Cyclic guanosine monophosphate improves salt tolerance in Solanum lycopersicum.

The cyclic nucleotide cyclic guanosine monophosphate (cGMP) is a powerful cell signaling molecule involved in biotic and abiotic stress perception and signal transduction. In the model plant Arabidopsis thaliana, salt and osmotic stress rapidly induce increase in cGMP which plays role by modulating the activity of monovalent cation transporters, possibly by direct binding to these proteins and by altering the expression of many abiotic stress responsive genes. In a recent study, a membrane permeable analogue of cGMP (8-bromo-cGMP) was found to have a promotive effect on soluble sugar, flavonoids and lignin content, and membrane integrity in Solanum lycopersicum seedlings under salt stress. However, it remains to be elucidated how salt stress affects the endogenous cGMP level in S. lycopersicum and if Br-cGMP-induced improvement in salt tolerance in S. lycopersicum involves altered cation fluxes. The current study was conducted to answer these questions. A rapid increase (within 30 s) in endogenous cGMP level was determined in S. lycopersicum roots after treatment with 100 mM NaCl. Addition of membrane permeable Br-cGMP in growth medium remarkably ameliorated the inhibitory effects of NaCl on seedlings' growth parameters, chlorophyll content and net photosynthesis rate. In salt stressed plants, Br-cGMP significantly decreased Na+ content by reducing its influx and increasing efflux while it improved plants K+ content by reducing its efflux and enhancing influx. Furthermore, supplementation with Br-cGMP improved plant's proline content and total antioxidant capacity, resulting in markedly decreased electrolyte leakage under salt stress. Br-cGMP increased the expression of Na+/H+ antiporter genes in roots and shoots of S. lycopersicum growing under salt stress, potentially enhancing plant's ability to sequester Na+ into the vacuole. The findings of this study provide insights into the mechanism of cGMP-induced salt stress tolerance in S. lycopersicum.

Genome-wide identification and characterization of wall-associated kinases, molecular docking and polysaccharide elicitation of monoterpenoid indole alkaloids in micro-propagated Catharanthus roseus.

Wall-associated kinases (WAKs) are a unique family of proteins that are predominantly localized on the plasma membrane and simultaneously bound to the cell wall. WAKs play a pivotal role in signal transduction to regulate growth, defense, and response to environmental stimuli in plants. These kinases have been identified and characterized in various plant species, however, similar information for Catharanthus roseus is scarce. C. roseus is an evergreen ornamental plant that produces a repertoire of biologically active compounds. The plant is best characterized for the production of antineoplastic monoterpenoid indole alkaloids (MIAs) namely vinblastine and vincristine. Owing to the diverse composition of phytochemicals, C. roseus is known as a "model non-model" plant for secondary metabolite research. Genome analyses showed 37 putative CrWAK genes present in C. roseus, largely localized on the plasma membrane. Phylogenetic analysis revealed six clusters of CrWAKs. Diverse cis-acting elements, including those involved in defense responses, were identified on the promotor regions of CrWAK genes. The highest binding affinity (- 12.6 kcal/mol) was noted for CrWAK-22 against tri-galacturonic acid. Tri-galacturonic acid stimulated 2.5-fold higher production of vinblastine, sixfold upregulation of the expression of ORCA3 transcription factor, and 6.14-fold upregulation of CrWAK-22 expression. Based on these results it was concluded that the expression of CrWAK genes induced by biotic elicitors may have an important role in the production of MIAs. The current findings may serve as a basis for functional characterization and mechanistic explanation of the role of CrWAK genes in the biosynthesis of MIAs upon elicitation.

Symptoms, Electrolyte Disturbances and Serum Albumin Levels in Palliative Oncology Patients Admitted Through Emergency: Characteristics and Survival Outcomes.

Objectives: Our research aimed to examine the characteristics of palliative oncology patients hospitalised through an emergency to look for the symptom profile, characteristics of dyselectrolytemia and blood investigations, and possible associations with mortality. Materials and Methods: After institutional review board approval, a retrospective, observational study of patients hospitalised in our tertiary care specialty oncology hospital was undertaken. Records of hospitalised cancer patients admitted from the emergency department under palliative care from January 2019 to October 2021 were examined. As all admissions during this period were through emergency due to institution COVID-19 protocols, all elective admissions were excluded from the study. Data collected included patient characteristics, blood investigations, and comorbid history of systemic diseases and factors that could be associated with electrolyte imbalance. Results: There were 157 emergency admissions during the study period. A majority were patients with solid tumours (92.4%). Pain was the most frequent cardinal symptom, along with other symptoms (68/157) or in isolation (33/157), followed by reduced oral intake (32/157) and altered sensorium (24/157). sixty-six patients died within the hospitalisation period. On long-term follow-up, only 8 (5.1%) were surviving. Hyponatraemia (43%), Hypoalbuminaemia (66%), and altered renal function (33.1%) were prevalent. We observed a weak positive correlation between sodium levels and outcome (r = 0.199, P = 0.016) and a strong positive correlation between albumin levels and survival outcomes (r = 0.329, P = 0.000). Patients with normal albumin had a higher chance of survival (odds ratio: 33.1225, 95% confidence interval: 3.415-321.20, P = 0.003). Conclusion: Pain-reduced oral intake and altered sensorium are common emergency symptoms in oncology palliative care. Mortality is high in these patients. Hyponatraemia, hypoalbuminaemia, and deranged renal functions were commonly seen. Normal sodium and albumin levels were associated with higher chances of survival, and the association was strong for serum albumin levels. This may have prognostic utility.

Df(h22q11)/+ mouse model exhibits reduced binding levels of GABAA receptors and structural and functional dysregulation in the inhibitory and excitatory networks of hippocampus.

The 22q11.2 hemizygous deletion confers high risk for multiple neurodevelopmental disorders. Inhibitory signaling, largely regulated through GABAA receptors, is suggested to serve a multitude of brain functions that are disrupted in the 22q11.2 deletion syndrome. We investigated the putative deficit of GABAA receptors and the potential substrates contributing to the inhibitory and excitatory dysregulations in hippocampal networks of the Df(h22q11)/+ mouse model of the 22q11.2 hemizygous deletion. The Df(h22q11)/+ mice exhibited impairments in several hippocampus-related functional domains, represented by impaired spatial memory and sensory gating functions. Autoradiography using the [3H]muscimol tracer revealed a significant reduction in GABAA receptor binding in the CA1 and CA3 subregions, together with a loss of GAD67+ interneurons in CA1 of Df(h22q11)/+ mice. Furthermore, electrophysiology recordings exhibited significantly higher neuronal activity in CA3, in response to the GABAA receptor antagonist, bicuculline, as compared with wild type mice. Density and volume of dendritic spines in pyramidal neurons were reduced and Sholl analysis also showed a reduction in the complexity of basal dendritic tree in CA1 and CA3 subregions of Df(h22q11)/+ mice. Overall, our findings demonstrate that hemizygous deletion in the 22q11.2 locus leads to dysregulations in the inhibitory circuits, involving reduced binding levels of GABAA receptors, in addition to functional and structural modulations of the excitatory networks of hippocampus.

Investigation of mutational spectrum in cytochrome P4501B1 (CYP1B1) as the principal cause of primary congenital glaucoma.

Objective: To identify the genetic variants in the CYP1B1 gene associated with Primary Congenital Glaucoma (PCG) and to predict its pathological effect. Method: A descriptive study was conducted in the time period of nine months (September 2021-May 2022) after the ethical approval was taken from The Children Hospital and Institute of Child Health (CH & ICH). Two milliliters of the blood sample from PCG-affected individuals were collected in EDTA vacutainers and genomic DNA was extracted by a phenol-chloroform method. The semi-quantification of extracted DNA was done by agarose gel electrophoresis. PCR amplification was performed by specific primers of CYP1B1 gene then termination sequencing (di-deoxy) was done to detect the genetic variants. Different bioinformatics tools such as BLAST, Ensembl, Clustal Omega, Polyphen and SIFT were used for the further analysis of mutation causing the disease. Result: A total of 85% of patients were bilaterally affected, while 15% were unilaterally affected. Mutation analysis identified five non related known variants. Two missense mutations (c.355 G/T p.A119S and c.685G/A p.E229K) occurred in 94% patients and intragenic SNP occurred in 29% patients along with the 1% somatic (c.693C/A p.F231L) and stop gained mutation (c.840C/A p.C280*). Conclusion: Genetic analysis in the current study showed that 85% of PCG affected patients were due to the CYP1B1 mutation, and disease heterogeneity might be reduced through genetic counseling.

Prospective randomized study comparing outcome of myocardial protection with Del-Nido Cardioplegia versus Saint Thomas Cardioplegia in adult cardiac surgical patients.

Objectives: To compare the effectiveness of Del-Nido cardioplegia as myocardial protective agent with Saint Thomas cardioplegia in adult cardiac surgical patients. Methods: This prospective randomized study was conducted in cardiac surgery department of Bahawal Victoria hospital Bahawalpur, from October 2020 to March 2021. Eighty adult patients who underwent primary Isolated coronary artery bypass grafting (CABG) or isolated Valve surgery requiring cardiopulmonary bypass were randomly divided into Del Nido (DN, n=40) and Saint Thomas (ST, n=40) groups. Data regarding operative and post-operative variables such as cardiopulmonary bypass (CPB) and aortic cross clamp (AXC) times, inotropic requirements, resumption of sinus rhythm, need for electrical defibrillation, post-operative CKMB, blood requirement and ICU stay were noted. Results: CPB and AXC times were statistically insignificantly different. Resumption of Sinus rhythm was seen significantly in more patients of DN group (95%) than in ST group (72.5%) [p-value 0.05]. Less patients of DN group (5%) were candidates of electrical defibrillation than ST group (17.5%) [p-value <0.001). Post- operative CKMB values were significantly lower in DN group as compared to ST group (30.5±22.6 IU vs 50.5±50.28 IU, p value.008). Blood transfusion was significantly lower in DN group; 50% versus 80% in ST group (p-value 0.005). Ventilation time was significantly less in DN group than ST group (165.95±48.09 minutes versus 165.95±48.09 minutes respectively, p-value 0.03). While ICU stay was also less in DN group; 5.2±0.8 days versus 6.05±1.6 days in ST group (p-value 0.003). Conclusion: Del-Nido cardioplegia is a reliable and better myocardial protective agent than Saint Thomas cardioplegia in adult cardiac surgical procedures.

Multi-level Kronecker Convolutional Neural Network (ML-KCNN) for Glioma Segmentation from Multi-modal MRI Volumetric Data.

The development of an automated glioma segmentation system from MRI volumes is a difficult task because of data imbalance problem. The ability of deep learning models to incorporate different layers for data representation assists medical experts like radiologists to recognize the condition of the patient and further make medical practices easier and automatic. State-of-the-art deep learning algorithms enable advancement in the medical image segmentation area, such a segmenting the volumes into sub-tumor classes. For this task, fully convolutional network (FCN)-based architectures are used to build end-to-end segmentation solutions. In this paper, we proposed a multi-level Kronecker convolutional neural network (MLKCNN) that captures information at different levels to have both local and global level contextual information. Our ML-KCNN uses Kronecker convolution, which overcomes the missing pixels problem by dilated convolution. Moreover, we used a post-processing technique to minimize false positive from segmented outputs, and the generalized dice loss (GDL) function handles the data-imbalance problem. Furthermore, the combination of connected component analysis (CCA) with conditional random fields (CRF) used as a post-processing technique achieves reduced Hausdorff distance (HD) score of 3.76 on enhancing tumor (ET), 4.88 on whole tumor (WT), and 5.85 on tumor core (TC). Dice similarity coefficient (DSC) of 0.74 on ET, 0.90 on WT, and 0.83 on TC. Qualitative and visual evaluation of our proposed method shown effectiveness of the proposed segmentation method can achieve performance that can compete with other brain tumor segmentation techniques.

Vertical financial disparity, energy prices and emission reduction: Empirical insights from Pakistan.

The economic and environmental aspects of energy production have become important due to the increasing complexity energy sector and envoirnmental pollution, warranting to test the connection between financial imbalances, energy prices and carbon emission. The study aims to test the impact of vertical fiscal imbalances (VFI) on energy prices and carbon emission trends by considering the dual-perspectives of environmental regulation and industrial structure. The empirical outcomes indicated that vertical fiscal imbalances limited the environmental quality of Pakistan. Furthermore, VFI also caused environmental degradation by affecting industrial structure. VFI inhibits the intensity of environmental regulation, promotes the upgrade of industrial structures, both of which cause additional carbon emissions. The study suggest to energy ministries and energy regulation offices to revisit the machinism of energy prices determination and revised machanisim should provide a user-friendly assessment to understand the actual costs associated with the rising concern of environmental pollution. By this, envoirnmental protection maximization and optimal energy conservation is expacted to increase. Based on empirical findings, the study extends the suggestion that vertical fiscal imbalances should be considered an active indicator by the key policy makers and other stakeholders for energy prices determination and environmental quality upgradation.

Structural, Optical and Electrical Properties of Cu0.6CoxZn0.4-xFe2O4 (x = 0.0, 0.1, 0.2, 0.3, 0.4) Soft Ferrites.

A series of cobalt-inserted copper zinc ferrites, Cu0.6CoxZn0.4-xFe2O4 (x = 0.0, 0.1, 0.2, 0.3, 0.4) having cubic spinel structure were prepared by the coprecipitation method. Various characterization techniques, including XRD, FTIR, UV-vis and I-V were used to investigate structural optical and electrical properties, respectively. The lattice constant was observed to be decreased as smaller ionic radii Co2+ (0.74 Å) replaced the higher ionic radii Zn2+ (0.82 Å). The presence of tetrahedral and octahedral bands was confirmed by FTIR spectra. Optical bandgap energy was determined in the range of 4.44-2.05 eV for x = 0.0 to 0.4 nanoferrites, respectively. DC electrical resistivity was measured and showed an increasing trend (5.42 × 108 to 6.48 × 108 Ω·cm) with the addition of cobalt contents as cobalt is more conductive than zinc. The range of DC electrical resistivity (108 ohm-cm) makes these nanomaterials potential candidates for telecommunication devices.

State-of-the-Art Traditional to the Machine- and Deep-Learning-Based Skull Stripping Techniques, Models, and Algorithms.

Several neuroimaging processing applications consider skull stripping as a crucial pre-processing step. Due to complex anatomical brain structure and intensity variations in brain magnetic resonance imaging (MRI), an appropriate skull stripping is an important part. The process of skull stripping basically deals with the removal of the skull region for clinical analysis in brain segmentation tasks, and its accuracy and efficiency are quite crucial for diagnostic purposes. It requires more accurate and detailed methods for differentiating brain regions and the skull regions and is considered as a challenging task. This paper is focused on the transition of the conventional to the machine- and deep-learning-based automated skull stripping methods for brain MRI images. It is observed in this study that deep learning approaches have outperformed conventional and machine learning techniques in many ways, but they have their limitations. It also includes the comparative analysis of the current state-of-the-art skull stripping methods, a critical discussion of some challenges, model of quantifying parameters, and future work directions.

Validity of STONE Score in Clinical Prediction of Ureteral Stone Disease.

OBJECTIVE: To determine the external validity of STONE score for predicting the probability of ureteral stone in patients presenting in emergency department with suspicion of ureteral stones. METHODS: In this prospective validation study, a total of 134 patients aged above 18 years, and first time arrived in the emergency unit for treatment of flank pain and then referred for the CT scan for suspected ureteral stone in Sandeman Provincial Hospital, Quetta, from 10-June-2018 to 15-Oct-2019 were included. STONE score calculation was done before sending the patient to the CT scan, using the same protocol as defined by Moore et al. Based on STONE score patients classified into the low-risk group (0 to 5), moderate-risk group (5 to 9) and the high-risk group (10 to13). The AUC, sensitivity, specificity and test characteristics were calculated for STONE score. RESULTS: The mean age was 39.2± 11.2 years, there were 86 (64.17%) men and 48 (35.83%) women. there were 26.8% patients having low-risk score, 52.23% moderate-risk and 21.97% high-risk score. On receiver operating curve (ROC) the area under curve (AUC) of the stone score was 0.75 (95% CI, 0.67 to 0.83), the lower band of AUC 0.67 and upper band 0.83. In high risk STONE score the sensitivity of STONE score was 66.7% and specificity was 75.0%. CONCLUSION: Based on our study results, CT scan and ultrasonography are standard diagnostic tools for suspected ureterolithiasis but in emergency unit, use of STONE score to categorize the patient as low risk, moderate-risk and high-risk of ureteral stone can help the physician (clinician) to take decision either there is a need of further investigation or not.

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.

Diffusion MRI and MR spectroscopy reveal microstructural and metabolic brain alterations in chronic mild stress exposed rats: A CMS recovery study.

Chronic mild stress (CMS) induced depression elicits several debilitating symptoms and causes a significant economic burden on society. High variability in the symptomatology of depression poses substantial impediment to accurate diagnosis and therapy outcome. CMS exposure induces significant metabolic and microstructural alterations in the hippocampus (HP), prefrontal cortex (PFC), caudate-putamen (CP) and amygdala (AM), however, recovery from these maladaptive changes are limited and this may provide negative effects on the therapeutic treatment and management of depression. The present study utilized anhedonic rats from the unpredictable CMS model of depression to study metabolic recovery in the ventral hippocampus (vHP) and microstructural recovery in the HP, AM, CP, and PFC. The study employed 1H MR spectroscopy (1H MRS) and in-vivo diffusion MRI (d-MRI) at the age of week 18 (week 1 post CMS exposure) week 20 (week 3 post CMS) and week 25 (week 8 post CMS exposure) in the anhedonic group, and at the age of week 18 and week 22 in the control group. The d-MRI data have provided an array of diffusion tensor metrics (FA, MD, AD, and RD), and fast kurtosis metrics (MKT, WL and WT). CMS exposure induced a significant metabolic alteration in vHP, and significant microstructural alterations were observed in the HP, AM, and PFC in comparison to the age match control and within the anhedonic group. A significantly high level of N-acetylaspartate (NAA) was observed in vHP at the age of week 18 in comparison to age match control and week 20 and week 25 of the anhedonic group. HP and AM showed significant microstructural alterations up to the age of week 22 in the anhedonic group. PFC showed significant microstructural alterations only at the age of week 18, however, most of the metrics showed significantly higher value at the age of week 20 in the anhedonic group. The significantly increased NAA concentration may indicate impaired catabolism due to astrogliosis or oxidative stress. The significantly increased WL in the AM and HP may indicate hypertrophy of AM and reduced volume of HP. Such metabolic and microstructural alterations could be useful in disease diagnosis and follow-up treatment intervention in depression and similar disorders.

A newly isolated Pseudomonas sp. can degrade endosulfan via hydrolytic pathway.

Endosulfan an organochlorinated pesticide was used extensively throughout the world. Its enormous and inadequate use creates environmental as well as health problems. A bacterial strain capable to utilize endosulfan as a sole source of sulfur was isolated from pesticide contaminated soil and identified as Pseudomonas sp. on the basis of 16S rRNA. Batch experiments were conducted at various initial concentrations of endosulfan, i.e. 5, 25, 50, 75 and 100 mg/l to study its rate of degradation. After three days of incubation, 70-80% of each initial concentration was degraded by the isolated strain as compared to the control. Degradation of endosulfan increased with the time of incubation and maximum degradation was observed after 5 days of incubation. GC-MS revealed that the major metabolite was endosulfan lactone, which accumulated after 5 days of incubation. Kinetic studies at various initial concentrations also revealed that the bacterium has very promising attitude to utilize endosulfan as sole source of sulfur. It was observed that the addition of auxiliary sulfur Fe(SO4)3 in any concentration (0.05, 0.01 and 0.1%) decreased the rate of degradation of endosulfan. The ratio of µmax/ Ks was high (0.03 mg/l) when endosulfan was single sulfur source as compared to the value recorded when Fe(SO4)3 was added alongwith the endosulfan. This indicates that the newly isolated bacterium attacks sulfur moiety for its degradation.

Frequency of nasal carriage of Staphylococcus Aureus among health care workers at a Tertiary Care Hospital.

OBJECTIVE: To determine the frequency of Methicillin resistance staphylococcus aureus (MRSA) and identification of drug susceptibility for MRSA isolates among health care workers (HCWs) of a tertiary care hospital of South Punjab Pakistan. METHODS: We included 225 HCWs including laboratory staff, doctors, nurses and paramedical staff in this cross-sectional study. The study was conducted in Nishtar medical university/Hospital Multan. The study duration was July-2016 to April-2017. HCWs having no signs of infections and any other systemic disease were included in this study. We used sterile nasal swab sticks for sample collection for determination of S. aureus prevalence. All these samples were processed in the laboratory for MRSA, methicillin sensitive S. aureus (MSSA) and for antimicrobial sensitivity of S. aureus. Chi-square test was used for comparison of frequency of MRSA and MSSA between different HCWs by assuming p-Value ≤0.05 as significant difference. RESULTS: There were 65.3% (147) female participants and only 34.7% (78) male participants. S. aureus was diagnosed in the nasal flora of 24% (54) participants, out of which 9.3% (21) were MRSA positive and remaining 14.7% (33) were MSSA positive. There was no significant difference in frequency of MRSA and MSSA among different HCWs (p-value 0.79). Amikacin and vancomycin were 100% sensitive for MRSA and MSSA. Clindamycin and ciprofloxacin was 80.9% (17) and 71.4% (15) sensitive for MRSA and 100% and 84.8% (28) for MSSA respectively. While oxacillin and Cefoxitin were 100% (21) resistant for MRSA and sensitive for MSSA. CONCLUSION: Prevalence of MRSA and MSSA is high among HCWs in Pakistan. Amikacin, vancomycin and clindamycin have high sensitivity for MRSA and can be used for empirical treatment of MRSA in suspected patients.

Doubly committed Subarterial Ventricular Septal defect repair: An experience of 51 cases.

OBJECTIVE: To review the surgical outcome of doubly committed subarterial (DCSA) ventricular septal defect repair. METHOD: Data of 51 patients of doubly committed sub arterial Ventricular septal defect from January 2012 to June 2017 that were referred to Chaudhary Pervaiz Elahi institute of Cardiology Multan was retrospectively reviewed using electronic database. All patients were operated by first author. In our study, we segregated patients into four main groups depending on presence or absence of aortic structural defect and degree of aortic valve regurgitation. Group-A comprised of nineteen (37%) patients who neither had aortic structural nor functional abnormality while Group-B had six (11.7%) patients, having aortic valve cusp prolapse without aortic regurgitation. Group-C and Group-D consists of seventeen (33.3%) and nine (17.6%) patients respectively depending upon degree of aortic regurgitation. Furthermore, six (11.7%) patients among these 51 had associated defects as well. RESULTS: Group-A patients had no aortic valve regurgitation post operatively and at follow up of 22.6 months (1.8 years) as well. In Group-B, aortic valve was not addressed and aortic regurgitation was also not present post operatively or on follow up of 33.6 months (2.8 years). Similarly, in Group-C aortic valve was not addressed, these patients also did not show progression of disease on regular follow up of 18 months (1.5 year). While, in Group-D, eight patients underwent aortic valve repair and one patient had aortic valve replacement. Aortic regurgitation improved significantly in all patients of this group and remained unchanged on follow up of 22.7 months (1.8 years). CONCLUSION: Early closure of doubly committed subarterial ventricular septal defect with appropriate management of aortic valve disease can halt the process of disease progression.

Incidence and risk factors of Pulmonary Complications after Cardiopulmonary bypass.

OBJECTIVE: To determine the frequency of post-operative pulmonary complications (PPCs) after cardio-pulmonary bypass and association of pre-operative and intraoperative risk factors with incidence of PPCs. METHODS: This study was an observational analysis of five hundred and seventeen (517) patients who underwent cardiac surgery using cardiopulmonary bypass. Incidence of PPCs and risk factors of PPCs were noted. Logistic regression was applied to determine the association of pre-operative and intraoperative risk factors with incidence of PPCs. RESULTS: Post-operative pulmonary complications occurred in 32 (6.2%) patients. Most common post-operative pulmonary complication was atelectasis that occurred in 20 (3.86%) patients, respiratory failure in 8 (1.54%) patients, pneumonia in 3 (0.58%) patients and acute respiratory distress syndrome in 1 (0.19%) patients. The main risk factor of PPCs were advance age ≥ 60 years [odds ratio 4.16 (1.99-8.67), p-value <0.001], prolonged CPB time > 120 minutes [odds ratio 3.62 (1.46-8.97) p-value 0.003], pre-op pulmonary hypertension [odds ratio 2.60 (1.18-5.73), p-value 0.016] and intraoperative phrenic nerve injury [odds ratio 7.06 (1.73-28.74), p-value 0.002]. Operative mortality was 9.4% in patients with PPCs and 1.0% in patients without PPCs (p-value 0.01). CONCLUSION: The incidence of post-operative pulmonary complications was 6.2% in this study. Advanced age (age ≥ 60 years), prolonged CPB time (CPB time > 120 minutes), pre-op pulmonary hypertension and intraoperative phrenic nerve injury are independent risk factors of PPCs after surgery.

Peripheral arterial blood pressure versus central crterial blood pressure monitoring in critically ill patients after Cardio-pulmonary Bypass.

OBJECTIVE: To determine the accuracy of peripheral (radial) arterial access as compared to central (femoral) arterial access for measurement of invasive blood pressure (IBP) in critically ill patients after cardiopulmonary bypass. METHODS: Sixty patients (60) who required high inotropic/vasopressor support on weaning from cardio-pulmonary bypass and weaned off in 2nd attempt were included in this study. The duration of this study was from June 2015 to August 2016. Radial and femoral arterial access was achieved in all patients for simultaneous measurement of blood pressure. Arterial pressures were noted after 5, 15 and 30 minutes of weaning from cardiopulmonary bypass for both radial and femoral artery simultaneously. RESULTS: Mean age of study patients was 56.48±11.17 years. 85% patients were male. There was significant difference in systolic blood pressure, diastolic blood pressure and mean arterial pressures between the radial artery and femoral artery cannulation. Mean arterial pressures were significantly high in femoral artery as compared to the radial artery. The mean arterial pressures after five minutes of weaning using central access were 76.28±10.21 mmHg versus 64.15±6.76 mmHg in peripheral arterial access (p-value <0.001). Similarly we also found significant difference in mean arterial pressures after 15 minutes of weaning from cardiopulmonary bypass 78.70±10.12 mmHg in central access versus 72.03±6.76 mmHg using peripheral arterial access (p-value <0.001). The difference in arterial pressures were less marked as compared to the previous differences after 30 minutes of weaning from cardiopulmonary bypass as compared to the earlier readings (p-value 0.001). CONCLUSION: Peripheral arterial pressures are unreliable in critically ill patients after cardiopulmonary bypass receiving high dose of inotropic drugs. Central arterial access should be used in these patients to get accurate estimates of patients' blood pressure in early periods after cardiopulmonary bypass.

Myocardial protection with Glucose-Insulin-Potassium infusion during adult cardiac surgery.

BACKGROUND & OBJECTIVE: Recent meta-analysis reports have called for more randomized trials to evaluate the effectiveness of GIK solution in patients of cardiac surgery. So this study was conducted to evaluate the effectiveness of Glucose-insulin-potassium (GIK) solutions in non-diabetic patients undergoing coronary artery bypass grafting. METHODS: A total number of one hundred and sixty (160) patients were randomized into two equal groups; GIK Group and non-GIK group. In GIK group, 5% dextrose containing 70 IU/L regular insulin and 70 meq/L of potassium was administered. The infusion was started at a rate of 30 ml/hour after induction of anesthesia and before the start of cardiopulmonary bypass. The infusion was started again after removal of aortic cross clamp and was continued for six hours after the operation. RESULTS: In early post-operative period, peak CKMB levels were high in non-GIK group 48.50±19.79 IU/L versus 33.40±14.69 IU/L in GIK group (p-value <0.001). There was no statistically significant difference in requirements of inotropic support between the groups. The mean duration of inotropic support in GIK group was only 5.50±6.88 hours in GIK group and 8.64±7.74 hours in non-GIK group (p-value 0.008). Mean ventilation time in GIK group was 5.06±2.39 hours versus 6.55±3.58 hours in non-GIK group (p-value 0.002). Similarly, ICU stay period was also shorter in GIK group (p-value 0.01). We did not found any detrimental effect of GIK infusion on non-cardiac complications e.g. renal, pulmonary and neurologic complications. CONCLUSION: Glucose-insulin-potassium (GIK) infusion has a beneficial role in myocardial protection and is associated with better post-operative outcomes without increasing the risk of non-cardiac complications.