PATHOPHYSIOLOGY, INVESTIGATIONS, AND MANAGEMENT OF VENTRICULAR SEPTAL DEFECT

Background: Ventricular septal defects (VSDs) are still one of the most prevalent surgical indications in newborns and children with congenital heart disease. With advances in echocardiography, cardiac catheterization is no longer necessary in the treatment of these individuals. Although perioperative mortality and morbidity for isolated defects are still low, unique scenarios such as surgical care of numerous VSDs and decision-making in patients with pulmonary hypertension remain difficult. This chapter examines both classic and recent evidence that has shaped the management of this condition, as well as the facts underlying developing interventional methods utilized in both the catheterization lab and the operating room. Conclusion: VSD is the most common congenital abnormality at birth. Small flaws should close on their own within the first year of life; however, larger faults can cause serious difficulties. The major interventions for big problems are surgical VSD closure and device closure

PATHOPHYSIOLOGY, INVESTIGATIONS, AND TREATMENT OF PATIENTS WITH BICUSPID AORTIC VALVE

Bicuspid aortic valve is a congenital anomaly of the heart in which the aortic valve has two loops instead of the normal three. It causes valve degeneration and is associated with dilation of the aorta. This exercise discusses the role of inter-professional team in improving the management of patients with bicuspid aortic valves and describes the diagnosis and management of this problem. The purpose of this review article is to describe the epidemiology of bicuspid aortic valve, describe the presentation of patients with bicuspid aortic valve, summarize the use of electrocardiogram and echocardiogram in bicuspid aortic valve evaluation, and explain the importance of collaboration and communication. Interprofessional team to improve care coordination for patients with bicuspid aortic valve

ETIOLOGY, INVESTIGATIONS, AND TREATMENT IN CASES OF CONSTRICTIVE PERICARDITIS

The fibroelastic sac that covers the heart is known as the pericardium. It has an effect on cardiac hemodynamics and serves as a protective barrier. Constrictive pericarditis is a condition in which the pericardium grows granulation tissue, causing a loss of pericardial elasticity and ventricular filling limitation. Although it is usually a chronic condition, subacute, transient, and occult variants have been reported. The pathogenesis, symptoms, and diagnosis of constrictive pericarditis, as well as the role of the interprofessional team in its treatment, are covered in this exercise. This review article aims to describe the pathophysiology of constrictive pericarditis, review a patient's presentation with constrictive pericarditis, summarise constrictive pericarditis options for treatment, and discuss the importance of improving care coordination among interprofessional team members to enhance constrictive pericarditis patient outcomes. The 10-year survival rate for patients who get a pericardiectomy is around 50%. Medical treatment alone results in a short lifespan

PATHOPHYSIOLOGY, INVESTIGATIONS, AND MANAGEMENT OF UNSTABLE ANGINA: A REVIEW

Unstable angina pectoris is a phenomenon that disrupts the early recovery phase of acute myocardial infection, the emergence of new ischemic symptoms, the development of more severe pain, usually at rest, or the formation of intermittent ischemic events. ۔ Acute myocardial infarction is the most serious complication of unstable angina pectoris, which can affect up to 25% of patients within three months of the onset of symptoms. Physically, changes in ECG and hemodynamics usually occur before the onset of pain. The following hemodynamic changes and an increase in oxygen demand in the already ischemic heart respond positively, leading to further instability in unstable angina. Hemodynamic changes may be the result of abnormal stress response or excessive chemotherapeutic discharge. While coronary spasm may play a role in the pathogenesis of unstable angina, other factors such as bleeding in the wall of the atherosclerotic plaque, peripheral embolization, alteration, or platelet aggregation in the coronary artery from nearby soft cholesterol "abscess". Feedback should also be considered. Along with medications such as nitrates, calcium antagonists, and warnings, beta-adrenergic blockers are used to stimulate coronary and peripheral vasodilation and reduce cardiac effort. Treatment with aortic counter-pulsating balloons is recommended for those who have failed to respond to pharmacological treatment. Emergency surgery should be performed voluntarily. The full clinical and pathological compatibility of unstable angina pectoris is still unknown. Future issues will revolve around further investigations into entity procedures, treatment and prevention. The purpose of this review is to explain the pathophysiology of unstable angina, highlight changes in ECG in the assessment of unstable angina, and improve the outcome of patients with unstable angina. Consider the need to strengthen the coordination of care within the team

A REVIEW ON MITRAL REGURGITATION: PATHOPHYSIOLOGY, INVESTIGATIONS AND TREATMENT

Background: The retrograde movement of blood from the left ventricle (LV) into the left atrium (LA) through the mitral valve (MV) causes a systolic murmur heard best at the apex of the heart with radiation to the left axilla. MR is the most common valvular anomaly in the globe, affecting around 2% of the population and increasing in incidence with age. This activity examines the diagnosis and treatment of mitral regurgitation, emphasizing the importance of the healthcare team in assessing and treating patients with this illness. Conclusion: The goal of this review article is to identify the etiology and epidemiology of mitral regurgitation medical conditions and emergencies, review the proper history, physical, and evaluation of mitral regurgitation, outline the treatment and management options for mitral regurgitation, and describe interprofessional team strategies for improving care coordination and communication to advance mitral regurgitation and improve outcomes

The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study

Background: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy. Methods: Consecutive women undergoing mastectomy ± IBR for breast cancer July–December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored. Results: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays. Conclusions: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients

Breast cancer management pathways during the COVID-19 pandemic: outcomes from the UK ‘Alert Level 4’ phase of the B-MaP-C study

Abstract: Background: The B-MaP-C study aimed to determine alterations to breast cancer (BC) management during the peak transmission period of the UK COVID-19 pandemic and the potential impact of these treatment decisions. Methods: This was a national cohort study of patients with early BC undergoing multidisciplinary team (MDT)-guided treatment recommendations during the pandemic, designated ‘standard’ or ‘COVID-altered’, in the preoperative, operative and post-operative setting. Findings: Of 3776 patients (from 64 UK units) in the study, 2246 (59%) had ‘COVID-altered’ management. ‘Bridging’ endocrine therapy was used (n = 951) where theatre capacity was reduced. There was increasing access to COVID-19 low-risk theatres during the study period (59%). In line with national guidance, immediate breast reconstruction was avoided (n = 299). Where adjuvant chemotherapy was omitted (n = 81), the median benefit was only 3% (IQR 2–9%) using ‘NHS Predict’. There was the rapid adoption of new evidence-based hypofractionated radiotherapy (n = 781, from 46 units). Only 14 patients (1%) tested positive for SARS-CoV-2 during their treatment journey. Conclusions: The majority of ‘COVID-altered’ management decisions were largely in line with pre-COVID evidence-based guidelines, implying that breast cancer survival outcomes are unlikely to be negatively impacted by the pandemic. However, in this study, the potential impact of delays to BC presentation or diagnosis remains unknown

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Proposal for a screening protocol for falls among old subjects attending the audio-vestibular clinic

Abstract Background Older adults suffer from falls. 30% of the elderly fall annually in United States of America (Otorhinolaryngol Head Neck Surg. 5:1-4 2020). Falls have also cost society and people heavily. The aim of this study is to identify fall risk factors in elderly visiting the audio-vestibular clinic and propose a screening strategy. Methods The study included 500 elderly participants over 60 years old who visited the audio-vestibular clinic for hearing and/or vestibular evaluations. All participants in this study underwent a full audiological and neuro-otological history, general examination, otological examination, audiological evaluation, and office vestibular testing. Results One hundred fifty-nine out of 500 (32%) of the study group had a history of vertigo, and 153 out of 500 (31%) had fallen at least once in the past two years. Dizziness and age were significantly associated. Dizziness was more common in people over 70 years old. Similar results were found for the fall history and age. Falls were more common in elderly participants with dizziness. 25% of participants with a history of falls had dizziness, compared to 14.5 percent of those without. Systemic diseases and falls were significantly associated. Falls and abnormal office vestibular test results were statistically significant. Multiple regression analysis showed that Diabetes Mellitus, hypertension, orthostatic hypotension, positional and positioning nystagmus, Romberg and Fukuda tests, and falls were all associated. Multiple risk factors cause older adult to fall. Dizziness increases the risk of falling, especially in the elderly. In our study, hypertension and diabetes were the two greatest independent fall risk factors. Office vestibular tests can detect elderly fallers

AFF1 and STAT4 genes polymorphism in Egyptian systemic lupus erythematosus patients: Association with disease development and activity

Aim of the work: To assess the possible association of ALF transcription elongation factor 1 (AFF1)(rs340630) and signal transducer and activator of transcription 4 (STAT4)(rs7582694) genes polymorphism in Egyptian systemic lupus erythematosus (SLE) cases and their relation with disease activity. Patients and methods: The study included 103 SLE patients and 103 matched controls. SLE disease activity index (SLEDAI-2 K) was assessed. Genotyping was implemented with amplification refractory mutation system polymerase chain reaction (PCR) for AFF1 and allele-specific multiplex PCR for STAT4. Results: The median age of the patients was 38 years, disease duration was 7 years and were 97 females and 6 males (F:M 16.2:1). The median SLEDAI-2 K was 5. AFF1 ‘G’ allele was associated with SLE at 1.52 higher odds ratio (p = 0.042). AFF1 genotypes showed no significant association with existence of SLE (p = 0.08). In SLE patients with A/A genotype, seizures (28.6 %), pleurisy (42.9 %), consumed C3 (85.7 %) and consumed C4 (71.4 %) was significantly more frequent compared to G/A (5.7 %,7.5 %, 56.6 % and 39.6 %) and G/G (0 %, 9.3 %, 39.5 % and 14 % respectively; p = 0.01,p = 0.046,p = 0.04 and p = 0.001). There was a significant association between STAT4 gene polymorphism and the 'C' allele with the occurrence of SLE (p = 0.005 and p < 0.001 respectively). No significant difference was found in clinical manifestations, laboratory investigations or disease activity among STAT4 genotypes. Conclusion: STAT4 polymorphism revealed a significant association with increased SLE risk. However, AFF1 ‘polymorphism showed no significant association with existence of SLE. No significant difference was found in the proportions of AFF1 and STAT4 genotypes among activity grades of SLE