Nitrates for the Management of Acute Heart Failure Syndromes, A Systematic Review

© The Author(s) 2016Intravenous nitrates are widely used in the management of acute heart failure syndrome (AHFS) yet with lack of robust evidence to support their use. We therefore sought to analyze all randomized studies that evaluated the effects of nitrates on clinical outcomes in patients with AHFS. In total, 15 relevant trials comparing nitrates and alternative interventions in 1824 patients were identified. All but 3 were conducted before 1998. No trials demonstrated a beneficial effect on mortality, apart from 1 trial reporting a reduction in mortality, which was related to the time of treatment. Retrospective review suggests that there is a lack of data to draw any firm conclusions concerning the use of nitrates in patients with AHFS. More studies are needed to evaluate the safety and efficacy of these agents in the modern era of guideline-directed use of heart failure therapy.Peer reviewedFinal Accepted Versio

Presentation of acute heart failure and its consequences

Background: Acute heart failure (AHF) is a heterogeneous in aetiology, pathophysiology and presentation and very difficult to classify. Despite this diversity, clinical trials in AHF deal with this syndrome as a single entity, which may be one reason for repeated failures. It is generally believed that patients with AHF present with severe breathlessness at rest but epidemiological data suggest otherwise.Methods: Different data sets were used to assess the presentation of AHF and its consequences. I conducted a detailed case note review to determine what proportions of patients were Short Of Breath At Rest (SOBAR) and Comfortable At Rest but Breathless On Slight Exertion (CARBOSE). Euro Heart Failure Survey 1 (EHFS1) screened consecutive deaths and discharges during 2000-2001 in 24 countries, to ascertain patients with known or suspected Heart Failure (HF). Information on presenting symptoms and signs were gathered. Mortality was assessed during hospital admission and then 3 months after discharge.Results: Of 697 patients, those with SOBAR (45%) had higher median heart rate blood pressure and respiratory rate and these changed quickly in first 24 hours after presentation as compare to CARBOSE (55%) but had better long term prognosis. Of all 10,701 patients admitted with suspected HF in EHFS1, Heart failure was considered to be the primary reason for admission in 4,234 (40%), secondary reason for admission if complicated or prolonged stay in further 1,772 (17%), and in 4,695 (43%) it was uncertain that HF is actively contributing in index admission. Mortality was highest in the secondary heart failure group and lowest in the uncertain group. Heart failure with cardiac arrest/ventricle arrhythmia had worst mortality followed by HF with ACS but considerable number of patients died in uncertain group.Conclusion: AHF is complex, with diverse presentations that are associated with very different subsequent prognosis. Attempts to investigate the effect of agents in all patients with a diagnosis of AHF may be futile. A more coherent approach of focused and tighter patient selection for drug therapy targeted by clinical presentation is more likely to succeed

Trees, Shrubs and Grasses for Saltlands: an Annotated Bibliography

Resource /Energy Economics and Policy,

Islam and Evolution

"This book attempts to equip the reader with a holistic and accessible account of Islam and evolution. It guides the reader through the different variables that have played a part in the ongoing dialogue between Muslim creationists and evolutionists. This work views the discussion through the lens of al-Ghazālī (1058-1111), a widely-known and well-respected Islamic intellectual from the medieval period. By understanding al-Ghazālī as an Ash’arite theologian, a particular strand of Sunni theology, his metaphysical and hermeneutic ideas are taken to explore if and how much Neo-Darwinian evolution can be accepted. It is shown that his ideas can be used to reach an alignment between Islam and Neo-Darwinian evolution. This book offers a detailed examination that seeks to offer clarity if not agreement in the midst of an intense intellectual conflict and polarity amongst Muslims. As such, it will be of great interest to scholars of Science and Religion, Theology, Philosophy of Religion, Islamic Studies, and Religious Studies more generally.

Analysis of Domestic versus Foreign Banks Efficiency in Pakistan

Banking sector reforms were introduced in 1972 in the light of many contemporary issues observed in the banking industry. The nationalization of banks in 1974 improved the financialӏ sector in many ways. The efficiency of the sector was compromised due to politicalӏ influence; over-branching and overstaffing that affected the banking industry. In 1990s many reforms were made in the banking sector to address the problems that existed in the nationalized banking system. The public sector’s ownership of commercial banks had created lot of problems (political intervention in credit allocation, loan recovery and deterioration in services quality). This study evaluated the efficiency of domestic and foreign banks for the period 2010-2016. DEA was used to explore the scale, technical, pure technical and scale efficiency of the domestic and foreign banks. The ӏeast efficient banks are Bank Alfalah, Nationaӏ Bank, Askari Bank and Standard chartered in terms of scale efficiency. Technicalӏ efficiency scores demonstrate that Aӏӏied Bank, Askari bank, Nationalӏ Bank, Standard Chartered Bank and Bank Alfalah did not perform efficiently whereas other banks of the sample did well. Pure technicalӏ efficiency scores under both orientations reveal that in 2010 and 2015, aӏӏ banks showed a perfect pure technicalӏ efficiency score of 1.00. Both domestic and foreign banks performance is mixed. Domestic banks are not less efficient in terms of all efficiencies than foreign banks. Both banks need attention to managerialӏ aspects and efficient utilization of technology in their operations. Sound macroeconomic policies may also help in improving the efficiency of banks