The accuracy and diagnostic value of gram staining joint aspirates in suspected joint infections.

BACKGROUND: Septic arthritis is a debilitating condition with prolonged treatment and adverse outcomes. A gram stain is often performed from the joint aspirate sample, followed by a definitive culture. In our study, we assessed the accuracy of gram staining for suspected septic arthritis and explored factors associated with positive culture growth and false negatives in the gram stain. METHODS: We retrospectively reviewed joint aspirates performed from 2015-2021 at a major trauma centre. Aspirates not cultured for septic arthritis were excluded. Data collected included aspirate site, gram stain and culture result delay, patient demographics, orthopaedic/rheumatological history, and comorbidities. Outcomes measured were gram stain sensitivity and specificity. Factors influencing positive cultures and false negative gram stain results were analysed using logistic regression. RESULTS: Of 408 joint aspirates meeting the criteria, 37 did not undergo initial gram staining. Gram stain sensitivity was 30.4%, specificity was 97.6%. The delay from aspirate to definitive gram stain and culture results was 1.1 and 5.4 days, respectively Logistic regression identified that prosthetic joint(p = 0.007), past joint infections(p = 0.006), arthritis(p < 0.001), hypertension(p = 0.007), diabetes(p = 0.019) were positively associated with positive cultures. Past joint infections(p = 0.004) were positively associated with false negative gram stain results. Patients on antibiotics during the aspirate had a higher risk of false negative gram stain results (OR = 5.538, 95%CI, 2.802-10.948; p < 0.001). CONCLUSIONS: In conclusion, the initial gram stain has limited sensitivity and caution should be exercised when interpreting negative results. Vigilance is crucial when the highlighted comorbidities or antibiotic use are present, to assess patients with potential joint infections.

Prevalence and Impact of Poorly Controlled Modifiable Risk Factors Among Patients Who Underwent Atrial Fibrillation Ablation.

Managing atrial fibrillation (AF) risk factors (RFs) improves ablation outcomes in obese patients. However, real-world data, including nonobese patients, are limited. This study examined the modifiable RFs of consecutive patients who underwent AF ablation at a tertiary care hospital from 2012 to 2019. The prespecified RFs included body mass index (BMI) ≥30 kg/m2, >5% fluctuation in BMI, obstructive sleep apnea with continuous positive airway pressure noncompliance, uncontrolled hypertension, uncontrolled diabetes, uncontrolled hyperlipidemia, tobacco use, alcohol use higher than the standard recommendation, and a diagnosis-to-ablation time (DAT) >1.5 years. The primary outcome was a composite of arrhythmia recurrence, cardiovascular admissions, and cardiovascular death. In this study, a high prevalence of preablation modifiable RFs was observed. More than 50% of the 724 study patients had uncontrolled hyperlipidemia, a BMI ≥30 mg/m2, a fluctuating BMI >5%, or a delayed DAT. During a median follow-up of 2.6 (interquartile range 1.4 to 4.6) years, 467 patients (64.5%) met the primary outcome. Independent RFs were a fluctuation in BMI >5% (hazard ratio [HR] 1.31, p = 0.008), diabetes with A1c ≥6.5% (HR 1.50, p = 0.014), and uncontrolled hyperlipidemia (HR 1.30, p = 0.005). A total of 264 patients (36.46%) had at least 2 of these predictive RFs, which was associated with a higher incidence of the primary outcome. Delayed DAT over 1.5 years did not alter the ablation outcome. In conclusion, substantial portions of patients who underwent AF ablation have potentially modifiable RFs that were not well controlled. Fluctuating BMI, diabetes with hemoglobin A1c ≥6.5%, and uncontrolled hyperlipidemia portend an increased risk of recurrent arrhythmia, cardiovascular hospitalizations, and mortality after ablation.

Nurse-led culturally relevant smoking reduction intervention among cardiovascular and respiratory patients in Pakistan.

INTRODUCTION: Socioeconomically deprived populations are at greater risk for smoking-induced diseases and death, such as cancers, and cardiovascular and respiratory illnesses. The initiation of a nurse-led smoking cessation program in clinical practice is an effective method to enhance smoking cessation among cardiovascular and respiratory patients in Pakistan. This study aimed to evaluate the effectiveness of nurse-led smoking reduction intervention performed at out-patient clinics in Karachi, Pakistan. METHODS: A single group pre-and post-test study was conducted on eligible patients (n = 83) with a typical profile of cardiovascular and respiratory diseases in a tertiary care hospital from December 2020 to July 2021. INTERVENTION: The multi-modal nurse-led intervention consisted of two face-to-face motivational counseling (30-min) and free nicotine replacement therapy with telephonic counseling and follow-ups offered to all eligible patients for 2 months. RESULTS: The nurse-led intervention resulted in a significant decrease in daily cigarette consumption in most of the patients (75.9%) by 50% and 16.9% of the patients reported smoking abstinence (quitter) at 1-week follow-up (p < .001), verified by a CO breath test. CONCLUSION: A nurse-managed smoking reduction intervention for even a short duration (2 months) in clinics is an effective approach in enhancing smoking abstinence and reduction among cardiovascular and respiratory patients.

Association of Anemia with Parathyroid Hormone Levels and Other Factors in Patients with End-Stage Renal Disease Undergoing Hemodialysis: A Cross-Sectional, Real-World Data Study in Pakistan.

End-stage renal disease (ESRD) patients are mostly managed with maintenance hemodialysis (MHD). ESRD patients on MHD also present with many complications, such as anemia, hyperparathyroidism, and hepatitis prevalence. This study depicts the real-world scenario of anemia among MHD and end-stage renal disease patients in the Pakistani population. A retrospective, multicentric, and real-world data analytical study was conducted at 4 dialysis centers in Pakistan. The study had a sample size of n = 342 patients on maintenance hemodialysis. The data were gathered from the medical records of patients. Data analysis was performed using STATA Version 16. Statistical significance was gauged at a 0.05 level of significance. According to our results, the mean age of the patients was 45 (±15) years. Most of the patients were male (n = 234, 68.4%), whereas 58.1% of the patients were maintained on twice-weekly hemodialysis. The most commonly reported comorbidities were hypertension and diabetes mellitus. The frequency of dialysis (P < 0.01) and comorbidities (P = 0.009) had a significant association with anemia in MHD patients. The majority of the patients had hyperparathyroidism (52%) with anemia. Upon performing binary logistic regression, multivariate analysis displayed a similar odds value for having anemia in patients with every additional month in the duration of hemodialysis (OR 1.01, P = 0.001), the odds of anemic patients having a positive antihepatitis-C antibody (OR 2.22, P = 0.013), and the odds of having anemia in patients in the age category below 45 years (OR 1.93, P = 0.013). In conclusion, the study results depict that every additional month in the duration of hemodialysis, age (<45 years), and positive anti-HCV antibody status, these variables were more likely to have anemia in our study MHD patients. While in our final multivariate model, no statistically significant association was observed between hyperparathyroidism and anemia.

Perception, attitude, and preference of trainees towards workplace-based assessment in dental education at a tertiary care institute in Multan, Pakistan.

BACKGROUND: Modern medical education has flourished with an emergent interest in a variety of assessment approaches that entails direct observation of performance and provision of feedback. Workplace-based assessment (WPBA) has been embraced into specialty training in the United Kingdom (UK) within National Health Service (NHS). In Pakistan, this educational framework is incorporated to gauge the clinical proficiency of trainees at the postgraduate and undergraduate levels. The present study was done to identify how WPBA is perceived by dental field postgraduate trainees in Pakistan. OBJECTIVE: The study explored and ascertained trainees' perceptions, attitudes, and preferences considering their experiences with the systematic organization and execution of WPBA in dental educational settings. METHODS: This cross-sectional study design involved the clinical trainees of various cadres in a tertiary care hospital in Multan. A structured and validated questionnaire previously used for another analysis was administered among 90 trainees at the institute. The results were analyzed and tabulated using SPSS-21. Influential statistics (Pearson's Chi-Square Test) was performed and the confidence interval was set at 95% (P≤0.05). RESULTS: The response rate was 88%. Opinions were more positive compared to the former surveys. The majority of the respondents (65.8%) have shown a positive attitude towards WPBA and preferred it to be a valuable assessment system as it fosters reflective practices in educational settings. In addition, it was shown that WPBA has the potential to improve clinical training (72.2%) and aid in the effective implementation of clinical practice (68.4%). As the system of digital education has been introduced ever since the pandemic, the highest percentage of participants (56%) preferred a combination of on-paper and online assessment systems. CONCLUSION: The study reported that WPBA proposes the opportunity to associate teaching, learning, and assessment. The faculty training program is a significant input to upholding the quality of WPBA. Empirical research on WPBA is essential to be carried out to overcome the inadequacies thus endorsing its application universally.

Clubfoot: an overview and the latest UK guidelines.

Clubfoot is one of the most common congenital anomalies, affecting every 1 of 1000 live births in the UK. Historically, clubfeet have been managed with a variety of conservative and operative techniques. Over the last two decades, the Ponseti serial casting method has become the gold standard of treatment. In July 2021, the British Society of Children's Orthopaedic Surgery (Gelfer et al, 2022) published a consensus statement that outlines the optimal management for clubfoot. This article provides an overview of clubfoot and a summary of the latest management guidelines.

Predictive value of interatrial block on electrocardiogram among obese patients undergoing atrial fibrillation ablation.

BACKGROUND: Determine a predictive value of interatrial block (IAB) on atrial fibrillation (AF) ablation outcomes in obese patients. METHODS: Medical records were retrospectively reviewed for 205 consecutive patients with body mass indices (BMI) ≥ 30 kg/m2 who underwent initial AF ablation. Evidence of partial IAB defined as P-wave duration (PWD) ≥ 120 ms and advanced IAB with PWD ≥ 120 ms and biphasic or negative P-wave in inferior leads was examined from sinus electrocardiograms (ECGs) within 1-year pre-ablation. The primary outcome was recurrent atrial arrhythmia after 3-month blanking period post-ablation. RESULTS: The mean BMI was 36.9 ± 5.7 kg/m2. Partial IAB and advanced IAB were observed in 155 (75.61%) and 42 (20.49%) patients, respectively. During the median follow-up of 1.35 (interquartile range 0.74, 2.74) years, 115 (56.1%) patients had recurrent atrial arrhythmias. In multivariable analysis adjusting for age, gender, persistent AF, use of antiarrhythmic drugs (AADs), left atrial volume index (LAVI), partial IAB, and advanced IAB were independent predictors of recurrent arrhythmia with hazard ratio (HR) of 2.80 (95% confidence interval [CI] 1.47-6.05; p = 0.001) and HR 1.79 (95% CI 1.11-2.82; p = 0.017), respectively. The results were similar in a subgroup analysis of patients who had no severe left atrial enlargement and a subgroup analysis of patients who were not on AADs. CONCLUSIONS: IAB is highly prevalent in patients with obesity and AF. Partial IAB, defined as PWD ≥ 120 ms, and advanced IAB with evidence of biphasic P-wave in inferior leads were independently associated with increased risk of recurrent arrhythmia after AF ablation. Its predictive value is independent of other traditional risk factors, LAVI, or use of AADs.

Challenges in the diagnosis and management of immune-mediated necrotising myopathy (IMNM) in a patient on long-term statins.

Immune-mediated necrotising myopathy (IMNM) is a severe and poorly understood complication of statin use. Prompt management with immunosuppressive treatment is often needed to control the condition, which differs from the management of the more commonly recognised statin-induced myopathy. We present a case report and brief review of the literature regarding the pathogenesis, diagnosis, and management of anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) positive IMNM (HMGCR IMNM). There are no randomised clinical trials, but several smaller studies and cases suggest a triple therapy of corticosteroids, IVIG, and a corticosteroid-sparing immunosuppressant appears efficacious in patients with IMNM and proximal weakness. The mechanism of statin-induced IMNM is uncertain, and this is further complicated by the reports of HMGCR IMNM in statin-naïve patients, including children. We present a case of biopsy-confirmed HMGCR IMNM in a woman taking daily statins for treatment of hypercholesterolaemia for 4 years. She presented with symptoms consistent with a urinary tract infection (UTI), including muscle weakness. She was treated as an isolated case of UTI. One month later, she presented again with worsening weakness in her shoulders and hips. Creatine kinase was elevated, and MRI showed increased signal with STIR sequences in both thighs. Anti-HMGCR was positive and leg biopsy-confirmed necrotising changes. Stopping her statin prescription and a short course of prednisolone did not improve her muscle weakness. Adding methotrexate resulted in eventual resolution of her symptoms. IMNM should be considered as a differential in any patient taking statins presenting with muscle weakness, and this case suggests that immunosuppressant therapy in addition to cessation of statins is effective at treating IMNM. Clinical trials are needed to further investigate the efficacy of different combinations of immunosuppressants.

Cigarette smokers' perceptions of smoking cessation and associated factors in Karachi, Pakistan.

OBJECTIVES: The study explored the perceptions of adult smokers with cardiovascular and respiratory diseases regarding cigarette smoking cessation. We also explored factors that may hinder or facilitate smoking cessation process. DESIGN: Qualitative descriptive exploratory design SAMPLE: Purposive sample of 13 adult smokers with cardiovascular or respiratory diseases visiting outpatient cardiac and respiratory clinics at a private tertiary care hospital MEASUREMENTS: In-depth, face-to-face, and semi-structured interviews were conducted. The interviews were digitally recorded and transcribed verbatim followed by a six steps process of manual thematic analysis of data. RESULTS: Meaningful statements were assigned codes and grouped into categories. Categories were clustered under three themes representing individual factors, socio-cultural factors, and institutional factors. CONCLUSIONS: Smoking cessation is influenced by personal, cultural, as well as social aspects. Institutionally, there is a need to recognize that smoking is a learned behavior; hence, prohibiting public smoking will potentially contribute to non-smoking behaviors. Although the nature of misconceptions varies, this is imperative to ensure consistency in messaging, programming, and supports led by healthcare professionals.

A 37-Year-Old Woman with Hypertrophic Cardiomyopathy with a Dual-Chamber Implantable Cardioverter-Defibrillator Requiring Percutaneous Transvenous Lead Extraction and Multidisciplinary Management.

BACKGROUND Percutaneous transvenous lead extraction (TLE) of cardiac implantable electronic devices can be performed with a high success rate. However, TLE has its limitations and challenges. Recognizing the challenges at an early stage during the procedure is vital for appropriate patient management. We present a challenging case of implantable cardioverter-defibrillator (ICD) lead extraction in which we aborted TLE in favor of elective surgical extraction (SE). This potentially prevented a major catastrophic complication of vascular tear, which would have required an emergent thoracotomy. CASE REPORT A 37-year-old woman with history of hypertrophic cardiomyopathy had a primary prevention dual-chamber ICD implant in 2001 and underwent right ventricular ICD lead revision in 2009 due to lead fracture. In 2019, she was again found to have right ventricular ICD lead malfunction. TLE was attempted, but no meaningful progression could be made despite using multiple extraction tools. Therefore, TLE was aborted in favor of SE. During elective SE, significant adhesions were noted, and the innominate vein was completely avulsed during removal of the leads, requiring venous reconstruction by the vascular surgery team. After SE and vascular reconstruction, an epicardial ICD system was placed, and the patient had an uneventful postoperative recovery. CONCLUSIONS This case report highlights the limitations of TLE and the importance of recognizing them in a timely manner. In all challenging cases, conversion to elective SE should be considered to avoid potential injuries warranting emergent surgical repair.

Relatively Benign yet a Reversible Cause of Dilated Cardiomyopathy.

Arrhythmia-induced cardiomyopathy secondary to frequent ventricular premature contractions is a well-studied phenomenon; however, there is a paucity of data showing a similar association with frequent atrial premature contractions (APCs). Early recognition and successful APC ablation can reverse left ventricular dysfunction in these patients. (Level of Difficulty: Beginner.).

Addressing opioid tolerance and opioid-induced hypersensitivity: Recent developments and future therapeutic strategies.

Opioids are a commonly prescribed and efficacious medication for the treatment of chronic pain but major side effects such as addiction, respiratory depression, analgesic tolerance, and paradoxical pain hypersensitivity make them inadequate and unsafe for patients requiring long-term pain management. This review summarizes recent advances in our understanding of the outcomes of chronic opioid administration to lay the foundation for the development of novel pharmacological strategies that attenuate opioid tolerance and hypersensitivity; the two main physiological mechanisms underlying the inadequacies of current therapeutic strategies. We also explore mechanistic similarities between the development of neuropathic pain states, opioid tolerance, and hypersensitivity which may explain opioids' lack of efficacy in certain patients. The findings challenge the current direction of analgesic research in developing non-opioid alternatives and we suggest that improving opioids, rather than replacing them, will be a fruitful avenue for future research.

Two Limitations of Subcutaneous Implantable Cardioverter Defibrillator in the Same Patient Warranting Its Explant.

BACKGROUND A subcutaneous implantable cardioverter defibrillator (S-ICD) is preferred over a transvenous implantable cardioverter defibrillator (TV-ICD) in selected cases owing to a lower rate of lead-related complications such as infections and venous thrombosis. However, the S-ICD has its own limitations, including inappropriate shocks due to oversensed events, and the inability to treat ventricular tachycardia (VT) below a heart rate of 170 beats per minutes (bpm). We present a patient case which showed manifestations of both of these limitations, warranting explant of the device. CASE REPORT A 50-year-old man with a history of nonischemic cardiomyopathy and VT had a S-ICD placed at an outside facility. However, he continued to have VT despite on anti-arrhythmic drugs and required recurrent S-ICD shocks. Device interrogation showed that he was intermittently receiving appropriate shocks for slower VT (with a heart rate ranging from 150 bpm to 160 bpm) due to oversensing of T waves. However, treatment was delayed for other VT episodes owing to appropriate sensing and the patient's heart rate being below the lowest detection zone for S-ICD. Due to slower VT cycle length and frequent oversensed events, the S-ICD was ultimately replaced by a TV-ICD system. CONCLUSIONS This case report emphasizes the importance of S-ICD pre-implant vector screening and the need for paying attention to VT cycle length to prevent inappropriate device shocks and/or delayed therapies.

COVID-19: A double threat to takotsubo cardiomyopathy and spontaneous coronary artery dissection?

Coronavirus disease 2019 (COVID-19) is an ongoing pandemic that has affected millions of individuals worldwide. Prior studies suggest that COVID-19 may be associated with an increased risk for various cardiovascular disorders, such as myocardial injury, arrhythmia, acute coronary syndrome, and venous thromboembolism. Early reports of non-COVID-19 patients have described the concurrence of takotsubo cardiomyopathy (TTC) and spontaneous coronary artery dissection (SCAD). However, the interplay between COVID-19, TTC and SCAD has not been well established. We herein propose two sets of two-hit hypotheses for the development of SCAD and TTC in the context of COVID-19. The first two-hit hypothesis explains the development of SCAD, in which TTC-associated formation of vulnerable coronary substrate serves as the first hit (predisposing factor), and COVID-19-associated inflammation and vascular disruption serves as the second hit (precipitating factor). The second two-hit hypothesis is proposed to explain the development of TTC, in which SCAD-associated formation of vulnerable myocardial substrate serves as the first hit, and COVID-19-associated sympathetic overactivity serves as the second hit. Under this conceptual framework, COVID-19 poses a double threat for the development of SCAD (among patients with underlying TTC) as well as TTC (among patients with underlying SCAD), thereby forming a reciprocal causation. This hypothesis provides a rationale for the joint assessment of TTC and SCAD in COVID-19 patients with pertinent cardiovascular manifestations.

Extended Thromboprophylaxis With Betrixaban or Rivaroxaban for Acutely Ill Hospitalized Medical Patients: Meta-Analysis of Prespecified Subgroups.

BACKGROUND: Betrixaban and rivaroxaban are the direct anticoagulants approved in the United States for extended venous thromboembolism (VTE) prophylaxis among acutely ill medical patients. The efficacy and safety in specific subgroups remain unclear. METHODS: A meta-analysis of 3 randomized trials involving extended thromboprophylaxis with betrixaban or rivaroxaban versus enoxaparin for medically ill patients was performed to compare VTE (composite of asymptomatic proximal and symptomatic deep vein thrombosis, pulmonary embolism, or VTE-related death) and major bleeding in subgroups by baseline D-dimer, age, sex, and major medical illness on hospitalization. Risk difference (RD) was computed with the Mantel-Haenszel method by fitting a fixed-effect model. Heterogeneity of treatment effect across subgroups was examined using the nominal thresholds of P < 0.05 and I2 > 75%. RESULTS: Compared with enoxaparin, extended betrixaban or rivaroxaban reduced VTE (RD = -1.51% [95% CI, -2.32% to -0.69%]; P = 0.0003) without excess major bleeding (RD = 0.12% [-0.05% to 0.29%]; P = 0.16). A significant effect modification was observed in the subgroups by D-dimer (P = 0.004) and age (P = 0.04). Patients with D-dimer >2× upper limit of normal (ULN) experienced a greater VTE reduction (RD = -2.39% [-3.57% to -1.21%]; P < 0.0001) than those with ≤2×ULN (RD = -0.26% [-1.08% to 0.56%]; P = 0.53). Similarly, patients aged ≥75 years had a greater VTE reduction (RD = -2.29% [-3.49% to -1.09%]; P = 0.0002) than those aged <75 years (RD = -0.63% [-1.70% to 0.44%]; P = 0.25). Treatment effect was consistent across the remaining subgroups. CONCLUSIONS: A more favorable efficacy and comparable safety outcome associated with extended betrixaban or rivaroxaban were observed among medical inpatients with D-dimer >2×ULN or aged ≥75 years. D-dimer and advanced age may assist in decision-making on pharmacological thromboprophylaxis for hospitalized medical patients.

Motivators and Deterrents to Diet Change in Low Socio-Economic Pakistani Patients With Cardiovascular Disease.

This study explores factors that affect the people of low socioeconomic status regarding food choices after diagnosis with cardiovascular disease. Qualitative approach was used to identify the important factors associated with dietary changes as a result of their disease. Twenty-four participants were interviewed from two cardiac facilities in Karachi, the largest metropolitan city of Pakistan. Data were analyzed to identify the themes using the interpretative description approach. While most participants understood the need for dietary changes, few were able to follow recommended diets. Their food choices were primarily influenced by financial constraints as well as cultural, familial, and religious values and practices. The challenge for health care providers lies in understanding the economical, sociocultural, and religious factors that influence behavioral changes which, in turn, affect dietary choices. It is apparent that cardiovascular risk and disease outcomes for the people of low socioeconomic status are likely to escalate. Thus, it is necessary to address the sociocultural, religious, and behavioral factors affecting dietary choices. Achieving this imperative requires an intersectorial, multilevel intervention for the prevention of cardiovascular diseases in people of low socioeconomic status.