Comparison of electrocardiogram diagnostic criteria in diagnosis of left ventricular hypertrophy using 3 D echocardiography as standard

Background: The echocardiogram (ECHO) has a better diagnostic performance for left ventricular hypertrophy (LVH) than the electrocardiogram (ECG), but ECG is most widely used diagnostic method. We aimed to assess the correlation between ECG based diagnosis of LVH with echocardiography-based diagnosis of LVH as standard. Methods: Patients with evidence of LVH using echocardiographic criteria were included in the study. Patients were subjected to four electrocardiographic criteria to assess the LVH: 1. Sokolow-Lyon criteria; 2. Romhilt and Estes scoring system; 3. Cornell voltage criteria; and 4. Gubner voltage criteria. After assessing the results of ECG and echocardiography diagnostic validity tests (by calculating specificity and sensitivity), the Kappa measure of agreement was performed. Results: In maximum patients (52.8%) LVH was detected by using ECG LVH Sokolow Lyon criteria, followed by Cornell voltage CR criteria that detected LVH in 38.9% cases. Sokolow Lyon ECG criteria showed high sensitivity while Romhilt and Estes criteria showed maximum 98% specificity in diagnosing LVH. Sokolow Lyon’s ECG criteria was highly sensitive in assessing all co-morbidities, except CKD where it was diagnosed better by using Cornell voltage criteria. Conclusions: In cases of diagnosing LVH in patients with co-morbidities, ECG LVH Sokolow Lyon CR was found to be the most sensitive criteria except CKD where it was diagnosed better by using Cornell voltage criteria. For assessing the patients for LVH, the role of ECG with all the commonly used criteria is of limited value and ECHO should be the method of choice.

The rectus sling to prevent loop colostomy retraction: a case series

Diverting stomas are being used increasingly in the management of rectal cancer, particularly with low anterior resection following neoadjuvant therapy. We describe a simple anchorage method for loop colostomy using a rectus fascial sling. This has been used successfully in fifteen patients with no complications or evidence of significant spill over of faecal contents into the efferent loop

Long term prognostic significance of thrombolysis in myocardial infarction risk score after revascularization in non-ST elevation acute coronary syndrome

Background: Non-ST elevation acute coronary syndrome (NSTE-ACS) patients are complex and varied population. Primarily thrombolysis in myocardial infarction (TIMI) risk score was developed to guide therapy and assess the short term (14 days) prognosis of these patients. However, few studies have evaluated the long term prognostic significance of TIMI risk score after revascularization. This study aims at assessing the long term prognostic significance of TIMI risk score, 36 months after revascularization in NSTE-ACS.Methods: This was a retrospective observational cohort study of consecutive NSTE-ACS patients (n=150) treated by percutaneous coronary intervention between January 2017 to June 2017 in a tertiary care center. TIMI risk score was calculated for each patient at admission. The primary endpoint was a composite of MACE (death, repeat target-vessel revascularization, and non-fatal recurrent MI) at the end of 36 months of follow up. Clinical secondary endpoints included the individual components of the primary endpoint, death, nonfatal recurrent MI, and repeat target vessel revascularization.Results: Baseline characteristics for 150 participants were as follows, age 56±9.5 years, 78.7% male, 25% diabetics, 82% hypertensives, and 36% had hypercholesterolemia. The event rates of the primary endpoint and its components after 36 months were 26.6%. Event rates increased significantly as the TIMI risk score increased as determined by regression analysis (p=0.004). The relative risk increased by 66% as the TIMI risk score increased from low risk category (TIMI score 0-2) to high risk (TIMI score 5-6).Conclusions: TIMI risk score can be used for long term prognostication of NSTE-ACS patients after revascularization, and thus can be used by clinicians for therapeutic decision making

Evaluation of clinical outcome of thrombolytic therapy in elderly patients in Western Rajasthan: a single centre experience

Background: Heart disease is the leading cause of mortality in population above the age of 65 years. Severity and prevalence of coronary artery disease (CAD) increase with increasing age. Thrombolysis remains the standard of care in the management of acute ST-elevation myocardial infarction (STEMI) in developing countries like India where primary percutaneous coronary intervention (PCI) is still not possible in the majority of patients. The risks and benefits of thrombolytic reperfusion therapy among the elderly patients with STEMI is much less known. Authors aimed to evaluate the outcome and complications of thrombolytic therapy in elderly patients admitted with acute STEMI.Methods: The present observational study was done between January 2017 and January 2019 in the department of cardiology, Dr. S.N. Medical College, Jodhpur, India. It included a study group comprising 102 consecutive elderly patients who had acute STEMI and underwent thrombolytic therapy and a control group comprising 102 consecutive elderly patients who had STEMI who were not given thrombolytic therapy. Both groups were evaluated for an outcome (in-hospital mortality) and complications.Results: The overall in-hospital mortality was less in thrombolytic therapy group as compared to control group although not statistically significant (8.82% versus 14.70%, p=0.277). Similarly, in-hospital mortality was less in thrombolytic therapy subgroup A (age 66-74 years) as compared to control subgroup A (6.45% versus 10.75%, p=0.583) and also less in thrombolytic therapy subgroup B (age 75-85years) as compared to control subgroup B (12.50% versus 21.62%, p=0.445).  Among the traditional risk factors, co-morbid conditions and complications, there was less prevalence of diabetes mellitus (4.90% versus 15.68%, p=0.021), hypertension (5.88% versus 6.86%, p=1.000), cardiogenic shock (8.82% versus 9.80%, p=1.000), left ventricular failure (LVF) (0.98% versus 3.92%, p=0.365) and atrioventricular (AV) block (0% versus 4.90%, p=0.245) but more acute kidney injury (AKI) (2.94% versus 0%, p=0.070) in thrombolytic therapy group patients as compared to control group patients.  Cerebrovascular accident (CVA) did not occur in both group patients.Conclusion: Despite the higher prevalence of co-morbidities and high risk features in elderly patients of acute STEMI, timely thrombolysis is beneficial. A mortality benefit was seen in all groups suggesting net benefit regardless of increasing age up to the age of 85 years

Histopathological study of ovarian lesions at a tertiary health-care center

Background: Ovary is the most common site of non-neoplastic and neoplastic lesions, can appear at any age, and is the leading cause of hospitalization and surgery. The ovary is made up of totipotent sex cells and multipotent mesenchymal cells. As a result, when it becomes neoplastic, almost any type of tumor can develop. Aims and Objectives: The aim of the study was to find out the histopathological findings of ovarian lesions. Materials and Methods: The present study was carried out in the Department of Pathology, Pacific Institute of Medical Sciences, Udaipur, from April 2021 to September 2022 and includes 102 cases of ovarian lesions. Histopathology department received the specimens in formalin filled container and performed routine grossing and H and E staining procedure. Results: The incidence of neoplastic ovarian lesion was 40.2%. Majority of non-neoplastic lesion of ovary was follicular cyst (42.6%) followed by simple cyst (36.1%). Surface epithelial tumor was diagnosed in majority of ovarian tumors (73.2%) followed by germ cell tumor (22.0%). The majority histopathological benign tumor type was serous cystadenoma (43.9%) and malignant was high-grade serous carcinoma (14.63%). Conclusion: The incidence rate increased with age, with the greatest number of new cases being diagnosed beyond 4th and 5th decade. In our study, the youngest patient was of 2 year and oldest was of more than 60 years. However, histopathological study of ovarian tumors is still considered as a gold standard method, our observations and results proved to be valuable base line information regarding frequency and pattern of ovarian tumors

Ward based goal directed fluid therapy (GDFT) in acute pancreatitis (GAP) trial: A feasibility randomised controlled trial

Background: Goal-directed fluid therapy (GDFT) reduces complications in patients undergoing major general surgery. There are no reports of cardiac output evaluation being used to optimise the fluid administration for patients with acute pancreatitis (AP) in a general surgery ward. / Method: 50 patients with AP were randomised to either ward-based GDFT (n = 25) with intravenous (IV) fluids administered based on stroke volume optimisation protocol or standard care (SC) (n = 25), but with blinded cardiac output evaluation, for 48-h following hospital admission. Primary outcome was feasibility. / Results: 50 of 116 eligible patients (43.1%) were recruited over 20 months demonstrating feasibility. 36 (72%) completed the 48-h of GDFT; 10 (20%) discharged within 48-h and 4 withdrawals (3 GDFT, 1 SC). Baseline characteristics were similar with only 3 participants having severe disease (6%, 1 GDFT, 2 SC). Similar volumes of IV fluids were administered in both groups (GDFT 5465 (1839) ml, SC 5211 (1745) ml). GDFT group had a lower heart rate, blood pressure and respiratory rate and improved oxygen saturations. GDFT was not associated with any harms. There was no evidence of difference in complications of AP (GDFT 24%, SC 32%) or in the duration of stay in intensive care (GDFT 0 (0), SC 0.7 (3) days). Length of hospital stay was 5 (2.9) days in GDFT and 6.3 (7.6) in SC groups. / Conclusion: Ward-based GDFT is feasible and shows a signal of possible efficacy in AP in this early-stage study. A larger multi-site RCT is required to confirm clinical and cost effectiveness

A bibliography of parasites and diseases of marine and freshwater fishes of India

With the increasing demand for fish as human food, aquaculture both in freshwater and salt water is rapidly developing over the world. In the developing countries, fishes are being raised as food. In many countries fish farming is a very important economic activity. The most recent branch, mariculture, has shown advances in raising fishes in brackish, estuarine and bay waters, in which marine, anadromous and catadromous fishes have successfully been grown and maintained

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017 : a systematic analysis for the Global Burden of Disease Study 2017

Background: The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk outcome pairs, and new data on risk exposure levels and risk outcome associations. Methods: We used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017. Findings: In 2017,34.1 million (95% uncertainty interval [UI] 33.3-35.0) deaths and 121 billion (144-1.28) DALYs were attributable to GBD risk factors. Globally, 61.0% (59.6-62.4) of deaths and 48.3% (46.3-50.2) of DALYs were attributed to the GBD 2017 risk factors. When ranked by risk-attributable DALYs, high systolic blood pressure (SBP) was the leading risk factor, accounting for 10.4 million (9.39-11.5) deaths and 218 million (198-237) DALYs, followed by smoking (7.10 million [6.83-7.37] deaths and 182 million [173-193] DALYs), high fasting plasma glucose (6.53 million [5.23-8.23] deaths and 171 million [144-201] DALYs), high body-mass index (BMI; 4.72 million [2.99-6.70] deaths and 148 million [98.6-202] DALYs), and short gestation for birthweight (1.43 million [1.36-1.51] deaths and 139 million [131-147] DALYs). In total, risk-attributable DALYs declined by 4.9% (3.3-6.5) between 2007 and 2017. In the absence of demographic changes (ie, population growth and ageing), changes in risk exposure and risk-deleted DALYs would have led to a 23.5% decline in DALYs during that period. Conversely, in the absence of changes in risk exposure and risk-deleted DALYs, demographic changes would have led to an 18.6% increase in DALYs during that period. The ratios of observed risk exposure levels to exposure levels expected based on SDI (O/E ratios) increased globally for unsafe drinking water and household air pollution between 1990 and 2017. This result suggests that development is occurring more rapidly than are changes in the underlying risk structure in a population. Conversely, nearly universal declines in O/E ratios for smoking and alcohol use indicate that, for a given SDI, exposure to these risks is declining. In 2017, the leading Level 4 risk factor for age-standardised DALY rates was high SBP in four super-regions: central Europe, eastern Europe, and central Asia; north Africa and Middle East; south Asia; and southeast Asia, east Asia, and Oceania. The leading risk factor in the high-income super-region was smoking, in Latin America and Caribbean was high BMI, and in sub-Saharan Africa was unsafe sex. O/E ratios for unsafe sex in sub-Saharan Africa were notably high, and those for alcohol use in north Africa and the Middle East were notably low. Interpretation: By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning

The global, regional, and national burden of oesophageal cancer and its attributable risk factors in 195 countries and territories, 1990-2017: A systematic analysis for the global burden of disease study 2017

© 2020 The Author(s). Background Oesophageal cancer is a common and often fatal cancer that has two main histological subtypes: oesophageal squamous cell carcinoma and oesophageal adenocarcinoma. Updated statistics on the incidence and mortality of oesophageal cancer, and on the disability-adjusted life-years (DALYs) caused by the disease, can assist policy makers in allocating resources for prevention, treatment, and care of oesophageal cancer. We report the latest estimates of these statistics for 195 countries and territories between 1990 and 2017, by age, sex, and Socio-demographic Index (SDI), using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD). Methods We used data from vital registration systems, vital registration-samples, verbal autopsy records, and cancer registries, combined with relevant modelling, to estimate the mortality, incidence, and burden of oesophageal cancer from 1990 to 2017. Mortality-to-incidence ratios (MIRs) were estimated and fed into a Cause of Death Ensemble model (CODEm) including risk factors. MIRs were used for mortality and non-fatal modelling. Estimates of DALYs attributable to the main risk factors of oesophageal cancer available in GBD were also calculated. The proportion of oesophageal squamous cell carcinoma to all oesophageal cancers was extracted by use of publicly available data, and its variation was examined against SDI, the Healthcare Access and Quality (HAQ) Index, and available risk factors in GBD that are specific for oesophageal squamous cell carcinoma (eg, unimproved water source and indoor air pollution) and for oesophageal adenocarcinoma (gastro-oesophageal reflux disease). Findings There were 473 000 (95% uncertainty interval [95% UI] 459 000-485 000) new cases of oesophageal cancer and 436 000 (425 000-448 000) deaths due to oesophageal cancer in 2017. Age-standardised incidence was 5.9 (5.7-6.1) per 100 000 population and age-standardised mortality was 5.5 (5.3-5.6) per 100 000. Oesophageal cancer caused 9.78 million (9.53-10.03) DALYs, with an age-standardised rate of 120 (117-123) per 100 000 population. Between 1990 and 2017, age-standardised incidence decreased by 22.0% (18.6-25.2), mortality decreased by 29.0% (25.8-32.0), and DALYs decreased by 33.4% (30.4-36.1) globally. However, as a result of population growth and ageing, the total number of new cases increased by 52.3% (45.9-58.9), from 310 000 (300 000-322 000) to 473 000 (459 000-485 000); the number of deaths increased by 40.0% (34.1-46.3), from 311 000 (301 000-323 000) to 436 000 (425 000-448 000); and total DALYs increased by 27.4% (22.1-33.1), from 7.68 million (7.42-7.97) to 9.78 million (9.53-10.03). At the national level, China had the highest number of incident cases (235 000 [223 000-246 000]), deaths (213 000 [203 000-223 000]), and DALYs (4.46 million [4.25-4.69]) in 2017. The highest national-level agestandardised incidence rates in 2017 were observed in Malawi (23.0 [19.4-26.5] per 100 000 population) and Mongolia (18.5 [16.4-20.8] per 100 000). In 2017, age-standardised incidence was 2.7 times higher, mortality 2.9 times higher, and DALYs 3.0 times higher in males than in females. In 2017, a substantial proportion of oesophageal cancer DALYs were attributable to known risk factors: tobacco smoking (39.0% [35.5-42.2]), alcohol consumption (33.8% [27.3-39.9]), high BMI (19.5% [6.3-36.0]), a diet low in fruits (19.1% [4.2-34.6]), and use of chewing tobacco (7.5% [5.2-9.6]). Countries with a low SDI and HAQ Index and high levels of indoor air pollution had a higher proportion of oesophageal squamous cell carcinoma to all oesophageal cancer cases than did countries with a high SDI and HAQ Index and with low levels of indoor air pollution. Interpretation Despite reductions in age-standardised incidence and mortality rates, oesophageal cancer remains a major cause of cancer mortality and burden across the world. Oesophageal cancer is a highly fatal disease, requiring increased primary prevention efforts and, possibly, screening in some high-risk areas. Substantial variation exists in age-standardised incidence rates across regions and countries, for reasons that are unclear

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)