Evaluating the use of coronary artery calcium scoring as a tool for coronary artery disease (CAD) risk stratification and its association with coronary stenosis and CAD risk factors: a single-centre, retrospective, cross-sectional study at a tertiary centre in Pakistan.

OBJECTIVE: Coronary artery disease (CAD) risk stratification plays a fundamental role in the early detection and optimal management of CAD. The aim of our study is to investigate the use of coronary artery calcium scoring (CACS) as a tool for CAD risk stratification through evaluation of its correlation with the degree of coronary stenosis and its association with conventional cardiovascular risk factors in asymptomatic patients. DESIGN: Single-centre, retrospective, cross-sectional study. SETTING: The study was conducted at a tertiary centre (Shifa International Hospital) in Islamabad, Pakistan, through review of medical records of patients who underwent coronary CT between the years 2016 and 2020. PARTICIPANTS: A total of 1014 patients were included in the study. The study population was analysed for presence of conventional risk factors (gender, age, diabetes, hypertension, body mass index, dyslipidaemia) and association with CACS (zero: n=534; minimal: 0 to ≤10, n=70; mild: >10 to ≤100, n=130; moderate: >100 to ≤400, n=118; and severe: >400, n=49). The association of CACS with the degree of coronary artery stenosis seen on CT scan (significant: ≥50% stenosis, n=216; non-significant: <50% stenosis, n=685) was also analysed. OUTCOME MEASURES: The main outcome was the association of coronary artery stenosis with CACS. The secondary outcome was the association of CACS with conventional CAD risk factors. RESULTS: A significant positive association was shown between CACS and coronary artery stenosis (zero vs minimal: OR 0.39, 95% CI 0.20 to 0.79, p=0.01; zero vs mild: OR 0.16, 95% CI 0.10 to 0.27, p<0.0001; zero vs moderate: OR 0.05, 95% CI 0.03 to 0.08, p<0.0001; zero vs severe: OR 0.02, 95% CI 0.01 to 0.050, p<0.0001). Age >45 (OR 1.03, 95% CI 1.01 to 1.05, p<0.0001), hypertension (OR 1.16, 95% CI 0.79 to 1.71, p=0.001) and diabetes (OR 1.33, 95% CI 0.88 to 1.99, p<0.0001) were associated with an increased risk of coronary artery stenosis. Moreover, plaques with higher calcium burden were found in the left anterior descending artery (mean CACS: 386.15±203.89), followed by right coronary (239.77±219.83) and left circumflex (175.56±153.54) arteries. CONCLUSION: The results indicate a strong positive association of CACS with coronary artery stenosis. CACS was also significantly associated with conventional CAD risk factors in this population.

Experiences of the physicians in the largest COVID-19 dedicated hospital of Bangladesh about COVID-19 and its aftermath

BackgroundThe doctors and the other health care workers are the first-line fighters against COVID-19. This study aims to identify the prevalence, risk factors, clinical severity of COVID-19 infection among the doctors working in the COVID unit. We also analyzed the hospital data for admission and RT-PCR positivity among the physicians. MethodsIt was a cross-sectional survey and review of the hospital database. We surveyed from September 2021 to October 2021 and explored the hospital data from march 2020 to September 2021.We included 342 physicians for analysis in the survey. We reviewed hospital data of 1578 total admitted patients and 336 RT-PCR test positive physicians for analyzing the hospital admission rate, the positivity rate for COVID-19 among the physicians and the other patients in the different COVID-19 surges. FindingsIn this study, we demonstrated the physicians sufferings during the pandemic era. We have observed four surges in the hospital admission and RT-PCR for COVID-19 positivity rate among the physicians and the general population. The physicians experienced a similar surge in the hospital admission and positivity rate to the general population. The hospital admission was lower in the fourth surge among the physicians than the general population. The positivity rate was higher in the first, second and third surge among the physicians. In the survey, a total of 146(42%) respondents had COVID-19 infection, and among them, 50(34.2%) had re-detectable positive SARS-CoV-2 infection. Most of them experienced mild (77[52.7%]) to moderate (41[28.1%]) symptoms. Increasing age (OR, 95%CI, p-value; 1.15, 1.05-1.25, 0.002), male sex (OR, 95%CI, p-value; 5.8, 3.2-9.8, <0.001), and diabetes (OR, 95%CI, p-value; 25.6, 2-327.2, 0.01) were the risk factor of having COVID-19. Female sex and diabetes were the risk factors for re-detectable positive SARS-CoV-2 infection. (OR, 95%CI, p-value; 0.24, 0.09-0.67, 0.006; 44, 8.9-218.7, <0.001 respectively). Most respondents suffered for 7-14 days. Total 98(67%) suffered from post-COVID fatigue. ConclusionsThe physicians observed four surges in hospital admission and COVID-19 positivity rate. A significant number of the COVID-warrior became positive for SARS-CoV-2, had re-detectable positive SARS-CoV-2 infection, and suffered in the post-COVID-19 state.

What have we learned about renal protection from the cardiovascular outcome trials and observational analyses with SGLT2 inhibitors?

Over the past 5 years, sodium-glucose cotransport 2 (SGLT2) inhibitors have been increasingly regarded as glycaemic agents with cardiovascular (CV) and renal protective effects. The CV benefits of SGLT2 inhibitors have been well established in patients with type 2 diabetes (T2D) and a range of CV comorbidities at baseline. Subsequently, the renal benefits of SGLT2 inhibitors were established in the CREDENCE trial, a dedicated renal outcome trial where canagliflozin reduced the primary composite renal outcome by 30%. In light of these trials, clinical practice guidelines have rapidly evolved, recommending the use of SGLT2 inhibitors as renal and cardioprotective agents in appropriate patient populations. Accordingly, it is important to have an in-depth understanding of the evidence underlying the use of SGLT2 inhibitors in patients with T2D based on published clinical trials and real-world evidence (RWE) studies, as well as information related to potential safety concerns. To accomplish this, we reviewed the evidence for renal protection and safety with SGLT2 inhibitors in the EMPA-REG OUTCOME, CANVAS Program and DECLARE-TIMI 58 CV safety trials, and in the growing body of evidence emerging from real-world studies. This body of work has shown that SGLT2 inhibitors reduce the risk of surrogate renal endpoints such as albuminuria and mitigate the risk of hard renal endpoints including doubling of serum creatinine and end-stage kidney disease in patients with T2D.

Dishonesty and research misconduct within the medical profession.

While there has been much discussion of how the scientific establishment's culture can engender research misconduct and scientific irreproducibility, this has been discussed much less frequently with respect to the medical profession. Here the authors posit that a lack of self-criticism, an encouragement of novel scientific research generated by the recruitment policies of the UK Royal Training Colleges along with insufficient training in the sciences are core reasons as to why research misconduct and dishonesty prevail within the medical community. Furthermore, the UK General Medical Council's own data demonstrates a historic inattentiveness to the ease with which doctors can engage in research misconduct. Suggestions are made as to how these issues can be investigated and alternative incentives for career advancement are adumbrated.

Lip Adhesion- A Viable Alternative To Pre-Surgical Orthodontics For The Management Of Wide Cleft Lips In Third World Countries.

BACKGROUND: Cleft lip and palate is a relatively common condition presenting a considerable technical challenge, especially the wide cleft (>8 mm), for the surgeons. Pre-surgical orthodontics, which reduces the cleft width and facilitates definitive repair, is expensive and not universally available, especially in the third world. Lip adhesion could be a cheaper alternative to pre-surgical orthodontics. METHODS: This six-year prospective observational study, from 2010 to 2016, was conducted at the paediatric surgical units of PNS Shifa Hospital, Karachi and Military Hospital Rawalpindi. All children with wide (8 mm or more gap in the alveolus) complete ULCP (unilateral cleft lip and palate) were included in the study. Lip adhesion with concomitant vomer flap palatal repair was followed by definitive lip repair once the desired moulding, i.e., alveolar gap <5 mm or adequate narrowing as per surgeon's subjective assessment during the 3 and 6 monthly follow up, had been achieved. RESULTS: A total of 53 children with the mean age 4.5±1.5 months were subjected to surgery, 32 (60.4 %) were males and 21 (39.6%) were females. The mean gap in the cleft alveolus was 11.1±1.7 mm, which was reduced to a mean of 3.2±1.3 mm, after a follow up of 4.3±1.1 months. The outcome of the lip repair, based on parental satisfaction, was excellent in 41 (77.3%), good in 10 (18.9%) and poor in 2 (3.8%) cases. CONCLUSIONS: Lip adhesion is a safe and effective substitute for pre-surgical orthodontics in wide ULCP.

Insulinoma and Tuberous Sclerosis: A Possible Mechanistic Target of Rapamycin (mTOR) Pathway Abnormality?

A 23-year-old New Zealand Maori male with tuberous sclerosis (TSC) and associated neurocognitive abnormalities presented with altered behavior and increasing seizure frequency. Endogenous hyperinsulinemia from an underlying insulinoma was confirmed and this was managed surgically. This case represents only the sixth description of insulinoma in TSC to date. The role of the hamartin-tuberin complex in regulation of the mechanistic target of rapamycin pathway provides a plausible pathogenetic mechanism between insulinoma and TSC. This rare disease association should be considered in TSC patients who present with otherwise unexplained worsening neurocognitive symptoms.

Allochthonous carbon is a major driver of the microbial food web - A mesocosm study simulating elevated terrestrial matter runoff.

Climate change predictions indicate that coastal and estuarine environments will receive increased terrestrial runoff via increased river discharge. This discharge transports allochthonous material, containing bioavailable nutrients and light attenuating matter. Since light and nutrients are important drivers of basal production, their relative and absolute availability have important consequences for the base of the aquatic food web, with potential ramifications for higher trophic levels. Here, we investigated the effects of shifts in terrestrial organic matter and light availability on basal producers and their grazers. In twelve Baltic Sea mesocosms, we simulated the effects of increased river runoff alone and in combination. We manipulated light (clear/shade) and carbon (added/not added) in a fully factorial design, with three replicates. We assessed microzooplankton grazing preferences in each treatment to assess whether increased terrestrial organic matter input would: (1) decrease the phytoplankton to bacterial biomass ratio, (2) shift microzooplankton diet from phytoplankton to bacteria, and (3) affect microzooplankton biomass. We found that carbon addition, but not reduced light levels per se resulted in lower phytoplankton to bacteria biomass ratios. Microzooplankton generally showed a strong feeding preference for phytoplankton over bacteria, but, in carbon-amended mesocosms which favored bacteria, microzooplankton shifted their diet towards bacteria. Furthermore, low total prey availability corresponded with low microzooplankton biomass and the highest bacteria/phytoplankton ratio. Overall our results suggest that in shallow coastal waters, modified with allochthonous matter from river discharge, light attenuation may be inconsequential for the basal producer balance, whereas increased allochthonous carbon, especially if readily bioavailable, favors bacteria over phytoplankton. We conclude that climate change induced shifts at the base of the food web may alter energy mobilization to and the biomass of microzooplankton grazers.

Progressive Fatal Myelopathy Secondary to Isolated Spinal Cord Vasculitis.

A 56-year-old woman with various neurological signs which developed over a 1-year period was admitted for evaluation. MRI showed a markedly abnormal signal in the cervical spine. Despite treatment with IV steroids, she developed a progressive myelopathy, became quadriplegic, and required intubation. Immunomodulatory treatment was ineffective. The patient died 24 days after admission. Histopathological investigation revealed spinal cord necrosis with a lymphocyte predominant meningovascular inflammation involving arteries and veins along with evidence of prior occlusive disease of the anterior spinal artery. The changes were confined to the spinal cord. The present case represents an unusual cause of myelitis for which early and aggressive immunomodulatory treatment may have influenced outcomes.

Corrigendum to "An Insight into Methods and Practices in Hip Arthroplasty in Patients with Rheumatoid Arthritis".

[This corrects the article DOI: 10.1155/2015/140143.].

What Does the Excised Stomach from Sleeve Gastrectomy Tell us?

INTRODUCTION: Staple-line leak and haemorrhage are the most serious complications following sleeve gastrectomy. The operation is often performed without prior endoscopy. Given that gastric inflammatory conditions are common, could they predispose patients to suffering a serious complication following sleeve gastrectomy? METHODS: Consecutive patients undergoing laparoscopic sleeve gastrectomy from March 2007 to May 2014 were included in the study. All final histologic reports were coded and investigated against whether or not the patient had a post-operative leak and/or haemorrhage. Associations were explored using Fisher's exact test. RESULTS: Over this period, 976 laparoscopic sleeve gastrectomies were performed with a pre-operative gastroscopy rate of 2.2%. Over half of the specimens demonstrated a histopathologic abnormality. Helicobacter pylori infection occurred in 8.6%, and the most common histopathologic abnormality was chronic gastritis in 38.9%. There was no association between H. pylori infection or inflammation and staple-line leak and/or haemorrhage. CONCLUSION: We conclude that inflammatory gastric conditions are unlikely to predispose patients to staple-line leaks or haemorrhages following sleeve gastrectomy and that selective pre-operative gastroscopy may be an appropriate standard of care.

An Insight into Methods and Practices in Hip Arthroplasty in Patients with Rheumatoid Arthritis.

Total hip arthroplasty (THA) has improved the quality of life of patients with hip arthritis. Orthopedic community is striving for excellence to improve surgical techniques and postoperative care. Despite these efforts, patients continue facing postoperative complications. In particular, patients with rheumatoid arthritis display a higher risk of certain complications such as dislocation, periprosthetic infection, and shorter prosthesis durability. In this review we present the current knowledge of hip arthroplasty in patients with rheumatoid arthritis with more insight into common practices and interventions directed at enhancing recovery of these patients and current shortfalls.

Massive surgical emphysema secondary to iatrogenic tracheal laceration.

A 78-year-old woman was admitted for a revision total hip replacement following a failed dynamic hip screw placed emergently 4 months earlier. Anaesthetic management consisted of general anaesthesia with endotracheal intubation and femoral nerve block. The patient's perioperative course was unremarkable except for a promptly recognised and corrected oesophageal intubation and a short period of breathing against a closed adjustable pressure limiting valve. In recovery, following a period of hypotension resistant to fluid therapy, she suddenly desaturated, developed severe facial and upper thoracic subcutaneous emphysema and type 2 respiratory failure. She was diagnosed with bilateral pneumothoraces, pneumomediastinum, pneumopericardium and surgical emphysema. This was treated emergently with supplemental oxygen and bilateral chest drains. A CT scan demonstrated a tracheal laceration, which was managed conservatively in the critical care unit. The patient had a tracheostomy on day 5 to treat an on-going air leak and later made a full recovery.

Five-year results after laparoscopic sleeve gastrectomy: a prospective study.

BACKGROUND: Whilst the early to mid-term efficacy of laparoscopic sleeve gastrectomy (SG) is well established, there is comparatively less detailing of long-term efficacy. The objectives of this study were to evaluate the long-term outcomes of patients undergoing SG at the authors' institution. METHODS: All patients undergoing SG during the past 5 or more years were eligible. Outcomes included baseline demographic data, preoperative characteristics, percentage excess weight loss (%EWL), co-morbidity improvement and resolution, serum hemoglobin A(1c) (HbA(1c)), serum lipid profile, and the Bariatric Analysis Reporting Outcome System (BAROS) questionnaire. A subset analysis was also performed with patients stratified in to super obese (body mass index ≥ 50 kg/m(2)). RESULTS: There were 96 patients who underwent surgery between March 2007 and July 2008. Of these, 10 declined to participate, 28 were unable to be contacted, and 3 were deceased; therefore, 55 patients were included in the analysis. The mean yearly %EWL to postoperative year 5 was 56% (year 1), 55% (year 2), 46% (year 3), 43% (year 4), and 40% (year 5). Combined improvement and resolution rates at 5 years were 79%, 61%, and 73% for type 2 diabetes, hypertension, and obstructive sleep apnea, respectively. The HbA(1c) was significantly reduced at long-term follow-up. The mean BAROS score was 3.13 (95% CI: 2.4, 3.9). Weight loss outcomes were less favorable in super obese patients. CONCLUSION: Weight loss outcomes at 5 year follow-up were modest after SG though improvement in co-morbidity status was maintained.

Rapid diagnostic tests to improve treatment of malaria and other febrile illnesses: patient randomised effectiveness trial in primary care clinics in Afghanistan.

OBJECTIVE: To assess the impact of rapid diagnostic tests on the diagnostic accuracy and treatment of malaria and non-severe fever in an Asian setting. DESIGN: Patient randomised trial in primary level clinics. SETTING: Two areas of Afghanistan where Plasmodium vivax and Plasmodium falciparum are endemic; one area with moderate transmission (eastern region) and one with low transmission (northern region). PARTICIPANTS: 5794 patients of all ages with suspected malaria enrolled by 80 clinicians in 22 clinics. INTERVENTIONS: Malaria rapid diagnostic tests were compared with clinical diagnosis where no parasite diagnostic test was available, longer established field microscopy, and recently introduced microscopy. MAIN OUTCOME MEASURES: Proportion of patients appropriately treated with an antimalarial, defined as patients with P vivax who received chloroquine, patients with P falciparum who received artemisinin based combination therapy, and patients with no malaria parasites who did not receive an antimalarial. Secondary outcomes included diagnostic test accuracy and the proportion of patients negative for malaria who received antibiotics and antimalarials. RESULTS: In the low transmission area, comparing rapid diagnostic tests with clinical diagnosis, 65% (212/325) versus 12% (40/321) of febrile patients were appropriately treated for malaria (adjusted odds ratio 92.7, 95% confidence interval 12.4 to 694.1, P<0.001). The proportion of patients who were negative for malaria and received an antibiotic was 57% (185/325) in the rapid diagnostic test arm compared with 14% (46/321) in the clinical diagnosis arm (16.9, 3.8 to 75.4, P<0.001). In the comparison of rapid diagnostic test with microscopy in the moderate transmission area, 83.6% (1696/2028) versus 76.3% (1512/1983) of patients were appropriately treated for malaria (1.70, 1.30 to 2.23, P<0.001). A higher proportion of P falciparum cases received appropriate treatment with artemisinin based combination therapy when malaria was diagnosed by rapid diagnostic test (82%, 58/71 v 32%, 24/76; 9.2, 3.88 to 21.66, P<0.001). CONCLUSIONS: In South and central Asian regions of low to moderate malaria transmission where clinics lack capacity for diagnosis with rapid diagnostic tests or microscopy, the introduction of the tests should be considered to improve clinical care, reduce the overuse of antimalarials, and improve disease surveillance.

Design and fabrication of branched polyamine functionalized mesoporous silica: an efficient absorbent for water remediation.

A novel branched polyamine (polyethyleneimine, PEI) functionalized mesoporous silica (MS) adsorbent is developed via a facile "grafting-to" approach. X-ray photoelectron spectroscopy (XPS) and Fourier transform infrared (FT-IR) spectroscopy verified the effective surface functionalization of MS with monolayer and polymer. The transmission electron microscopy (TEM) was employed to reveal the morphology of the fabricated materials. The adsorption behavior of the polyamine functionalized mesoporous silica (MS-PEI) is assessed against anionic dyes. The adsorbent characteristics of MS-PEI are compared with a monolayer platform comprising of 3-aminopropyltriethoxy silane (APTES) functionalized mesoporous silica (MS-APTES). The adsorption behavior of the MS-PEI and MS-APTES toward anionic dyes is further evaluated by studying the effect of adsorbent dosage, pH, contact time, and temperature. Langmuir and Freundlich isotherm models are employed to understand the adsorption mechanism. The obtained kinetic data support a pseudo-second-order adsorption behavior for both monolayer and polymer functionalized MS. The associated thermodynamic parameters (ΔG°, ΔH°, and ΔS°) reveal that the process of adsorption with MS-PEI is more spontaneous and energetically favored as compared to the adsorption with MS-APTES. Taken together, the novel adsorbent system derived from a combination of MS and branched polymer (MS-PEI) shows the higher absorption efficiency and capacity toward the anionic dyes than the monolayer based adsorbent (MS-APTES).

Pulmonary oedema mimicking bronchiectasis.

A previously completely fit and well 62-year-old man presented with a 4-week history of lethargy and increasing shortness of breath. This had been preceded by a flu-like illness that had been treated in the community with ciprofloxacin to no effect. There was no history of smoking, tuberculosis exposure or significant exposure to birds. Clinically the patient appeared well and was comfortable and conversant with no peripheral oedema. Chest auscultation revealed normal breath sounds and a loud pansystolic murmur over the cardiac apex. A chest radiograph and a subsequent CT scan showed widespread fibrotic and bronchiectatic changes, predominantly in the right upper lobe, with bilateral pleural effusions. Echocardiography revealed a posterior mitral valve prolapse. He was treated with loop diuretics and a mitral valve repair that resolved his symptoms and radiographic findings. This is the first English language case report of pulmonary oedema causing bronchiectatic lung appearances.