National Clinical Guidance for the Management of Cardiovascular Intervention in the COVID-19 Pandemic: From Bangladesh Society of Cardiovascular Interventions (BSCI)

Since the first recorded case of SARS-CoV-2 in Bangladesh on 8th March 2020, COVID-19 has spread widely through different regions of the country, resulting in a necessity to re-evaluate the delivery of cardiovascular services, particularly procedures pertaining to interventional cardiology in resource-limited settings. Given its robust capacity for human-to-human transmission and potential of being a nosocomial source of infection, the disease has specific implications on healthcare systems and health care professionals faced with performing essential cardiac procedures in patients with a suspected or confirmed diagnosis of COVID-19. The limited resources in terms of cardiac catheterization laboratories that can be designated to treat only COVID positive patients are further compounded by the additional challenges of unavailability of widespread rapid testing on-site at tertiary cardiac hospitals in Bangladesh. This document prepared for our nation by the Bangladesh Society of Cardiovascular Interventions (BSCI) is intended to serve as a clinical practice guideline for cardiovascular health care professionals, with a focus on modifying standard practice of care during the COVID-19 pandemic, in order to ensure continuation of adequate and timely treatment of cardiovascular emergencies avoiding hospital-based transmission of SARS-COV-2 among healthcare professionals and the patients. This is an evolving document based on currently available global data and is tailored to healthcare systems in Bangladesh with particular focus on, but not limited to, invasive cardiology facilities (cardiac catheterization, electrophysiology & pacing labs). This guideline is limited to the provision of cardiovascular care, and it is expected that specific targeted pharmaco-therapeutics against SARS-CoV-2 be prescribed as stipulated by the National Guidelines on Clinical Management of Corona virus Disease 2019 (COVID-19) published by the Director General of Health Services, Ministry of Health and Family Welfare of Bangladesh.

Sulphur doses and application times on yield and oil quality of canola grown in calcareous soil

Pakistan has been constantly deficient in its oil seed production and it is very difficult to meet the edible oil requirement of its ever-increasing population. A field experiment was conducted at the Agronomy Research Farm, The University of Agriculture Peshawar, Northern Pakistan during winter (2013–14). Five sulphur levels (15, 30, 45, 60 and 75 kg·ha-1) and times of application (at seedling, bolting and flowering stages) were used for the canola variety Abasin-95. The experiment was laid out in a randomized complete block design replicated four times on a 5 m × 3.2 m plot size. The results showed that the sulphur-applied plots gave the highest seed yield, biological yield, glucosinolate, erucic acid, oil content, protein content, oleic acid and linoleic acid compared to the control plots. Sulphur applied at the rate of 60 kg·ha-1 and applied at the bolting stage increased seed yield, biological yield, oil content, and protein content.

Incidence of central diabetes insipid us among the patients undergoing pituitary tumor surgery 06 through trans-sphenoidal approach

Background: Diabetes insipidus (DI) is a common complication following pituitary surgery. Thiscondition can be transient or permanent and the signs and symptoms of this disorder can bemimicked by the normal postoperative course. Objective: This study was carried out to find out the incidence of central diabetes insipidus (DI)among the patients undergoing pituitary tumor surgery through trans-sphenoidal approach eitherendoscopic or microsurgical for the first time.Study Design: Cross sectional observational study Methods: Patients with central (Neurogenic) diabetes insipidus prior to surgery, co-morbiditieslike diabetes mellitus, kidney diseases, electrolyte imbalance, recurrent cases were excludedfrom this study. Patients were followed up to 7th postoperative day by recording and analyzingfindings of postoperative serum electrolytes, urinary specific gravity, hourly urinary volume forestablishing diabetes insipid us. Results: 76.9% of patients developed diabetes insipidus and 70.0% of patients did not developdiabetes insipid us those who underwent pituitary tumour surgery by trans-sphenoidal endoscopicapproach; 23.1% of patients developed diabetes insipid us and 30.0% of patients did not developdiabetes insipid us those who underwent pituitary tumour surgery by trans-sphenoidal mlcrosurgicalapproach. Conclusion: Prediction of DI help us in pre-operative counseling and post-operative managementof the patients as well as to reduce complications related morbidity after pituitary tumor surgery. Journal of Surgical Sciences (2017) Vol. 21 (1) :6-10

Corrigendum to "Dietary administration of Nexrutine inhibits rat liver tumorigenesis and induces apoptotic cell death in human hepatocellular carcinoma cells". [Toxicol. Rep. 2 (2014) (November) 1-11]

[This corrects the article DOI: 10.1016/j.toxrep.2014.11.006.].

Regioselective synthesis of 7-acetyl-11c-methyl-4b,5,7,11c-tetrahydro[1]benzofuro[2′,3′:4,5]thiopyrano[2,3-b]indoles by sequential Claisen rearrangement of 2-(4′-aryloxybut-2′-ynylthio)-1-acetylindoles

Hitherto unreported indole-annulated pentacyclic heterocycles containing oxygen, nitrogen and sulfur have been synthesised by thermal Claisen rearrangement followed by Lewis acid catalysed Claisen rearrangement. 9-Acetyl-4-aryloxymethyl-2,9-dihydrothiopyrano[2,3- b]indoles are regioselectively synthesised in 80–85 % yield by thermal rearrangement of 2-(4′-aryloxybut-2′-ynylthio)-1-acetylindoles. A second, Lewis acid catalysed, rearrangement gave 7-acetyl-11c-methyl-4b,5,7,11c-tetrahydro[1]benzofuro[2′,3′: 4,5]thiopyrano[2,3- b]indoles in yields of 85–90 %. The thermal Claisen rearrangement in refluxing N,N-diethylaniline for 3 h gave the same products in lower yield (50–54 %).

Evaluation of Fixation for Distal Humeral Diaphyseal Fracture by Locking Compression Plate

Treatment of extra-articular distal humeral shaft fractures with plating techniques is often difficult. The recent development of LCP has improved the surgical treatment of fractures by overcoming the few drawbacks of older fixators. The aim of this prospective observational study was to assess the effectiveness of osteosynthesis of extra-articular diaphyseal fractures of the distal third of the humerus using a single locking compression plate (LCP) and was conducted from July 2016 to June 2018 at the National Institute of Traumatology and Orthopedic Rehabilitation (NITOR), Dhaka, Bangladesh. Thirty (30) patients with closed fracture distal 3rd extra-articular humeral shaft fractures were treated by open reduction and internal fixation by locking compression plate. Two cases were excluded from the evaluation of final outcome due to their discontinued follow up. Detailed clinical conditions of all patients, technical difficulty with the implant, postoperative hospital stay period were recorded. Patients were followed up at 2nd week, 4th week, then 4 weekly upto 6 months. The patients were evaluated clinically and radiologically for outcomes. The progresses of healing as well as occurrence of complications were recorded. The range of motion of the shoulder and elbow were evaluated according to the criteria by Rommens grading. Functional evaluation was made according to the criteria by Modified Constant and Murley Scoring System. Union was achieved in all the patients after a mean of 15 weeks (range 12-20 weeks). There were no complications like deep infection, nonunion, malunion, implant failure, or nerve injury occurs in any of the patients. Two patients had transient radial nerve palsy. Two patients developed superficial infection. All patients were relieved pain postoperatively. Functional outcome were excellent in 10 patients, good in 15 patients which constituted 89% satisfactory results. The study has shown that the LCP is an effective, dependable solution for the management of distal third diaphyseal fractures of the humerus.

'At the end of the day, it is more important that he stays happy': an interpretative phenomenological analysis of people who have a sibling with 22q11.2 deletion syndrome

BACKGROUND

22q11.2 deletion syndrome (22q11.2DS) is the most common microdeletion syndrome. However, there is little research examining the effect of this multisystem disorder on the family, particularly siblings. The current study was a phenomenological exploration of sense-making in siblings of a person with 22q11.2DS.

METHOD

Interpretative phenomenological analysis informed a detailed and open examination of being a sibling of a person with 22q11.2DS. Using in-depth semistructured interviews, five typically developing siblings (two men, three women) of people with 22q11.2DS were individually interviewed, providing the data set for transcription and thematic analysis.

RESULTS

The theme 'They are the priority' overarched two subordinate themes that emerged from participants' descriptions of the struggle with acceptance and finding positive meaning. Participants oscillated between conflicting feelings about their sibling with 22q11.2DS always taking centre stage. For example, they felt anger, guilt and resentment; yet, they also embraced patience, empathy and gratitude.

CONCLUSIONS

This phenomenological study provides a foundation for future research relating to 22q11.2DS and fostering family wellbeing, particularly around acceptance and psychological growth. The siblings in this study actively withdrew from their family to allow prioritisation of their affected sibling. However, this does not mean that their needs should be overlooked. There are easily accessible resources to support siblings of individuals with disabilities, and it is important for health professionals and parents to consider these options.

A rare case of Theileria annulata induced corneal opacity in a calf

A 10 months old male cross-bred calf was presented in OPD Medicine, Referral Veterinary Polyclinic, ICAR-Indian Veterinary Research Institute, Izatnagar with the history of anorexia, impaired vision, heavy tick infestation and diarrhoea for the last 1 week. The clinical examination revealed enlarged pre-scapular lymph nodes, prominent cloudiness in eyes and exophthalmos. The presence of Koch blue bodies in biopsied lymph nodes and a PCR assay confirmed it to be bovine tropical theileriosis associated with unique corneal opacity. Treatment with buparvaquone at a dose of 2.5 mg/kg i.m. two doses 48 h apart was successful and typical ocular manifestations completely subsided after 2 weeks of therapy.

Raman-shifted wavelength-selectable pulsed fiber laser with high repetition rate and high pulse energy in the visible

A high-pulse-energy, diffraction-limited, wavelength-selectable, visible source, based on Raman frequency shifting of a frequency-doubled Yb-doped fiber laser, has been studied. The relative length-scaling laws of Raman gain and self-phase modulation push the design towards short fiber lengths with large core size. It is experimentally demonstrated that the Raman clean-up effect in a graded-index multi-mode fiber is not sufficient to obtain diffraction-limited beam quality in the short fiber length. Thus, a large-core photonic crystal fiber is used to maintain diffraction-limited performance and output pulse energies of ~1 μJ, at a 1-MHz repetition rate and 1.3-ns pulse-width are successfully achieved. This step-tunable visible source should find applications in photoacoustic microscopy.

Regional Anesthesia: Preferred Technique for Venodilatation in the Creation of Upper Extremity Arteriovenous Fistulae

Owing to the overall poor medical health of patients with end-stage renal disease, we have sought alternatives to the use of general anesthesia for access procedures. Furthermore, since local anesthesia (1) does not offer the motor block that is sometimes desired and (2) can be difficult to maintain when a large amount of vein needs to be transposed, we examined whether regional blocks can be useful for the creation of new arteriovenous fistulae (AVF).

From August 2002 to January 2005, 41 patients scheduled for AVF placement underwent a regional block with the use of a lidocaine and ropivacaine mixture using a nerve stimulator. Either axillary, interscalene, or infraclavicular blocks or a combination was used. Intraoperative duplex ultrasonography was used to assess the degree of venodilatation of the basilic and cephalic veins before and after the block. The site of each measurement was marked on the skin and selected by a clearly identifiable branch point. Each measurement was recorded three times and was made in the (1) native state, (2) after application of a tourniquet with opening and closing of the hand for 15 seconds, and (3) after placement of the block.

The average age of the patients was 65 ± 14 years (SD), with ages ranging from 33 to 91 years, and the prevalence of diabetes mellitus was 50%. Complete brachial plexus block was achieved in 34 patients (83%). Sensory block was accomplished within 10 to 15 minutes and usually lasted 4 to 6 hours. Motor block was accomplished in 10 to 25 minutes. Venodilatation was not noted in patients whose blocks did not work ( n = 7) or whose vein was found to be phlebitic on exploration ( n = 3). The degree of venodilatation noted as a percentage increase after application of the tourniquet compared with the native state for these 34 patients (in whom the block worked) was 37% for the distal cephalic, 31% for the midcephalic, and 32% for the midbasilic vein. The degree of venodilatation noted as a percentage increase after placement of the block compared with after tourniquet application for these 34 patients was 42% for the distal cephalic, 19% for the midcephalic, and 26% for the midbasilic vein. No instances of systemic toxicity, hematomas, or nerve injury from the block were noted. Accesses placed included 20 radiocephalic AVF, 8 brachiobasilic AVF, 8 brachiocephalic AVF, 2 arteriovenous grafts, 2 radiobasilic AVF, and 1 brachial vein AVF.

Regional block is a safe and, in our opinion, preferred technique for providing anesthesia for upper extremity vascular surgery. The venodilatation observed is augmented compared with that using a tourniquet and may allow more options for access placements.

ID: 25: SOCIAL DETERMINANTS OF PATIENT ANTIBIOTIC MISUSE IN HARYANA, INDIA

Background

Antibiotic resistance is recognized globally as an urgent health crisis. Multidrug resistant organisms lead to deadly hospital and community acquired infections and complicate patients' underlying health issues. In the United States, antibiotic resistance causes 23,000 deaths and direct healthcare costs of $20 billion a year. In the developing world, the costs are estimated to be even higher. In India alone, antibiotic resistance is responsible for an estimated 58,000 infant deaths annually. While its severity is agreed upon, the causes and solutions to antibiotic misuse are complex. Antibiotic dispensing laws are poorly enforced in many developing nations, including India. Patient and provider contributions are intertwined, thus confronting the problem requires a better understanding of the motivations of several populations.

Methods

We conducted a mixed methods study in the northern state of Haryana, India, between June and August 2015. We qualitatively assessed the antibiotic knowledge and use practices of 20 local community members using semi-structured interviews. We also completed 64 surveys of community members and healthcare workers. Both populations were given the same survey, which focused on the participant's experience obtaining antibiotics as a patient. The interviews and surveys were conducted in English and Hindi, as applicable, by bilingual members of the research team. Interview data was coded for themes using NVivo software, and quantitative survey responses were analyzed in SAS. We used DAGitty software to construct a directed acyclic graph to determine the minimally sufficient adjustment sets needed to block confounders of the relationship between antibiotic knowledge and antibiotic misuse.

Results

Over a third of survey participants reported antibiotic misuse, defined as purchasing medication from a pharmacy without a doctor's prescription (36.5%). Furthermore, none of the 20 community member interviewees were able to correctly define antibiotics without prompting. The interviews also revealed that limited health education, inadequate access to a doctor, and poverty all influence patients' antibiotic decision making. Participants with these characteristics were more likely to bypass doctors and seek medical care directly from a pharmacist.

The effect of antibiotic knowledge on antibiotic misuse was significant in our pilot survey data, even after adjusting for the variables in the minimally sufficient adjustment set: first vs. fourth quartile of knowledge, OR=72.09, p=0.014; second vs. fourth quartile, OR=44.09, p=0.006. The covariates in the model include age, income, healthcare occupation, education, having a doctor in the family, and having access to a doctor in your local community.

Discussion

This study highlights the need for public health education regarding antibiotics and the extensive health implications of their misuse. Local and national governments should consider social factors when enacting future antibiotic policies.

The Role of Selective Nerve Root Block in the Treatment of Lumbar Radicular Leg Pain

The objective of this retrospective study was to investigate the clinical effectiveness of nerve root blocks (i.e., periradicular injection of Lidocaine and triamcinolone) for lumbar monoradiculopathy in patients with a mild neurological deficit in National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh from March 2014 to December 2014. We Included 24 patients (32-74 years) with a minor sensory/motor deficit and an unequivocal MRI finding (18 disc herniations, 6 foraminal stenosis) treated with a selective nerve root block. Based on the clinical and imaging findings, surgery (decompression of the nerve root) was justifiable in all cases. Seventeen patients (87%) had rapid (1-4 days) and substantial regression of pain, four required a repeat injection. Sixty percent (60%) of the patients with disc herniation or foraminal stenosis had permanent resolution of pain, so that an operation was avoided over an average of 6 months (2-9 months) follow-up. Nerve root blocks are very effective in the non-operative treatment of minor monoradiculopathy and should be recommended as the initial treatment of choice for this condition.

Highly efficient Yb-free Er-La-Al doped ultra-low NA large mode area single-trench fiber laser

We demonstrate a 60µm core diameter Yb free Er-La-Al doped single-trench fiber having a 0.038 ultra-low-NA, fabricated using conventional MCVD process in conjunction with solution doping technique. Numerical simulations predict an effective single mode operation with effective area varying from 1,820µm(2) to 1,960µm(2) (taking bend-induced modal distortion into account) for different thicknesses of trenches and resonant rings at a constant bend radius of 25cm. Moreover, all solid structure favors easy cleaving and splicing. Experimental measurements demonstrate a robust effective single mode operation. Furthermore, with a 4%-4% laser cavity, this fiber shows a record efficiency of 46% with respect to the absorbed pump power.

High power, compact, picosecond MOPA based on single trench fiber with single polarized diffraction-limited output

We experimentally demonstrate an all-solid Yb-doped 30 μm core diameter single trench fiber. Measurements ensure a robust effective single-mode operation without the need of tight coiling as required for conventional fibers thanks to the ultralow NA (∼0.038) and resonant ring surrounding the core. All-solid and cylindrical design ensures the suitability for mass scale production with the added benefit of all-fiberized device structure. A compact master oscillator power amplifier (MOPA) has been built using this fiber delivering ∼23.5  ps pulses at 13.5 MHz repetition rate delivering up to ∼52  W of average output power corresponding to a pulse energy of ∼3.8  μJ and peak power of >160  kW, while maintaining ∼76% slope efficiency. The output beam exhibits a polarization extinction ratio of more than 15 dB and a M2 less than 1.15.

Review article: cytomegalovirus and inflammatory bowel disease

BACKGROUND

The association between ulcerative colitis and cytomegalovirus (CMV) has been recognised for over 50 years; and the role of CMV in ulcerative colitis in general, and steroid resistance in particular, remains a topic of ongoing controversy. The outcome for patients with CMV reactivation appears worse than that for patients without reactivation, but it is not entirely clear whether CMV is a contributor or a bystander and if treatment with anti-virals alters the course of inflammatory bowel disease (IBD).

AIM

To review the role of CMV associated with IBD, including epidemiology, clinical features, diagnosis and management strategies.

METHODS

By reviewing literature available on CMV associated with IBD in adult patients. A PubMed literature search was performed using the following terms individually or in combination: CMV colitis, cytomegalovirus colitis, IBD and CMV, CMV treatment.

RESULTS

Cytomegalovirus reactivation is common in patients with severe colitis, with a reported prevalence of 4.5-16.6%, and as high as 25% in patients requiring colectomy for severe colitis. The outcome for this group of patients appears worse than that for patients without reactivation; however, reported remission rates following treatment with anti-viral therapy are as high as 71-86%.

CONCLUSIONS

Evidence, although not conclusive, supports testing for CMV colonic disease in cases of moderate to severe colitis, by processing biopsies for haematoxylin and eosin staining with immunohistochemistry and/or, CMV DNA real-time polymerase chain reaction; and if present treating with ganciclovir.