Quality improvement initiative: improving obstetric triaging practices in a rural maternal hospital in central India.

Triaging of obstetric patients by emergency care providers is paramount. It helps provide appropriate and timely management to prevent further injury and complications. Standardised trauma acuity scales have limited applicability in obstetric triage. Specific obstetric triage index tools improve maternal and neonatal outcomes but remain underused. The aim was to introduce a validity-tested obstetric triage tool to improve the percentage of correctly triaged patients (correctly colour-coded in accordance with triage index tool and attended to within the stipulated time interval mandated by the tool) from the baseline of 49% to more than 90% through a quality improvement (QI) process.A team of nurses, obstetricians and postgraduates did a root cause analysis to identify the possible reasons for incorrect triaging of obstetric patients using process flow mapping and fish bone analysis. Various change ideas were tested through sequential Plan-Do-Study-Act (PDSA) cycles to address issues identified.The interventions included introduction and application of an obstetric triage index tool, training of triage nurses and residents. We implemented these interventions in eight PDSA cycles and observed outcomes by using run charts. A set of process, output and outcome indicators were used to track if changes made were leading to improvement.Proportion of correctly triaged women increased from the baseline of 49% to more than 95% over a period of 8 months from February to September 2020, and the results have been sustained in the last PDSA cycle, and the triage system is still sustained with similar results. The median triage waiting time reduced from the baseline of 40 min to less than 10 min. There was reduction in complications attributable to improper triaging such as preterm delivery, prolonged intensive care unit stay and overall morbidity. It can be thus concluded that a QI approach improved obstetric triaging in a rural maternity hospital in India.

Atypical presentations of ectopic pregnancies in a rural tertiary care hospital-A case series.

In spite of advances in medical sciences, diagnosis of ectopic pregnancy eludes the clinician. In this case series, we describe three variants of life-threatening pregnancies. The successful management of these cases hinged on a strong index of suspicion and early detection. Heterotopic pregnancy is the occurrence of two pregnancies in different implantation sites at the same time, which is uncommon. Heterotopic pregnancy is uncommon in natural conception, despite its prevalence in assisted reproductive technologies. A strong index of suspicion and timely laparotomy was life-saving for the woman. Caesarean scar pregnancy is a form of ectopic pregnancy in which an aberrant pregnancy is implanted at the hysterotomy site of a prior caesarean procedure. Unexplained excessive bleeding at the time of medical termination of pregnancy prompted us to explore and make a timely diagnosis of caesarean scar pregnancy. Finally, tubal choriocarcinoma is a very aggressive, extremely rare trophoblastic tumour that can be either gestational or non-gestational. High serum beta HCG raised the suspicion and timely laparotomy confirmed the diagnosis. An alert clinician who takes timely decisions can avert life-threatening complications in these pregnancies.

Unexpected Thrombocytopenia in a Parturient With Evans Syndrome Complicated by COVID-19 Infection.

We report the case of a 23-year-old parturient who received epidural analgesia and was subsequently diagnosed with Evans syndrome (ES). The diagnosis was made after a complete blood count (CBC) resulted in severe anemia and a platelet count of less than 10K/µL. To further complicate this case, the patient developed post-delivery pleuritic chest pain and pulmonary emboli (PE), and a chest computed tomography (CT) scan showed bilateral ground-glass lung opacities. This prompted a COVID-19 testing and ultimately confirmed infection.

Diagnosis of Genital Tuberculosis in Infertile Women by Using the Composite Reference Standard.

Female genital tuberculosis (FGTB) can be asymptomatic or even masquerade as other gynecological conditions. Conventional methods of FGTB diagnosis include various imaging, bacteriological, molecular, and pathological techniques that are only positive in a small percentage of patients, leaving many cases with undiagnosed condition. In the absence of a perfect diagnostic method, composite reference standards (CRSs) have been advocated in this diagnostic study. This study assesses the agreement between traditional diagnostic modalities using CRS and prevalent TB groups among different fallopian tube infertility manifestations. A total of 86 women with primary and secondary infertility were included in the study and subjected to bacteriological, pathological, and radiological examination for the diagnosis of FGTB. Results were evaluated statistically for concordance of the diagnostic tests to the CRS by sensitivity and specificity, while PPV and NPV were calculated for the performance of diagnostic tests of FGTB. We observed that 11.2% of women were found to be true positives by means of CRS. The positive findings by CRS were as follows: ultrasonography (13.9%), laparoscopy (14%), hysteroscopy (12%), GeneXpert (4.8%), culture (4.8%), polymerase chain reaction (4.8%), and histopathology (6.4%). GeneXpert and culture were found to have a perfect agreement with CRS. Hysterosalpingography, laparoscopy, and hysteroscopy have a fair agreement with CRS. Out of 43 women with tubal factor infertility, 6 women were found in the definitive TB group with mixed conditions of tubal manifestations. This study evaluates and demonstrates the reliability of the collective assessment of various diagnostic methods with CRS findings that help in identifying different TB groups of genital tuberculosis patients from all infertile patients by applying the criteria of CRS.

Clinical Use of a Real-World Low Carbohydrate Diet Resulting in Reduction of Insulin Dose, Hemoglobin A1c, and Weight.

Introduction: Type 2 Diabetes Mellitus (T2DM) is increasing in epidemic proportions. In addition to the morbidity and mortality, for those treated with insulin, the physical, psychological, and financial tolls are often greater. Our real-world study evaluated a Low Carbohydrate Diet (LCD) in patients with T2DM on insulin with respect to glycemic control, insulin reduction, and weight loss. Materials and Methods: A prospective cohort study was conducted via an Electronic Medical Record search for patients attending the Virginia Commonwealth University Medical Weight Loss Program from 2014 to 2020 with Type 2 Diabetes Mellitus who initially presented on insulin. Data was extracted for 1 year after enrollment. The weight loss program focuses on a LCD. Results: Of 185 participants, the mean (± SD) age was 56.1 (9.9) years. Seventy percent were female and 63% were black. Eighty-five completed 12 months (45.9%), reduced their median (25-75% interquartile range, IQR) insulin dose from 69 to 0 units (0-18, p < 0.0001), HbA1c from 8 to 6.9% (6.2-7.8, p < 0.0001), and weight from 116 to 99 kg (85-120, p < 001). Eighty six percent who completed 12 months were able to reduce or discontinue insulin, with 70.6% completely discontinuing. Among all participants who completed 3, 6, or 12 months, 97.6% were able to reduce or eliminate insulin use. Conclusion: In patients with T2DM on a LCD, it is possible to reduce and even discontinue insulin use while facilitating weight loss and achieving glycemic control. A Low Carbohydrate Diet should be offered to all patients with diabetes, especially those using insulin.

Increasing adherence to plotting e-partograph: a quality improvement project in a rural maternity hospital in India.

Abnormal prolonged labour and its effects are important contributors to maternal and perinatal mortality and morbidity worldwide. E-partograph is a modern tool for real-time computerised recording of labour data which improves maternal and neonatal outcome. The aim was to improve the rates of e-partograph plotting in all eligible women in the labour room from existing 30% to achieve 90% in 6 months through a quality improvement (QI) process.A team of nurses, obstetricians, postgraduates and a data entry operator did a root cause analysis to identify the possible reasons for the drop in e-partograph plotting to 30%. The team used process flow mapping and fish bone analysis. Various change ideas were tested through sequential Plan-Do-Study-Act (PDSA) cycles to address the issues identified.The interventions included training labour room staff, identification of eligible women and providing an additional computer and internet facility for plotting and assigning responsibility of plotting e-partographs. We implemented these interventions in five PDSA cycles and observed outcomes by using control charts. A set of process, output and outcome indicators were used to track if the changes made were leading to improvement.The rate of e-partograph plotting increased from 30% to 93% over the study period of 6 months from August 2018 to January 2019. The result has been sustained since the last PDSA cycle. The maternal outcome included a decrease in obstructed and prolonged labour with its associated complications from 6.2% to 2.4%. The neonatal outcomes included a decrease in admissions in the neonatal intensive care unit for birth asphyxia from 8% to 3.4%. It can thus be concluded that a QI approach can help in improving adherence to e-partography plotting resulting in improved maternal health services in a rural maternity hospital in India.

Burden of congenital rubella syndrome (CRS) in India based on data from cross-sectional serosurveys, 2017 and 2019-20.

BACKGROUND: India has set a goal to eliminate measles and rubella/Congenital Rubella Syndrome (CRS) by 2023. Towards this goal, India conducted nationwide supplementary immunization activity (SIA) with measles-rubella containing vaccine (MRCV) targeting children aged between 9 months to <15 years and established a hospital-based sentinel surveillance for CRS. Reliable data about incidence of CRS is necessary to monitor progress towards the elimination goal. METHODS: We conducted serosurveys in 2019-20 among pregnant women attending antenatal clinics of 6 hospitals, which were also sentinel sites for CRS surveillance, to estimate the prevalence of IgG antibodies against rubella. We systematically sampled 1800 women attending antenatal clinics and tested their sera for IgG antibodies against rubella. We used rubella seroprevalence data from the current survey and the survey conducted in 2017 among antenatal women from another 6 CRS surveillance sites to construct a catalytic models to estimate the incidence and burden of CRS. RESULT: The seroprevalence of rubella antibodies was 82.3% (95% CI: 80.4-84.0). Rubella seropositivity did not differ by age group and educational status. Based on the constant and age-dependent force of infection models, we estimated that the annual incidence of CRS in India was 225.58 per 100,000 live births (95% CI: 217.49-232.41) and 65.47 per 100,000 live births (95% CI: 41.60-104.16) respectively. This translated to an estimated 14,520 (95% CI: 9,225-23,100) and 50,028 (95% CI: 48,234-51,543) infants with CRS every year based on age-dependent and constant force of infection models respectively. CONCLUSIONS: Our findings indicated that about one fifth of women in the reproductive age group in India were susceptible for rubella. The estimates of CRS incidence will serve as a baseline to monitor the impact of MRCV SIAs, as well progress towards the elimination goal of rubella/CRS.

Diaphyseal Fracture of the Humerus during Elective Cesarean Section - A Rare Case Report.

Introduction: Humeral fractures are the second common long bone fractures of the neonatal period after clavicle. Most cases of birth-related humerus fracture are reported during a vaginal breech delivery. The cesarean section does not eliminate the risk of long bone fractures. A humerus fracture is less common but still can happen due to forceful maneuvers like traction during cesarean which can go unnoticed to operating obstetrician or misinterpreted as brachial plexus injury by an inexperienced orthopedic surgeon. Case Report: We received a call from the neonatal intensive care unit (NICU) for a 2-day-old 2.4 kg male baby delivered to primigravida at 37 weeks by elective cesarean for transverse lie, for not moving his right upper limb. On examination by orthopedic surgeon, swelling, contusion, crepitus, and abnormal mobility at the right arm were noticed. Gentle manipulation made the neonate cry. Range of movements (ROMs) of wrist, elbow, and hand were within normal limit without any neurovascular deficit. Hence, the initial diagnosis of brachial plexus injury/Erb's palsy was revised. X-ray of the right upper limb was ordered which showed an isolated mid-shaft humerus bicortical fracture. A high above elbow slab was applied with an arms chest bandage for a week and the baby was discharged with proper advice to the mother to follow-up on the next week. Conclusion: Obstetricians and pediatricians should remain vigilant for the rare occurrence of humerus fracture during cesarean so that they are not missed and managed timely to prevent future disability and deformity.

Clinical Profile of Obstetric Patients Getting Admitted to ICU in a Tertiary Care Center Having HDU Facility: A Retrospective Analysis.

BACKGROUND: The critically ill obstetric patient represents a challenge that usually requires a multidisciplinary approach. Lack of awareness and the absence of regular antenatal care make the critically ill patients to be referred late and sometimes in moribund conditions. The objective of the present study is to determine the incidence, predictors and outcome of obstetric ICU admissions. METHODS: This retrospective study was conducted over a period of 2 year from July 2015 to June 2017 in Department of Obstetrics and Gynecology at Institute of Medical Sciences, BHU, Varanasi, India. RESULTS: Out of a total of 4986 deliveries, 756 patients underwent HDU admission, while 92 obstetric patients were admitted to ICU during this study period. Maximum number of patients (73.91%) were in the age-group of 20-35 years, 64.13% of patients constitute lower socioeconomic status group, 68.47% of patients reside in rural area and there was inadequacy in receiving antenatal care in case of 60.86% of patients. Maximum number of patients were admitted for a period of 4-7 days. Blood transfusion (64.1%), the use of inotropic drugs (45.6%), central line placement (44.5%) and mechanical ventilation (26.08%) were the major interventions performed in ICU. Obstetric hemorrhage was found to be the most frequent clinical diagnosis leading to ICU admission (31.5%) followed by hypertensive disorders (25%). CONCLUSION: In addition to timely referral, health education and training of health professionals may improve clinical outcome and better obstetric practice, especially in countries like India. Obstetric ICU dedicated for the management of only obstetric patients should be constructed in order to compensate for heavy burden critically ill women.

Effect of Orlistat Versus Metformin in Various Aspects of Polycystic Ovarian Syndrome: A Systematic Review of Randomized Control Trials.

BACKGROUND: Polycystic ovarian syndrome (PCOS), a commonly prevalent endocrinopathy among reproductive age group women, is most often associated with obesity. Increased insulin resistance appears to be the central pathophysiologic mechanism responsible for various complications of PCOS. This makes 'weight loss' as the first-line treatment approach in PCOS. So various trials have tried to compare metformin (an insulin-sensitizing agent) and orlistat (an anti-obesity drug) aiming to achieve weight loss and hence higher ovulation rate for the group of obese PCOS patients. Keeping an eye on all these background facts, we designed this systematic review and metaanalysis to compare the effects of metformin and orlistat on various aspects of PCOS and to pick the better among the two drugs. MATERIALS AND METHODS: This is a systemic review of randomized control trials that studied the effectiveness of orlistat versus metformin in terms of improvement in ovulation rate, weight loss, lipid profile, etc. Systematic literature search over the period January 2000-December 2016 was performed in the following electronic databases: Medline, embase, google scholar, pubmed and The Cochrane Library and only randomized controlled clinical trials were included in our study. All authors carefully went through all sources of information independently. RESULTS: According to this study, weight loss, testosterone level after 4 weeks of treatment, total serum cholesterol and triglyceride level showed significant fall in orlistat-treated group. CONCLUSION: Our review shows that orlistat is a more effective drug than metformin and should be the preferred drug in obese PCOS in combination with weight loss.

C-reactive protein and white blood cell count as predictors of maternal and neonatal infections in prelabour rupture of membranes between 34 and 41 weeks of gestation.

Prelabour rupture of the membranes (PLROM) is defined as rupture of membranes before the onset of labour. It is one of the most common clinical events, where pregnancy can turn into a high-risk situation for mother and foetus. As prevention of PLROM is difficult, one has to concentrate on management to reduce its complications. Accurate prediction of infection remains a main challenge in cases of PLROM. We conducted a prospective study of all women admitted for PLROM at or after 34-41 weeks of gestation to investigate the predictive value of C-reactive protein (CRP) and white blood cell (WBC) count for early-onset neonatal infection (EONI) and maternal chorioamnionitis. The analysis was done by comparing areas under ROC curves and sensitivity. Lowest best cut off of maternal serum CRP level >4.9 mg/l and lowest cut off of WBC count 12,450/cumm have good predictive values for maternal chorioamnionitis and EONI. Impact statement What is already known on this subject? The ability to detect chorioamnionitis and predict neonatal infection at an early stage would be helpful in its treatment and would make it possible to prolong the pregnancy. What do the results of this study add? Maternal serum CRP level and WBC count obtained at admission are predictors of chorioamnionitis and EONI although WBC count alone is not a good indicator of them. A lowest best cut off of serum CRP level >4.9 mg/l and lowest cut off of WBC count 12,450/cumm have good predictive values for maternal chorioamnionitis and EON. What are the implications of these findings for clinical practice and/or further research? We propose that maternal serum CRP level and WBC count should be used as screening test for EONI and chorioamnionitis rather than a diagnostic test.

Prediction of significant hyperbilirubinemia in term neonates by early non-invasive bilirubin measurement.

BACKGROUND: Neonatal jaundice is a common problem. We evaluated the utility and best cut-off values of 24-and 48-hour transcutaneous bilirubin indices (TcBI) in predicting subsequent significant hyperbilirubinemia and evaluated various associated maternal and fetal risk factors. METHODS: TcBI at 24 and 48 hours and serum bilirubin levels at 72 hours of age were obtained for healthy, term, appropriate for gestational age neonates. Neonates with prematurity, birth weight <2500 g, ABO or Rh incompatibility, onset of clinical jaundice <24 hours, clinical suspicion of septicemia, positive pressure ventilation at birth, admission in neonatal intensive care unit and contraindications for BiliChek were excluded. Twently-four and 48-hour TcB indices were assessed as predictors of subsequent hyperbilirubinemia, defined as serum bilirubin >17 mg/dL after 72 hours of life and various cut-offs, and were evaluated by calculating sensitivity, specificity and predictive values. RESULTS: Of 500 newborns, 4.6% had significant hyperbilirubinemia, 27% had TcBI (mg/dL) <5 at 24 hours, and 27.4% had TcBI <8 at 48 hours. None of them had subsequent hyperbilirubinemia (100% negative predictive value). The percentage of newborns with subsequent hyperbilirubinemia increased from 3.4% to 13.2% as their 24-hour TcBI increased from 6 to above 9 mg/dL and from 4.2% to 7.4% as their 48-hour TcBI increased from 8 to above 11 mg/dL. The best cut-off value was TcBI (mg/dL) 7 (odd ratio=4.86, 95% confidence interval: 1.66-15.22) at 24 hours and 10 (odd ratio=2.87, 95% confidence interval: 1.04-8.29) at 48 hours. Area under the receiver operating characteristic curve for 24- and 48-hour measurements was 0.750 and 0.715, respectively. Maternal premature rupture of membranes, deep transverse arrest, post-date pregnancy, and fetal distress were significant risk factors for hyperbilirubinemia. CONCLUSIONS: Twenty-four and 48-hour TcB indices are good predictors of subsequent hyperbilirubinemia. Twenty-four-hour TcBI had better predictive ability than 48-hour TcBI.

Fetomaternal outcome among women with mitral stenosis after balloon mitral valvotomy.

OBJECTIVE: To compare pregnancy outcomes among patients with non-operated mitral stenosis and those who had balloon mitral valvotomy before pregnancy. METHODS: In a study at a tertiary-care referral hospital in Kolkata, India, 48 women with mitral stenosis who delivered between July 2007 and June 2008 were separated into 2 groups according to whether they had cardiac surgery before pregnancy. Eighteen women in the test group had balloon mitral valvotomy before pregnancy, whereas 30 women in the control group had no cardiac surgery. Fetomaternal outcomes were compared between the 2 groups. RESULTS: In the control group, significantly more patients had palpitations (P=0.032) and severe dyspnea (P=0.017) than in the test group. The incidence of preterm labor in the test group (1/18) was lower than that in the control group (10/30) (P=0.035). However, the groups did not differ in mode of delivery, mean birth weight, or neonatal complications. CONCLUSION: Balloon mitral valvotomy improved maternal symptoms and should be done to prevent maternal morbidity and to reduce the incidence and complications of preterm labor.

Melatonin and its correlation with testosterone in polycystic ovarian syndrome.

CONTEXT: Polycystic ovarian syndrome (PCOS) is considered to be the most common endocrine disorder affecting women. Melatonin, a small lipophilic indoleamine, and reproductive hormones may be interrelated. Melatonin influences sex steroid production at different stages of ovarian follicular maturation as melatonin receptors have been demonstrated at multiple sites in ovary and in intrafollicular fluid. It plays role as an antioxidant and free radical scavanger which protects follicles from oxidative stress, rescuing them from atresia, leading to complete follicular maturation and ovulation. AIMS: To study the role of melatonin in PCOS and to investigate its correlation with testosterone in patients suffering from PCOS. SETTINGS AND DESIGN: A total of 50 women with PCOS (Rotterdam criteria, 2003) and 50 age and weight matched healthy controls were selected and serum melatonin estimation was done in both the groups and correlated with serum total testosterone levels. MATERIALS AND METHODS: In a case-control study, detailed history, clinical examination and hormonal evaluation [basal levels of leutinizing hormone, follicle-stimulating hormone, thyroid-stimulating hormone, prolactin, insulin, total testosterone, progesterone and melatonin] were carried out in all the participants including both cases and controls. For melatonin estimation, blood samples were collected between 12:00 am and 04:00 am on day 2(nd) of menstrual cycle and analyzed by using commercially available enzyme-linked immunosorbent assay kit. STATISTICAL ANALYSIS: Student's t-test was used to compare the significant difference in mean values between cases and control groups. Chi-square test was used to test the significant association between the qualitative variables. Linear correlation coefficient and regression analysis were done to see the amount and direction of relationship between quantitative variables. RESULTS: The mean melatonin level was observed to be significantly increased in patients (63.27 ± 10.97 pg/mL) than in controls (32.51 ± 7.55 pg/mL). Melatonin was found to be raised in all the cases of PCOS (above cut-off value of ≥45 pg/mL, P < 0.001). Total testosterone level was also raised in 72% of patients. Melatonin levels were found to be positively associated with increased testosterone (P < 0.001). In regression analysis using melatonin as dependent variable and testosterone as an independent variable, the value of R2 Χ 100 (percent variation) was found to be 72.1%. CONCLUSIONS: Women with PCOS have significantly raised serum melatonin levels and hyperandrogenemia along with increased number of atretic follicles. Further studies are required to establish a definite role of melatonin in PCOS cases with disturbed hormonal milieu. This could open up the way for therapeutic role of melatonin in treatment of patients suffering from PCOS.

MTHFR C677T polymorphism is associated with hyperlipidemia in women with polycystic ovary syndrome.

CONTEXT: Women with polycystic ovary syndrome (PCOS) are prone for coronary artery disease (CAD), and hyperhomocysteinemia is an independent risk factor for CAD. MTHFR deficiency is the most common cause of hyperhomocysteinemia, thereby provoking a possible association between PCOS and MTHFR C677T polymorphism. AIMS: The aim of this study was to investigate an association of MTHFR C677T polymorphism with PCOS. SETTINGS AND DESIGN: 92 women with PCOS (Rotterdam criteria) and 95 age-matched controls were compared with respect to MTHFR C677T polymorphism. The 2 genotypes (CC and CT) obtained were compared with clinical and laboratory parameters in women with PCOS. MATERIALS AND METHODS: In a case-control study, clinical, biochemical, hormonal and genetic analysis (PCR-RFLP of peripheral leucocytes) was carried out on all women with PCOS as well as controls. STATISTICAL ANALYSIS: Student "t" test for quantitative and Chi-square test for nominal variables was used. For estimation of risk, odds ratio and 95% confidence interval were calculated. RESULTS: The odds ratio of bearing a heterozygous genotype (CT) was 1.32 in women with PCOS as compared to controls (P = 0.48). No homozygous mutation (TT) was found in the study population. Serum cholesterol was more in heterozygous (CT) genotype (215.48 ± 25.56 mg/dl) as compared to normal (CC) genotype (203.29 ± 16.35 mg/dl) in women with PCOS (P = 0.01). Similarly, serum triglyceride was more in heterozygous (CT) genotype (95.86 ± 37.34 mg/dl) as compared to normal (CC) genotype (82.36 ± 20.88 mg/dl) in women with PCOS (P = 0.04). CONCLUSIONS: Although not statistically significant, there is a slightly higher prevalence of heterozygous (CT) genotype in women with PCOS. MTHFR C677T polymorphism when present may confer an increased susceptibility to develop hyperlipidemia in women with PCOS. More prospective studies are needed to confirm whether this hyperlipidemia due to MTHFR C677T polymorphism clinically manifests into CAD in long term in women with PCOS.

The effect of dyslipidemic drugs on mortality: A meta-analysis.

Most of the previously published meta-analyses include studies exploring the effect of statins, rather than all dyslipidemic drugs, on mortality. We explored the overall effect of all dyslipidemic drugs on coronary artery disease mortality, cardio-vascular disease mortality and all-cause mortality. A meta-analysis of all randomized controlled trials that were published before February 2006 was carried out. Data sources were published articles in bibliographic electronic databases and medical journals. The article selection criteria included all randomized placebo-controlled trials of at least one year duration and those which measured at least one of the following clinical endpoints: coronary artery disease mortality, cardio-vascular mortality or all-cause mortality. Information on sample size, follow up period, drug used, and clinical outcomes was abstracted independently by two authors. Disagreements were resolved by consensus. The meta-analysis (19 trials, 59033 patients) showed a significant relative risk reduction of coronary artery disease mortality of 23% (P<0.00001), cardiovascular disease mortality of 19% (P<0.00001) and all-cause mortality of 14% (P<0.0001), without any significant heterogeneity and inconsistency between the trials. It was concluded from this meta-analyses that dyslipidemic drugs are indeed highly effective medicines and confer benefit to patients, in terms of primary and secondary prevention of coronary artery disease.