Assessment of three-dimensional (3-D) left ventricular ejection fraction and speckled tracking echocardiographic strain parameters in non-ischemic left bundle branch block (LBBB) patients and their association with cardiovascular events - A prospective observational study.

OBJECTIVE: To investigate the association between three-dimensional (3-D) left ventricular ejection fraction (LVEF) and various speckle tracking echocardiographic (STE) strain parameters in non-ischemic left bundle branch block (LBBB) patients with major adverse cardiovascular events (MACE) during a one-year follow-up phase. METHOD: A total of 50 patients with non-ischemic LBBB were assessed using various parameters of 3-D echocardiography. They were compared with their same-age and sex control group and then followed up with repeat 3-D echocardiography for MACE for one year. RESULTS: Composite outcomes were seen in (n = 11 [22 %], including cardiovascular mortality (n = 2 [4.0 %]) and hospitalization for heart failure (n = 9 [18.0 %]). Mean values of the left ventricle (LV) global longitudinal (GLS), circumferential (GCS), and radial (GRS) strains were -14.4 ± 5.6, -14.3 ± 5.8, and 15.3 ± 5.9 respectively in the study cases. Initial GLS values were significantly impaired among those who had clinical events (-9.2 vs -15.9). Also, significant worsening of GLS (p value < 0.001) was seen in patients with composite outcomes on follow-up. Cut-off values in receiver operating characteristic analyses for composite outcomes were: GLS more than -13.5, GCS more than -12.5, and GRS less than 14.5. Intra-class correlations for both intra-observer and inter-observer variability were found to be good. CONCLUSION: Impaired LV GLS and low 3-D LVEF are significantly associated with the occurrence of MACE in patients with non-ischemic LBBB. This strong association of LV GLS with outcomes can aid in risk stratification, prognostication, and clinical decision-making in non-ischemic LBBB.

Association between Vitamin D deficiency and Breast Cancer.

OBJECTIVE: To determine the association between vitamin D deficiency and breast cancer. METHODS: This case control study included 94 female patients aged 20-75 years of any marital status and parity. Newly diagnosed 42 breast cancer patients who presented to surgical OPD of Dow University Hospital from Jan 2016 to June 2016 were included into the study as "cases" after informed consent. Age-matched 52 females who presented to OPD for complain other than breast pathology were included as the "control group". The sociodemographic of both cases and controls and histopathological characteristics of cases were recorded. Serum 25-(OH)2D levels were studied by the ELISA technique and recorded in ng/ml. Vitamin D deficiency was considered at serum level less than 20 ng/ml. RESULTS: Mean age was 40.1 Years for controls and 47.6 Years for cases. Mean height, weight and BMI did not differ between cases and controls. Serum Vitamin D levels were significantly lower in cases (85.7%) than controls (55.8%). The unadjusted and adjusted ORs for breast cancer in cases and controls showed a statistically significantly increased risk of breast cancer with low vitamin D concentration (p value0.003). After adjustment for age, parity, BMI, sun exposure, economic status and education status the ORs (95% CIs) for breast cancer risk was7.8 (1.99 - 30.58) for women with vitamin D concentrations <20 ng/mL. CONCLUSION: Findings of our study conclude that vitamin D deficiency is associated with risk of breast cancer.

Comparison of hemorrhoidectomy by LigaSure with conventional Milligan Morgan's hemorrhoidectomy.

OBJECTIVE: To compare the efficacy of haemorrhoidectomy done by using LigaSure with conventional Milligan Morgan haemorrhoidectomy. METHODS: This randomized controlled trial was done at Department of Surgery Dow University Hospital Karachi during January 2013 to September 2015. A total of 55 patients were included in the study. Patients were randomly allocated to group A (Haemorrhoidectomy by Ligasure) and group B (Milligan Morgan Haemorrhoiectomy). Efficacies of both procedures were compared by operative time, Blood loss, wound healing, and pain score on immediate, 1st and 7(th) post operative day. RESULTS: Out of total 55 patients 23 were male and 32 were females. The most common group of age involved was between 40 - 60 years. Third degree Heamorrhoids were present in 37 (67.3%) of patients while remaining 18 (32.7%) had fourth degree Heamorrhoids. Group A included 29 cases while Group B included 26 cases. The mean operating time of Group A was 52.5 with standard deviation of 11.9 while it was 36.6± 9.8 in the other group. The mean blood loss in group A was 51.92 with standard deviation of 15.68 while it was 70.34±25.59 in group B. Overall pain score was less in those patients who underwent Heamorrhoidectomy by Ligasure method. CONCLUSION: The efficacy of Heamorrhoidectomy by Ligasure is better than the traditional Milligan Morgan Heamorrhoidectomy but we need more clinical trials with large sample size and long term follow ups.

Sentinel lymph node identification by blue dye in patients with breast carcinoma.

OBJECTIVE: To determine the diagnostic accuracy of methylene blue dye to detect axillary lymph node metastases in patients with breast carcinoma by taking histopathology as gold standard. METHODS: This quasi experimental study was done at Department of Surgery of Dow University Hospital Karachi during January 2013 to September 2015 after the approval of Hospital Ethical Committee. A total number of 85 patients with biopsy proven carcinoma were included in the study.1% methylene blue dye was infiltrated in the peri tumoural area of the diseased breast. The blue stained node called sentinel lymph node (SLN) was recognized and carefully dissected out. SLN and mastectomy with axillary clearance specimen was sent for histopathology in two separate bottles and the report of the histopathology was compared. RESULTS: The axillary lymph nodes were positive for carcinoma in 61 cases out of 85(71.7%). Two of the patients had negative sentinel lymph node but positive non sentinel lymph node (false negative), and in three cases sentinel lymph node were involved only but not the rest of the axilla (False positive). The sensitivity, specificity and accuracy were 96.8%,86.36% and 94.1% respectively. CONCLUSION: Methylene blue dye technique is a reliable and safe diagnostic modality for detection of Sentinel lymph node in breast cancer patient because of its high accuracy.

Prediction and impact of sea level rise on properties and infrastructure of Washington, DC.

The city of Washington, District of Columbia (DC) will face flooding, and eventual geographic changes, in both the short- and long-term future because of sea level rise (SLR) brought on by climate change, including global warming. To fully assess the potential damage, a linear model was developed to predict SLR in Washington, DC, and its results compared to other nonlinear model results. Using geographic information systems (GIS) and graphical visualization, analytical models were created for the city and its underlying infrastructure. Values of SLR used in the assessments were 0.1 m for the year 2043 and 0.4 m for the year 2150 to model short-term SLR; 1.0 m, 2.5 m, and 5.0 m were used for long-term SLR. All necessary data layers were obtained from free data banks from the U.S. Geological Survey and Washington, DC government websites. Using GIS software, inventories of the possibly affected infrastructure were made at different SLR. Results of the analysis show that low SLR would lead to a minimal loss of city area. Damages to the local properties, however, are estimated at an assessment value of at least US$2 billion based on only the direct losses of properties listed in real estate databases, without accounting for infrastructure damages that include military installations, residential areas, governmental property, and cultural institutions. The projected value of lost property is in excess of US$24.6 billion at 5.0 m SLR.

Estimated prevalence of acoustic cranial windows and intracranial stenosis in the US elderly population: ultrasound screening in adults for intracranial disease study.

BACKGROUND: Intracranial atherosclerosis is an important etiology of stroke in the USA, but its prevalence in the general population remains unknown. This study was performed to determine the feasibility of transcranial Doppler ultrasound (TCD) for general population screening and to estimate the prevalence of intracranial stenosis in the USA. METHODS: We used a public database to randomly select 99 subjects aged 65-84 years residing in a well-defined geographic area. For all subjects clinical history was reviewed, blood pressure was recorded and TCD examination was performed to identify intracranial stenosis. RESULTS: The mean age of subjects was 72 years, 42 were men, and 17 were African-Americans. All acoustic windows were present in 77 subjects. After multivariate adjustment, the odds of absence of a bone window were higher in African-Americans [odds ratio (OR) 6.0, 95% confidence interval (CI) 1.8-2.0], nonsmokers (OR 3.1, 95% CI 1.0-9) and those with a high BMI (9% higher odds per index point). Among 77 subjects who had all acoustic windows present, intracranial stenosis of >50% was identified in 6.5%, and intracranial stenosis of any severity was identified in 16% of the persons. Intracranial stenosis was most prevalent in the middle cerebral artery (6%). CONCLUSION: Presence of acoustic windows is associated with vascular risk factors. Based on the high prevalence of significant intracranial stenosis in the US elderly population, it is feasible and important to perform a large-scale population-based study for this disease entity.

Comparison between angioplasty using compliant and noncompliant balloons for treatment of cerebral vasospasm associated with subarachnoid hemorrhage.

BACKGROUND: Considerable controversy exists regarding the choice of balloon used for performing angioplasty as treatment of cerebral vasospasm associated with subarachnoid hemorrhage. OBJECTIVE: To determine the impact of compliant and noncompliant balloons on angiographic and clinical outcomes among patients with subarachnoid hemorrhage-related cerebral vasospasm. METHODS: Consecutive patients with cerebral vasospasm who underwent balloon angioplasty were included. Patient characteristics, rate of angiographic recurrence, and occurrence of cerebral infarcts in the affected vessel distribution were compared between arteries treated using different balloons. RESULTS: A total of 30 patients underwent a first-time angioplasty using compliant (n = 34) or noncompliant (n = 51) balloons. At admission, patients were classified Hunt and Hess grade I to III (n = 20) and Hunt and Hess grade IV to V (n = 10). Fisher grades in patients were I (n = 1), II (n = 3), III (n = 20), and IV (n = 6). No significant differences in the rate of angiographic recurrence (32% vs 53%; P = .14), need for repeat angioplasty (21% vs 20%; P = .97), and occurrence of cerebral infarcts in the affected arterial distribution (21% vs 10% P = .39) were observed with compliant and noncompliant balloons, respectively. Independent of the balloon type, a significant reduction in the need for repeat angioplasty was observed when the initial angioplasty resulted in a normal or supranormal diameter compared with a subnormal diameter (63.5% vs 36.5%; P = .01). CONCLUSION: No clear difference was observed between compliant and noncompliant balloons for therapeutic angioplasty in preventing angiographic recurrence or the need for repeat angioplasty in patients with subarachnoid hemorrhage-related cerebral vasospasm. An immediate normal or supranormal vessel diameter after the first-time angioplasty resulted in a significant reduction in the need for repeat angioplasty.