Preoperative systemic inflammation and perioperative myocardial injury: prospective observational multicentre cohort study of patients undergoing non-cardiac surgery.

BACKGROUND: Systemic inflammation is pivotal in the pathogenesis of cardiovascular disease. As inflammation can directly cause cardiomyocyte injury, we hypothesised that established systemic inflammation, as reflected by elevated preoperative neutrophil-lymphocyte ratio (NLR) >4, predisposes patients to perioperative myocardial injury. METHODS: We prospectively recruited 1652 patients aged ≥45 yr who underwent non-cardiac surgery in two UK centres. Serum high sensitivity troponin T (hsTnT) concentrations were measured on the first three postoperative days. Clinicians and investigators were blinded to the troponin results. The primary outcome was perioperative myocardial injury, defined as hsTnT≥14 ng L-1 within 3 days after surgery. We assessed whether myocardial injury was associated with preoperative NLR>4, activated reactive oxygen species (ROS) generation in circulating monocytes, or both. Multivariable logistic regression analysis explored associations between age, sex, NLR, Revised Cardiac Risk Index, individual leukocyte subsets, and myocardial injury. Flow cytometric quantification of ROS was done in 21 patients. Data are presented as n (%) or odds ratio (OR) with 95% confidence intervals. RESULTS: Preoperative NLR>4 was present in 239/1652 (14.5%) patients. Myocardial injury occurred in 405/1652 (24.5%) patients and was more common in patients with preoperative NLR>4 [OR: 2.56 (1.92-3.41); P<0.0001]. Myocardial injury was independently associated with lower absolute preoperative lymphocyte count [OR 1.80 (1.50-2.17); P<0.0001] and higher absolute preoperative monocyte count [OR 1.93 (1.12-3.30); P=0.017]. Monocyte ROS generation correlated with NLR (r=0.47; P=0.03). CONCLUSIONS: Preoperative NLR>4 is associated with perioperative myocardial injury, independent of conventional risk factors. Systemic inflammation may contribute to the development of perioperative myocardial injury. CLINICAL TRIAL REGISTRATION: NCT01842568.

Association between preoperative pulse pressure and perioperative myocardial injury: an international observational cohort study of patients undergoing non-cardiac surgery.

BACKGROUND: The management of elevated blood pressure before non-cardiac surgery remains controversial. Pulse pressure is a stronger predictor of cardiovascular morbidity in the general population than systolic blood pressure alone. We hypothesized that preoperative pulse pressure was associated with perioperative myocardial injury. METHODS: This is a secondary analysis of the Vascular Events in Non-cardiac Surgery Patients Cohort Evaluation (VISION) international cohort study. Participants were aged ≥45 yr and undergoing non-cardiac surgery at 12 hospitals in eight countries. The primary outcome was myocardial injury, defined using serum troponin concentration, within 30 days after surgery. The sample was stratified into quintiles by preoperative pulse pressure. Multivariable logistic regression analysis explored associations between pulse pressure and myocardial injury. We accounted for potential confounding by systolic blood pressure and other co-morbidities known to be associated with postoperative cardiovascular complications. RESULTS: One thousand one hundred and ninety-one of 15 057 (7.9%) patients sustained myocardial injury, which was more frequent amongst patients in the highest two preoperative pulse pressure quintiles {63-75 mm Hg, risk ratio (RR) 1.14 [95% confidence interval (CI): 1.01-1.28], P =0.03; >75 mm Hg, RR 1.15 [95% CI: 1.03-1.29], P =0.02}. After adjustment for systolic blood pressure, preoperative pulse pressure remained the dominant predictor of myocardial injury (63-75 mm Hg, RR 1.20 [95% CI: 1.05-1.37], P <0.01; >75 mm Hg, RR 1.25 [95% CI: 1.06-1.48], P <0.01). Systolic blood pressure >160 mm Hg was not associated with myocardial injury in the absence of pulse pressure >62 mm Hg (RR 0.67 [95% CI: 0.30-1.44], P =0.31). CONCLUSIONS: Preoperative pulse pressure >62 mm Hg was associated with myocardial injury, independent of systolic blood pressure. Elevated pulse pressure may be a useful clinical sign to guide strategies to reduce perioperative myocardial injury.

Preoperative heart rate and myocardial injury after non-cardiac surgery: results of a predefined secondary analysis of the VISION study.

BACKGROUND: Increased baseline heart rate is associated with cardiovascular risk and all-cause mortality in the general population. We hypothesized that elevated preoperative heart rate increases the risk of myocardial injury after non-cardiac surgery (MINS). METHODS: We performed a secondary analysis of a prospective international cohort study of patients aged ≥45 yr undergoing non-cardiac surgery. Preoperative heart rate was defined as the last measurement before induction of anaesthesia. The sample was divided into deciles by heart rate. Multivariable logistic regression models were used to determine relationships between preoperative heart rate and MINS (determined by serum troponin concentration), myocardial infarction (MI), and death within 30 days of surgery. Separate models were used to test the relationship between these outcomes and predefined binary heart rate thresholds. RESULTS: Patients with missing outcomes or heart rate data were excluded from respective analyses. Of 15 087 patients, 1197 (7.9%) sustained MINS, 454 of 16 007 patients (2.8%) sustained MI, and 315 of 16 037 patients (2.0%) died. The highest heart rate decile (>96 beats min(-1)) was independently associated with MINS {odds ratio (OR) 1.48 [1.23-1.77]; P<0.01}, MI (OR 1.71 [1.34-2.18]; P<0.01), and mortality (OR 3.16 [2.45-4.07]; P<0.01). The lowest decile (<60 beats min(-1)) was independently associated with reduced mortality (OR 0.50 [0.29-0.88]; P=0.02), but not MINS or MI. The predefined binary thresholds were also associated with MINS, but more weakly than the highest heart rate decile. CONCLUSIONS: Preoperative heart rate >96 beats min(-1) is associated with MINS, MI, and mortality after non-cardiac surgery. This association persists after accounting for potential confounding factors. CLINICAL TRIAL REGISTRATION: NCT00512109.

2022 TB programme review in Pakistan: strengthening governance, with better patient diagnosis and treatment.

BACKGROUND: In Pakistan, 84% of healthcare is provided by the private sector. We conducted an epidemiological and programme review for TB to document progress and guide further efforts. METHODS: Surveillance and data systems were assessed before analysing epidemiological data. We reviewed the programme at federal, provincial and peripheral levels and compiled national data along with WHO estimates to describe the evolution of epidemiological and programme indicators. RESULTS: In 2021, of the estimated number of TB cases, 55% of overall cases and 18% of drug-resistant cases were diagnosed and treated respectively. The contribution of the private sector in case detection increased from 30% in 2017 to 40% by 2021. For newly diagnosed pulmonary TB cases, the overall proportion of confirmed cases was 52%. In 2021, testing for rifampicin resistance among confirmed cases was 66% for new and 84% for previously treated patients. The treatment success rate exceeded 90% for drug susceptible TB. The main challenges identified were a funding gap (60% in 2021-2023), fragmented electronic systems for data collection and suboptimal coordination among provinces. CONCLUSIONS: The main challenges prevent further progress in controlling TB. By addressing these, Pakistan could improve coverage of interventions, including diagnosis and treatment. Bacteriological confirmation using recommended diagnostics also requires further optimisation.

CONTEXTE: Au Pakistan, le secteur privé assure 84% des services de santé. Une étude épidémiologique et programmatique a été réalisée sur la TB afin de recueillir des informations sur les avancées réalisées et de guider les actions à venir. MÉTHODES: Les systèmes de surveillance et de données ont été évalués préalablement à l'analyse des données épidémiologiques. Nous avons examiné le programme aux niveaux fédéral, provincial et local et compilé les données nationales ainsi que les estimations de l'OMS afin de décrire l'évolution des indicateurs épidémiologiques et du programme. RÉSULTATS: En 2021, environ 55% de l'ensemble cas de TB et 18% des cas résistants aux médicaments ont été diagnostiqués et traités respectivement. La contribution du secteur privé dans la détection des cas est passée de 30% en 2017 à 40% en 2021. La proportion totale de cas confirmés pour les nouveaux diagnostics de TB pulmonaire s'élevait à 52%. En 2021, les tests de résistance à la rifampicine parmi les cas confirmés s'élevaient à 66% pour les nouveaux patients et de 84% pour les patients déjà traités. Le taux de réussite du traitement a dépassé 90% pour la TB sensible aux médicaments. Les défis majeurs comprennent un manque de financement (60% pour la période 2021­2023), des systèmes électroniques de collecte de données fragmentés et une coordination insuffisante entre les provinces. CONCLUSIONS: Les défis majeurs entravent les avancées dans la lutte contre la TB. En les mettant en évidence, le Pakistan pourrait améliorer la portée des interventions, y compris le diagnostic et le traitement. Il est également essentiel d'optimiser la confirmation bactériologique en utilisant les diagnostics recommandés.

Day case Laparoscopic Cholecystectomy: experience at the Bangabandhu Sheikh Mujib Medical University.

Day case surgery offers convenience to the patients and cost saving to the healthcare institutes. In this prospective study, the authors reviewed their experience with day case Laparoscopic Cholecystectomy (LC) to determine its outcome in the government healthcare settings of Bangladesh. Selection criteria's for the day case LC were patients with symptomatic cholelithiasis with ASA (American Society of anesthesiologists) grade I or II, the availability of a responsible carer, absence of morbid obesity, low risk for concomitant presence of bile duct stones and domicile within Dhaka and around. Patients were admitted in the post operative ward as day case (DC) in the morning and were discharged on the next morning with a standard analgesia. Two hundred ten patients were admitted for LC as day cases over the last 7 years from October 2003 to October 2010 on the morning operation theatre lists. Five patients later required admission to the inpatient department for conversion to the open procedure. None of the patients was readmitted after discharge. Majority patients were followed up after 1st and 6th week. Two hundred seven patients attended for the follow up at the 1st week and 158 patients were reported for the 6th week. One hundred ninety six patients resumed their normal job or activities after one week. Patient's satisfaction was assessed by questionnaires. Two hundred five patients were either satisfied or very satisfied with the day-case procedure. It appears that for selected groups of patients, day-case LC can be safely done in government healthcare settings of Bangladesh with good patient satisfaction.

Community- vs. hospital-based management of multidrug-resistant TB in Pakistan.

BACKGROUND Multidrug-resistant TB (MDR-TB) treatment takes 18-24 months and is complex, costly and isolating. We provide trial evidence on the WHO Pakistan recommendation for community-based care rather than hospital-based care.METHODS Two-arm, parallel-group, superiority trial was conducted in three programmatic management of drug-resistant TB hospitals in Punjab and Sindh Provinces, Pakistan. We enrolled 425 patients with MDR-TB aged >15 years through block randomisation in community-based care (1-week hospitalisation) or hospital-based care (2 months hospitalisation). Primary outcome was treatment success.RESULTS Among 425 patients with MDR-TB, 217 were allocated to community-based care and 208 to hospital-based care. Baseline characteristics were similar between the community and hospitalised arms, as well as in selected sites. Treatment success was 74.2% (161/217) under community-based care and 67.8% (141/208) under hospital-based care, giving a covariate-adjusted risk difference (community vs. hospital model) of 0.06 (95% CI -0.02 to 0.15; P = 0.144).CONCLUSIONS We found no clear evidence that community-based care was more or less effective than hospital-based care model. Given the other substantial advantages of community-based care over hospital based (e.g., more patient-friendly and accessible, with lower treatment costs), this supports the adoption of the community-based care model, as recommended by the WHO.

Endoscopic para-thyroidectomy: a new approach.

Two patients (one male and one female) underwent endoscopic para-thyroidectomy for parathyroid adenoma at the Department of Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Three ports (one mid line and two laterals) were employed, a 10 mm telescope was used for the visualization and a harmonic scalpel was used for the dissection. To the best of our knowledge, there was no report of endoscopic para-thyroidectomy from Bangladesh. Both patients were fed on the first post operative day and discharged from the 4th and 8th operative day. Both patient's parathyroid hormone (PTH) level dropped to about one fourth the level in 12 to 20 minutes after enucleation (as compared to the immediate pre operative level). Endoscopic para-thyroidectomy appears to be a technically feasible patient friendly modality of treatment for the selected cases of para-thyroid pathology in experienced hand with excellent cosmetic outcome.

Results of emergency appendectomy for appendicular mass.

Emergency appendectomy was done on 1142 patients during the period of July 1990 to January 2003 to evaluate the results. Of which 656(57.44%) were male and 496(42.56%) were female. The mean age was 22.21+/-3.93 years (04-85 years). The duration of pain before admission was 3.05+/-0.94 days (01-17 days) and 708(62%) patients presented with palpable mass; ultrasonogram revealed additional lump in 114(9.98%) patients, rest of the lump (28.02%) was detected during operation. 342(30%) patients had appendix abscess and 228(19.96%) had loculated collection. Eight patients had tuberculosis and four had carcinoma in addition. All had appendicitis except two of which one patient had carcinoid tumor and one had enteric fever perforation. Operative time ranged from 15-85 minutes (29.38+/-3.19 minutes). The average hospital stay was 4.22+/-0.82 days (03-17 days). There was no failure, faecal fistula or death. The overall wound related complication was 22.86% of which 14.62% was very minor and overall intra abdominal complication was 4.12%. Persistent wound pain was in 43(3.87%) and hypertrophied scar was found in 05 (0.45%) patients. 05(0.45%) patients needed exploration for persistent sinus one of which was tuberculosis and remaining was due to suture material. Remote complications like RTI, UTI, and DVT was found in 04(0.35%) patients. There was no death, no faecal fistula and no failure. It seems that emergency appendectomy could safely be done in appendix mass without any increased risk of mortality and morbidity.

Same admission colostomy closure: a prospective, randomised study in selected patient groups.

BACKGROUND: Despite a recent trend towards primary repair, colostomy still has an important place in the management of different colorectal pathologies. Timing of colostomy closure is a debatable issue among general surgeons. We carried out a prospective, randomised study to compare the outcome after same admission colostomy closure (SACC) and conventional delayed colostomy closure (CDCC) in patients with predominantly traumatic injury of the large bowel. METHODS: Sixty patients, the majority with traumatic colorectal pathologies, were prospectively randomised to SACC [30 patients, 23 men, mean age 27.9 +/- 9.7 (range, 18-65) years] or (CDCC) [30 patients, 24 men, mean age 28.6 +/- 10.6 (range, 18-63) years]. All colostomies were closed using an intraperitoneal closure technique. Pre-operative data and post-operative outcomes were collected and analysed. RESULTS: A total of seven patients (23.3%) with SACC developed complications compared with eight patients (26.6%) having CDCC (p = 0.83). The mean hospital stay (p < 0.01), as well as the overall cost (p < 0.001), were significantly less in the SACC group. CONCLUSIONS: Same admission colostomy closure is a safe and cost-effective technique for colostomy closure in selected groups of patients.

Hypertension and its determinants among adults in high mountain villages of the Northern Areas of Pakistan.

We studied the prevalence and determinants of hypertension among adults in mountainous rural villages in the Ghizar district Northern Areas of Pakistan, an area that recently has undergone substantial economic development. We selected a stratified random sample of 4203 adults (age > 18 years) from 16 villages in Punial Valley of Ghizar district where the number of study subjects from each village was proportionate to the size of the village. We obtained blood pressure (BP) records by taking the mean of the second and third BP measurement, using a standard mercury sphygmomanometer, and assessed risk factors for hypertension in the study subjects. The mean +/- s.d. blood pressures (mm Hg) were 125 +/- 19 systolic and 80 +/- 12 diastolic in men and 125 +/- 22 systolic and 78 +/- 14 diastolic in women. The 125 +/- 22 systolic and 78 +/- 14 diastolic in women. The mm Hg, or systolic BP > or = 140 mm Hg or currently taking antihypertensive medication) was 15%, increasing from 4% in the 18-29 year age group to 36% among persons 60 years of age or older. The age-standardised prevalence of hypertension was 14% (12.5% among men and 14% among women). There was no significant difference in prevalence of hypertension in males, and in females. Multivariate analysis revealed that age, and higher body mass index (overweight and obesity) were independently associated with higher prevalence of hypertension. People with hypertension were more likely to have a first-degree relative with physician-diagnosed hypertension (OR = 1.90, 95% CI 1.49, 2). Hypertension is a significant health problem in rural northern Pakistan. The primary health care programme in the Northern Areas of Pakistan needs to address this problem, especially identifying people at risk.

Prognostic significance of intratumoural microvessel density (IMD) in resected pancreatic and ampullary cancers to standard histopathological variables and survival.

AIM: Angiogenesis is required for tumour growth. Its evaluation, by intratumoural microvessel density (IMD), has prognostic significance in many solid tumours. There is controversy regarding its use in pancreatic cancer and little is known about its role in ampullary tumours. The aim is to study IMD as a prognostic marker in resected ductal adenocarcinomas of head of pancreas and cancers of the ampullary region. METHODS: Forty-seven patients (23 pancreatic and 24 ampullary, mean age 62.0 years) surviving a potentially curative (R0/R1) resection were analysed. Paraffin-embedded sections of these tumours were immunohistochemically stained for CD-34 and IMD was determined (magnification x200). This was correlated with histopathological data and survival using Cox's multivariate analysis. RESULTS: Mean survival for the pancreatic cancer group was 18.4 months (SE=2.7) and 81.2 months (SE=9.9) for the ampullary cancer group. In the pancreatic cancer group, IMD was found to have independent prognostic significance to survival on multivariate analysis (P=0.002, Hazard Ratio (HR) 13.60) along with microscopic resection margin involvement (P=0.003, HR 15.18). For ampullary cancers, IMD was higher in those with lymph node metastasis (P=0.02, Mann-Whitney U -test). CONCLUSION: IMD in resected pancreatic cancers correlates with survival.

Some factors causing variation in the texture of similar muscles from comparable animals.

This paper reviews recent studies on pre- and postmortem changes in muscle tissue that cause variation in quality of similar muscles from animals of equal age, similar breeding and rearing, and processed under identical conditions. These studies indicate that the nervous state of the animal and struggling at death cause an undesirably high rate of glycolysis and breakdown of high-energy phosphates immediately before or after death in some animals. This results in a low pH at death or shortly after death and a rapid onset of rigor when the temperature of the carcass is still high. These conditions cause denaturation of sarcoplasmic and myofibrillar proteins and excessive shortening-and consequently toughness and loss of water-holding capacity. The extent of these changes varies widely between similar muscles from comparable animals which leads to concomitant variations in tenderness and juiciness of the meat. Another causal factor in this variation is the lack of activation of an intrinsic enzyme system which dissociates the Z-lines and improves tenderness.

Effects of freezing, thawing and storage on some quality factors for portion-size beef cuts.

Portion-size beef cuts packaged in oxygen impermeable plastic bags were used to study the effects of rates of freezing and thawing, and storage time and temperature on drip and cooking losses, shear force, destruction of glutathione and accumulation of protein-breakdown products in meat. Portions weighing 150 g or over and frozen in an air-blast at -30°C gave lower losses of drip and lower amounts of nitrogenous constituents in drip than samples weighing less than 150 g or samples frozen in cardboard boxes in still air at -18°C. Freezing and thawing or frozen storage had no significant effect on shear force of meat frozen after ageing. During frozen storage, the destruction of glutathione and accumulation of protein-breakdown products increased, depending directly on storage temperature and time. The results show that a test based on these two biochemical changes would be suitable for assessing the quality of frozen beef.

Prevalence of chronic suppurative otitis media among the children living in two selected slums of Dhaka City.

Chronic Suppurative Otitis Media (CSOM) is one of the important health problems in our country. Serious complications may arise from it. As such the study was aimed to find out the prevalence of CSOM among the children of two-selected slum dwellers in Dhaka City. This was a descriptive type of cross-sectional study. A total of 203 samples were interviewed and examined. Altogether 7.39% of children were observed to have CSOM. Among CSOM cases, 60% had hearing impairment. Ear discharge and perforation were observed in 26.7% in right ear, 46.7% in left ear and 26.7% in both ears. Central perforation was present in 93% cases. Cholesteatoma was present in 6.7% cases. Among CSOM cases, 53.3% children were in 2-5 years age group, 80% were dependent, 53.3% cleaned ear by cotton buds, 93.3% lived in Kutcha house, 73.3% had a monthly income of TK. 1001-2000 and 46.7% belonged to families having 6 members. Out of 15 CSOM, 11 cases were seen among children of 141 illiterate mothers. Four cases of CSOM were found among children of 62 literate mothers. Among the 203 mothers, 65.52% were found aware, and 34.48% were not aware about the disease and sequel of CSOM. Here 39.9% mothers had knowledge and 60.01% had no knowledge about the treatment of CSOM. Among the CSOM cases 46.67% cases did not receive any treatment. In treatment receiving group, only 3(20%) children received it from MBBS doctor or Hospital.

Transformation of sitosterol to androsta-1, 4-diene-3, 17-dione by immobilized Mycobacterium cells.

Transformation of sitosterol to androsta-1, 4-diene-3, 17-dione was studied with Mycobacterium cells entrapped in various polymeric matrices. Of the three supports viz. alginate, carageenan, agarose and polyacrylamide, studied, the polyacrylamide immobilized cells showed optimum catalytic stability and reusability.

Outpatient pediatric surgery in a developing country.

OBJECTIVE: To access the prospects of daycare pediatric surgery in a developing country like Pakistan in view of economic advantages, parent's acceptability and utilization of hospital resources. METHODS: This prospective study was carried out in Karachi from 1st January 1994 to 31st December 1996 in three different private hospitals having optimum operating, anaesthetic and recovery facilities. Selection criteria included general fitness for surgical procedure, not requiring hospitalization, no associated congenital malformation and co-operative parents residing in Karachi. An evening before surgery, all patients were examined thoroughly and detailed instructions for pre-operative fasting and pre-medications were given to the family. Operations were carried out by same surgical team with different set of anesthetists. After surgery and recovery from anesthesia, the children were observed in a holding area adjacent to operating room till fully conscious and alert. Before leaving the hospital, the parents were briefed about post-operative care at home like feeding, ambulation and use of analgesics. A contact telephone number was also provided to the family for any difficulty or emergency. All patients were re-examined 36-48 hours post-operatively in clinic, for any problem at home and the parents were assessed for their attitude toward this modality. RESULTS: In 3-year period a total of 368 surgical procedures were carried out of whom 129 operations were done in children under 1-year of age and the youngest patient was one week old with a weight of 2.9 kg. The average age was 2.9 years and average weight was 13 kg. Male:female ratio was 3.6:1. The average operating time was 28 min, average anaesthesia time was 38 min and average recovery time was 17 min, which was not affected by the use of endotracheal tube. Majority of parents managed their children very well at home and only 17% of them called one of the surgeons to inquire about their apprehension at home and all were explained and satisfied. On an average 37% children required two doses of post-operative oral analgesia and 59% returned to normal activity after 24 hours. The overall incidence of complication was 3.6% and there were no deaths or major complications. Only one patient required post surgical hospitalization due to post-operative pneumonia. The mode of management was cost effective and also the parents appreciated the avoidance of hospitalization because of less disruption of their routine work at home and office. CONCLUSION: Based on the above experience, we recommended that a variety of common pediatric operations can be done safely as out patients in infants and children, with economic advantages, high parent's acceptability and better utilization of hospital resources without scarifying the quality of health services.

Radio-decontamination efficacy and safety studies on optimized decontamination lotion formulation.

Objective of the present study was to optimize decontamination lotion and to evaluate its relative decontamination efficacy using three radio-isotopes (Technetium-99m, Iodine-131 and Thallium-201) as contaminants with varying length of contaminant exposure (0-1h). Experiments were performed on Sprague Dawley rat's intact skin and human tissue equivalent models. Rat's hair was removed by using depilator after trimming with scissors. Relative decontamination efficacy of the optimized lotion was investigated and compared with water as control. Static counts were recorded before and after decontamination using single photon emission computed tomography (SPECT). Measured decontamination efficacy (DE) values were analyzed using one way ANOVA and Student's t-test (p value<0.05) and were found statistically significant. Decontamination efficacy of the lotion was observed to be 90 ± 5%, 80 ± 2% and 85 ± 2%, for the (131)I, (201)Tl and (99m)Tc radio-contaminants respectively on skin. Reduced contaminant removal was recorded for the skin which was cleaned by depilator (50-60%). Skin decontamination was found more efficacious for rat skin decontamination than the human tissue equivalent model. Decontamination efficacy of the lotion against (99m)Tc was recorded 70 ± 15% at 0-1h on the tissue equivalent model. In vitro chelation efficacy of the lotion was also established by using the instant thin layer chromatography-slica gel (ITLC-SG) and >95% of (99m)Tc was recorded. Neither erythema nor edema was scored in the primary skin irritancy test visually observed for two weeks.