Outcomes of ketorolac versus depomedrol infiltrations for subacromial impingement syndrome: a randomized controlled trial.

PURPOSE: Local subacromial infiltration with steroids is a common method of treatment of subacromial impingement syndrome. However, the use of steroids has concerns like tendon rupture, articular cartilage changes and infections. Local NSAIDs infiltration has recently been tried in literature. This study compares the effect of subacromial injections of ketorolac with steroids. METHODS: A randomized controlled study was planned with 35 patients in each group. Patients in group-1 were infiltrated with subacromial ketorolac (60 mg with 2% lignocaine) and in group-2 with a steroid (methylprednisolone-40 mg with 2% lignocaine). A similar rehabilitation protocol was followed, and clinical outcomes were analyzed using visual analog scale (VAS) for pain and shoulder pain and disability score (SPADI) and range of motion at one-month and three-months follow-up. RESULTS: Total data of 67 patients were analyzed, as three patients were lost to follow-up. In group 1, mean VAS improved from 7.9 [Formula: see text] 0.95 to 3.19 [Formula: see text] 0.81 (p < 0.001) and SPADI improved from 61.41 [Formula: see text] 11.86 to 28.91 [Formula: see text] 9.06 (p < 0.001) at three months, respectively. In group 2, mean VAS improved from 8.05 [Formula: see text] 0.94 to 2.9 [Formula: see text] 0.64 (p < 0.001) and SPADI improved from 63.45 [Formula: see text] 9.64 to 25.32 [Formula: see text] 6.87 (p < 0.001) at three months, respectively. However, there were no differences in functional outcomes between the groups (p = 0.21 for VAS, p = 0.16 for SPADI). CONCLUSION: Subacromial ketorolac infiltration has an equivalent outcome as that of steroid infiltration. Ketorolac could be considered as a reasonable alternative to steroids in cases where it is contraindicated.

The Role of Urinary LH and FSH in the Diagnosis of Pubertal Disorders.

BACKGROUND: Various hormonal parameters used to differentiate between different causes of pubertal disorders are invasive, cumbersome, and has variable sensitivity and specificity. Thus, the use of a noninvasive test like urinary gonadotropin for the diagnosis of pubertal disorders will offer a significant advantage. OBJECTIVE: To study the role of urinary gonadotropins (uLH, uFSH) for the diagnosis of various pubertal disorders and in the monitoring of Gonadotrophin releasing hormone, Hypothalamic-pituitary-gonadal (GnRHa) therapy in patients with central precocious puberty (CPP). MATERIALS AND METHODS: We evaluated 35 healthy children and 96 patients with disorders of puberty out of which 31 cases had early puberty and 65 cases had delayed puberty. We used Spearman's correlation coefficient to evaluate the correlation between the serum and urinary gonadotropins. We used Mann-Whitney U test (for 2 groups) and Kruskal-Wallis test (for > 2 groups) to compare the median urinary and serum gonadotropins of different groups. RESULTS: The urinary gonadotropins correlated strongly with serum gonadotropins in both healthy controls and individuals with pubertal disorders. The uLH level of ≥0.76 IU/L had 100% sensitivity and specificity to differentiate CPP from peripheral precocious puberty, whereas uLH level of ≥1.07 IU/L had 100% sensitivity and specificity for differentiating CPP from PT. In patients with delayed puberty, uFSH of ≥20.51 IU/L had 94.7% sensitivity and 91.3% specificity for the diagnosis of Hyper-Hypo cases and uLH level of ≥0.5 IU/L had sensitivity of 96.2% and specificity of 85% to differentiate constitutional delay in growth and puberty from hypogonadotropic-hypogonadism. In CPP patients on GnRHa therapy, the uLH level of ≥0.13 IU/L had 100% sensitivity and 86.7% specificity to identify those who had nonsuppressed serum LH levels. CONCLUSION: The urinary gonadotropins can be used as a reliable noninvasive test for the diagnosis of various pubertal disorders and also for monitoring of CPP patients on GnRHa therapy.

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.

Extra-Spinal Osteoarticular Tuberculosis: A Retrospective Analysis of 103 Cases.

INTRODUCTION: Many studies in the literature deals with epidemiology, diagnosis and management of spinal tuberculosis but there is scant amount of such data for extraspinal osteoarticular TB. MATERIAL AND METHODS: Demographic patient data like age, sex, bone and joint involved, side involved, duration of symptoms was noted. All suspected cases of extra-spinal musculoskeletal TB with positive acid-fast bacilli (AFB) staining or positive cartridge based nucleic acid amplification test (CBNAAT) or histopathological evidence of granulomatous infection and minimum 1 year follow up after completion of 12-month ATT were included in the study. Outcome evaluation was done on the basis of residual pain, range of motion of joint along with deformity of the affected part, if any. RESULTS: A total of 103 patients (55 males, 48 females) were analyzed. The mean duration of treatment was 14.2±2.8 months. The mean age of the patients at presentation was 30.5±18.5 years. The most common site affected was the ankle joint followed by hip and knee. 95 cases (92.2%) were diagnosed by histopathological examination of synovial tissue or material obtained from core biopsy. 90 cases (87.3%) were treated conservatively on oral drugs only while 13 cases (12.7%) were treated operatively. Outcome after completion of ATT were graded as good in 46 (46.9%), fair and poor each in 26 patients (26.5%). CONCLUSION: Extraspinal osteoarticular TB can be managed effectively by 12-month ATT if diagnosed early. Some cases with advanced arthritis can be salvaged with implant arthroplasty or arthrodesis under cover of ATT.

Visceral Adiposity Index Score is the Better Predictor of Clinical and Coronary Angiographic Severity Assessment than Other Adiposity Indices in Patients with Acute Coronary Syndrome.

Acute coronary syndrome (ACS) is one of the leading causes of death throughout the world and obesity especially visceral adiposity is one of the important concerns globally due to its huge impact on coronary artery disease particularly on ACS. There are several traditional methods like BMI, WC, WHR, WHtR etc. but none of these can measure visceral fat accurately. In this regard visceral adiposity index (VAI) is a novel sex specific index which has significant correlation with visceral adiposity and can express the distribution as well as function of visceral fat precisely. This cross sectional study was done in the Cardiology Department of National Institute of Cardiovascular Diseases, Dhaka, Bangladesh from August 2015 to July 2016 to compare the VAI with other adiposity indices for clinical and coronary angiographic severity assessment in patients with acute coronary syndrome. A total of 200 patients (Case 100 patients of ACS and Control 100 patients of non ACS) were included. Afterward clinical, biochemical, echocardiographic and coronary artery angiographic indexes determined by Gensini score were acquired. Adiposity indices like BMI, Waist and Hip circumference, Waist Hip and Waist Height ratio (WHR, WHtR) and finally VAI were calculated using appropriate formula. Patient with ACS had more severe form of clinical features like severe chest pain & shortness of breath (p=0.001), pulse, BP, abnormal precordial findings, BMI, WC, WHR, WHtR, HC, VAI (p=0.001) and angiographic severity (p=0.001) than non ACS group. Multivariate binary logistic regression analysis for clinical and coronary angiographic severity assessment (GS>36) by adiposity indices showed VAI was the better predictor of clinical and coronary angiographic severity assessment with OR's being 5.61 than others. An ROC curve was plotted for each adiposity indices for clinical and coronary angiographic severity assessment showed VAI to have the maximal AUC. A VAI of OR-5.61 was provided as the cutoff value which had a sensitivity of 73.3% and specificity of 76.6% (AUROC=0.839, CI-0.760-0.918, p<0.001) which indicates better than other adiposity indices in patients under study. VAI is an excellent, simple, noninvasive tool to detect the visceral adipose mass & was markedly associated with the clinical and coronary angiographic severity assessment in patients with ACS.

Association of Prolonged QTc Dispersion with Diastolic Dysfunction of the Left Ventricle in Patients with Non ST Segment Elevation Myocardial Infarction.

Diastolic function usually declines before systolic function, and this precedes clinical signs in patients with acute coronary syndrome. Therefore, diagnosis of diastolic dysfunction is very important for early diagnosis, follow-up, treatment, and prognostic evaluation in heart failure with preserved ejection fraction (HFpEF) patients. The main objective of the study was to find out association between prolonged QTc dispersion and left ventricular diastolic dysfunction in Non ST Segment Elevation Myocardial Infarction (NSTEMI) patients in HFpEF. This cross sectional analytical study was conducted in the Department of Cardiology and 60 patients were included as study population from August 2015 to July 2016. Then the study population was divided into two groups, each group consisted of 30 patients. NSTEMI patients with prolonged QTc dispersion treated as Group I and NSTEMI patients with normal QTc dispersion treated as Group II. The study shows 20.0% vs. 26.6% patients had detected as Grade I in Group I and Group II respectively with statistically insignificant association (p=0.16). On the contrary, 30.0% vs. 13.4% patients had detected as Grade II in Group I and Group II respectively with statistically significant association (p=0.001). Again, 40.0% vs. 10.0% patients had detected as Grade III in Group I and Group II respectively with statistically significant association (p=0.001). QTc dispersion was found sequentially significant increased (p=0.007) among 3 grades of LVDD (63.6±4.9 vs. 79.4±8.6 vs. 98.2±28.8). QTc dispersion in surface ECG which is a cheap, non-invasive, easily available tool can help us predicting left ventricular diastolic dysfunction in patients with NSTEMI.

Comparison between retrograde and transeptal approach in radiofrequency catheter ablation of left accessory pathways.

To study a series of patients submitted to radiofrequency catheter ablation (RFA) of left accessory pathways (AP) using the transeptal approach (TSA) as compared to the conventional retrograde arterial approach (RAA). Sixty consecutive patients (44 male; mean age of 35.60±11.63 years) with 60 left APs (39 overt and 21 concealed) underwent catheter ablation using the TS method (30 patients) and the RAA method (30 patients) in an alternate fashion. The analysis was performed according to the intention-to-treat principle. The transeptal puncture was successfully performed in 29 patients (96%). This access allowed primary success in the ablation in all the patients without any complication. When we compared this approach with the RAA there was no difference as regards the primary success (p=0.103), fluoroscopy time (p=0.565) and total time (p=0.1917). Three patients in the RAA group presented a vascular complication. The TSA allowed shorter ablation times (p=0.006) and smaller number of radiofrequency applications (p=0.042) as compared to the conventional RAA. The patients who had unsuccessful ablation in the first session in each approach underwent with the opposite technique (cross-over), with a final ablation success rate of 100%.The TS and RA approaches showed similar efficacy and safety for the ablation of left accessory pathways. The TSA allowed shorter ablation times and smaller number of radiofrequency applications. When the techniques were used in a complementary fashion, they increased the final efficacy of the ablation.

Association between elevated B-type Natriuretic Peptide levels with extent of coronary artery disease in patients with unstable angina and NSTEMI.

The study was undertaken to find out the correlation of elevated B-type Natriuretic Peptide (BNP) levels with the severity of coronary artery disease in patients with unstable angina and NSTEMI. This cross sectional analytical study was carried out in the department of cardiology, National Institute of Cardiovascular Diseases, Dhaka during a period of August 2011 to June 2012. A total of 100 consecutive patients with unstable angina and NSTEMI undergoing coronary angiography were included in the study. BNP assay was done by Architect system, a chemo luminescent microparticle immunoassay (CMIA). CAG was done by conventional method within 14 days of index hospital admission. Study patients were divided into two groups on the basis of BNP levels. In Group I, BNP Levels were ≤80pg/ml and in Group II, BNP levels were elevated >80pg/ml. with 50 patients in each group. Angiographic severity of CAD was assessed by vessel score and Friesinger score. Vessel score showed single vessel was involved in 21(47.7%) patients while multi vessel in 23(52.3%) patients was found in Group I. On the contrary 11(22.4%) single vessel patients and 38(77.6%) multivessel patients were found in Group II. There was significant association between vessel involvement (p=0.01). Friesinger score revealed that less severe CAD was found in 22(44%) patients and significant severe CAD in 28(56.0%) patients in Group I. On the contrary 7(14.0%) less severe CAD patients and 43(86.0%) severe CAD patients were found in Group II. There was significant difference between severity of CAD among the study groups (p=0.01). There was linear correlation between BNP pg/ml and coronary artery disease severity in terms of Vessel score (r=0.38, p=0.01) and Friesinger score (r=0.51, p=0.01). The present study concluded that increased BNP level >80pg/ml was significantly associated with the presence and severity of CAD in patient with UA and NSTEMI.

Cardiac contractility modulation device-new hope for refractory heart failure patients.

A large number of patients with advanced heart failure (HF) are refractory to optimal standard medical therapy. This has given rise to development and testing of a host of new device based therapies. One recent and potentially broadly applicable treatment under investigation is cardiac contractility modulation (CCM) electrical signals. The CCM signals are relatively high-voltage electrical impulses applied to the myocardium during the absolute refractory period. These signals do not initiate a new contraction or modify activation sequence as is the case with other therapies such as cardiac resynchronization therapy. Rather, CCM signals are intended to enhance systolic function of the failing myocardium. A device similar to a pacemaker is typically implanted in the right pectoral region. Three standard pacemaker leads are placed intravenously. One right arterial lead is used to sense atrial activity, and two right ventricular leads are used to sense ventricular activity and deliver the CCM pulse trains. The electrodes of the ventricular leads are placed on the right ventricular septum at least 2cm apart. In contrast to a Pacemaker and defibrillator the system is designed to modulate the strength of contraction of the heart muscle rather than the rhythm. Application of CCM signals to the failing heart is associated with improved gene expression which ultimately causes LV global, cellular and biochemical remodeling as a result improved LV systolic function.

Ad-hoc percutaneous coronary intervention and staged percutaneous coronary intervention.

Percutaneous coronary intervention (PCI) is a catheter based procedure where a catheter system is introduced through a systemic artery under local anesthesia in a stenotic coronary artery by controlled inflation of a distensible balloon. At early period, PCI was done in a separate session following coronary angiogram (Staged PCI) and it was more costly and hospital stay was long. As the expertization and laboratory facilities improved, the health care providers think about cost, hospital stay and patient convenience. So, to reduce the cost and patient preferred more PCI being done immediately following diagnostic catheterization (Ad-hoc PCI). Subsequently this Ad-hoc procedure becomes popular and now most of the PCI are Ad-hoc PCI worldwide. Rate of combined procedure (Ad-hoc) progressively increased from 54% in 1990 to 88% in 2000 with a significant decrease in rate of complications. In the initial study of Ad-hoc PCI suggested that Ad-hoc PCI should be done in selected group of patients as there was some potential risk factors (e.g. Multivessel diseases, unstable angina, aortic valve disease, and recent infarction or thrombolytic therapy) for Ad-hoc procedure and some (e.g. Older age, multivessel PTCA and complex lesion PTCA) for staged procedure. But recent studies showed that no significant difference in respect of safety and efficacy between Ad-hoc and staged PCI. Previous studies, in the era of balloon angioplasty from 1985 to 1995, Haraphonges et al. (1988), Rozenman et al. (1995) and Kimmel et al. (1997) suggested that an ad hoc approach is safe, with potentially more complications in patients with unstable angina pectoris or other high-risk factors. However, these reports have been limited to observational studies representing single institution experiences with small samples and inclusion of patients who underwent emergency PCI procedures. In Bangladesh a prospective observational study was done among 120 patients to compare the outcome of Ad-hoc and staged PCI and high angiographic, procedural and clinical success rate with minimum complications were observed in Ad-hoc PCI in comparison to Staged PCI.

Diagnosis of visceral leishmaniasis by enzyme-linked immunosorbent assay using urine samples.

A diagnostic method has been developed to detect anti-Leishmania donovani immunoglobulin G (IgG) in urine by enzyme-linked immunosorbent assay (ELISA). In measuring anti-L. donovani IgG, IgA, and IgM in urine, the method performed best in the detection of IgG. The sensitivity and specificity of the assay were determined with panels of urine samples from 62 visceral leishmaniasis (VL) patients, 59 healthy controls from areas of endemicity, 53 healthy controls from areas of nonendemicity, 59 malaria patients, 13 tuberculosis patients, 23 cutaneous leishmaniasis patients, and 7 patients with other diseases. Using L. donovani promastigote crude antigen, the test had 93.5% sensitivity (58 positives of 62 VL patient samples) and 89.3% specificity (191 negatives of 214 non-VL patient samples). The ELISA with acetone-treated L. donovani promastigote antigen raised the sensitivity and specificity to 95.0 and 95.3%, respectively. Western blot analysis revealed that most of the samples that cross-reacted with crude antigen in ELISA did not recognize any antigenic component of L. donovani crude antigen. We also checked 40 serum samples from the same group of VL patients for anti-L. donovani IgG and got 90.0% sensitivity with both crude and acetone-treated antigens. As collection of urine is much easier than collection of serum, the detection of anti-L. donovani IgG in urine with acetone-treated antigen will be useful in epidemiological studies. It could be an adjunct of laboratory diagnosis.

Synthesis and DNA cleavage activity of a novel bleomycin A(5) glycoconjugate.

[structure in text] To explore the possibility of modifying bleomycin in a fashion that could alter its physiological distribution in a therapeutic setting, a new analogue of bleomycin has been prepared. This analogue is intended to target the asialoglycoprotein receptor on liver cells. Critically, despite the large C-substituent, the bleomycin conjugate was found to degrade DNA in the same fashion as bleomycin A(5) itself, and with only modestly decreased efficiency.

Characterisation of Bangladeshi Leishmania isolated from kala-azar patients by isoenzyme electrophoresis.

To identify the prevalent Leishmania species in Bangladesh, a total of nine patients aged 4-35 years, were studied; six (66.7%) of them were below 20 years of age. All the patients were clinically diagnosed to have visceral leishmaniasis; their haematological profile was in accordance with leishmaniasis and all were improved after treatment with sodium stibogluconate. All the aspirated materials (eight bone marrows and one splenic aspirate) yielded growth of Leishmania parasite in NNN media; Leishman-Donovan bodies were found in seven (77.8%) of them in a Giemsa stained smear. Aldehyde test (AT) was positive in all the nine cases examined, whereas, complement fixation test (CFT) was positive in seven (77.8%) and indirect fluorescent antibody test (IFAT) in eight (88.9%) cases. In this study, five of the nine isolates from kala-azar patients were characterised by isoenzyme analysis comparing with five WHO reference strains viz., Leishmania (Leishmania) donovani (DD8), L.(L.) donovani (HU3), L.(L.) infantum (IPT-1), L.(L.) tropica (K-27) and L.(L.) major (5-ASKH) using cellulose acetate electrophoresis. By analysing 11 soluble isoenzymes it was found that all five WHO reference strains had distinct electrophoretic mobility of the isoenzymes studied. No interspecies difference was observed amongst the five isolates from kala-azar patients examined and their isoenzyme profiles were consistent with WHO reference strain of L.(L.) donovani (DD8) but different from L.(L.) donovani (HU3).

Traumatic rupture of diaphragm.

Traumatic diaphragmatic rupture remains a diagnostic challenge, and associated injuries determine the outcome in those diagnosed early, whereas that of latent cases is dependent on the consequence of the diaphragmatic rupture: namely, the diaphragmatic hernia. To analyze the clinical and radiologic features and the therapeutic implications, we reviewed 980 patients reported in the English-language literature. This injury affects predominantly males (male:female = 4:1) in the third decade of life, and is often caused by blunt trauma (75%). There were 1,000 injuries, of which 685 (68.5%) were left-sided, 242 (24.2%) right-sided, 15 (1.5%) bilateral, and 9 (0.9%) pericardial ruptures; 49 cases were unclassified. Chest (43.9%) and splenic (37.6%) trauma were the most common associated injuries. The diagnosis was made preoperatively in 43.5% of cases, whereas in 41.3% it was made at exploration or at autopsy and on the remaining 14.6% of the cases the diagnosis was delayed. The mortality was 17% in those in whom acute diagnosis was made, and the majority of the morbidity in the group that underwent operation was due to pulmonary complications. Uniform diagnosis depends on a high index of suspicion, careful scrutiny of the chest roentgenogram in patients with thoracoabdominal or polytrauma, and meticulous inspection of the diaphragm when operating for concurrent injuries. Repeated evaluation for days after injury is necessary to discern injury in patients not requiring laparotomy. Acute diaphragmatic injuries are best approached through the abdomen, as more than 89% of patients with this injury have an associated intraabdominal injury. Patients with diaphragmatic rupture presenting in the latent phase have adhesion between the herniated abdominal and intrathoracic organs, and thus the rupture is best approached via a thoracotomy.

Topical urea in dermatology.

For years research has been conducted to find a cutaneous moisturizer that is effective, easily available and relatively inexpensive urea, as a atopical agent, is all of this and is also a mild keratolytic. A trial was conducted over 200 patients suffering from a variety of disorders that were selected and using urea topically as urea 10 (10%), urea-20 lotion (20%), Urea-HC (with hydrocartisanl). The agent was applied twice daily for a maximum period of 8 weeks. Results indicate that urea is an effective moisturizer and in promotes the penetration of hydrocelisone into the skin.

Repair of burns of the scrotum using a gracilis myocutaneous flap.

An unusual case of isolated burns of the scrotum reconstructed by a unilateral gracilis myocutaneous flap is reported because of its clinical rarity.

Diphenhydramine in Orientals and Caucasians.

The kinetics and psychomotor effects of diphenhydramine were investigated in Orientals and Caucasians. Each of 5 Oriental and 5 Caucasian young adults received on 1 of 3 occasions diphenhydramine 50 mg/70 kg body weight either intravenously or orally, or placebo. Plasma levels of diphenhydramine were measured hourly for 8 hr at each session. Tests of subjective sedation and psychomotor performance were performed at hourly intervals. The results showed that after both intravenous and oral diphenhydramine, at all times Orientals had plasma levels approximately half those of Caucasians. With the assumption of linear kinetics and a 1-compartment open model, analysis of the data showed that the volume of distribution (VD) and plasma clearance (Cl) but not plasma half-life (t 1/2) were higher in Orientals than Caucasians: [VD = 480 +/- 24 (SEM) and 292 +/- 36 1/70 kg; Cl = 79 +/- 7 and 51 +/- 7 1/70 kg/hr; t 1/2 = 4.1 +/- 0.4 and 4.3 +/- 0.4 hr]. Unbound diphenhydramine in fresh plasma was higher in Orientals than Caucasians [24.0 +/- 1.9% (SEM) and 14.8 +/- 1.5%] and probably explains the increased VD in Orientals. Orientals had significantly less sedation and deterioration in psychomotor performance.