Pain Assessment and Management Practices via Education & Reinforcement (PAMPER): A Quality Improvement Initiative.

OBJECTIVES: To establish neonatal pain management practices as an essential developmental supportive measure at a tertiary care unit. METHODS: This quality improvement initiative was conducted as per Point-of-Care-Quality-Improvement Model over 6 mo, followed by 2 y of sustenance phase at a Neonatal Intensive Care Unit (NICU) in northern India. Infants of birth weight ≤1800 g were included and assessed for pain. Pain Assessment and Management Practices via Education and Reinforcement (PAMPER) group was created by resident doctors and nursing staff. The Premature Infant Pain Profile score was used for the assessment of pain. Limiting factors were analyzed using a fishbone diagram and interventions were done in multiple Plan-Do-Study-Act cycles. RESULTS: At the end of interventions, 100% of procedures were assessed for pain. The mean (standard deviation) documented pain score for the first seven days was reduced from 12.8 (0.3) in the baseline phase to 7 (2.5). These interventions helped to sustain the practice in >70% of infants in the next 2 y. CONCLUSIONS: Low-cost interventions improved the pain assessment and management policy of authors' NICU with the establishment of a standard protocol. Audits and reinforcement at regular intervals helped in its long-term sustenance.

Does left atrial appendage morphology and dimension differ amongst etiological stroke subtypes in patients without known atrial fibrillation? Results from the left atrial appendage morphology and dimension assessment by TEE in patients with stroke without known atrial fibrillation (LAMDA-STROKE) study.

CONTEXT: Complex left atrial appendage (LAA) morphology is increasingly associated with cryptogenic ischemic stroke as compared to cardioembolic stroke due to atrial fibrillation (AF). However, data on such an association in patients with other etiological stroke subtypes in the absence of AF is limited. AIM: The study aimed to assess the LAA morphology, dimension and other echocardiographic parameters by transesophageal echocardiography (TEE) in patients with embolic stroke of undetermined source (ESUS) and compare it with other etiological stroke subtypes without known AF. METHODS: This was a single-Centre, observational study involving comparison of echocardiographic parameters including LAA morphology and dimension in ESUS patients (group A; n = 30) with other etiological stroke subtypes i.e., TOAST (Trial of Org 10172 in Acute Stroke Treatment) class I-IV without AF (group B; n = 30). RESULTS: Complex LAA morphology was predominant in group A (18 patients in group A versus 5 patients in group B, p-Value = 0.001). Mean LAA orifice diameter (15.3 + 3.5 mm in group A versus 17 + 2.0 mm in group B, p-Value = 0.027) and LAA depth were significantly lower in group A (28.4 + 6.6 mm in group A versus 31.7 + 4.3 mm in group B, p-Value = 0.026). Out of these three parameters only complex LAA morphology was found to be independently associated with ESUS [OR = 6.003, 95% CI {1.225-29.417}, p = 0.027]. CONCLUSION: Complex LAA morphology is a predominant feature in ischemic stroke patients with ESUS and may contribute to an increased risk of stroke in these patients.

Reply to a letter to the editor written by Phansalkar et al, regarding publication entitled "Do we need a simplified model to predict outcomes in patients hospitalized with Acute Decompensated Heart Failure? Results from The Role of Sodium in Heart Failure Outcomes Prediction ('SHOUT-PREDICTION') study. Indian Heart J. 2021;73(4):458-463. doi:10.1016/j.ihj.2021.06.007".

This is the Reply to a letter to the Editor written by Phansalkar et al, regarding publication entitled "Do we need a simplified model to predict outcomes in patients hospitalized with Acute Decompensated Heart Failure? Results from The Role of Sodium in Heart Failure Outcomes Prediction ('SHOUT-PREDICTION') study. Indian Heart J. 2021; 73(4):458-463. doi: 10.1016/j.ihj.2021.06.007".

Do we need a simplified model to predict outcomes in patients hospitalized with Acute Decompensated Heart Failure? Results from The Role of Sodium in Heart Failure Outcomes Prediction ('SHOUT-PREDICTION') study.

CONTEXT: Hyponatremia is associated with high in-hospital mortality in patients with acute decompensated Heart Failure (ADHF) and is one of the components in various risk scores in heart failure (HF). However, some risk scores predict outcomes in these patients without using hyponatremia as its component. AIM: The study was aimed to evaluate the relationship between serum sodium levels at admission and clinical outcomes during the in-hospital course and three months' follow-up, in patients admitted in the intensive cardiac care unit (ICCU) with ADHF. METHODS AND MATERIAL: This was a single-center prospective, observational study in which 130 consecutive patients admitted with ADHF were observed for clinical characteristics and blood investigation at admission and their clinical outcomes during the in-hospital course and follow-up of 3 months. RESULTS: Hyponatremia and systolic blood pressure (SBP) both were found to be the independent predictor of in-hospital mortality. The SXS score (calculated as a product of SBP and serum sodium, divided by 1000) as a new prediction variable was significantly associated with in-hospital mortality and was compared with the Get with the guideline HF (GWTG-HF) score and ADHF national registry (ADHERE) score. The SXS score showed the best overall accuracy in predicting in-hospital mortality [area under the curve (AUC) = 0.899] as compared to the ADHERE (AUC = 0.780) and the GWTG (AUC = 0.815). CONCLUSIONS: A score derived from the product of serum sodium and SBP (SXS score) had a significant association with in-hospital mortality, and better predictive value as compared to GWTG and ADHERE risk score in these patients.

Time to rethink: Conscious sedation in an obese during pacemaker implantation.

We report a case of pulmonary embolism while performing pacemaker implantation in an obese patient and its management as well as certain precautions that one must consider in an obese patient especially under conscious sedation. Air embolism during pacemaker implantation although rare can be life-threatening in certain conditions such as massive pulmonary embolism. Air embolism during this procedure mainly occurs through open sheath just before inserting the lead. Certain risk factors associated with this condition include deep inspiration, frequent coughing, advanced age, sheath with larger diameter, and sedatives. Obesity along with associated factors including sleep apnea, restrictive lung disease, and challenges during airway management can create troubles during pacemaker implantation. Conscious sedation is usually required when a patient becomes restless during the procedure either due to pain or prolonged supine position. At times a patient can transiently go into the deep sedation and a deep inspiration during this phase can be detrimental in a procedure where it is undesirable and adds to the risk of air embolism. Here we discuss the management and alternative methods which can be used to avoid such complications. .

Percutaneous coronary intervention provided better long term results than optimal medical therapy alone in patients with chronic total occlusion: A meta-analysis.

AIMS: Studies comparing the outcome of percutaneous coronary intervention (PCI) along with optimal medical therapy (OMT) versus OMT alone in treatment of chronic total occlusion (CTO) are limited by observational design, variable follow-up period, diverse clinical outcomes, high drop-out and cross-over rates. This study aims to conduct a meta-analysis of published data of observational as well as randomized studies comparing long term outcomes of PCI+OMT versus OMT alone. METHODS AND RESULTS: PubMed, Embase and Cochrane databases were systematically reviewed. 15 studies meeting criteria were included in the meta-analysis. The New-castle Ottawa scale was used to appraise the overall quality of the studies. Random-effects model with inverse variance method was undertaken. Major adverse cardiovascular events (MACE) which comprises of cardiac death, myocardial infarction, stroke, and un-planned revascularization were significantly lower in the PCI+OMT group (RR:0.76; 95% CI:0.61 to 0.95; P=<0.00001; I2 = 85%). All-cause mortality and cardiac death were significantly lower in the PCI+OMT group (P=<0.00001 in both). Myocardial infarction and stroke rates were lower in the PCI+OMT group, however they did not reach statistical significance (P = 0.24, P = 0.15 respectively). Unplanned revascularizations (of any vessel) were also similar in both the groups (P = 0.78, I2 = 88%). CONCLUSION: PCI of CTO is rewarded with better long term outcome, in terms of MACE, all-cause mortality and cardiac death with similar rates of un-planned revascularization.

Successful occlusion of a large pulmonary arterio-venous fistula with Amplatzer septal occluder in a 16-year-old cyanotic boy.

Pulmonary arterio-venous fistula is an uncommon cause of cyanosis and should be suspected when normal cardiac examination is associated without evidence of intra-cardiac shunt. Diagnosis of extra-cardiac shunt can be suspected by contrast echocardiography using agitated saline and confirmation of pulmonary arterio-venous fistula can be made by computed tomography pulmonary angiography with information regarding the size feeding vessels necessary for the planning of intervention. With the advancement of trans-catheter devices, fistula can be occluded successfully by embolotherapy. Coils, duct occluders, and vascular plugs are some of the commonly used trans-catheter devices among the armamentarium. Each device has its own inherent advantages and limitations. However, operators' familiarity and expertise is an important parameter to choose the device to be employed in closure of fistula. The experience of Amplatzer family of devices in closure of pulmonary arterio-venous fistula is limited in the literature. We report a case of large pulmonary arterio-venous fistula successfully closed with a 20 mm Amplatzer septal occluder device in a 16-year-old cyanotic boy. Post-procedure contrast echocardiography confirmed absence of right to left shunt and computed tomography pulmonary angiography confirmed the device in situ closing the feeding vessel. Over a follow-up of six months reversal of clubbing and cyanosis was noted. .

Disseminated Cryptococcosis Mimicking Miliary Tuberculosis with Generalized Lymphadenopathy in Immunocompetent Host.

Cryptococcosis is a rare opportunistic infection in the immunocompromised host.1,2 Diagnosis of disseminated fungal infections is rarely thought of in immunocompetent hosts. In developing countries where tuberculosis is endemic, Cryptococcosis is often misdiagnosed as tuberculosis.3,4 A 14 year old girl, misdiagnosed as miliary tuberculosis with Koch's abdomen on ATT, presented with seizures. After extensive workup, she was found to have disseminated Cryptococcosis, not tuberculosis. This case report shows the similarity in presentation of tuberculosis and Cryptococcosis, and hence Cryptococcosis should always be kept as a differential diagnosis of tuberculosis.