Psychosocial responses to COVID-19 among nurses in two hospitals: a mixed method study at Eastern Nepal.

BACKGROUND: Most documented studies have focused on mental health status of health care workers during the pandemic but there are very few studies, focusing on mitigation of mental health problems among nurses. AIM: To study psychosocial responses to COVID-19 and the effectiveness of intervention among nurses. MATERIALS AND METHODS: A mixed-method study was conducted, including 278 nurses from two COVID-19 hospitals of the province by purposive sampling. Depression, anxiety and stress and a composite measure of personal financial burden scales for quantitative; and interview guide for qualitative data were used. A psychosocial strengthening session was introduced and the effectiveness of the program was assessed after 4-5 weeks of intervention. RESULTS: Mild, moderate and severe depression was found among 13.7%, 9.4% and 1.1% of the participants correspondingly. Mild, moderate, severe and extremely severe anxiety was found among 21.2%, 8.6%, 3.2% and 2.2% of the participants respectively. Stress was mild among 9% and moderate in 1.4% of the participants. Lack of PPE and fear of transmitting infection were found as frequent causes of problems. Mean scores of depression, anxiety and stress were significantly decreased after the psychosocial strengthening program. CONCLUSION: Depression, anxiety and stress are common issues of nurses. Common causes of problems were lack of resources, fear of being infected and fear of transmitting to family members. The psychosocial strengthening program was effective in reducing the problems.

Echocardiographic linear fractional shortening for quantification of right ventricular systolic function-A cardiac magnetic resonance validation study.

BACKGROUND: Echocardiography (echo)-based linear fractional shortening (FS) is widely used to assess left ventricular dysfunction (LVdys ), but has not been systematically tested for right ventricular dysfunction (RVdys ). METHODS: The population comprised LVdys patients with and without RVdys (EF<50%) on cardiac MRI (CMR): Echo included standard RV indices (fractional area change [FAC], TAPSE, S', and FS in parasternal long-axis (RV outflow tract [RVOT ]) and apical four-chamber views (width [RVWD ], length [RVLG ]). RESULTS: A total of 168 patients underwent echo and CMR (3±3 days); FAC (46±9 vs 28±11), TAPSE (1.9±0.4 vs 1.5±0.3), and S' (11.4±2.3 vs 10.0±2.6, all P≤.001) were lower among RVdys patients, as were FS indices (RVOT 32±8 vs 17±10 | RVWD 40±11 vs 22±12 | RVLG 16±5 vs 9±4%; all P<.001). FS indices yielded similar magnitude of correlation with CMR RVEF (r=.73-.56) as did FAC (r=.70), which was slightly higher than TAPSE (r=.47) and S' (r=.31; all P<.001). FS indices decreased stepwise vs CMR RVEF tertiles, as did FAC (all P<.001). In multivariate analysis, FS in RVOT (regression coefficient .51 [CI 0.37-0.65]), RVWD (0.30 [0.19-0.41]), and RVLG (0.45 [0.20-0.71]; all P≤.001) was independently associated with CMR RVEF. FS indices yielded good overall diagnostic performance (AUC: RVOT 0.89 [CI 0.82-0.97] | RVWD 0.87 [0.78-0.96] | RVLG 0.80 [0.70-0.90]; all P<.001) for CMR-defined RVdy (RVEF<50%). CONCLUSIONS: RV linear FS provides RV functional indices that parallel CMR RVEF. Parasternal long-axis RVOT width, four-chamber RV width, and length are independently associated with RVEF, supporting use of multiple FS indices for RV functional assessment.

Iron deficiency thrombocytopenia: a case report.

OBJECTIVE: To describe a rare case of thrombocytopenia secondary to iron deficiency. CLINICAL PRESENTATION AND INTERVENTION: A 34-year-old woman presented with severe microcytic hypochromic anemia and thrombocytopenia. Her ferritin was 1 ng/dl. A diagnosis of iron deficiency anemia and thrombocytopenia was made and the patient was treated with packed red blood cell transfusion and intravenous iron. Thrombocytopenia rapidly improved to normal. CONCLUSION: This case showed that iron deficiency should be considered as a cause of thrombocytopenia in the appropriate setting after ruling out common causes.

Comparision of Quality of Life of Senior Citizens Residing in Old Age Homes and Own Residence.

BACKGROUND: Quality of life of elderly is becoming even more relevant with demographic shift happening towards an ageing society. With fast changing family condition and social contexts, lives of elderly people in Nepal have been changing dramatically. Old age homes have sprung up to cater to the needs of the elderly from different socio-economic backgrounds. The objective of this study is to compare the quality of life of senior citizens of selected old age homes and own residence and to find the association of quality of life with selected study variables. METHODS: A comparative study was conducted among 120 senior citizens from Dhankuta, Morang and Sunsari districts of Koshi zone. Two strata were formed based on their residence, i.e., old age homes and own residence. Equal proportion of the samples were selected from both the settings. Data was collected using interview schedule through pretested semi-structured and standard World Helth Organization, quality of life - old questionnaires. RESULTS: More than one fifth (23.33%) of research participants were from the age group 65-69 and 75-79 and more than half (55%) of them were female. More than half (58.33%) of the research participants residing in their own residence had high quality of life level, while among those residing in the old age homes, only about 40% had high quality of life level. Quality of life level was found to be significantly associated with sex and educational status of the research participants. CONCLUSIONS: Quality of life was found to be better among the people residing in their own residence as compared to those residing in old age homes.

Enhancer Reprogramming Confers Dependence on Glycolysis and IGF Signaling in KMT2D Mutant Melanoma.

Histone methyltransferase KMT2D harbors frequent loss-of-function somatic point mutations in several tumor types, including melanoma. Here, we identify KMT2D as a potent tumor suppressor in melanoma through an in vivo epigenome-focused pooled RNAi screen and confirm the finding by using a genetically engineered mouse model (GEMM) based on conditional and melanocyte-specific deletion of KMT2D. KMT2D-deficient tumors show substantial reprogramming of key metabolic pathways, including glycolysis. KMT2D deficiency aberrantly upregulates glycolysis enzymes, intermediate metabolites, and glucose consumption rates. Mechanistically, KMT2D loss causes genome-wide reduction of H3K4me1-marked active enhancer chromatin states. Enhancer loss and subsequent repression of IGFBP5 activates IGF1R-AKT to increase glycolysis in KMT2D-deficient cells. Pharmacological inhibition of glycolysis and insulin growth factor (IGF) signaling reduce proliferation and tumorigenesis preferentially in KMT2D-deficient cells. We conclude that KMT2D loss promotes tumorigenesis by facilitating an increased use of the glycolysis pathway for enhanced biomass needs via enhancer reprogramming, thus presenting an opportunity for therapeutic intervention through glycolysis or IGF pathway inhibitors.

Functional Mitral Regurgitation in Heart Failure.

Functional mitral regurgitation (FMR) in the setting of left ventricular (LV) dysfunction and heart failure portends a poor prognosis. Guideline-directed medical therapy remains the cornerstone of initial treatment, with emphasis placed on treatment of the underlying LV dysfunction, as FMR is a secondary phenomenon and a disease due to LV remodeling. Surgical correction of FMR is controversial because it typically does not address the underlying mechanism and etiology of the condition. However, new, minimally invasive transcatheter therapies, in particular the MitraClip system, have shown promise in the treatment of FMR in selected patients. This review will summarize the pathophysiology underlying FMR, the prognosis of patients with heart failure and FMR, and the various medical and procedural treatment options currently available and under investigation.

Availability of Life Support Equipment and its Utilization by Ambulance Drivers.

BACKGROUND: An effective ambulance is a vital requirement for providing an emergency medical service. Well-equipped ambulances with trained paramedics can save many lives during the golden hours of trauma care. The objective was to document the availability and utilization of basic life support equipment in the ambulances and to assess knowledge on first aid among the drivers. METHODS: Descriptive design was used. Total of 109 ambulances linked to B.P. Koirala Institute of Health Sciences were enrolled using purposive sampling method. Self- constructed observation checklist and semi structured interview schedule was used for data collection. RESULTS: More than half of the respondents had less than five years of experience and were not trained in first aid. About two-third of the respondents had adequate knowledge on first aid. About 90% of the ambulance had oxygen cylinder and adult oxygen mask which was 'usually' used equipment. More than half of ambulance had equipment less than 23% as compared to that of national guidelines. There was significant association of knowledge with the experience (p = 0.004) and training (p = 0.001). Availability of equipment was associated with training received (p = 0.007),organization (p= 0.032)and district (p = 0.023) in which the ambulance is registered. CONCLUSIONS: The study concludes that maximum ambulance linked to BPKIHS, Nepal did not have even one fourth of the equipment for basic life support. Equipment usually used was oxygen cylinder and oxygen mask. Majority of driver had adequate knowledge on first aid and it was associated with training and experience.

Multimodality Imaging of the Right Ventricle.

OPINION STATEMENT: Right ventricular (RV) structure and function is clinically important in a wide range of conditions. While conventional echocardiography (echo) methods are widely used, its limitations in RV assessment due its complex geometry are well recognized. New applications of traditional echo methods as well as emerging echo techniques including 3-dimensional (3D) echo and speckle tracking strain have the potential to overcome limitations of conventional echo, though widespread clinical use remains to be seen. Volumetric methods using cardiac magnetic resonance (CMR) and computed tomography (CT) provide accurate assessment of RV function without geometric assumptions. In addition, tissue characterization imaging for myocardial scar and fat using CMR and CT provides important information regarding the RV beyond structure and function alone and has clinical applications for diagnosis and prognosis in a broad range of pathologies. Limitations also exist for these two advanced modalities including availability and patient suitability for CMR and need for contrast and radiation exposure for CT. The complementary role of each modality for the RV as well as emerging evidence for the use of each imaging method in diagnosis and management of RV pathologies is outlined in this study.

Fractional flow reserve to guide surgical coronary revascularization.

Coronary angiography has traditionally been used as the final diagnostic tool in the evaluation of coronary artery disease (CAD). However, conventional angiography identifies anatomically obstructive coronary disease, but it is limited in its ability to identify hemodynamically significant lesions. The emergence of fractional flow reserve (FFR) technology, in conjunction with angiography, offers a functional, as well as anatomic, assessment of epicardial coronary obstructions. Several pivotal studies have demonstrated that FFR-guided coronary revascularization is a safe and effective in patients with single and multivessel CAD. There are emerging data to suggest that FFR may also play an integral role in planning surgical revascularization and in the evaluation of post-coronary artery bypass patients and their graft patency. This review will explore the physiologic underpinnings of FFR methodology, its clinical value and limitations, and its applications in coronary artery bypass grafting (CABG) surgery.

Practical Considerations of Fractional Flow Reserve Utilization to Guide Revascularization.

OPINION STATEMENT: Invasive angiography has long been the gold standard for the diagnosis of obstructive coronary artery disease (CAD). However, the relationship between angiographic measures of stenosis and coronary blood flow is complex, and there is frequent discordance between the visual assessment of a stenotic lesion and its effect on myocardial perfusion. Fractional flow reserve is a rapidly emerging invasive means of assessing the physiologic significance of an epicardial stenosis. This review provides a pragmatic understanding of the physiologic principles that guide fractional flow reserve (FFR), sheds light on its nuances, and explores the most landmark investigations. We will also discuss how the measurement of FFR can be helpful or limiting in several common clinical situations.

Comparison of Recent Trends in Patients With and Without Major Depression and Acute ST-Elevation Myocardial Infarction.

Depression has been associated with adverse outcomes after acute coronary syndrome, including ST-elevation myocardial infarction (STEMI). However, trends over time in the incidence and inhospital treatment of STEMI for patients with co-morbid depression in the current era are unknown. We conducted a serial, cross-sectional analysis of patients with STEMI (weighted n = 3,057,998) in the National Inpatient Sample from 2003 to 2012. We examined trends in STEMI incidence and percutaneous coronary intervention (PCI) for patients with and without depression. We used multivariate logistic regression to assess observed differences and to explore trends in inhospital mortality. Depression was present in 153,180 (5%) of the sample. Patients with depression were more likely to be female (55% vs 37%), of white race (86% vs 78%), and had lower crude mortality (12.0% vs 14.2%; p <0.001 for all). Over time, STEMI incidence decreased 52% in patients without depression (p for trend <0.001) but remained stable in those with depression (p for trend 0.74). Although the use of PCI increased in all subgroups over the study duration (p for trend <0.001), depression was associated with lower adjusted odds of PCI (odds ratio 0.90, 95% confidence interval 0.89 to 0.92, p <0.001). In conclusion, in contrast to the wider population, the incidence of STEMI is not decreasing in patients with co-morbid depression. Patients with STEMI and co-morbid depression are less likely to receive revascularization therapy with PCI. These concerning differences warrant further attention.

Gender Differences in In-Hospital Outcomes After Coronary Artery Bypass Grafting.

Women historically have a greater risk of operative mortality than men after coronary artery bypass grafting (CABG). There is paucity of contemporary data in gender outcomes of surgical revascularization and understanding modifiable factors that contribute to gender differences are critical for quality improvement and practice change. We, therefore, sought to examine whether the gender gap in CABG outcomes is closing in the contemporary era by conducting a retrospective analysis from the Nationwide Inpatient Sample database from 2003 to 2012. We included all patients who underwent isolated CABG surgery (n = 2,272,998; female n = 623,423 [27.4%]; male n = 1,649,575 [72.6%]). The annual rate of CABG surgeries decreased by 53.7% in men and 57.8% in women over the 10-year study period. Although internal mammary artery use in women was less frequent than in men in 2003 (77.4% vs 81.9%, p <0.001), a significant uptrend closed this gap by 2012 (86.2% vs 87.0%, ptrend 0.003). Overall, unadjusted in-hospital mortality was greater in women (3.2% vs 1.8%, p <0.001). Female gender remained an independent predictor of mortality after multivariate adjustment (odds ratio 1.40, 95% CI 1.36 to 1.43, p <0.001) across all age groups. However, in-hospital mortality decreased at a faster rate in women (3.8% to 2.7%, RR -29.1%, ptrend 0.002) than in men (2.2% to 1.6%, RR -25.7%, ptrend <0.001) from 2003 to 2012. In conclusion, CABG rates in the United States are decreasing over time, yet in-hospital mortality continues to improve. Women have worse in-hospital outcomes than men; however, the gender gap is slowly closing.

Right Ventricular Dysfunction Impairs Effort Tolerance Independent of Left Ventricular Function Among Patients Undergoing Exercise Stress Myocardial Perfusion Imaging.

BACKGROUND: Right ventricular (RV) and left ventricular (LV) function are closely linked due to a variety of factors, including common coronary blood supply. Altered LV perfusion holds the potential to affect the RV, but links between LV ischemia and RV performance, and independent impact of RV dysfunction on effort tolerance, are unknown. METHODS AND RESULTS: The population comprised 2051 patients who underwent exercise stress myocardial perfusion imaging and echo (5.5±7.9 days), among whom 6% had echo-evidenced RV dysfunction. Global summed stress scores were ≈3-fold higher among patients with RV dysfunction, attributable to increments in inducible and fixed LV perfusion defects (all P≤0.001). Regional inferior and lateral wall ischemia was greater among patients with RV dysfunction (both P<0.01), without difference in corresponding anterior defects (P=0.13). In multivariable analysis, inducible inferior and lateral wall perfusion defects increased the likelihood of RV dysfunction (both P<0.05) independent of LV function, fixed perfusion defects, and pulmonary artery pressure. Patients with RV dysfunction demonstrated lesser effort tolerance whether measured by exercise duration (6.7±2.8 versus 7.9±2.9 minutes; P<0.001) or peak treadmill stage (2.6±0.9 versus 3.1±1.0; P<0.001), paralleling results among patients with LV dysfunction (7.0±2.9 versus 8.0±2.9; P<0.001|2.7±1.0 versus 3.1±1.0; P<0.001 respectively). Exercise time decreased stepwise in relation to both RV and LV dysfunction (P<0.001) and was associated with each parameter independent of age or medication regimen. CONCLUSIONS: Among patients with known or suspected coronary artery disease, regional LV ischemia involving the inferior and lateral walls confers increased likelihood of RV dysfunction. RV dysfunction impairs exercise tolerance independent of LV dysfunction.

Alloimmune induction of endothelial cell-derived interferon-gamma-inducible chemokines.

BACKGROUND: The interaction between host lymphocytes and endothelial cells on the transplanted organ is believed to play an important role in acute and chronic graft rejection. Trafficking and recruitment of lymphocytes to the site of inflammation is known to be controlled by several cytokines and chemokines. It is unclear whether endothelial cells themselves can be a source of inflammatory chemoattractant molecules on alloimmune induction. METHODS: Using a semiquantitative polymerase chain reaction method, the authors analyzed the expression of chemokine mRNA coding for interferon (IFN)-gamma-induced protein 10 (IP-10) and monokine induced by IFN-gamma (Mig) in a pool of human aortic endothelial cells. Both of these chemokines are known to be induced by IFN-gamma. Endothelial cell-derived chemokine mRNA was assayed at rest, after IFN-gamma activation, and after co-culture with allogeneic peripheral blood mononuclear cells (PBMC) from normal blood donors with and without a monoclonal antibody to IFN-gamma. Finally, protein release into the media was assayed using an enzyme-linked immunosorbent assay to IP-10. RESULTS: Mig and IP-10 were expressed in human endothelial cells both after IFN-gamma treatment and after PBMC co-culture. Furthermore, the expression of both of these endothelial cell-derived chemokines was dependent on IFN-gamma because PBMC-induced expression was blocked with anti-IFN-gamma. IP-10 levels in the endothelial cell supernatant increased from a baseline of 13.4+/-10.8 pg/mL to 299.5+/-13.4 pg/mL (P<0.0001) with exposure to PBMC and was likewise inhibited by anti-IFN-gamma A-b (33.8+/-17.8 pg/mL). CONCLUSIONS: Vascular endothelial cells are capable of producing inflammatory chemokines when activated and potentially serve to amplify the allogeneic response.