Prevalence of Aortic Root Pathologies in Platypnea-Orthodeoxia Syndrome Secondary to Intra-Cardiac Shunts.

Background: Atrial septal defects can allow right to left shunting of venous blood which presents clinically as platypnea-orthodeoxia syndrome. It is believed that concomitant presence of aortic root pathologies increases the likelihood of shunting. Methods: The study included a review of 510 articles listed in PubMed of patients with platypnea-orthodeoxia syndrome. Case reports of patients with extra-cardiac etiologies of platypnea-orthodeoxia were excluded. Results: We reviewed 191 case reports, and 98 cases (51.3%) had evidence of concomitant aortic root pathology. Furthermore, of the remaining 93 case reports, 69 ones excluded any mention of the nature of the aortic root altogether, further suggesting that this is an underreported number. Conclusions: There is a high prevalence of aortic root pathologies in patients with platypnea-orthodeoxia syndrome secondary to intra-cardiac shunts. In patients with unexplained hypoxemia and incidental finding of aortic root pathology, it may be worthwhile to obtain postural oxygen saturation measurements to exclude intra-cardiac shunts as the potential cause.

Integrated computational and experimental evaluation of phenolic constituents of Apricot fruit L. for antiqourum sensing, antibiofilm, antioxidant, and 15-lox inhibitory properties.

The present study investigated the antioxidant profile together with the antibacterial potential of Apricot L. with the aim to find a functional food based anti-infective lead. Additionally the study evaluated the biofilm and QS inhibitory potential of the plant using Pseudomonas aeruginosa (ATCC 15442) and Chromo bacterium Violaceum (DSM 30191) respectively. Several fractions of the peel of Apricot were subjected to initial antimicrobial and antibiofilm screening. Among all the fractions, methanol and ethyl acetate fractions displayed significant antimicrobial activity against the strains selected with MIC values 1.25 mg/dL and 1.68 mg/dL respectively. Similarly, while evaluating antiqourum-sensing potential, methanol extract showed remarkable zone of inhibition (14mm) with Violaceum inhibition (58%) while aqueous part presented moderately good inhibition (32%) with zone of inhibition of (4mm). N-hexane fraction was least active in this regard. In case of free radicals scavenging aptitudes, Ethanolic fraction displayed the highest free radicals scavenging potential (IC50µg/mL 13.76 ± 23.61) while Aqueous and ethyl acetate part exhibited moderate to good antioxidant behaviors with IC50µg/mL of 26.74 ± 22.00 and 19.49 ± 2.91 respectively. Then the selected compounds were screened for putative binding sites and molecular docking studies followed by enzyme inhibition assays. The negative binding energies and close proximity to residues in the binding pocket of selected targets including human α- soybean lox (PDB ID 1IK3), quorum sensing regulators LasR (2UV0) were observed which indicated high affinity and tight binding capacity of compounds 1 and 5 towards the active sites of LasR 2UV0 and 15-lipoxygenase. The physicochemical characteristics and toxicity expectation were computationally accomplished. Bioactivity prediction study revealed that all of the selected Phytoconstituents displayed incredible Bioactivity score. None of the selected chemical compound was found to be toxic as discovered by toxicity studies. Compound 4 exhibited the highest inhibition of 15-lipoxygenase in vitro (69%, at 0.037 mM final concentration) and that is accompanied by compound 5 (60%) whereas in the biofilm inhibition assay, compound 1 was most active (IC50 0.05 mM), followed by compound 3 (IC50 0.07 mM). It was therefore determined that compounds 1 and 3 had the highest biofilm inhibitory activity, whereas compounds 4 and 5 were potent 15-lipoxygenase inhibitors with potentially anti-inflammatory properties. Future investigations are suggested for the characterization and formulation development.

Association Between Venous Thromboembolism Prophylaxis and the Incidence of Thromboembolism Following Orthopedic Procedures: A Cross-Sectional Study.

INTRODUCTION: Venous thromboembolism (VTE) is a significant concern following orthopedic procedures, necessitating effective prophylactic measures. The rates of VTE prophylaxis, however, vary widely between institutions and nations, falling between 13% and 70% on average. In the absence of adequate thromboprophylaxis, pulmonary embolism, which accounts for 5% to 10% of mortality in hospitalized patients, is one of the leading causes of death. This study investigates the relationship between VTE prophylaxis and thromboembolism incidence, considering patient characteristics, risk assessment completion, anticoagulant prescription, and weight-bearing status. OBJECTIVES: To evaluate the knowledge gap by examining the relationship between VTE prevention and the prevalence of thromboembolism also to examine the anticoagulant prescription trends for patients being discharged from orthopedic operations and to investigate the connection between post-procedure weight-bearing status and the development of VTE problems. METHODOLOGY: A retrospective, cross-sectional design was employed, analyzing 200 orthopedic procedure patients from January to June of 2023 performed at Rehman Medical Institute. After getting ethical approval from the institutional ethical approval board, data were collected on the basis of variables encompassing patient attributes, surgery details, VTE risk factors, prophylaxis type, and VTE complications. Data was entered and analyzed via IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States), and the data were run through various tests including descriptive statistics, cross-tabulations, and chi-square. Results were then presented in the form of a table. RESULTS: Among 200 individuals 24 individuals experienced VTE, while 176 did not. Significant gender-based VTE differences were observed (p = 0.01). Hypertension (HTN) showed a significant association (p = 0.04) with VTE. Major surgeries were correlated with higher VTE incidence (p = 0.03). Pharmacological prophylaxis reduced the occurrence of VTE (p = 0.01). Early mobilization and Ted stockings were correlated with lower VTE incidence (p = 0.04, p = 0.12). CONCLUSION: This study reveals gender-specific VTE differences, emphasizes the role of HTN, surgical nature, and prophylaxis in VTE incidence, and supports tailored prophylactic strategies. Our findings align with previous research and emphasize the significance of tailored prophylaxis strategies. By examining multiple factors, including gender, co-morbidities, surgical characteristics, and prophylactic methods, our study contributes to the evidence base that supports clinical decision-making and enhances patient safety in orthopedic surgery.

Efficacy of Platelet-Rich Plasma versus 5% Topical Monixidil for the Treatment of Androgenetic Alopecia.

OBJECTIVE: To compare the efficacy of platelet-rich plasma (PRP) versus 5% topical minoxidil for the treatment of androgenetic alopecia (AGA). STUDY DESIGN: Randomised-controlled trial. Place and Duration of the Study: Department of Dermatology, PNS Shifa Hospital, Karachi, Pakistan, from 1st November 2021 to 31st July 2022. METHODOLOGY: Seventy AGA patients aged between 18-60 years of either gender were randomly divided into two groups. Group A was given 5% topical minoxidil and Group B was given PRP. Both groups were followed up over a period of 6 months, and the final analysis was done with the help of global photography, hair pull test, and patient satisfaction score. RESULTS: At the end of 6th month, 27 patients (77%) in Group A had a negative hair pull test as compared to only 14 (40%) in Group B (p = 0.001). In Group A, 32 patients (91.4%) reported improvement in hair scalp from baseline. Whereas, in Group B, 26 patients (74.3%) reported improvement from baseline (p = 1.00). PRP was effective in 26 patients (74.5%) and 5% topical minoxidil in 15 patients (43.7%) (p = 0.007). CONCLUSION: PRP therapy can be a useful alternative to topical minoxidil in the treatment of AGA. KEY WORDS: Androgenetic alopecia, Global photography, Platelet-rich plasma, 5% Topical minoxidil, Treatment.

Implementation of World Health Organization behaviorally anchored rating scale and checklist utilization: promising results for LMICs.

Background: Operating teams can decrease the likelihood of patient risk by using the WHO Surgical Safety Checklist. To ascertain the impact of demographic factors on behaviorally anchored ratings and investigate operating room (OR) staff attitudes toward checklist administration, we set out to better understand how OR personnel use the checklist in a tertiary care hospital in Pakistan. Materials and methods: A monocentric sequential mixed-methods study employing a quantitative approach of using World Health Organization Behaviorally Anchored Rating Scale (WHOBARS) assessments of surgical cases by OR personnel and two independent observers, who were certified surgeons having extensive experience in the rating of the WHOBARS scale for more than 1 year, followed by a qualitative approach of staff interviews were carried out in a tertiary care setting. In June and July 2022, over the period of 8 weeks, an intervention (training delivery) was implemented and evaluated. The information, skills, and behavior adjustments required to apply the checklist were taught in the course using lectures, videos, small group breakouts, participant feedback, and simulations. Results: After the introduction of WHOBARS, 50.81% of respondents reported always using the checklist, with another 30.81% using it in part. Participants' years in practice, hospital size, or surgical volume did not predict checklist use. Checklist use was associated with always counting instruments (51.08%), patient identity (67.83%), difficult intubation risk (39.72%), the risk of blood loss (51.08%), prophylactic administration of an antibiotic (52.43%), and the use of pulse oximeter (46.75%). Interviewees felt that the checklist could promote teamwork and a safe culture, particularly enabling speaking up. Senior staff were of key importance in setting the appropriate tone. Conclusion: The use of a multi-disciplinary course for checklist implementation resulted in 50.81% of participants always using the checklist and an increase in counting surgical instruments. Successful checklist implementation was not predicted by the participant's length of medical service, hospital size, or surgical volume. If reproducible in other countries, widespread implementation in LMICs becomes a realistic possibility.

Sudden Cardiac Death in Athletes: Consensuses and Controversies.

Exercise is widely considered beneficial for cardiovascular health. However, on rare occasions, athletes experience sudden cardiac death without any preceding symptoms. The devastating nature of these events necessitates us to understand the underlying causes. In younger athletes (age <35), the underlying causes are usually hereditary/genetic, whereas in older athletes (age >35), coronary artery disease is prevalent. Sudden cardiac death in athletes can occur regardless of the presence of any structural abnormality in the heart. Despite divergence between guidelines, the majority of cardiology societies recommend at least taking a comprehensive history and performing physical examinations for initial screening for all athletes. This article reviews the consensuses and controversies regarding the incidence, causes, and prevention of sudden cardiac death in athletes.

The Spectrum of Heart Failure Management.

Heart failure, a complex cardiovascular condition, is a huge burden on patients, caregivers, and healthcare systems and it is prevalent worldwide. Heart failure is caused by a wide variety of underlying conditions that include both cardiac and non-cardiac pathologies. Identifying the underlying cause enables us to apply etiology-based interventions. The spectrum of heart failure management ranges from classification to transplantation. In addition to its classification and monitoring, this article reviews various management strategies, including both conventional methods and the latest innovations. These include lifestyle interventions, pharmacotherapy, device therapy, transplantation, and regenerative medicine.

Comparing Dermatoscopic Features With Slit Skin Smear and Histopathology in Diagnosis of Cutaneous Leishmaniasis.

OBJECTIVE: To evaluate dermatoscopic features of cutaneous leishmaniasis and to compare its diagnostic accuracy against slit skin smear and skin histopathology. METHODS:  This cross-sectional study was conducted at the Department of Dermatology, Pakistan Navy Station (PNS) Shifa Hospital, Karachi, Pakistan, from August 2021 to August 2022. A total of 200 lesions from 70 patients of cutaneous leishmaniasis diagnosed with slit skin smear for Leishmania-Donovan (LD) bodies and skin biopsy were included via non-probability consecutive sampling technique. Dermatoscopic evaluation was performed via a handheld dermatoscope (DELTA 20T; HEINE, Gilching, Germany) on 10x magnification. All dermatoscopic images were analyzed by two different observers who had command of dermatoscopy. Data analysis was done using Statistical Package for the Social Sciences SPSS version 27 (IBM Corp., Armonk, NY, USA). RESULTS: Common dermatoscopic findings were erythema 200 (100%), hyperkeratosis 140 (70%), crusting 50 (25%), ulceration 42 (21%), milia-like structure 58 (29%), tear drop-like structure 46 (23%), yellow tears 70 (35%), and white starburst pattern 68 (34%). Less common findings were yellow hue 28 (14%), orange areas 26 (13%) and scar seven (3.5%). Vascular structures frequently observed were linear vessels 109 (54.5%), dotted vessels 80 (40%), and hairpin vessels 61 (30.5%); less common findings were comma-shaped vessels 52 (26%), arborizing vessels 20 (10%), crown vessels nine (4.5%). Comparison of dermatoscopic features was done with slit skin smear for LD bodies (p value = 0.003 ) and histopathology (p value = 0.001). CONCLUSIONS: Dermatoscopy is a non-invasive technique that is helpful in diagnosing cutaneous leishmaniasis, saving time in making rapid diagnosis and saving the need to undergo extensive invasive investigation. Yield of dermatoscopy was comparable to slit smear for LD bodies and histopathology and was found to be effective in making rapid diagnosis with significant accuracy (p value <0.05).

Distributions of the Wigner reaction matrix for microwave networks with symplectic symmetry in the presence of absorption.

We report on experimental studies of the distribution of the reflection coefficients, and the imaginary and real parts of Wigner's reaction (K) matrix employing open microwave networks with symplectic symmetry and varying size of absorption. The results are compared to analytical predictions derived for the single-channel scattering case within the framework of random-matrix theory (RMT). Furthermore, we performed Monte Carlo simulations based on the Heidelberg approach for the scattering (S) and K matrix of open quantum-chaotic systems and the two-point correlation function of the S-matrix elements. The analytical results and the Monte Carlo simulations depend on the size of absorption. To verify them, we performed experiments with microwave networks for various absorption strengths. We show that deviations from RMT predictions observed in the spectral properties of the corresponding closed quantum graph and attributed to the presence of nonuniversal short periodic orbits does not have any visible effects on the distributions of the reflection coefficients and the K and S matrices associated with the corresponding open quantum graph.

Effectiveness of Autoinoculation in Patients with Multiple Warts Presenting at a Tertiary Care Hospital.

OBJECTIVE: To determine the effectiveness of autoinoculation in patients with multiple skin warts. STUDY DESIGN: A Quasi-experimental study. PLACE AND DURATION OF STUDY: Dermatology department of PNS Shifa Hospital, from April to October 2021. METHODOLOGY: Ninety-six patients with multiple warts were enrolled in this study after informed consent. Under strict aseptic measures and local anaesthesia, wart tissue was removed and crushed on a glass slide with the scalpel. Autoinoculation was done on flexor aspects of bilateral forearms after making a subcutaneous pocket which was then stitched. Patients were assessed at monthly intervals for 03 months and after 01 month of the last autoinoculation to see sustained response. Effectiveness was recorded according to ordinal scale; worsening of lesions/no response at <50% resolution/partial response at >50%- <100% resolution and complete response at 100% resolution. RESULTS: Complete response was observed in 88 (91.66%) of the cases, no response was observed in 2 (2.1%) cases where as 6 (6.3%) showed worsening. All patients were compliant with the follow-up. No new eruptions were observed. CONCLUSION: Autoinoculation is a minimally invasive and cost-effective procedure with excellent response to wart. It also decreases recurrence by generating viral-specific immunity. KEY WORDS: Viral warts, Autoinoculation, Multiple, Immunotherapy, Verrucous, Treatment, HPV, Resistant.

Diffuse Coronary Artery Disease - A Challenge To Revascularize And The Role Of Coronary Endarterectomy.

Coronary endarterectomy is a useful adjunct procedure in patients with diffuse coronary artery disease when isolated coronary artery bypass grafting does not permit adequate revascularization. The primary aim of this procedure is to enable ample blood flow by removing the obstructing plaque. Herein we discuss the case of a middle-aged patient who underwent coronary endarterectomy.

Comparison Of Topical 0.1% Adapalene Gel Versus Cryotherapy In Patients With Plantar Warts.

BACKGROUND: Plantar wart is a common viral infection of the plantar surface of the foot. Multiple treatment modalities are available but there is no definitive management option. The aim of this study is to compare topical adapalene gel 0.1% with cryotherapy in patients presenting with plantar warts in terms of time taken for complete clearance of the lesions. METHODS: The study was conducted at the Department of Dermatology, PNS Shifa Hospital, Karachi from 28th April to 28th October 2020. Eighty-four patients with plantar warts who fulfilled the inclusion and exclusion criteria were included in the study. Approval from the institutional ethical review committee was sought and written informed consent was taken from all the patients. Patients were divided into two groups, A (Adapalene 0.1% gel) and B (Cryotherapy) of 42 patients each. Adapalene gel was applied twice daily under occlusion at home and cryotherapy was done at the clinic after every two weeks. Patients were followed weekly from the onset of treatment and days taken for complete clearance of plantar warts were noted. Both the groups were compared for the outcome, i.e., time taken for complete clearance of lesions. RESULTS: The mean time for complete clearance of plantar warts in group A was 35.619±3.154 days and in group B, it was 50.404±3.178 days. CONCLUSIONS: Adapalene gel 0.1% used for the treatment of plantar warts helped in complete clearance of lesions faster than cryotherapy.

Airway Management of a Patient With Tracheoesophageal Fistula and Tracheal Stent.

A 69-year-old male patient, a known case of squamous cell carcinoma of the esophagus on palliative care and Do Not Attempt Resuscitation (DNAR) status, presented for urgent laparoscopic gastrostomy tube insertion under general anesthesia. The patient had developed an iatrogenic tracheoesophageal fistula (TEF) because of the tracheal stent, which was placed for tracheal stenosis. A preoperative assessment was done, and a plan of airway management via one-lung ventilation (OLV) through an endobronchial tube was devised by the anesthesia team and discussed with the surgery team. The airway was secured via asleep fiberoptic right endobronchial intubation using a microlaryngeal tube (MLT) size 6 since there was uncertainty regarding adequate patency of the airway due to the invasion by the tumor and the presence of the stent. The patient remained hemodynamically stable. After surgical incision and insufflation of CO2 in the abdominal cavity, the patient's airway pressures were increased and we were unable to deliver adequate tidal volumes. Surgery was stopped; the presence of a kink in the circuit or endotracheal tube (ETT), the possibility of laryngospasm/bronchospasm, and pneumothorax were ruled out. Fiberoptic bronchoscopy (FOB) revealed that the endobronchial tube was abutting the secondary carina. We pulled the MLT by 2 cm. The rest of the procedure was uneventful and we extubated the patient at the end of the procedure under vision using a fiber optic bronchoscope. The patient was discharged after two days of stay in the hospital. Our patient with TEF and tracheal stent posed a significant challenge for airway management. A thorough plan was drawn up and a team briefing was done. Perioperatively, the difficulty in ventilation was identified, and various other etiologies were ruled out with the successful identification and management of the problem.

The Generalized Euler Characteristics of the Graphs Split at Vertices.

We show that there is a relationship between the generalized Euler characteristic Eo(|VDo|) of the original graph that was split at vertices into two disconnected subgraphs i=1,2 and their generalized Euler characteristics Ei(|VDi|). Here, |VDo| and |VDi| denote the numbers of vertices with the Dirichlet boundary conditions in the graphs. The theoretical results are experimentally verified using microwave networks that simulate quantum graphs. We demonstrate that the evaluation of the generalized Euler characteristics Eo(|VDo|) and Ei(|VDi|) allow us to determine the number of vertices where the two subgraphs were initially connected.

Improvement in growth and yield attributes of cluster bean through optimization of sowing time and plant spacing under climate change scenario.

Cluster bean (Cyamopsis tetragonoloba L.) yield has plateaued due to reduction in rainfall and rise in temperature. Therefore, its production cycle could not get appropriate water and temperature. It becomes important to standardize the sowing time and plant spacing of cluster beans in changing climate scenarios to get higher productivity. Therefore, a field study was conducted in 2019 at the Research area of MNS-University of Agriculture, Multan, Pakistan to evaluate the effect of four sowing times (15th May, 1st June, 15th June, and 1st July) and three plant spacings (10, 12 and 15 cm) on crop growth, yield, and physiological functions of cluster bean genotype BR-2017 under split plot arrangement under randomized complete block design (RCBD) with three replications. The sowing times (15th May, 1st June, 15th June, and 1st July) were placed in the main plot, while plant spacing (10, 12 and 15 cm) was maintained in subplots. The significant effect of sowing time and plant spacing was observed on pod plant-1, pod length, grain yield, and 1000-grain weight. Results showed that 1st June sowing performed better over 15th May, 15th June, and 1st July, while plant spacing 15 cm about in all sowing times showed higher results on growth and yield parameters of cluster bean over plant spacing 10, 12, and 15 cm. The 1st June sowing time at 15 cm plant spacing showed 8.0, 22.7, and 28.5% higher grains pod-1 than 15th May, 15th June, and 1st July sowing, respectively. Maximum grain yield was observed on 1st June in all three spacings (10, 12, and 15 cm). The chord diagram indicates that the crop has received optimum environmental conditions when sown 1st June over other sowing times. In conclusion, 1st June sowing with 15 cm plant spacing could be a good option to achieve maximum productivity of cluster bean under changing climate scenario.

Comparison of the Efficacy of Tap Water Iontophoresis Versus Aluminum Chloride Hexahydrate in the Treatment of Palmoplantar Hyperhidrosis.

OBJECTIVE: To compare the efficacy of tap water iontophoresis (TWI) versus aluminum chloride (AC) hexahydrate in the treatment of palmoplantar hyperhidrosis. METHODS: The study was a randomized control trial performed at the dermatology department of Pakistan Navy Station (PNS) Shifa Hospital, Karachi from March 2022 to September 2022. A total of 70 palmoplantar hyperhidrosis patients were included in the study after getting approval from the ethical committee. Patients were divided into two groups. Group A patients were treated with TWI three times a week for four weeks. Group B patients were treated with a 20% AC topical solution applied at night to the affected areas for four weeks. The Hyperhidrosis Disease Severity Scale (HDSS) score for both groups was calculated at baseline, one, two, three, and four weeks. The final response was labeled at four weeks by comparing mean HDSS reduction in both groups. SPSS version 28 (IBM Corp., Armonk, NY) was used for data analysis. RESULTS: Mean HDSS was compared for both groups at the end of the study, which showed a significant reduction in the mean score from 3.40 ± 0.65 to 1.48 ± 0.78 in group A, as compared to a decline in scores in group B from 3.28 ± 0.67 to 2.14 ± 0.94 (p = 0.002). In group A, zero, one, two, and three points HDSS improvement was 2.9%, 25.7%, 48.6%, and 22.9%, respectively. Whereas in group B, it was 34.3%, 22.9%, 34.3%, and 8.6%, respectively (p = 0.001). CONCLUSION: As compared to AC topical solution, TWI is an effective, safe, and inexpensive management option for palmoplantar hyperhidrosis. It causes more improvement in HDSS scores and has lesser side effects.

Integrated phosphorus nutrient sources improve wheat yield and phosphorus use efficiency under sub humid conditions.

Majority of Pakistani soils are deficient in phosphorus. Phosphorus is usually applied in form of synthetic fertilizer. However integrated use of P from synthetic and organic sources can be more profitable and beneficial on sustainable basis. Field trials were conducted at research farm University of Poonch, Rawalakot, AJK, Pakistan for two consecutive years to check the comparative effects of synthetic fertilizer and organic manures applied alone and in combinations on the phosphorus use efficiency (PUE), wheat yield and yield components. Shafaq-06 cultivar of wheat was used as test cultivar. Ten treatments were included: (I) Control (P0) without application of fertilizer; (II) SSP @ 60 kg/ha (P60SSP); (III) SSP @ 90 kg/ha (P90SSP); (IV) SSP @ 120 kg/ha (P120SSP); (V) PM @60 kg/ha (P60PM); (VI) PM @90 kg/ha (P90PM); (VII) PM @120 kg/ha (P120PM); (VIII) SSP @30 kg/ha + PM @30 kg/ha (P30SSP+30PM); (IX) SSP @45 kg/ha + PM @45 kg/ha (P45SSP+45PM); (X) SSP @60 kg/ha + PM @60 kg/ha (P60SSP+60PM) which were laid out under the Randomized Complete Block Design. Significantly higher values for yield of grain (2397 kg/ha) was recorded with PM + SSP @ 60 kg P2O5 ha-1 each. Likewise, FPUE, PIR of wheat and AFPUE was quite higher with combined use of PM and SSP i.e. P60SSP+60PM treatment. Additionally, increase in PUE, wheat yield and yield components associated with combined treated plot would help to minimize the use of high cost synthetic mineral fertilizers and represents an environmentally and agronomically sound management strategy.

Incidence and Causes of Reintubation Other Than Reopening of the Chest in Post-Cardiac Surgical Patients in a Tertiary Care Hospital.

Objective To determine the incidence of endotracheal reintubation, excluding surgical reopening, in post-cardiac surgical patients in a tertiary care hospital. Material and methods A retrospective descriptive analysis of 408 patients who underwent different cardiac surgeries during this period. Post-operative extubation was performed when patients fulfilled the preset criteria for extubation, which include consciousness (awake and aware), stable vital signs, acceptable arterial blood gases, acceptable respiratory mechanics, a maximum inspiratory force greater than 20-25 cm H2O, chest tube drainage less than 100 ml per hour, normal temperature and electrolytes. The total number of patients who were reintubated within 72 hours of extubation was noted. The criteria for reintubation included altered conscious level with Glasgow Coma Score (GCS) of less than 8, respiratory failure, unstable hemodynamics, and arrhythmias such as ventricular tachycardia (VT) and fibrillation. All of the information was collected retrospectively on a specifically prepared form. Data was entered and evaluated in Statistical Package for the Social Sciences. The research was piloted in the Cardiac Intensive Care Unit (CICU) of Northwest General Hospital and Research Center, Hayatabad, Peshawar from December 2018 to March 2020. Results Out of 408 patients who had cardiac surgeries, only nine (2.2%) were reintubated after initial extubation. The average time for which patients remained on the ventilator was 8 ± 2 hours. The reasons for reintubation were recorded. Among those reintubated, eight patients (88.88%) had undergone coronary artery bypass grafting (CABG) whereas one patient (11.11%) had undergone mitral valve replacement (MVR). In three (33.33%) patients, stroke (hemiplegia in two and global brain ischemia in one) with low GCS was the primary cause of reintubation. Arrhythmias - which included VT, ventricular fibrillation (VF), and supraventricular tachyarrhythmias (SVT) - were responsible for three (33.33%) cases of reintubation. Respiratory failure - with a partial pressure of oxygen in arterial blood less than 60 mmHg, along with tachypnea - was responsible for reintubation in two (22.22%) patients. In one (11.11%) patient who had MVR, cardiac arrest was the underlying reason; the cause of arrest could not be retrieved from the retrospective data. Notably, as a common variable, five (62.5%) out of the eight reintubated CABG patients had a poor left ventricular function.  Conclusion Causes of reintubation were primarily cardiac (arrhythmias) and neurological, followed by respiratory causes in our center. Patients with poor left ventricular function and diffuse coronary artery disease appear to have a higher incidence of reintubation which can lead to extended CICU and hospital stay, elevated mortality, and higher costs.

Early Chest Re-Exploration for Excessive Bleeding in Post Cardiac Surgery Patients: Does It Matter?

Introduction Re-explorations after open-heart surgery are often required if the patient is bleeding or shows features of cardiovascular instability and does not improve with conservative measures. Our study aims to determine whether timely re-exploration of patients who are bleeding has an impact on the morbidity and mortality of the patients. Methods A retrospective analysis of 75 patients that underwent open-heart surgery and subsequently underwent chest re-exploration for excessive bleeding between March 2018 and March 2020. Patients who were reopened post-op for indications other than excessive bleeding were excluded. Results A total number of cases were 700, out of which 75 (9.3%) patients were reopened, as compared to the literature, which shows worldwide 2-11% being reopened. Post-operative drain output was 1000ml to 1500ml in 47 (62.7%) and more than 1500ml in 28 (37.3%) patients before they were reopened. In 67 (89.3%) patients, three to five units of blood were transfused, and in eight (10.7%) patients, more than five units of blood were transfused. We believe our mortality in the reopened patients was low, because of timely intervention and early re-exploration, and is probably the reason why our figures land in a higher range (2-11%) of reopened cases (9.3%). Reopening time was less than five hours in 49 (65.3%) patients and less than 10 hours in 26 (34.7%) patients in our study. We tried to minimize the loss of blood and re-explored the patients before they lose excessive blood, the average time for reopening in our study was less than 10 hours. The average intensive care unit (ICU) stay was 4.2 days (range three to six days). Wound infections were reported in one of three patients. There was no mortality in these patients. Surgical site of bleeding was identified in 54 (72%) patients and no particular site was found in 21 (28%) patients. Suggesting that it is common to have a surgical bleeder than coagulopathy induced bleeding in post-cardiac surgery patients Conclusions We believe our low mortality (0%) is due to early reopening in patients who are bleeding excessively after cardiac surgery.

Effect of Concomitant Tricuspid Annuloplasty on Early Outcomes of Mitral Valve Replacement: A Study on Rheumatic Heart Disease Patients.

Introduction Mitral valve abnormalities in rheumatic heart disease commonly lead to functional tricuspid regurgitation. Tricuspid annuloplasty (TA) is often performed in these cases along with mitral valve replacement (MVR). Our aim was to compare the perioperative morbidity and mortality among those patients that underwent mitral valve replacement with tricuspid annuloplasty versus those that underwent isolated mitral valve replacement. Methods A retrospective analysis of 158 patients that underwent mitral valve replacement, with or without tricuspid annuloplasty, secondary to rheumatic heart disease between January 2017 and August 2020. Patients who underwent additional cardiothoracic surgical procedures (aortic valve replacement and coronary artery bypass grafting) were excluded to reduce confounders. Results The study group consisted of 158 patients (mean age 41; 73 male, 85 female) that underwent MVR with TA (n=22; 13.9%) or without TA (n=136; 86.1%). Both groups had similar comorbidity frequencies and medication history. Preoperative echocardiography showed a comparable degree of pulmonary hypertension and ejection fraction between the two groups. The TA+MVR group had similar intraoperative (81.8% vs 66.9%; p=0.161) and postoperative (45.5% vs 45.6%; p=0.991) blood products usage compared to the MVR only group. Concurrent TA resulted in similar in-hospital mortality (4.5% vs 4.4%; p=0.977) as well as early postoperative complications, namely, prolonged ICU stay (13.6% vs 10.3%; p=0.639), prolonged ventilation (0 vs 2.2%; p=0.482), re-intubation (9.1% vs 2.9%; p= 0.161), and reopening for bleeding tamponade (0 vs 5.1%; p=0.276). Conclusions TA concurrently with MVR does not appear to increase in-hospital mortality or early postoperative complications.