Are BP readings taken after a patient-physician encounter in a real-world clinic scenario the lowest of all the readings in a clinic visit.

Objective: To determine the difference in Blood Pressure (BP) readings taken before, during and after the clinic encounter. Study Design: Descriptive study. Place and Duration of Study: Cardiology Clinic, The Aga Khan University Hospital, Karachi, from January to August 2013. Methodology: Hypertensive and normotensive participants aged ≥ 18 years were recruited. Pre-clinic BP was measured by a nurse and in-clinic BP by a physician. After 15 minutes, two post-clinic BP readings were taken at 1 minute interval. All readings were taken using Omron HEM7221-E. Results: Out of 180 participants, males were 57% and 130 (71%) were hypertensive. Mean SBP (Systolic BP) taken preclinic, in-clinic, post-clinic 1 and post-clinic 2 were: 126 ± 20 mmHg, 131 ± 23 mmHg, 126 ± 20 mmHg and 121 ± 21 mmHg respectively (p \u3c 0.001). Mean DBP (Diastolic BP) taken pre-clinic, in-clinic, post-clinic 1 and post-clinic 2 were 77 ± 12 mmHg, 81 ± 13 mmHg, 79 ± 12 mmHg and 79 ± 11 mmHg respectively (p \u3c 0.001). Conclusion: BP taken in the post-clinic setting may significantly be the lowest reading in a clinic encounter, making in-clinic BP unreliable to diagnose or manage hypertension

Defining the hemodynamic response of hypertensive and normotensive subjects through serial timed blood pressure readings in the clinic

Background: Every third patient in the clinic is misdiagnosed due to white-coat phenomenon, necessitating needless and costly treatment. We aimed to study the hemodynamic response of the physician\u27s visit on hypertensive and normotensive patients by investigating the trend of blood pressure (BP) before, during and 15 min after the physician-patient encounter.Methods: A descriptive, cross-sectional study was conducted over a period of 8 months in the cardiology clinics at the Aga Khan University Hospital, Karachi. Both hypertensive and normotensive patients, aged ≥18 years, were recruited. Pregnant females or those with a history of volume loss were excluded. BP readings were taken using an automated, validated device (Omron-HEM7221-E) at three points: pre-clinic BP by the assessment nurse, in-clinic BP by the attending physician and post-clinic BP 15-min after the physician-patient encounter by a research assistant. Independent samples t-test was used to calculate the statistical difference between hypertensive and normotensive BP values.Results: Of 180 participants, 71% (n = 128) were hypertensive and 57% (n = 103) of all were males. The mean age of the participants was 57 ± 15 years. The mean and standard deviation(±SD) systolic BP (SBP) taken pre-clinic, in-clinic and 15-min post-clinic for hypertensive population was 128.7 ± 20 mmHg, 137.1 ± 21 mmHg and 127.9 ± 19 mmHg. The mean and standard deviation(±SD) SBP taken pre-clinic, in-clinic and 15 min post-clinic for normotensive population was 112 ± 16 mmHg, 115.8 ± 20 mmHg and 111.8 ± 15 mmHg. The hypertensive SBP values showed statistically significant difference from the normotensive values (difference in pre-clinic SBP: 16.7 mmHg, p-value \u3c 0.001; in-clinic SBP: 21.3 mmHg, p-value \u3c 0.001; and 15 min post-clinic: 16.1 mmHg, p-value \u3c 0.001).Conclusions: Hypertensive and normotensive patients display congruent hemodynamics upon visiting the physician, the alert response being accentuated amongst the hypertensive group. In-clinic BP readings are higher for both hypertensive and normotensive patients making them unreliable for screening and management of hypertension amongst both the groups

QRS duration and echocardiographic evidence of left ventricular dyssynchrony in patients with left ventricular systolic dysfunction

OBJECTIVE: To determine the association between left ventricular (LV) dyssynchrony assessed by tissue Doppler imaging (TDI) in patients with left ventricular ejection fraction (LVEF) \u3c 35% and prolonged ventricular depolarization on electrocardiography. STUDY DESIGN: A cross-sectional study. PLACE AND DURATION OF STUDY: The Aga Khan University, Karachi, from June to September 2007. METHODOLOGY: All patients with LVEF \u3c 35% were included. Apical 2-D images were obtained in 4 chamber and 2 chamber views. TDI pulse wave Doppler parameters were measured from these 2 color-coded images. Time interval between the onset of QRS complex and the peak systolic velocity per region was derived. Patients with valvular heart disease, mitral annular calcification, atrial fibrillation and paced rhythm were excluded. Fischer\u27s exact test was used to determine the association between QRS duration and left ventricular dyssynchrony. RESULTS: A total of 60 patients were included. Twenty one patients had QRS duration of \u3e 120 msec. Out of those 21 patients, a total of 6 patients (28.6%) had evidence of dyssynchrony on TDI. Five patients (23.8%) had dyssynchrony on the basis of basal septal and basal lateral velocity difference (p=0.045) and 6 patients (28.6%) had evidence of dyssynchrony based on basal anterior and basal inferior velocity difference (p=0.018). Out of the remaining 39 patients with narrow QRS complex, only 2 patients (5.1%) had dyssynchrony on TDI. CONCLUSION: The study demonstrates a significant association between prolonged QRS duration and left ventricular dyssynchrony on TDI. Therefore, such patients should be screened for prolonged QRS duration on ECG before cardiac resynchronization therapy (CRT)

Extra pulmonary uptake of Tc-99m-MAA perfusion lung scan as a result of right to left intra cardiac shunt

Extra pulmonary accumulation of Tc-99m-macroaggregate of albumin (MAA) is rarely seen on perfusion lung scan, and has been reported in less than 4% of a study population of nearly 380 patients1. It occurs when the agent bypasses the lungs due to a right to left (R-L) cardiac or pulmonary shunt, when it is shunted to the portal vein before reaching the right atrium and ventricle of the heart, and when the agent is degraded to a submicron particle size.2 When a pharmaceutical problem is excluded, extra-pulmonary uptake implies unusual hemodynamics with a shunt

Extra [corrected] pulmonary uptake of Tc-99m-MAA perfusion lung scan as a result of right to left intra cardiac shunt

Extra pulmonary accumulation of Tc-99m-macroaggregate of albumin (MAA) is rarely seen on perfusion lung scan, and has been reported in less than 4% of a study population of nearly 380 patients. It occurs when the agent bypasses the lungs due to a right to left (R-L) cardiac or pulmonary shunt, when it is shunted to the portal vein before reaching the right atrium and ventricle of the heart, and when the agent is degraded to a submicron particle size. When a pharmaceutical problem is excluded, extra-pulmonary uptake implies unusual hemodynamics with a shunt. A case is reported in which a clinically unsuspected shunt was diagnosed from the lung perfusion scintigraphy

Clinical profile and outcome of infective endocarditis at the Aga Khan University Hospital

Background: The spectrum of infective endocarditis (IE) is significantly different in developed and developing countries. The present study was conducted to study the clinical profile and outcome of infective endocarditis in Pakistan.Methods: A descriptive cross-sectional study with review of medical records for 188 patients admitted to our teaching hospital with a diagnosis of IE from January 1988 to December 2001. One hundred fifty-nine subjects fulfilled the modified Duke diagnostic criteria.Results: Definite IE was found in 59.7% (95/159) patients, while the rest had possible IE. One-third of subjects had acute IE 55/159 (34.5%). Subacute IE was found in 62% (99/159) and Nosocomial IE in 3% of the cases. Eighty six (54%) were classified as having culturenegative endocarditis and 73 (46%) as culture positive. Ninty four patients (59%) had an underlying predisposing factor including congenital heart disease (31%) and rheumatic heart disease (21%). The most frequently isolated organisms were streptococci (52%) and followed by staphylococci (29%). Fourteen (8.1%) patients had right-sided cardiac involvement. Using univariate analysis, patients with heart failure, neurologic or renal complications, septicemia, nosocomial endocarditis, and prosthetic valve endocarditis were at increased risk of death (p ≤ 0.05), however no individual microorganism, or specific site, size, or morphology of vegetation seen on echocardiogram were significantly associated with death. Thirty-seven (23%) patients died of endocarditis or its complications.Conclusion: Endocarditis continues to be an important contributor to morbidity and mortality in Pakistan, especially in young adults. Our patients differ from the west in terms of epidemiology, predisposing factors, microbiology, complications, and outcom

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

Digital Information Credibility: Towards a Set of Guidelines for Quality Assessment of Grey Literature in Multivocal Literature Review

Credibility, in general, can be interpreted as a sense of trust in someone. The credibility of information remarkably influences the public’s willingness to do or not to do some things. In this research study, the credibility of digital news stories can be interpreted as the sense of confidence a person has in a source of available information that affects their behavior. Humans spread less credible information instead of more credible information very quickly because humans take an interest in fear, disgust, and surprise. Less credible news may affect individuals as well as economies. Therefore, there is a dire need in the current digital era to find out what affects the credibility of digital news stories. This study aims to review the published literature and the grey literature to determine the factors affecting digital news credibility and the factors that build credibility in digital news stories. In this paper, we have developed a multivocal literature review protocol to assess the credibility of digital news stories. The multivocal literature review is an advanced version of the systematic literature review that searches for grey literature in addition to the published literature. The expected outcomes after implementing our protocol will be a list of credibility factors and their practices that can play a vital role in ensuring the credibility of digital news stories. Based on this protocol, we formulated guidelines for the quality assessment of grey literature. The future direction of this research is to analyze the factors through multi-criteria decision-making (MCDM), i.e., analytical hierarchical process

Congenital absence of left circumflex artery with a dominant right coronary artery

Case 1: a 40-year-old man was admitted to our hospital with progressively worsening post myocardial infarction angina. Cardiac catheterisation was performed, which showed total occlusion of the left anterior descending artery (LAD) and the left circumflex artery (LCX) was not visualised. The right coronary artery (RCA) was a large artery supplying the left ventricular inferior and posterolateral walls and filling the LAD artery in retrograde. The patient was referred for coronary artery bypass grafting. Peroperative findings confirmed the angiographic evidence of congenitally absent LCX artery