary), event rates in treatment and control groups for the composite outcome and of its components according to predefined criteria. RESULTS: Of the 45.8% (316/689) cardiovascular RCTs which used a composite outcome, 79.4% set the composite as the primary outcome. Death was the most common component (89.8%) followed by myocardial infarction (66.1%). About 80% of the trials reported complete data for each component. One hundred forty-seven trials (46.5%) incorporated a "soft" end point as part of their composite. Death contributed the least to the estimate of effects (R2 change = 0.005) of the composite, whereas revascularization contributed the most (R2 change = 0.423). CONCLUSIONS: Cardiovascular RCTs frequently use composite end points, which include "soft" end points, as components in nearly 50% of studies. Higher event rates in composite end points may create a misleading interpretation of treatment impact due to large contributions from end points with less clinical significance.

Left bundle branch pacing vs biventricular pacing in heart failure patients with left bundle branch block: A systematic review and meta-analysis.

BACKGROUND: Left bundle branch pacing (LBBP) is a novel pacing modality of cardiac resynchronization therapy (CRT) that achieves more physiologic native ventricular activation than biventricular pacing (BiVP). AIM: To explore the validity of electromechanical resynchronization, clinical and echocardiographic response of LBBP-CRT. METHODS: Systematic review and Meta-analysis were conducted in accordance with the standard guidelines as mentioned in detail in the methodology section. RESULTS: In our analysis, the success rate of LBBP-CRT was determined to be 91.1%. LBBP-CRT significantly shortened QRS duration, with significant improvement in echocardiographic parameters, including left ventricular ejection fraction, left ventricular end-diastolic diameter and left ventricular end-systolic diameter in comparison with BiVP-CRT. CONCLUSION: A significant reduction in New York Heart Association class and B-type natriuretic peptide levels was also observed in the LBBP-CRT group vs BiVP-CRT group. Lastly, the LBBP-CRT cohort had a reduced pacing threshold at follow-up as compared to BiVP-CRT.

Vasoplegia: A Review.

Vasoplegia is a condition characterized by persistent low systemic vascular resistance despite a normal or high cardiac index, resulting in profound and uncontrolled vasodilation. Vasoplegia may occur due to various conditions, including cardiac failure, sepsis, and post-cardiac surgery. In the cardiac cohort, multiple risk factors for vasoplegia have been identified. Several factors contribute to the pathophysiology of this condition, and various mechanisms have been proposed, including nitric oxide, adenosine, prostanoids, endothelins, the renin-angiotensin-aldosterone system, and hydrogen sulfide. Early identification and prompt management of vasoplegia is crucial to prevent development of shock. This review expands upon the different vasopressors used in management of vasoplegia, including catecholamines such as norepinephrine, dopamine, epinephrine, phenylephrine, and other agents including vasopressin, methylene blue, angiotensin II, hydroxocobalamin, vitamin C, thiamine, and corticosteroids (ie, hydrocortisone). It also emphasizes the importance of conducting further research and making advancements in treatment regimens for vasoplegia.

Diabetes among Muslims during Ramadan: A narrative review.

Fasting during the month of Ramadan is one of the five fundamental principles of Islam, and it is obligatory for healthy Muslim adults and adolescents. During the fasting month, Muslims usually have two meals a day, suhur (before dawn) and iftar (after dusk). However, diabetic patients may face difficulties when fasting, so it is important for medical staff to educate them on safe fasting practices. Prolonged strict fasting can increase the risk of hypoglycemia and diabetic ketoacidosis, but with proper knowledge, careful planning, and medication adjustment, diabetic Muslim patients can fast during Ramadan. For this review, a literature search was conducted using PubMed and Google Scholar until May 2023. Articles other than the English language were excluded. Current strategies for managing blood sugar levels during Ramadan include a combination of patient education on nutrition, regular monitoring of blood glucose, medications, and insulin therapy. Insulin therapy can be continued during fasting if properly titrated to the patients' needs, and finger prick blood sugar levels should be assessed regularly. If certain symptoms such as hypoglycemia, hyperglycemia, dehydration, or acute illness occur, or blood glucose levels become too high (> 300 mg/dL) or too low (< 70 mg/dL), the fast should be broken. New insulin formulations such as pegylated insulin and medications like tirzepatide, a dual agonist of gastric-inhibitory peptideand glucagonlike-peptide 1 receptors, have shown promise in managing blood sugar levels during Ramadan. Non-insulin-dependent medications like sodium-glucose-cotransporter-2 inhibitors, including the Food and Drug Administration-approved ertugliflozin, are also being used to provide additional cardiovascular benefits in patients with type 2 diabetes.

Evolving paradigm of thrombolysis in pulmonary embolism: Comprehensive review of clinical manifestations, indications, recent advances and guideline.

Thrombolytic therapy has been the mainstay for patients with pulmonary embolism (PE). Despite being linked to a higher risk of significant bleeding, clinical trials demonstrate that thrombolytic therapy should be used in patients with moderate to high-risk PE, in addition to hemodynamic instability symptoms. This prevents the progression of right heart failure and impending hemodynamic collapse. Diagnosing PE can be challenging due to the variety of presentations; therefore, guidelines and scoring systems have been established to guide physicians to correctly identify and manage the condition. Traditionally, systemic thrombolysis has been utilized to lyse the emboli in PE. However, newer techniques for thrombolysis have been developed, such as endovascular ultrasound-assisted catheter-directed thrombolysis for massive and intermediate-high submassive risk groups. Additional newer techniques explored are the use of extracorporeal membrane oxygenation, direct aspiration, or fragmentation with aspiration. Because of the constantly changing therapeutic options and the scarcity of randomized controlled trials, choosing the best course of treatment for a given patient may be difficult. To help, the Pulmonary Embolism Reaction Team is a multidisciplinary, rapid response team that has been developed and is used at many institutions. Hence to bridge the knowledge gap, our review highlights various indications of thrombolysis in addition to the recent advances and management guidelines.