Inflammatory myofibroblastic tumor of the lung in an adolescent boy

Inflammatory myofibroblastic tumors of the lung are rare, here, an unusual case is described. A 14-year-old boy presented with a history of weight loss and clubbing and was found to have a solitary circumscribed mass in right lower lobe treated with lobectomy. This case indicates the need for early and complete removal of the inflammatory myofibroblastic tumor of the lung

Bidirectional cavopulmonary shunt for cyanotic heart disease: surgical experience from a developing country

Objective: The importance of bidirectional cavopulmonary anastomosis for palliation of complex cyanotic con-genital heart disease is widely recognized. This study was conducted to highlight our surgical experience withthis procedure in a developing country.Methods: A retrospective study was conducted using medical records at the Aga Khan University Hospital,Karachi, Pakistan. Clinical findings at presentation, anatomical defects seen on transthoracic echocardiography,pre-operative McGoon index, cardiopulmonary bypass time, use of cardioplegia,post-procedure oxygen satura-tions and complications were evaluated. Results: A total of 8 patients underwent bidirectional cavopulmonary anastomosis. There were 6 males (75%)and 2 females (25%). Ages and weights atoperation averaged 5.7 ± 3.7 years (range 2-14 years) and 18.6 ±10.4 kg (range 8.5-35.5 kg) respectively. The most common symptoms were the presence of cyanosis in all(100%) patients followed by recurrent respiratory tract infections in 3 (37.5%) patients. Transthoracic echocar-diography revealed 6 (75%) patients with atrial septal defects, 5 (62.5%) with tricuspid atresia, 3 (37.5%) with ventricular septal defects, 3 (37.5%) with malposition of great vessels, 2 (25%) with pulmonary stenosis and 2(25%) with double inlet left ventricles. The mean pre-procedure McGoon index was 2.1 ± 0.5 (range 1.37-2.80).All patients received cardioplegia. Cardiopulmonary bypass was used in all patients for a mean time of 154.1 ± 83.6 minutes (range 60-298 minutes). All patients were ventilated for a mean period of 1.5 ± 0.7 days (range 1-3 days). The ICU stay was 3.0 ± 0.6 days (range 2-5 days) with a total hospital stay of 9.8 ± 3.8 days (range 7-18 days). The mean post-procedure oxygen saturation was 82.6 ± 3.5% (range 76-86%). The most commonpost-operative complication was supraventricular arrhythmia in 2 (25.0%) patients. There were no intra-opera- tive or early (within 7 days of procedure) deaths. One patient developed pulmonary artery hypertension and died 23 months later due to cardiac arrest. Conclusion: Patients tolerated the procedure well. After a mean follow-up of 10 months, 6 patients were assessed to be in New York Heart Association (NYHA) functional class I and one patient in NYHA class II.Clinical and post-procedural data gathered from our experience confirms the safety of bidirectional cavopul-monary anastomosi

Rare relapsed extrapulmonary hydatid disease

Hydatid cysts are rarely seen at the extrapulmonary sites. We report relapsed hydatid cysts with abdominal origin in a 25 years old woman. Over 1000 Hydatid cysts were removed through right posterolateral thoracotomy without any complications. Only very few cases are reported in the literature

Outcome and factors associated with hospital mortality in patients with impaired left ventricular function undergoing coronary artery bypass grafting: where do we stand?

Objective: Impaired ventricular function is a known risk factor for mortality after coronary artery bypass grafting however increasingly more patients with impaired ventricular function are referred for surgery. Currently no large data is available from Pakistan regarding this aspect of coronary surgery. Our objectives were to find out the hospital mortality and mid term functional improvement in patients with impaired ventricular function undergoing coronary artery by pass grafting and identify the risk factors for mortality. Methodology: Retrospective analysis of preoperative, operative and postoperative variables of patients with impaired ventricular function who were operated for isolated first time coronary artery bypass between October 2006 to April 2009. Results: Total 190 patients with impaired ventricular function underwent isolated first time coronary artery bypass grafting during this period with a male predominance (82.6%). Mean ejection fraction of the group was 25.4±5.3%. Mean predicted mortality on logistic Euro score was 10.9±2.7%. Actual in hospital mortality of the group was 4.7% which is comparable to contemporary published results. Multivariate analysis identified use of intra aortic balloon pump, non use of internal mammary artery and preoperative NYHA functional class as factors associated with mortality. Conclusion: Coronary artery bypass grafting can be performed in patients with impaired ventricular function with acceptable hospital mortality and mid term functional improvement

Peer-taught virtual research workshops for surgical residents: Protocol for a novel and sustainable solution to improving surgical research in Pakistan

Objective: To generate a protocol describing the methodology for a study assessing the effectiveness of a comprehensive series of peer-taught online research workshops for surgical residents across Pakistan in terms of improving research-related knowledge and skills, and long-term research involvement and output.Methods: The quasi-experimental study will consist of a series of six online research workshops conducted over Zoom for surgical residents across Pakistan. An online sign-up form will be circulated on social media to current surgical residents throughout Pakistan. Curricular content covered in the workshops will be developed in collaboration with experienced research faculty at the Departments of Surgery and Community Health Sciences at the Aga Khan University Hospital, Karachi. Facilitators of the workshops will be current surgical residents with a solid track record of research involvement at the hospital. Improvement in research-related knowledge and skills will be assessed through pre- and post-tests for each workshop. A post-series feedback form will assess satisfaction with the organisation, content relevance, peer-teaching and online delivery of the workshops. Long-term research involvement and output will be assessed by follow-up surveys at 6 months and 1 year post-workshop. All data-collection will be done via Google Forms. For ethical purposes, informed consent will be taken from participants prior to enrolment; data will be collected using a unique identifier number to maintain anonymity; and the only incentive provided to participants will be a Certificate of Completion for the research workshop series.Results: We expect that surgical trainees participating in the series of six research workshops will demonstrate a highly significant percentage improvement (p80%) to rate the overall organisation, effectiveness of online mode of instruction, and relevance to surgical training of the workshops as excellent/good. We also expect that most participants (\u3e80%) would strongly agree/agree that peer-education is an effective model of teaching in research workshops. Finally, we expect statistically significant improvement (pConclusions: In light of the ever-growing need for academic surgeons in Pakistan, this research protocol details a comprehensive strategy for research capacity-building among surgical trainees across the country. By equipping trainees with the knowledge and skills to conduct high-quality research, virtual research workshops provide a novel, grassroots-level and sustainable solution for addressing the surgical research crisis in Pakistan

Knowledge of modifiable risk factors of heart disease among patients with acute myocardial infarction in Karachi, Pakistan: a cross sectional study

BACKGROUND: Knowledge is an important pre-requisite for implementing both primary as well as secondary preventive strategies for cardiovascular disease (CVD). There are no estimates of the level of knowledge of risk factor of heart disease in patients with CVD. We estimated the level of knowledge of modifiable risk factors and determined the factors associated with good level of knowledge among patients presenting with their first acute myocardial infarction (AMI) in a tertiary care hospital in Karachi, Pakistan. METHODS: A hospital based cross-sectional study was conducted at the National Institute of Cardiovascular Disease, a major tertiary care hospital in Karachi Pakistan. Patients admitted with their first AMI were eligible to participate. Standard questionnaire was used to interview 720 subjects. Knowledge of four modifiable risk factors of heart disease: fatty food consumption, smoking, obesity and exercise were assessed. The participants knowing three out of four risk factors were regarded as having a good level of knowledge. A multiple logistic regression model was constructed to identify the determinants of good level of knowledge. RESULTS: The mean age (SD) was 54 (11.66) years. A mere 42% of our study population had a good level of knowledge. In multiple logistic regression analysis, independent predictors of "good" level of knowledge were (odds ratio [95% confidence interval]) more than ten years of schooling were 2.5 [1.30, 4.80] (verses no schooling at all) and nuclear family system (verses extended family system) 2.54 [1.65, 3.89]. In addition, Sindhi ethnicity OR [3.03], higher level of exercise OR [2.76] and non user of tobacco OR [2.53] were also predictors of good level of knowledge. CONCLUSION: Our findings highlight the lack of good level of knowledge of modifiable risk factors for heart disease among subjects admitted with AMI in Pakistan. There is urgent need for aggressive and targeted educational strategies in the Pakistani population

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Lipoprotein‐Associated Phospholipase A2 Activity Is a Marker of Risk But Not a Useful Target for Treatment in Patients With Stable Coronary Heart Disease

Background: We evaluated lipoprotein‐associated phospholipase A2 (Lp‐PLA2) activity in patients with stable coronary heart disease before and during treatment with darapladib, a selective Lp‐PLA2 inhibitor, in relation to outcomes and the effects of darapladib in the STABILITY trial. Methods and Results: Plasma Lp‐PLA2 activity was determined at baseline (n=14 500); at 1 month (n=13 709); serially (n=100) at 3, 6, and 18 months; and at the end of treatment. Adjusted Cox regression models evaluated associations between Lp‐PLA2 activity levels and outcomes. At baseline, the median Lp‐PLA2 level was 172.4 μmol/min per liter (interquartile range 143.1–204.2 μmol/min per liter). Comparing the highest and lowest Lp‐PLA2 quartile groups, the hazard ratios were 1.50 (95% CI 1.23–1.82) for the primary composite end point (cardiovascular death, myocardial infarction, or stroke), 1.95 (95% CI 1.29–2.93) for hospitalization for heart failure, 1.42 (1.07–1.89) for cardiovascular death, and 1.37 (1.03–1.81) for myocardial infarction after adjustment for baseline characteristics, standard laboratory variables, and other prognostic biomarkers. Treatment with darapladib led to a ≈65% persistent reduction in median Lp‐PLA2 activity. There were no associations between on‐treatment Lp‐PLA2 activity or changes of Lp‐PLA2 activity and outcomes, and there were no significant interactions between baseline and on‐treatment Lp‐PLA2 activity or changes in Lp‐PLA2 activity levels and the effects of darapladib on outcomes. Conclusions: Although high Lp‐PLA2 activity was associated with increased risk of cardiovascular events, pharmacological lowering of Lp‐PLA2 activity by ≈65% did not significantly reduce cardiovascular events in patients with stable coronary heart disease, regardless of the baseline level or the magnitude of change of Lp‐PLA2 activity

Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomised, sham-controlled, blinded, phase 3 trial

Background High blood pressure is common in acute stroke and is a predictor of poor outcome; however, large trials of lowering blood pressure have given variable results, and the management of high blood pressure in ultra-acute stroke remains unclear. We investigated whether transdermal glyceryl trinitrate (GTN; also known as nitroglycerin), a nitric oxide donor, might improve outcome when administered very early after stroke onset. Methods We did a multicentre, paramedic-delivered, ambulance-based, prospective, randomised, sham-controlled, blinded-endpoint, phase 3 trial in adults with presumed stroke within 4 h of onset, face-arm-speech-time score of 2 or 3, and systolic blood pressure 120 mm Hg or higher. Participants were randomly assigned (1:1) to receive transdermal GTN (5 mg once daily for 4 days; the GTN group) or a similar sham dressing (the sham group) in UK based ambulances by paramedics, with treatment continued in hospital. Paramedics were unmasked to treatment, whereas participants were masked. The primary outcome was the 7-level modified Rankin Scale (mRS; a measure of functional outcome) at 90 days, assessed by central telephone follow-up with masking to treatment. Analysis was hierarchical, first in participants with a confirmed stroke or transient ischaemic attack (cohort 1), and then in all participants who were randomly assigned (intention to treat, cohort 2) according to the statistical analysis plan. This trial is registered with ISRCTN, number ISRCTN26986053. Findings Between Oct 22, 2015, and May 23, 2018, 516 paramedics from eight UK ambulance services recruited 1149 participants (n=568 in the GTN group, n=581 in the sham group). The median time to randomisation was 71 min (IQR 45–116). 597 (52%) patients had ischaemic stroke, 145 (13%) had intracerebral haemorrhage, 109 (9%) had transient ischaemic attack, and 297 (26%) had a non-stroke mimic at the final diagnosis of the index event. In the GTN group, participants’ systolic blood pressure was lowered by 5·8 mm Hg compared with the sham group (p<0·0001), and diastolic blood pressure was lowered by 2·6 mm Hg (p=0·0026) at hospital admission. We found no difference in mRS between the groups in participants with a final diagnosis of stroke or transient ischaemic stroke (cohort 1): 3 (IQR 2–5; n=420) in the GTN group versus 3 (2–5; n=408) in the sham group, adjusted common odds ratio for poor outcome 1·25 (95% CI 0·97–1·60; p=0·083); we also found no difference in mRS between all patients (cohort 2: 3 [2–5]; n=544, in the GTN group vs 3 [2–5]; n=558, in the sham group; 1·04 [0·84–1·29]; p=0·69). We found no difference in secondary outcomes, death (treatment-related deaths: 36 in the GTN group vs 23 in the sham group [p=0·091]), or serious adverse events (188 in the GTN group vs 170 in the sham group [p=0·16]) between treatment groups. Interpretation Prehospital treatment with transdermal GTN does not seem to improve functional outcome in patients with presumed stroke. It is feasible for UK paramedics to obtain consent and treat patients with stroke in the ultraacute prehospital setting. Funding British Heart Foundation