Search results for: pontine hemorrhage from venous infarction

Authors: N. Haj Salem, M. Belhadj, S. Ben Jomâa, S. Saadi, R. Dhouieb, A. Chadly

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Introduction: Sudden death in young is seen as a dramatic phenomenon requiring knowledge of its impact and determining their causes. Aim: We aim to study the epidemiological characteristics of sudden death in young, and to discuss the mechanism and the importance of autopsy in these situations. Material and methods: We performed a retrospective cohort study using autopsy data from the department of forensic medicine at the University Hospital of Fattouma Bourguiba, Monastir-Tunisia. A review of all autopsies performed during 23 years was done. In each case, clinical information and circumstances of death were obtained. We have included all sudden death in persons aged between 1 year and 35 years for the male and from one year to 45 years for female. We collected 312 cases of sudden death during the studied period. The collected data were processed using SPSS 20. The significance level was set at 0.05. Results: Thirty-two cases of cardiac ischemic sudden death have been collected. Myocardial infarction was the second cause of sudden death in young patients. There was a male predominance. The most affected subjects were aged between 25-45 years. The death occurred more frequently at rest. Coronary artery disease has been discovered in twenty-four cases (75%). A severe coronary artery disease was observed in two children with medical history of familial hypercholesterolemia. The myocardial infarction occurred in healthy coronary arteries in eight cases. An anomalous course of coronary arteries, in particular, myocardial bridging, was found in eight cases (25%). Toxicological screening was negative in all cases. Second cause of death was hypertrophic cardiomyopathy. Neurological and respiratory causes of death were implicated respectively in 10% and 15%. Conclusion: Identifying epidemiological characteristics of sudden death in this population is important for guiding approaches to prevention that must be based on dietary hygienic measures and the control of cardiovascular risk factors.

Keywords: autopsy, cardiac death, sudden death, young

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Authors: Dinoo Kirthinanda, Sujani Wijeratne

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Pseudohyperkalaemia is a common benign in vitro phenomenon caused by the release of potassium ions (K+) from cells during specimen processing. Analysis of haemolysed blood samples for predominantly intracellular electrolytes may lead to re-investigation and potentially harmful interventions. We report a case of a 52-year male with myeloproliferative disease manifested as Polycythaemia Rubra Vera, Hypertension and hypertensive nephropathy with stage 3 chronic kidney disease admitted to Neuro-intensive care unit (NICU) with an intra-cerebral haemorrhage secondary to hypertensive bleed. His initial blood investigations showed hyperkalemia with serum K+ 6.2 mmol/L yet the bedside arterial blood gas analysis yielded K+ of 4.6 mmol/L. The patient was however given hyperkalemia regime twice based on venous electrolyte analysis. The discrepancy between the bedside electrolyte analysis using arterial blood and venous blood prompted further evaluation. The 12 lead Electrocardiogram showed U waves and sinus bradycardia corresponding to the serum K+ of 2.8 mmol/L on arterial blood gas analysis. Immediate K+ replacement ensured the patient did not develop life-threatening cardiac complications. Pseudohyperkalaemia may pose diagnostic challenges in the absence of detectable haemolysis and should be suspected in susceptible patients with normal Electrocardiogram and Glomerular Filtration Rate to avoid potentially life-threatening interventions. When in doubt, rapid analysis of arterial blood gas may be useful for accurate quantification of potassium.

Keywords: patient safety, pseudohyperkalaemia, haemolysis, myeloproliferative disorder

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Authors: Ramuel Spirituel Mattathiah A. San Juan, Neil Ambasing

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Background: In lateral medullary strokes, hemiparesis doesn't typically manifest due to the distinct vascular supply to the corticospinal tract located within the medulla's tegmentum. Hemiparesis resulting from a medullary infarct would likely be attributable to a medial medullary stroke characterized by contralateral hemiparesis since the corticospinal tract fibers at this level have yet to cross over. This paper reports a unique case of a lateral medullary stroke variant that presented with ipsilateral hemiparesis. Objective: There have only been 23 other cases of reported Opalski syndrome, making this only the 24th and 25th case reported worldwide. Case Presentation: A 53-year-old male was admitted with slurring of speech with gait instability, numbness on the right face, Horner’s syndrome, and 4/5 motor strength on the right extremities. Hyperreflexia was noted on the right, together with a Babinski’s sign. Cranial magnetic resonance imaging (MRI) showed an infarct on the right dorsolateral medulla. A 48-year-old male was admitted complaining of dizziness, ataxic gait, veering to the left during ambulation, left facial numbness, left hemiplegia, crossed sensory disturbance, and right limb ataxia. MRI revealed an acute left lateral medullary infarction. Conclusion: A rare type of lateral medullary infarction, the Opalski Syndrome, is a weakness ipsilateral to the lesion of the infarct. The lesion involves the ipsilateral corticospinal tract below the pyramidal decussation. The considerable diversity in the posterior brain circulation serves as a contributing factor to the clinical observation of incomplete textbook syndromes, underscoring the significance of the neurological clinical approach and a solid foundation in neuroanatomy.

Keywords: Opalski syndrome, rare stroke, stroke, Wallenberg's syndrome

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Authors: M. E. Kolpakova, A. A. Jakovleva, L. S. Poliakova, H. El Amghari, S. Soliman, D. R. Faizullina, V. V. Sharoyko

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Brain neuroplasticity is associated with blood-brain barrier vascular endothelial proteoglycans and post-stroke microglial activation. The study of the mechanisms of reperfusion injury limitation by remote ischemic postconditioning (RC) is of interest due to the effects on functional recovery after cerebral ischemia. The goal of the study is the assessment of the role of syndecan-1 (SDC-1) in restriction of ischemic-reperfusion injury on middle cerebral artery model in rats using RC protocol. Randomized controlled trials were conducted. Ischemia was performed by middle cerebral artery occlusion by Belayev L. (1996) on the Wistar rat-males (n= 87) weighting 250 ± 50 g. under general anesthesia (Zoletil 100 и Xylazine 2%). Syndecan-1 (SDC-1) concentration difference in plasma samples of false operated animals and animals with brain ischemia was 30% (30 min. МСАо: 41.4 * ± 1.3 ng/ml). SDC-1 concentration in animal plasma samples with ischemia + RC protocol was 112% (30 min МСАо+ RC): 67.8**± 5.8 ng/ml). Calculation of infarction volume in the ischemia group revealed brain injury in 31.97 ± 2.5%; the volume of infarction was 13.6 ± 1.3% in 30 min. МCАо + RC group. Swelling of tissue in the group 30 min. МCАо + RC was 16 ± 2.1%; it was 47 ± 3.3%. in 30 min. МCАо group. Correlation analysis showed a high direct correlation relationship between infarct area and muscle strength in the right forelimb (КК=0.72) in the 30 min. МCАо + RC group. Correlation analysis showed very high inverse correlation between infarct area and capillary blood flow in the 30 min. МCАо + RC group (p <0.01; r = -0.98). We believe the SDC-1 molecule in blood plasma may play role of potential messenger of ischemic-reperfusion injury restriction mechanisms. This leads to infarct-limiting effect of remote ischemic postconditioning and early functioning recovery.

Keywords: ischemia, МСАо, remote ischemic postconditioning, syndecan-1

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Authors: Mahmut Sozmen, Alparslan Kadir Devrim, Yonca Betil Kabak, Tuba Devrim

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Acute myocardial infarction is the leading cause of deaths in the worldwide. Mature cardiomyocytes do not have the ability to regenerate instead fibrous tissue proliferate and granulation tissue to fill out. Periostin is an extracellular matrix protein from fasciclin family and it plays an important role in the cell adhesion, migration, and growth of the organism. Periostin prevents apoptosis while stimulating cardiomyocytes. The main objective of this project is to investigate the effects of the recombinant murine periostin peptide administration for the cardiomyocyte regeneration in a rat model of acute myocardial infarction. The experiment was performed on 84 male rats (6 months old) in 4 group each contains 21 rats. Saline applied subcutaneously (1 ml/kg) two times with 24 hours intervals to the rats in control group (Group 1). Recombinant periostin peptide (1 μg/kg) dissolved in saline applied intraperitoneally in group 2 on 1, 3, 7, 14 and 21. days on same dates in group 4. Isoproterenol dissolved in saline applied intraperitoneally (85mg/kg/day) two times with 24 hours intervals to the groups 3 and 4. Rats in group 4 further received recombinant periostin peptide (1 μg/kg) dissolved in saline intraperitoneally starting one day after the final isoproterenol administration on days 1, 3, 7, 14 and 21. Following the final application of periostin rats continued to feed routinely with pelleted chow and water ad libitum for further seven days. At the end of 7th day rats sacrificed, blood and heart tissue samples collected for the immunohistochemical and biochemical analysis. Angiogenesis in response to tissue damage, is a highly dynamic process regulated by signals from the surrounding extracellular matrix and blood serum. In this project, VEGF, ANGPT, bFGF, TGFβ are the key factors that contribute to cardiomyocyte regeneration were investigated. Additionally, the relationship between mitosis and apoptosis (Bcl-2, Bax, PCNA, Ki-67, Phopho-Histone H3), cell cycle activators and inhibitors (Cyclin D1, D2, A2, Cdc2), the origin of regenerating cells (cKit and CD45) were examined. Present results revealed that periostin stimulated cardiomyocye cell-cycle re-entry in both normal and MCA damaged cardiomyocytes and increased angiogenesis. Thus, periostin contributes to cardiomyocyte regeneration during the healing period following myocardial infarction which provides a better understanding of its role of this mechanism, improving recovery rates and it is expected to contribute the lack of literature on this subject. Acknowledgement: This project was financially supported by Turkish Scientific Research Council- Agriculture, Forestry and Veterinary Research Support Group (TUBİTAK-TOVAG; Project No: 114O734), Ankara, TURKEY.

Keywords: cardiotoxicity, immunohistochemistry, isoproterenol, periostin

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Authors: Devendra Gupta, Vikash Arya, Prabhat K. Singh

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Background: Ultrasound guidance could be beneficial in placing central venous catheters by improving the success rate, reducing the number of needle passes, and decreasing complications. Central venous cannulation set has a single puncture needle of a fixed length of 6.4 cm. However, the average distance of midpoint of IJV to the skin is around 1 cm to 2 cm. The long length needle has tendency to go in depth more than required and this is very common during learning period of any individual. Therefore, we devised a long needle with a guard which can be adjusted according to the required length. Methods: After approval from the institute ethics committee and patient’s written informed consent, a prospective, randomized, single-blinded controlled study was conducted. Adult patient aged of both sexes with ASA grade 1-2 undergoing surgery requiring internal jugular venous (IJV) access was included. After intubation, the head was rotated to the contralateral side at 30 degree head rotation on the position of the right IJV. The transducer probe a 6.5 to 13-MHz linear transducer (Sonosite, USA) had been placed at the apex of triangle with minimal pressure to avoid IJV compression. The distance from skin to midpoint of the right IJV and skin to anterior wall of Common Carotid Artery (CCA) had been done using B-mode duplex sonography with a 6.5 to 13-MHz linear transducer. Depending upon the results of randomization 420 patients had been divided into two groups of equal numbers (n=210). Group 1. USG guided right sided IJV cannulation was done with conventional (6.4 cm) needle; and Group 2. USG guided right sided IJV cannulation was done with conventional (6.4 cm) needle with guard fixed to a required length (length between skin and midpoint of IJV) by an experienced anesthesiologist. Independent observer has noted the number of attempts and occurrence of complications (CCA puncture, pneumothorax or adjacent tissue damage). Results: Demographic data were similar in both the group. The groups were comparable when considered for relationship of IJV to CCA. There was no significant difference between groups as regard to distance of midpoint of IJV to the skin (p<0.05). IJV cannulation was successfully done in single attempts in 180 (85.7%), in two attempts in 27 (12.9%) and three attempts in 3 (1.4%) in group I, whereas in single attempt in 207 (98.6%) and second attempts in 3 (1.4%) in group II (p <0.000). Incidence of carotid artery puncture was significantly more in group I (7.1%) compared to group II (0%) (p<0.000). Incidence of adjacent tissue puncture was significantly more in group I (8.6%) compared to group II (0%) (p<0.000). Conclusion: Therefore IJV catheterization using guard over the needle at predefined length with the help of real-time ultrasound results in better success rates and lower immediate complications.

Keywords: ultrasound guided, internal jugular vein cannulation, measured guided needle, common carotid artery puncture

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Authors: Arina V. Tankanag, Gennady V. Krasnikov, Nikolai K. Chemeris

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The development of respiration-dependent oscillations in the peripheral blood flow may occur by at least two mechanisms. The first mechanism is related to the change of venous pressure due to mechanical activity of lungs. This phenomenon is known as ‘respiratory pump’ and is one of the mechanisms of venous return of blood from the peripheral vessels to the heart. The second mechanism is related to the vasomotor reflexes controlled by the respiratory modulation of the activity of centers of the vegetative nervous system. Early high phase synchronization of respiration-dependent blood flow oscillations of left and right forearm skin in healthy volunteers at rest was shown. The aim of the work was to study the effect of deep controlled breathing on the phase synchronization of skin blood flow oscillations. 29 normotensive non-smoking young women (18-25 years old) of the normal constitution without diagnosed pathologies of skin, cardiovascular and respiratory systems participated in the study. For each of the participants six recording sessions were carried out: first, at the spontaneous breathing rate; and the next five, in the regimes of controlled breathing with fixed breathing depth and different rates of enforced breathing regime. The following rates of controlled breathing regime were used: 0.25, 0.16, 0.10, 0.07 and 0.05 Hz. The breathing depth amounted to 40% of the maximal chest excursion. Blood perfusion was registered by laser flowmeter LAKK-02 (LAZMA, Russia) with two identical channels (wavelength 0.63 µm; emission power, 0.5 mW). The first probe was fastened to the palmar surface of the distal phalanx of left forefinger; the second probe was attached to the external surface of the left forearm near the wrist joint. These skin zones were chosen as zones with different dominant mechanisms of vascular tonus regulation. The degree of phase synchronization of the registered signals was estimated from the value of the wavelet phase coherence. The duration of all recording was 5 min. The sampling frequency of the signals was 16 Hz. The increasing of synchronization of the respiratory-dependent skin blood flow oscillations for all controlled breathing regimes was obtained. Since the formation of respiration-dependent oscillations in the peripheral blood flow is mainly caused by the respiratory modulation of system blood pressure, the observed effects are most likely dependent on the breathing depth. It should be noted that with spontaneous breathing depth does not exceed 15% of the maximal chest excursion, while in the present study the breathing depth was 40%. Therefore it has been suggested that the observed significant increase of the phase synchronization of blood flow oscillations in our conditions is primarily due to an increase of breathing depth. This is due to the enhancement of both potential mechanisms of respiratory oscillation generation: venous pressure and sympathetic modulation of vascular tone.

Keywords: deep controlled breathing, peripheral blood flow oscillations, phase synchronization, wavelet phase coherence

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Authors: Wu Liching

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Aim This case aims to discuss the pathogenesis, clinical manifestations and medical treatment of strokes caused by mitochondrial gene mutations. Methods Diagnosis of ischemic stroke caused by mitochondrial gene defect by means of "next-generation sequencing mitochondrial DNA gene variation detection", imaging examination, neurological examination, and medical history; this study took samples from the neurology ward of a medical center in northern Taiwan cases diagnosed with acute cerebral infarction as the research objects. Result This case is a 49-year-old married woman with a rare disease, mitochondrial gene mutation inducing ischemic stroke. She has severe hearing impairment and needs to use hearing aids, and has a history of diabetes. During the patient’s hospitalization, the blood test showed that serum Lactate: 7.72 mmol/L, Lactate (CSF) 5.9 mmol/L. Through the collection of relevant medical history, neurological evaluation showed changes in consciousness and cognition, slow response in language expression, and brain magnetic resonance imaging examination showed subacute bilateral temporal lobe infarction, which was an atypical type of stroke. The lineage DNA gene has m.3243A>G known pathogenic mutation point, and its heteroplasmic level is 24.6%. This pathogenic point is located in MITOMAP and recorded as Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like episodes (MELAS) , Leigh Syndrome and other disease-related pathogenic loci, this mutation is located in ClinVar and recorded as Pathogenic (dbSNP: rs199474657), so it is diagnosed as a case of stroke caused by a rare disease mitochondrial gene mutation. After medical treatment, there was no more seizure during hospitalization. After interventional rehabilitation, the patient's limb weakness, poor language function, and cognitive impairment have all improved significantly. Conclusion Mitochondrial disorders can also be associated with abnormalities in psychological, neurological, cerebral cortical function, and autonomic functions, as well as problems with internal medical diseases. Therefore, the differential diagnoses cover a wide range and are not easy to be diagnosed. After neurological evaluation, medical history collection, imaging and rare disease serological examination, atypical ischemic stroke caused by rare mitochondrial gene mutation was diagnosed. We hope that through this case, the diagnosis of rare disease mitochondrial gene variation leading to cerebral infarction will be more familiar to clinical medical staff, and this case report may help to improve the clinical diagnosis and treatment for patients with similar clinical symptoms in the future.

Keywords: acute stroke, MELAS, lactic acidosis, mitochondrial disorders

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Authors: Masaaki Ii, Takashi Saito, Yasuhiko Tabata, Shintaro Nemoto

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Background: Clinical trials of autologous adipose-derived stem cell (AdSC) therapy for ischemic heart diseases (IHD) are now on-going. We have investigated the hypothesis that combination of AdSCs and statin, an agent with pleiotropic effects, could augment the therapeutic effect on myocardial infarction (MI). Methods and Results: Human AdSC functions with different doses of simvastatin-conjugated nanoparticle (STNP) uptake were evaluated by in vitro assays. STNP promoted the migration activity without changing the proliferation activity, and also up-regulated growth factors. Next, MI was induced by LAD ligation in nude mice, and the mice were assigned in the following groups 3 days after MI: 1) PBS (control), 2) NP-AdSCs (50000 cells), 3) STNP, and 4) STNP-AdSCs (50000 cells). Cardiac functional recovery assessed by echocardiography was improved at 4 weeks after surgery in STNP-AdSC group. Masson’s trichrome-stained sections revealed that LV fibrosis length was reduced, and the number of TUNEL-positive cardiomyocytes was less in STNP-AdSC group. Surprisingly, a number of de novo endogenous Nkx-2.5/GATA4 positive immature cardiomyocytes as well as massive vascular formation were observed in outer layer of infarcted myocardium despite of a few recruited/retained transfused STNP-AdSCs 4 weeks after MI in STNP-AdSC group. Finally, massive myocardial regeneration was observed 8 weeks after MI. Conclusions: Intravenously injected small number of statin nanoparticle-loaded hAdSCs exhibited a potent therapeutic effect inducing endogenous cardiac tissue regeneration.

Keywords: statin, drug delivery system, stem cells, cardiac regeneration

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Authors: Camelia Porey, Binaya Kumar Jaiswal

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BACKGROUND: Antiphospholipid antibody (APLA) syndrome is an autoimmune disorder predisposing to thrombotic complications affecting CNS either by arterial vasooclusion or venous thrombosis. Cerebral venous sinus thrombosis (CVST) secondarily causes raised intracranial pressure (ICP). However, intracranial hypertension without evidence of CVST is a rare entity. Here we present two cases of elevated ICP with absence of identifiable CVST. CASE SUMMARY: Case 1, 28-year female had a 2 months history of holocranial headache followed by bilateral painless vision loss reaching lack of light perception over 20 days. CSF opening pressure was elevated. Fundoscopy showed bilateral grade 4 papilledema. MRI revealed a partially empty sella with bilateral optic nerve tortuosity. Idiopathic intracranial hypertension (IIH) was diagnosed. With acetazolamide, there was complete resolution of the clinical and radiological abnormalities. 5 months later she presented with acute onset right-sided hemiparesis. MRI was suggestive of acute left MCA infarct.MR venogram was normal. APLA came positive with high titres of Anticardiolipin and Beta 2 glycoprotein both IgG and IgM. Case 2, 23-year female, presented with headache and diplopia of 2 months duration. CSF pressure was elevated and Grade 3 papilledema was seen. MRI showed bilateral optic nerve hyperintensities with nerve head protrusion with normal MRV. APLA profile showed elevated beta 2 glycoprotein IgG and IgA. CONCLUSION: This is an important non thrombotic complication of APLA syndrome and requires further large-scale study for insight into the pathogenesis and early recognition to avoid future complications.

Keywords: APLA syndrome, idiopathic intracranial hypertension, MR venogram, papilledema

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Authors: G. Dadashova, A. Bakhshaliyev

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Aim: Determine gender differences in the etiology and clinical outcomes, as well as in the remodeling of the left ventricle (LV) in patients with chronic heart failure (CHF), suffering from arterial hypertension (AH) and coronary heart disease (CHD). Material and methods: The study included 112 patients of both sexes; aged 45 to 60 years with postinfarction cardiosclerosis had functional class (FC) heart failure II-IV of NYHA which were examined on the basis of Azerbaijan Scientific Research Institute of Cardiology. The patients were divided into 2 groups: 1st c. 60 males, mean age 54,8 ± 3,3 years, and 2nd gr 52 women, mean age 55,8 ± 3,1 years. To assess cardiac hemodynamic all patients underwent echocardiography (B-M-modes) using ‘Vivid 3’. Thus on the basis of indicators such as the index of the relative thickness of the left ventricle wall and the index of left ventricular mass (LVMI) was identified the architectonic model of the left ventricle. Results: According to our research leading cause of heart failure in women is 50.5% of cases of hypertension, ischemic heart disease 23.7% (with 79.5% of the cases developed in patients with chronic heart failure who did not have a history of myocardial infarction). While in men is the undisputed leader of CHD, forming 78.3% of CHF (80.3% in men with CHF occurred after myocardial infarction). According to our research in women more often than men CHF develops a type of diastolic dysfunction (DD, and left ventricular ejection fraction remained unchanged. Since DD occurs in men at 65,8% vs. 76,4% of women when p < 0,05. In the group of women was more common prognostic neblagopryatnye remodeling - eccentric hypertrophy of the left ventricle: 68% vs. 54.5% among men (p < 0,05), concentric left ventricular hypertrophy: 21% in women vs 19,1% (p > 0,05 ). Conclusions: Patients with heart failure are a number of gender-specific: the prevalence of hypertension in women, and coronary heart disease in men. While in women with heart failure often recorded diastolic dysfunction and characterized by the development of prognostically unfavorable remodeling types: eccentric and concentric LV hypertrophy.

Keywords: chronic heart failure, arterial hypertension, remodeling, diastolic dysfunction, men, women, ischemic heart disease

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Authors: Chee Wai Ku, Pui See Chin

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As an emerging alternative to hysterectomy, uterine artery embolization (UAE) has been widely used in the management of fibroids and in controlling postpartum hemorrhage (PPH) unresponsive to other therapies. Research has shown UAE to be a safe, minimally invasive procedure with few complications and minimal effects on future fertility. We present two cases highlighting the use of UAE in preventing PPH in a patient with a large fibroid at the time of cesarean section and in the treatment of secondary PPH refractory to other therapies in another patient. We present a 36-year primiparous woman who booked at 18+6 weeks gestation with a 13.7 cm subserosal fibroid at the lower anterior wall of the uterus near the cervix and a 10.8 cm subserosal fibroid in the left wall. Prophylactic internal iliac artery occlusion balloons were placed prior to the planned classical midline cesarean section. The balloons were inflated once the baby was delivered. Bilateral uterine arteries were embolized subsequently. The estimated blood loss (EBL) was 400 mls and hemoglobin (Hb) remained stable at 10 g/DL. Ultrasound scan 2 years postnatally showed stable uterine fibroids 10.4 and 7.1 cm, which was significantly smaller than before. We present the second case of a 40-year-old G2P1 with a previous cesarean section for failure to progress. There were no antenatal problems, and the placenta was not previa. She presented with term labour and underwent an emergency cesarean section for failed vaginal birth after cesarean. Intraoperatively extensive adhesions were noted with bladder drawn high, and EBL was 300 mls. Postpartum recovery was uneventful. She presented with secondary PPH 3 weeks later complicated by hypovolemic shock. She underwent an emergency examination under anesthesia and evacuation of the uterus, with EBL 2500mls. Histology showed decidua with chronic inflammation. She was discharged well with no further PPH. She subsequently returned one week later for secondary PPH. Bedside ultrasound showed that the endometrium was thin with no evidence of retained products of conception. Uterotonics were administered, and examination under anesthesia was performed, with uterine Bakri balloon and vaginal pack insertion after. EBL was 1000 mls. There was no definite cause of PPH with no uterine atony or products of conception. To evaluate a potential cause, pelvic angiogram and super selective left uterine arteriogram was performed which showed profuse contrast extravasation and acute bleeding from the left uterine artery. Superselective embolization of the left uterine artery was performed. No gross contrast extravasation from the right uterine artery was seen. These two cases demonstrated the superior efficacy of UAE. Firstly, the prophylactic use of intra-arterial balloon catheters in pregnant patients with large fibroids, and secondly, in the diagnosis and management of secondary PPH refractory to uterotonics and uterine tamponade. In both cases, the need for laparotomy hysterectomy was avoided, resulting in the preservation of future fertility. UAE should be a consideration for hemodynamically stable patients in centres with access to interventional radiology.

Keywords: fertility preservation, secondary postpartum hemorrhage, uterine embolization, uterine fibroids

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Authors: Nabiha Bouafia, Asma Ben Cheikh, Asma Ammar, Olfa Ezzi, Mohamed Mahjoub, Khaoula Meddeb, Imed Chouchene, Hamadi Boussarsar, Mansour Njah

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Background: Hospital acquired infections (HAI) cause significant morbidity, mortality, length of stay and hospital costs, especially in the intensive care unit (ICU), because of the debilitated immune systems of their patients and exposure to invasive devices. The aims of this study were to determine the rate and the risk factors of HAI in an ICU of a university hospital in Tunisia. Materials/Methods: A prospective study was conducted in the 8-bed adult medical ICU of a University Hospital (Sousse Tunisia) during 14 months from September 15th, 2015 to November 15th, 2016. Patients admitted for more than 48h were included. Their surveillance was stopped after the discharge from ICU or death. HAIs were defined according to standard Centers for Disease Control and Prevention criteria. Risk factors were analyzed by conditional stepwise logistic regression. The p-value of < 0.05 was considered significant. Results: During the study, 192 patients had admitted for more than 48 hours. Their mean age was 59.3± 18.20 years and 57.1% were male. Acute respiratory failure was the main reason of admission (72%). The mean SAPS II score calculated at admission was 32.5 ± 14 (range: 6 - 78). The exposure to the mechanical ventilation (MV) and the central venous catheter were observed in 169 (88 %) and 144 (75 %) patients, respectively. Seventy-three patients (38.02%) developed 94 HAIs. The incidence density of HAIs was 41.53 per 1000 patient day. Mortality rate in patients with HAIs was 65.8 %( n= 48). Regarding the type of infection, Ventilator Associated Pneumoniae (VAP) and central venous catheter Associated Infections (CVC AI) were the most frequent with Incidence density: 14.88/1000 days of MV for VAP and 20.02/1000 CVC days for CVC AI. There were 5 Peripheral Venous Catheter Associated Infections, 2 urinary tract infections, and 21 other HAIs. Gram-negative bacteria were the most common germs identified in HAIs: Multidrug resistant Acinetobacter Baumanii (45%) and Klebsiella pneumoniae (10.96%) were the most frequently isolated. Univariate analysis showed that transfer from another hospital department (p= 0.001), intubation (p < 10-4), tracheostomy (p < 10-4), age (p=0.028), grade of acute respiratory failure (p=0.01), duration of sedation (p < 10-4), number of CVC (p < 10-4), length of mechanical ventilation (p < 10-4) and length of stay (p < 10-4), were associated to high risk of HAIS in ICU. Multivariate analysis reveals that independent risk factors for HAIs are: transfer from another hospital department: OR=13.44, IC 95% [3.9, 44.2], p < 10-4, duration of sedation: OR= 1.18, IC 95% [1.049, 1.325], p=0.006, high number of CVC: OR=2.78, IC 95% [1.73, 4.487], p < 10-4, and length of stay in ICU: OR= 1.14, IC 95% [1.066,1.22], p < 10-4. Conclusion: Prevention of nosocomial infections in ICUs is a priority of health care systems all around the world. Yet, their control requires an understanding of epidemiological data collected in these units.

Keywords: healthcare associated infections, incidence, intensive care unit, risk factors

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Authors: Zia Ul Haq, Saleem Muhammad, Naeem Ullah, Abbas Shah, Abdullah Shah

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Pakistan being the developing country is facing double burden of communicable and non-communicable disease. The aspect of secondary prevention of ischemic heart disease in developing countries is the dire need for public health specialists, clinicians and policy makers. There is some evidence that psychotherapeutic measures, including psychotherapy, recreation, exercise and stress management training have positive impact on secondary prevention of cardiovascular diseases but there are some contradictory findings as well. Cardiac rehabilitation program (CRP) has not yet fully implemented in Pakistan. Psychological, physical and specific health-related quality of life (HRQoL) outcomes needs assessment with respect to its practicality, effectiveness, and success. Objectives: To determine the effect of cardiac rehabilitation program (CRP) on the health-related quality of life (HRQoL) measures of post MI patients compared to the usual care. Hypothesis: Post MI patients who receive the interventions (CRP) will have better HRQoL as compared to those who receive the usual cares. Methods: The randomized control trial was conducted at a Cardiac Rehabilitation Unit of Lady Reading Hospital (LRH), Peshawar. LRH is the biggest hospital of the Province Khyber Pakhtunkhwa (KP). A total 206 participants who had recent first myocardial infarction were inducted in the study. Participants were randomly allocated into two group i.e. usual care group (UCG) and cardiac rehabilitation group (CRG) by permuted-block randomization (PBR) method. CRP was conducted in CRG in two phases. Three HRQoL outcomes i.e. general health questionnaire (GHQ), self-rated health (SRH) and MacNew quality of life after myocardial infarction (MacNew QLMI) were assessed at baseline and follow-up visits among both groups. Data were entered and analyzed by appropriate statistical test in STATA version 12. Results: A total of 195 participants were assessed at the follow-up period due to lost-to-follow-up. The mean age of the participants was 53.66 + 8.3 years. Males were dominant in both groups i.e. 150 (76.92%). Regarding educational status, majority of the participants were illiterate in both groups i.e. 128 (65.64%). Surprisingly, there were 139 (71.28%) who were non-smoker on the whole. The comorbid status was positive in 120 (61.54%) among all the patients. The SRH at follow-up among UCG and CRG was 4.06 (95% CI: 3.93, 4.19) and 2.36 (95% CI: 2.2, 2.52) respectively (p<0.001). GHQ at the follow-up of UCG and CRG was 20.91 (95% CI: 18.83, 21.97) and 7.43 (95% CI: 6.59, 8.27) respectively (p<0.001). The MacNew QLMI at follow-up of UCG and CRG was 3.82 (95% CI: 3.7, 3.94) and 5.62 (95% CI: 5.5, 5.74) respectively (p<0.001). All the HRQoL measures showed strongly significant improvement in the CRG at follow-up period. Conclusion: HRQOL improved in post MI patients after comprehensive CRP. Education of the patients and their supervision is needed when they are involved in their rehabilitation activities. It is concluded that establishing CRP in cardiac units, recruiting post-discharged MI patients and offering them CRP does not impose high costs and can result in significant improvement in HRQoL measures. Trial registration no: ACTRN12617000832370

Keywords: cardiovascular diseases, cardiac rehabilitation, health-related quality of life, HRQoL, myocardial infarction, quality of life, QoL, rehabilitation, randomized control trial

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Authors: Asma Qudrat, Abid Ullah, Rafi Ullah, Ali Raza, Shah Zeb, Syed Ali Shan Ul-Haq, Shahkar Ahmed Shah, Attiya Hameed Khan, Saad Zaheer, Umama Qasim, Kiran Jamal, Zahoor khan

Abstract:

Objectives: Coronary artery disease (CAD) is the major public health issue associated with high mortality and morbidity rate worldwide. Young patients with ACS have unique characteristics with different demographic profiles and risk factors. The precise diagnosis and early risk stratification is important in guiding treatment and predicting the prognosis of young patients with ACS. To evaluate the associated demographics, risk factors, and outcomes profile of ACS in young age patients. Methods: The research follow a retrospective design, the single centre study of patients diagnosis with the first event of ACS in young age (>18 and <40) were included. Data collection included demographic profiles, risk factors, and in-hospital outcomes of young ACS patients. The patient’s data was retrieved through Electronic Medical Records (EMR) of Peshawar Institute of Cardiology (PIC), and all characteristic were assessed. Results: In this study, 77% were male, and 23% were female patients. The risk factors were assessed with CAD and shown significant results (P < 0.01). The most common presentation was STEMI, with (45%) most in ACS young patients. The angiographic pattern showed single vessel disease (SVD) in 49%, double vessel disease (DVD) in 17% and triple vessel disease (TVD) was found in 10%, and Left Artery Disease (LAD) (54%) was present to be the most common involved artery. Conclusion: It is concluded that the male sex was predominant in ACS young age patients. SVD was the common coronary angiographic finding. Risk factors showed significant results towards CAD and common presentations.

Keywords: coronary artery disease, Non-ST elevation myocardial infarction, ST elevation myocardial infarction, unstable angina, acute coronary syndrome

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Authors: Sheng Yu Chen, Shi-Heng Wang

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Aim: Based on human, animal experiments, and genetic studies, cysteinyl leukotrienes, LTC4, LTD4, and LTE4, are inflammatory substances that are metabolized by 5-lipooxygenase from arachidonic acid, and these substances trigger asthma. In addition, the synthetic pathway of cysteinyl leukotriene is relevant to the increase in cardiovascular diseases such as myocardial ischemia and stroke. Given the situation, we aim to investigate whether cysteinyl leukotrienes receptor antagonist (LTRA), montelukast which cures those who have asthma has potential protective effects on cardiovascular diseases. Method: We conducted a cohort study, and enrolled participants which are newly diagnosed with asthma (ICD-9 CM code 493. X) between 2002 to 2011. The data source is from Taiwan National Health Insurance Research Database Patients with a previous history of myocardial infarction or ischemic stroke were excluded. Among the remaining participants, every montelukast user was matched with two randomly non-users by sex, and age. The incident cardiovascular diseases, including myocardial infarction and ischemic stroke, were regarded as outcomes. We followed the participants until outcomes come first or the end of the following period. To explore the protective effect of montelukast on the risk of cardiovascular disease, we use multivariable Cox regression to estimate the hazard ratio with adjustment for potential confounding factors. Result: There are 55876 newly diagnosed asthma patients who had at least one claim of inpatient admission or at least three claims of outpatient records. We enrolled 5350 montelukast users and 10700 non-users in this cohort study. The following mean (±SD) time of the Montelukast group is 5 (±2.19 )years, and the non-users group is 6.2 5.47 (± 2.641) years. By using multivariable Cox regression, our analysis indicated that the risk of incident cardiovascular diseases between montelukast users (n=43, 0.8%) and non-users (n=111, 1.04%) is approximately equal. [adjusted hazard ratio 0.992; P-value:0.9643] Conclusion: In this population-based study, we found that the use of montelukast is not associated with a decrease in incident MI or IS.

Keywords: asthma, inflammation, montelukast, insurance research database, cardiovascular diseases

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Authors: Syed Dawood Md. Taimur, Md. Hasanur Rahman, Syeda Fahmida Afrin, Farzana Islam

Abstract:

The concept of myocardial injury, although first recognized from animal studies, is now recognized as a clinical phenomenon that may result in microvascular damage, no-reflow phenomenon, myocardial stunning, myocardial hibernation and ischemic preconditioning. The final consequence of this event is left ventricular (LV) systolic dysfunction leading to increased morbidity and mortality. The typical clinical case of reperfusion injury occurs in acute myocardial infarction (MI) with ST segment elevation in which an occlusion of a major epicardial coronary artery is followed by recanalization of the artery. This may occur either spontaneously or by means of thrombolysis and/or by primary percutaneous coronary intervention (PCI) with efficient platelet inhibition by aspirin (acetylsalicylic acid), clopidogrel and glycoprotein IIb/IIIa inhibitors. In recent years, percutaneous coronary intervention (PCI) has become a well-established technique for the treatment of coronary artery disease. PCI improves symptoms in patients with coronary artery disease and it has been increasing the safety of procedures. However, peri- and post-procedural myocardial injury, including angiographical slow coronary flow, microvascular embolization, and elevated levels of cardiac enzyme, such as creatine kinase and troponin-T and -I, has also been reported even in elective cases. Furthermore, myocardial reperfusion injury at the beginning of myocardial reperfusion, which causes tissue damage and cardiac dysfunction, may occur in cases of the acute coronary syndrome. Because patients with myocardial injury is related to larger myocardial infarction and have a worse long-term prognosis than those without myocardial injury, it is important to prevent myocardial injury during and/or after PCI in patients with coronary artery disease. To date, many studies have demonstrated that adjunctive pharmacological treatment suppresses myocardial injury and increases coronary blood flow during PCI procedures. In this review, we highlight the usefulness of pharmacological treatment in combination with PCI in attenuating myocardial injury in patients with coronary artery disease.

Keywords: coronary artery disease, percutaneous coronary intervention, myocardial injury, pharmacology

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Authors: Nalan Kaya, Gonca Ozan, Elif Erdem, Neriman Colakoglu, Enver Ozan

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The toxic effects of tobacco smoke exposure have been detected in numerous studies. Ellagic acid (EA), (2,3,7,8-tetrahydroxy [1]-benzopyranol [5,4,3-cde] benzopyran 5,10-dione), a natural phenolic lactone compound, is found in various plant species including pomegranate, grape, strawberries, blackberries and raspberries. Similar to the other effective antioxidants, EA can safely interact with the free radicals and reduces oxidative stress through the phenolic ring and hydroxyl components in its structure. The aim of the present study was to examine the protective effects of ellagic acid against oxidative damage on lung tissues of rats induced by tobacco smoke. Twenty-four male adult (8 weeks old) Spraque-Dawley rats were divided randomly into 4 equal groups: group I (Control), group II (Tobacco smoke), group III (Tobacco smoke + corn oil) and group IV (Tobacco smoke + ellagic acid). The rats in group II, III and IV, were exposed to tobacco smoke 1 hour twice a day for 12 weeks. In addition to tobacco smoke exposure, 12 mg/kg ellagic acid (dissolved in corn oil), was applied to the rats in group IV by oral gavage. Equal amount of corn oil used in solving ellagic acid was applied to the rats by oral gavage in group III. At the end of the experimental period, rats were decapitated. Lung tissues and blood samples were taken. The lung slides were stained by H&E and Masson’s Trichrome methods. Also, galactin-3 stain was applied. Biochemical analyzes were performed. Vascular congestion and inflammatory cell infiltration in pulmonary interstitium, thickness in interalveolar septum, cytoplasmic vacuolation in some macrophages and galactin-3 positive cells were observed in histological examination of tobacco smoke group. In addition to these findings, hemorrhage in pulmonary interstitium and bronchial lumen was detected in tobacco smoke + corn oil group. Reduced vascular congestion and hemorrhage in pulmoner interstitium and rarely thickness in interalveolar septum were shown in tobacco smoke + EA group. Compared to group-I, group-II GSH level was decreased and MDA level was increased significantly. Nevertheless group-IV GSH level was higher and MDA level was lower than group-II. The results indicate that ellagic acid could protect the lung tissue from the tobacco smoke harmful effects.

Keywords: ellagic acid, lung, rat, tobacco smoke

Procedia PDF Downloads 185

Authors: Lourenço Bastos, Filipa Carneiro, Bruno Vale, Rita Marques Joana Silva, Ricardo Freitas, Ângelo Marques, Sara Cortez, Alberta Coelho, Pedro Parreira, Liliana Sousa, Anabela Salgueiro, Bruno Silva

Abstract:

The process of flushing is considered to be an adequate technique to reduce the risk of infection during the clinical practice of venous catheterization. Nonetheless, there is still a lack of adhesion to this method, in part due to the complexity of this procedure. The project SeringaDuo aimed to develop an innovative double-chamber syringe for intravenous sequential administration of drugs and serums. This device served the purpose of improving the adherence to the practice, through the reduction of manipulations needed, which also improves patient safety, and though the promotion of flushing practice by health professionals, by simplifying this task. To assist on the development of this innovative syringe, a numerical methodology was developed and validated in order to predict the syringe’s mechanical and flow behavior during the fluids’ loading and administration phases, as well as to allow the material behavior evaluation during its production. For this, three commercial numerical simulation software was used, namely ABAQUS, ANSYS/FLUENT, and MOLDFLOW. This methodology aimed to evaluate the concepts feasibility and to optimize the geometries of the syringe’s components, creating this way an iterative process for product development based on numerical simulations, validated by the production of prototypes. Through this methodology, it was possible to achieve a final design that fulfils all the characteristics and specifications defined. This iterative process based on numerical simulations is a powerful tool for product development that allows obtaining fast and accurate results without the strict need for prototypes. An iterative process can be implemented, consisting of consecutive constructions and evaluations of new concepts, to obtain an optimized solution, which fulfils all the predefined specifications and requirements.

Keywords: Venous catheterization, flushing, syringe, numerical simulation

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Authors: Firouz Amani, Adalat Hoseinian, Sajjad Hakimian

Abstract:

Background: The mortality due to Myocardial Infarction (MI) is often occur during the first hours after onset of symptom. So, for taking the necessary treatment and decreasing the mortality rate, timely visited of the hospital could be effective in this regard. The aim of this study was to investigate the impact of effective factors in mortality of MI patients by using Linear Logistic Regression. Materials and Methods: In this case-control study, all patients with Acute MI who referred to the Ardabil city hospital were studied. All of died patients were considered as the case group (n=27) and we select 27 matched patients without Acute MI as a control group. Data collected for all patients in two groups by a same checklist and then analyzed by SPSS version 24 software using statistical methods. We used the linear logistic regression model to determine the effective factors on mortality of MI patients. Results: The mean age of patients in case group was significantly higher than control group (75.1±11.7 vs. 63.1±11.6, p=0.001).The history of non-cardinal diseases in case group with 44.4% significantly higher than control group with 7.4% (p=0.002).The number of performed PCIs in case group with 40.7% significantly lower than control group with 74.1% (P=0.013). The time distance between hospital admission and performed PCI in case group with 110.9 min was significantly upper than control group with 56 min (P=0.001). The mean of delay time from Onset of symptom to hospital admission (patient delay) and the mean of delay time from hospital admissions to receive treatment (system delay) was similar between two groups. By using logistic regression model we revealed that history of non-cardinal diseases (OR=283) and the number of performed PCIs (OR=24.5) had significant impact on mortality of MI patients in compare to other factors. Conclusion: Results of this study showed that of all studied factors, the number of performed PCIs, history of non-cardinal illness and the interval between onset of symptoms and performed PCI have significant relation with morality of MI patients and other factors were not meaningful. So, doing more studies with a large sample and investigated other involved factors such as smoking, weather and etc. is recommended in future.

Keywords: acute MI, mortality, heart failure, arrhythmia

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Authors: Naim Izet Kajtazi

Abstract:

Context: Increased intracranial pressure and associated symptoms such as headache, papilledema, motor or sensory deficits, seizures, and conscious disturbance are well-known in acute CVT. However, visual loss is not commonly associated with this disease, except in the case of secondary IIH associated with it. Process: We report a case of a 40-year-old male with Behçet’s disease and cerebral venous thrombosis, and other multiple comorbidities admitted with a four-day history of increasing headache and rapidly progressive visual loss bilaterally. The neurological examination was positive for bilateral papilledema of grade 3 with light perception on the left eye and counting fingers on the right eye. Brain imaging showed old findings of cerebral venous thrombosis without any intraparenchymal lesions to suggest a flare-up of Behçet’s disease. The lumbar puncture, followed by the lumbar drain insertion, gave no benefit in headache or vision. However, he completely lost sight. The right optic nerve sheath fenestration did not result in vision improvement. The acute spinal shock complicated the lumbar drain removal due to epidural hematoma. An urgent lumbar laminectomy with hematoma evacuation undertook. Intra-operatively, the neurosurgeon noted suspicious abnormal vessels at conus medullaris with the possibility of an arteriovenous malformation. Outcome: In a few days following the spinal surgery, the patient vision started to improve. Further improvement was achieved after plasma exchange sessions followed by cyclophosphamide. In the recent follow-up in the clinic, he reported better vision, drove, and completed his Ph.D. studies. Relevance: Visual loss in patients with Behçet’s disease should always be anticipated and taken reasonable care of, ensuring that they receive well-combined immunosuppression with anticoagulation and agents to reduce intracranial pressure. This patient’s story is significant for a high disease burden and complicated hospital course by acute spinal shock due to spinal lumbar drain removal with a possible underlying spinal arteriovenous malformation.

Keywords: Behcet disease, optic neuritis, IIH, CVT

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Authors: Faezeh Jahanpour, Shahin Dezhdar, Saeedeh Firouz Bakht, Afshin Ostovar

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Objective: The hospitalized premature babies often undergo various painful procedures such as venous sampling. The Kangaroo mother care (KMC) method is one of the pain reduction methods, but as mother’s presence is not always possible, this research was done to compare the effect of swaddling and KMC method on venous sampling pain on premature neonates. Methods: In this randomized clinical trial 90 premature infants selected and randomly alocated into three groups; Group A (swaddling), Group B (the kangaroo care), and group C (the control). From 10 minutes before blood sampling to 2 minutes after that in group A, the infant was wrapped in a thin sheet, and in group B, the infant was under Kangaroo care. In all three groups, the heart rate and arterial oxygen saturation in time intervals of 30 seconds before, during, 30-60-90, and 120 seconds after sampling were measured and recorded. The infant’s face was video recorded since sampling till 2 minutes and the videos were checked by a researcher who was unaware of the kind of intervention and the pain assessment tools for infants (PIPP) for time intervals of 30 seconds were completed. Data analyzed by t-test, Q square, Repeated Measure ANOVA, Kruskal-Wallis, Post-hoc and Bonferroni test. Results: Findings revealed that the pain was reduced to a great extent in swaddling and kangaroo method compared to that in control group. But there was not a significant difference between kangaroo and swaddling care method (P ≥ 0.05). In addition, the findings showed that the heart rate and arterial oxygen saturation was low and stable in swaddling and Kangaroo care method and returned to base status faster, whereas, the changes were severe in control group and did not return to base status even after 120 seconds. Discussion: The results of this study showed that there was not a meaningful difference between swaddling and kangaroo care method on physiological indexes and pain in infants. Therefore, swaddling method can be a good substitute for kangaroo care method in this regard.

Keywords: Kangaroo mother care, neonate, pain, premature, swaddling, venipuncture,

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Authors: Behcet Al, Mustafa Bogan, Mehmet Murat Oktay, Suat Zengin, Hasan Bayram

Abstract:

Objective: In the last two decades there is a strong scientific interest regarding the role of aerosols for the Earth’s climate and associated changes. Aerosol particles are very important to the Earth-atmosphere climate system playing a crucial role in cloud and precipitation processes, air quality and climate. Here, we evaluated the association between saharran dust and emergency department admission, hospitalization, and mortality. Method: The records of admission to emergency department of Gaziantep University and the dust stroms of 31 months were studied. Patients admitted to ED at dust strom with chronic obstructive lung disease (COLD), asthma bronchiale (AB), serebrovascular events (SVE), acute myocardial infarction (AMI), stabile and unstabile angina pectoris (SAAP andUSAP); and the days with and without dust stroms were included. The study was realized from March 2010 to October 2012. The admission of three days before strom (group 1), during strom days (group 2) and three days after strom (group 3) were determined. The mean level of dust PM10 particulate was calculated, and the results were compared. Results: 5864 patients with chronic obstructive lung disease, asthma bronchiale, serebrovascular events, acute myocardial infarction, stabile and unstabile angyina pectoris admitted during the days with and without dust stroms. 28 dust stroms ocurred during 31 months. The totaliy of stroms continiued 78 days. Of admissions, 35.5% (n=2075) were in group1, 29.8% (n=1746) in group 2, and 34.8% (n=2043) were in group 3. The mean of PM10 for groups (group 1, 2 and 3) were 78.53 mg/m3 (range 19–276) particulate, 108.7 mg/m3 (range 34–631) particulate, and 60.9 mg/m3 (range 17–160) particulate respectively. The mean admission per a day for groups were 24.86, 22.55, and 24.50 respectively. The mortality was 12 in group 1, 12 in group 2, and 17 in grou 3. The hospitalization ratio for groups were 0.24, 0.27, and 0.27 respectively. Conclusion: However, the mean level of PM10 particulate for groups 2 (in dust strom days) is significantly higher (p=0.001) than the days before (group 1) and after (group 3) dust stroms, the mean admissions/day, hostilalization and mortality related to deseases (COLD, AB, SVE, AMI, SAAP andUSA) for group 2 is lower than the group 1 and group 3.

Keywords: Saharran dust, PM10 particulate, emergency department admission, mortality

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Authors: Mostafa Najim, Alaa Rahhal, Fadi Khir, Safae Abu Yousef, Amer Aljundi, Feryal Ibrahim, Aliaa Amer, Ahmed Soliman Mohamed, Samira Saleh, Dekra Alfaridi, Ahmed Mahfouz, Sumaya Al-Yafei, Faraj Howady, Mohamad Yahya Khatib, Samar Alemadi

Abstract:

Background: Coronavirus disease 2019 (COVID-19) increases the risk of coagulopathy among critically ill patients. Although the presence of antiphospholipid antibodies (aPLs) has been proposed as a possible mechanism of COVID-19 induced coagulopathy, their clinical significance among critically ill patients with COVID-19 remains uncertain. Methods: This prospective observational study included patients with COVID-19 admitted to intensive care units (ICU) to evaluate the prevalence and clinical significance of aPLs, including anticardiolipin IgG/IgM, anti-β2-glycoprotein IgG/IgM, and lupus anticoagulant. The study outcomes included the prevalence of aPLs, a primary composite outcome of all-cause mortality, and arterial or venous thrombosis among aPLs positive patients versus aPLs negative patients during their ICU stay. Multiple logistic regression was used to assess the influence of aPLs on the primary composite outcome of mortality and thrombosis. Results: A total of 60 critically ill patients were enrolled. Of whom, 57 (95%) were male, with a mean age of 52.8 ± 12.2 years, and the majority were from Asia (68%). Twenty-two patients (37%) were found to have positive aPLs; of whom 21 patients were positive for lupus anticoagulant, whereas one patient was positive for anti-β2-glycoprotein IgG/IgM. The composite outcome of mortality and thrombosis during ICU did not differ among patients with positive aPLs compared to those with negative aPLs (4 (18%) vs. 6 (16%), aOR= 0.98, 95% CI 0.1-6.7; p-value= 0.986). Likewise, the secondary outcomes, including all-cause mortality, venous thrombosis, arterial thrombosis, discharge from ICU, time to mortality, and time to discharge from ICU, did not differ between those with positive aPLs upon ICU admission in comparison to patients with negative aPLs. Conclusion: The presence of aPLs does not seem to affect the outcomes of critically ill patients with COVID-19 in terms of all-cause mortality and thrombosis. Therefore, clinicians may not screen critically ill patients with COVID-19 for aPLs unless deemed clinically appropriate.

Keywords: antiphospholipid antibodies, critically ill patients, coagulopathy, coronavirus

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Authors: Mohammed Abdurabu, Akram Al-Warqi, Ebrahim M. A. Ebrahim, Jouhar Kollari, Salman Mirza

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The novel coronavirus (COVID-19) is one of the most recent pandemics that invaded earth that left and still leaving hundreds of thousands of patients and ended with high morbidity and mortality rates with no clear cure till this moment. COVID-19 has been proven to be associated with pathologic changes in coagulation, characterized by either thromboembolic or bleeding events. We present this case of a 44-year-old male patient that presented to our Emergency Department with flank pain that later was found to have renal angiomyolipoma (AML) rupture during his COVID-19 infection, ultimately requiring admission for hemorrhage control via Interventional Radiology (IR) drainage. Here, we discuss the role of the front-line physicians and how they should keep a low threshold for the different presentations that could be associated with COVID-19 infection.

Keywords: angiomyolipoma, COVID-19, renal, rupture

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Authors: Angelis P. Barlampas

Abstract:

The purpose of this study is to inform the reader, about the various applications of artificial intelligence (AI), in cardiac imaging. AI grows fast and its role is crucial in medical specialties, which use large amounts of digital data, that are very difficult or even impossible to be managed by human beings and especially doctors.Artificial intelligence (AI) refers to the ability of computers to mimic human cognitive function, performing tasks such as learning, problem-solving, and autonomous decision making based on digital data. Whereas AI describes the concept of using computers to mimic human cognitive tasks, machine learning (ML) describes the category of algorithms that enable most current applications described as AI. Some of the current applications of AI in cardiac imaging are the follows: Ultrasound: Automated segmentation of cardiac chambers across five common views and consequently quantify chamber volumes/mass, ascertain ejection fraction and determine longitudinal strain through speckle tracking. Determine the severity of mitral regurgitation (accuracy > 99% for every degree of severity). Identify myocardial infarction. Distinguish between Athlete’s heart and hypertrophic cardiomyopathy, as well as restrictive cardiomyopathy and constrictive pericarditis. Predict all-cause mortality. CT Reduce radiation doses. Calculate the calcium score. Diagnose coronary artery disease (CAD). Predict all-cause 5-year mortality. Predict major cardiovascular events in patients with suspected CAD. MRI Segment of cardiac structures and infarct tissue. Calculate cardiac mass and function parameters. Distinguish between patients with myocardial infarction and control subjects. It could potentially reduce costs since it would preclude the need for gadolinium-enhanced CMR. Predict 4-year survival in patients with pulmonary hypertension. Nuclear Imaging Classify normal and abnormal myocardium in CAD. Detect locations with abnormal myocardium. Predict cardiac death. ML was comparable to or better than two experienced readers in predicting the need for revascularization. AI emerge as a helpful tool in cardiac imaging and for the doctors who can not manage the overall increasing demand, in examinations such as ultrasound, computed tomography, MRI, or nuclear imaging studies.

Keywords: artificial intelligence, cardiac imaging, ultrasound, MRI, CT, nuclear medicine

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Authors: Sara Zelman, Courtney Meyer, Hiren Patel, Lisa Philpotts, Sue Lahey, Thomas Burke

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Background: As the global burden of disease shifts from infectious diseases to noncommunicable diseases, there is growing urgency to provide treatment for time-sensitive illnesses, such as ST-Elevation Myocardial Infarctions (STEMIs). The standard of care for STEMIs in developed countries is Percutaneous Coronary Intervention (PCI). However, this is inaccessible in resource-limited settings. Before the discovery of PCI, Streptokinase (STK) and other thrombolytic drugs were first-line treatments for STEMIs. STK has been recognized as a cost-effective and safe treatment for STEMIs; however, in settings which lack access to PCI, it has not become the established second-line therapy. A systematic literature review was conducted to geographically map the use of STK for STEMIs in resource-limited settings. Methods: Our literature review group searched the databases Cinhal, Embase, Ovid, Pubmed, Web of Science, and WHO’s Index Medicus. The search terms included ‘thrombolytics’ AND ‘myocardial infarction’ AND ‘resource-limited’ and were restricted to human studies and papers written in English. A considerable number of studies came from Latin America; however, these studies were not written in English and were excluded. The initial search yielded 3,487 articles, which was reduced to 3,196 papers after titles were screened. Three medical professionals then screened abstracts, from which 291 articles were selected for full-text review and 94 papers were chosen for final inclusion. These articles were then analyzed and mapped geographically. Results: This systematic literature review revealed that STK has been used for the treatment of STEMIs in 33 resource-limited countries, with 18 of 94 studies taking place in India. Furthermore, 13 studies occurred in Pakistan, followed by Iran (6), Sri Lanka (5), Brazil (4), China (4), and South Africa (4). Conclusion: Our systematic review revealed that STK has been used for the treatment of STEMIs in 33 resource-limited countries, with the highest utilization occurring in India. This demonstrates that even though STK has high utility for STEMI treatment in resource-limited settings, it still has not become the standard of care. Future research should investigate the barriers preventing the establishment of STK use as second-line treatment after PCI.

Keywords: cardiovascular disease, global health, resource-limited setting, ST-Elevation Myocardial Infarction, Streptokinase

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Authors: Basma Hassabo, Sarah Ahmed, Aisha Hameed

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Aims and Objectives: To determine the incidence of maternal mortality amongst pregnant women with sickle cell disease (SCD) in the United Kingdom and to determine exact cause of death in these women. Background: SCD is caused by the ‘sickle’ gene and is characterized by episodes of severe bone pain and other complications like acute chest syndrome, chronic pulmonary hypertension, stroke, retinopathy, chronic renal failure, hepato-splenic crises, avascular bone necrosis, sepsis and leg ulcers. SCD is a continual cause of maternal mortality and fetal complications, and it comprises 1.5% of all Direct and Indirect deaths in the UK. Sepsis following premature rupture of membranes with ascending infection, post-partum infection and pre-labour overwhelming septic shock is one of its leading causes of death. Over the last fifty years of maternal mortality reports in UK, between 1 to 4 pregnant women died in each triennium. Material and Method: This is a retrospective study that involves pregnant women who died from SCD complications in the UK between 1952-2012. Data were collected from the UK Confidential Enquiries into Maternal Death and its causes between 1952–2012. Prior to 1985, exact cause of death in this cohort was not recorded. Results: 33 deaths reported between 1964 and 1984. 17 deaths were reported due to sickle cell disease between 1985 and 2012. Five women in this group died of sickle cell crisis, one woman had liver sequestration crisis, two women died of venous thromboembolism, two had myocardial fibrosis and three died of sepsis. Remaining women died of amniotic fluid embolism, SUDEP, myocardial ischemia and intracranial haemorrhage. Conclusion: The leading causes of death in sickle cell sick pregnant women are sickle cell crises, sepsis, venous thrombosis and thromboembolism. Prenatal care for women with SCD should be managed by a multidisciplinary team that includes an obstetrician, nutritionist, primary care physician, and haematologist. In every sick Sickle Cell woman Sickle Cell crises should be on the top of the list of differential diagnosis. Aggressive treatment of complications with low threshold to commence broad-spectrum antibiotics and LMWH contribute to better outcomes.

Keywords: incidence, maternal mortality, sickle cell disease (SCD), uk

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Authors: Hashem Al Argha

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Cerebral Aneurysms are the ballooning and defect that occurs in the arteries of the brain. This ballooning might enlarge in size due to mechanical forces and could lead to rupture and death. Computational Fluid Dynamics has been used in the recent years in creating a link between engineering sciences and medical sciences. In this paper, the effects of mechanical forces on cerebral aneurysms will be studied. Results of this study show that mechanical forces could lead to rupture of the aneurysm and could lead to death. High mechanical forces including stresses up to 1.7 MPa could pop aneurysms and lead to a brain hemorrhage.

Keywords: computational fluid dynamics, numerical, aneurysm, mechanical forces

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Authors: Osama Moustafa Zayed

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Aim of the work: To evaluate the effectiveness of venous glucose, levels of serum lactate and base deficit in polytraumatized patients as simple parameters to predict the mortality in these patients. Compared to the predictive value of Trauma and injury severity (TRISS) and Acute Physiology And Chronic Health Evaluation IV (APACHE IV). Introduction: Trauma is a serious global health problem, accounting for approximately one in 10 deaths worldwide. Trauma accounts for 5 million deaths per year. Prediction of mortality in trauma patients is an important part of trauma care. Several trauma scores have been devised to predict injury severity and risk of mortality. The trauma and injury severity score (TRISS) was most common used. Regardless of the accuracy of trauma scores, is based on an anatomical description of every injury and cannot be assigned to the patients until a full diagnostic procedure has been performed. So we hypothesized that alterations in admission glucose, lactate levels and base deficit would be an early and easy rapid predictor of mortality. Patient and Method: a comparative cross-sectional study. 282 Polytraumatized patients attended to the Emergency Department(ED) of the Suez Canal university Hospital constituted. The period from 1/1/2012 to 1/4/2013 was included. Results: We found that the best cut off value of TRISS probability of survival score for prediction of mortality among poly-traumatized patients is = 90, with 77% sensitivity and 89% specificity using area under the ROC curve (0.89) at (95%CI). APACHE IV demonstrated 67% sensitivity and 95% specificity at 95% CI at cut off point 99. The best cutoff value of Random Blood Sugar (RBS) for prediction of mortality was>140 mg/dl, with 89%, sensitivity, 49% specificity. The best cut off value of base deficit for prediction of mortality was less than -5.6 with 64% sensitivity, 93% specificity. The best cutoff point of lactate for prediction of mortality was > 2.6 mmol/L with 92%, sensitivity, 42% specificity. Conclusion: According to our results from all evaluated predictors of mortality (laboratory and scores) and mortality based on the estimated cutoff values using ROC curves analysis, the highest risk of mortality was found using a cutoff value of 90 in TRISS score while with laboratory parameters the highest risk of mortality was with serum lactate > 2.6 . Although that all of the three parameter are accurate in predicting mortality in poly-traumatized patients and near with each other, as in serum lactate the area under the curve 0.82, in BD 0.79 and 0.77 in RBS.

Keywords: APACHE IV, emergency department, polytraumatized patients, serum lactate

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