Areca nut chewing and the risk of re-hospitalization and mortality among patients with acute coronary syndrome in Pakistan

Objectives: Areca nut is widely consumed in many parts of the world, especially in South and Southeast Asia, where cardiovascular disease (CVD) is also a huge burden. Among the forms of CVD, acute coronary syndrome (ACS) is a major cause of mortality and morbidity. Research has shown areca nut chewing to be associated with diabetes, hypertension, oropharyngeal and esophageal cancers, and CVD, but little is known about mortality and re-hospitalization secondary to ACS among areca nut users and non-users. Methods: A prospective cohort was studied to quantify the effect of areca nut chewing on patients with newly diagnosed ACS by categorizing the study population into exposed and non-exposed groups according to baseline chewing status. Cox proportional hazards models were used to examine the associations of areca nut chewing with the risk of re-hospitalization and 30-day mortality secondary to ACS. Results: Of the 384 ACS patients, 49.5% (n=190) were areca users. During 1-month of follow-up, 20.3% (n=78) deaths and 25.1% (n=96) re-hospitalizations occurred. A higher risk of re-hospitalization was found (adjusted hazard ratio [aHR], 2.05; 95% confidence interval [CI], 1.29 to 3.27; p=0.002) in areca users than in non-users. Moreover, patients with severe disease were at a significantly higher risk of 30-day mortality (aHR, 2.77; 95% CI, 1.67 to 4.59; p<0.001) and re-hospitalization (aHR, 2.72; 95% CI, 1.73 to 4.26; p<0.001). Conclusions: The 30-day re-hospitalization rate among ACS patients was found to be significantly higher in areca users and individuals with severe disease. These findings suggest that screening for a history of areca nut chewing may help to identify patients at a high risk for re-hospitalization due to secondary events

CAUSES OF DELAY IN THE EXECUTION PHASE OF CONSTRUCTION PROJECTS IN KHYBER PUKHTOONKHWA PAKISTAN

Construction phase is the big problem in large construction business in the Islamic Republic of Pakistan. The construction of large industry plays important role for economy growth, development and evolution in the Islamic Republic of Pakistan. Delay causes a wide range of negative impact on construction projects. Current research focuses on the main flaws which impart delay in projects in sight of various industrial stakeholders which are clients, consultants and contractors. Current study is intended to identify and evaluate the factors causing delay and effects of delays in construction projects of Khyber Pukhtoonkhwa, Pakistan. The survey was conducted through validated questionnaire from structured interview and pilot survey to collect the responses on the causes of delay and delay effects. Client, consultants, and contractors were asked by questionnaire on the causes and effects of the delays. To analyze the data, statistical formula used to calculate the importance of the causes and effects of the delay through Relative important index (RII). After the outcome of the research fifteen (15) factors to cause delays and nine (9) factors of the effects of delays are examined. The top ranked of the reasons for the delays is the lack of Fund to finance the project to completion. While the top ranked of the effects of the delays is time overrun. By adding weight to these factors of trust in the people of the province will be restored to the correct way of mega-projects. Also provide these crucial attention factors, projects can be abstained from more than budgeting and will be useful to gain time and work area.Â

Renal Artery Pseudo-aneurysms: Do All of Them Require Endovascular Management?

Purpose: Our study examines the etiological profile, clinical and imaging features of renal artery pseudo aneurysms (RAPs), as well as the efficacy and need for the angioembolization of RAPs in a resource-constrained setting. Materials and Methods: A total of 36 patients with RAPs were included in our study. Initial diagnosis was made by Doppler Ultrasonography (USG) followed by CT renal angiography in all cases. DSA was performed in 28 patients, as eight patients showed spontaneous resolution by thrombosis on immediate pre-procedure Doppler study. Angioembolization with a microcoil was performed for 30 aneurysms in 28 patients. Technical success was confirmed at the end of the procedure by a renal angiogram. To assess clinical success, we followed up with patients (with clinical and Doppler USG) for a period of six months. Results: The most common cause of RAPs in our study was percutaneous nephrolithotomy (PCNL), seen in 21 patients (58.3%), followed by trauma (25%), and partial nephrectomy (11%). All patients presented to us were within 21 days of the etiological event of hematuria or flank pain. USG was able to detect the RAP in 22 cases (61%). CT renal angiography was diagnostic in all patients but failed to demonstrate two additional aneurysms in one patient. RAP size ≤ 4 mm and absence of brisk filling on CT renal angiography was associated with spontaneous resolution in eight patients, probably an indication of the beginning of spontaneous thrombosis. Angioembolization was done using microcoils and showed 100% technical and clinical success. Conclusion: PCNL is the most common etiological factor for RAPs in our setting. Such patients should have a Doppler USG done prior to discharge from the hospital. CT angiographic flow dynamics (delayed peak enhancement) may be helpful in the identification of RAPs with a high probability of subsequent spontaneous resolution. Angiography followed by embolization using microcoils is the most effective and safe treatment for RAPs with no significant loss of renal parenchyma, although cost remains a limiting factor in our setting

High resolution ultrasonography of thyroid nodules: can ultrasonographic assessment obviate the need for invasive aspiration cytology in ultrasonographically benign lesions?

The use of high-resolution ultrasound (HRUS) thyroid imaging has resulted in a significant revolution in the treatment of thyroid nodules. The enigma of thyroid nodules has been a blind spot for radiologists for a long period. Reporting a thyroid nodule as benign or malignant is quite difficult and many times not accurate. The American Collage of Radiology-Thyroid Imaging Reporting and Data System (ACR-TIRADS) 2017 classification has solved this problem to a large extent. However, the classification needed pathological confirmation for it to be highly accurate. We compared our HRUS-based TIRADS labeling of thyroid nodules with thyroid cytopathology using revised Bethesda classification system. Patients detected with thyroid nodules by HRUS were categorized using ACR-TIRADS and further were taken for fine needle aspiration cytology (FNAC) in our department. The pathological results were compared with the initial TIRADS category of the nodule and the effectiveness of the TIRADS classification in categorizing nodules into benign and malignant was assessed using various statistical variables. The initial USG and the FNAC were performed by a single radiologist with over 10 years of experience. A total of 201 patients underwent HRUS followed by FNAC after obtaining written consent in our department. The thyroid nodules labeled as true benign on ACR-TIRADS (TIRADS 2) were all true benign on Bethesda cytopathology (less than Bethesda III), confirming the high accuracy of HRUS. The diagnostic accuracy of HRUS in cases of ACR-TIRADS 3 nodules was approximately 90.6% with an error rate of 9.4%. Nodules labeled as ACR-TIRADS 4 and 5 had error rates of 47% and 10% in labeling nodules as malignant. The ultrasound-based ACR-TIRADS system can accurately predict the likelihood of specific nodules being benign. There is a strong concordance between Bethesda cytology and ACR-TIRADS classification, particularly for benign nodules. In resource-constrained system like ours, patients with TIRADS 2 and 3 nodules can be safely followed obviating the need for an invasive procedure like FNAC

Styloid Process: What Length Is Abnormal?

The length of the styloid process varies greatly in different populations and depends on ethnicity and geographical background. The elongated styloid process may be associated with Eagle’s syndrome. Therefore, the mean normal length of the styloid process in different population groups needs to be calculated and the upper cutoff limit for elongated styloid process should be found. The objective of the research was to evaluate the styloid process length in the Kashmiri population using multidetector computed tomography. Materials and Methods. We retrospectively evaluated 304 patients who underwent computed tomography of the head and paranasal sinuses, and the mean styloid process length was calculated on both sides. The mean of three measurements of styloid process length was taken. The study population was grouped as follows: Group I included patients at the age of 21-30 years; Group II comprised patients at the age of 31-40 years; Group III included 68 patients at the age of 41-50 years; Group IV comprised patients > 50 years old. Results. The mean length of the styloid process in the studied population varied from 20 to 51 mm (mean 31.3 ± 4.5 mm). There was no significant difference in the length on both sides (p=0.835). The mean length of the styloid process was 30.1 ± 4.2 mm in females and 32.3 ± 4.8 mm in males (p< 0.034). The lengths of the styloid process in different age groups were as follows: in Group I - 30.9 ± 4.4 mm; in Group II - 31.2 ± 4.8 mm; in Group III - 31.6 ± 4.3 mm; in Group IV - 31.5 ± 4.5 mm. Conclusions. The mean length of the styloid process in our population was higher as compared to many other ethnic groups. The styloid process in males was longer. The elongated styloid process on computed tomography scan should not be labeled as Eagle’s syndrome unless clinical symptoms are present

Imaging Evaluation of Mesenteric Ischemia: Is There a Golden Period for This Entity?

Background.The study was aimed at assessing the role of ultrasonography and multidetector computed tomography angiography in evaluating patients with suspected mesenteric ischemia, as well as assessing the effect of the time from presentation to management on mortality and morbidity. Materials and Methods. Patients with clinically suspected mesenteric ischemia underwent Doppler ultrasound and contrast-enhanced computed tomography. On ultrasonography, we assessed any filling defect in the superior mesenteric artery/vein, narrowing or occlusion of the proximal superior mesenteric artery, ascites, bowel wall thickening, and pneumatosis/portal venous gas. Computed tomography angiography was performed looking for any filling defect in the superior mesenteric artery/vein, superior mesenteric artery/vein calibre, bowel wall thickening, calibre and enhancement and pneumatosis/portal vein gas. Most of our patients underwent emergency surgery and the findings correlated with imaging. All the patients were divided into Group A (n=30) and Group B (n=17) based on the time from presentation to management: within 48 hours of presentation and 48 hours after presentation, respectively. Results. On computed tomography scan, mesenteric vascular involvement was seen in 27 (55%) patients, mesenteric/intestinal twist was observed in 12 (25%) patients, and non-occlusive mesenteric ischemia was found in 6% of patients. The computed tomography findings were found to have a sensitivity of 86%, a specificity of 94% and an accuracy of 90% in cases of mesenteric ischemia. Among 35 patients operated on, those presenting within 48 hours, had a significantly less mortality (63%) in comparison to those presenting after 48 hours (90%). Conclusions. Clinical, laboratory and ultrasound features are non-specific in diagnosing mesenteric ischemia. Computed tomography angiography is a sine qua non in mesenteric ischemia diagnosis. Patients with venous ischemia respond well to conservative management. Early intervention within the first 48 hours is associated with better prognosis

CAUSES OF DELAY IN THE EXECUTION PHASE OF CONSTRUCTION PROJECTS IN KHYBER PUKHTOONKHWA PAKISTAN

Construction phase is the big problem in large construction business in the Islamic Republic of Pakistan. The construction of large industry plays important role for economy growth, development and evolution in the Islamic Republic of Pakistan. Delay causes a wide range of negative impact on construction projects. Current research focuses on the main flaws which impart delay in projects in sight of various industrial stakeholders which are clients, consultants and contractors. Current study is intended to identify and evaluate the factors causing delay and effects of delays in construction projects of Khyber Pukhtoonkhwa, Pakistan. The survey was conducted through validated questionnaire from structured interview and pilot survey to collect the responses on the causes of delay and delay effects. Client, consultants, and contractors were asked by questionnaire on the causes and effects of the delays. To analyze the data, statistical formula used to calculate the importance of the causes and effects of the delay through Relative important index (RII). After the outcome of the research fifteen (15) factors to cause delays and nine (9) factors of the effects of delays are examined. The top ranked of the reasons for the delays is the lack of Fund to finance the project to completion. While the top ranked of the effects of the delays is time overrun. By adding weight to these factors of trust in the people of the province will be restored to the correct way of mega-projects. Also provide these crucial attention factors, projects can be abstained from more than budgeting and will be useful to gain time and work area.

Computed Tomography Severity Grading of Chronic Obstructive Pulmonary Disease based on Volumetric Assessment of Inspiratory and Expiratory Scans

Background & Aims:  To determine attenuation threshold for detection and quantification of air trapping in obstructive airway disease. Quantify airway dysfunction in patients of obstructive airway disease & its correlation with pulmonary function tests. Materials & Methods: Paired HRCT scans of 48 patients were done and correlated with Pulmonary Function Tests taken within 2 weeks of the study. Threshold attenuation value on expiratory scan that signifies air trapping was obtained by correlating relative volumes with PFT parameters (PEF 25-75% & RV/TLC). The lung volumes at this threshold were then correlated with PFT values signifying airway dysfunction (FEV1, FEV1/FVC and PEF 25-75%) and airway dysfunction was then quantified based on these volumes. Results: Maximum correlation of PFT parameters signifying air trapping is with relative volume of limited lung at -850HU (l850) (p -10%). Conclusion: l850 can be used as a CT parameter to quantify airway dysfunction irrespective of presence or absence of emphysema. Severity classification of obstructive airway disease was formulated based on l850

Healthy lifestyle as a preventive measure against victimization among school-going adolescents

Background: Bullying and violence are problems of aggression in adolescents. Healthy lifestyle practices are common health promotion approaches in school settings; however, their association with aggressive behaviours in school-going adolescents is less explored. Aims: This study examined the associations of healthy lifestyle behaviours including good hygiene, physical activity, recommended diet and refrainment from tobacco use with bully victimization and violence among adolescents. Methods: Data were obtained from the Global School Health Survey conducted in Pakistan (2009). The study population consisted of school-going adolescents aged 13 to 15 years. We constructed our final dataset using information from 4102 participants. Association of healthy lifestyle behaviours with bully victimization and violence experience were assessed using multivariate logistic regression. Results: Results indicate lower odds of being bullied (good hygiene: OR = 0.62, 95% CI 0.50–0.76, P Conclusions: Our study supports the significance of healthy lifestyle as a preventive measure against victimization. Anti-bullying programmes focusing on social–emotional skill development may also consider promotion of healthy lifestyle behaviours among adolescents, aiming at reducing victimization and its related consequences

The Lived Experiences of Foreign Women: Influences on their International Working Lives.

The lived experiences of foreign women were explored to discover influences on their international working lives. Life history narratives were collected in interviews with twelve participants who were female, foreign (nationality differs to their country of employment), and employed or a business owner in the United Arab Emirates. A phenomenological framework of analysis resulted in identification of three emergent themes around life experiences that had shaped participants’ working lives: becoming a new generation of expatriates; adjustment to socio-cultural change; centrality of womanhood. The implication of these themes was the influence from lived experiences on the development and professional identity of foreign working-women. Findings offer insight about influences on the actual and potential economic participation of foreign women for business practitioners and policy makers. A new classification of foreign worker, the ‘Foreign Working-Woman’ (FW-W), extends the body of academic knowledge. A research direction is proposed for further international study about influences from life experiences on the FW-W