Exploring the Long-Term Disability Outcomes in Trauma Patients: Study Protocol

Objectives

Post-discharge patient-reported outcomes from trauma registries can be used to measure trauma care quality. However, studies reflecting the Asian experience are limited. Therefore, we aim to develop a digital trauma registry to prospectively capture patient-reported outcomes (PROs) at one-, three-, six-, and twelve-months post-injury in Pakistan.

Methods

We will use a cohort study design to develop a digital trauma registry at two tertiary care facilities (Aga Khan University Hospital & Jinnah Postgraduate Medical Center) in Karachi, Pakistan. The registry will include all admitted adult trauma patients (≥18 years). Data collection will be digital using tablets, with mortality, level of disability, and functional status, quality of life being the outcomes. Telephonic interviews will be conducted with the patients and caregivers for follow-up data collection.

Discussion

The high disability burden following accidental trauma imposes a significant burden and cost on individuals and society. Therefore, the trauma registry would fill this gap by capturing post-discharge long-term PROs. It will provide the injured patient's post-discharge situation, challenges, and future directions for incorporating long-term PROs in low-resource settings. Including long-term measures in routine follow-ups will provide insights into physical, social, and policy barriers and help advance injury care research.

Assessing the Feasibility of a Multifaceted Intervention Package for Improving Respiratory Health of Textile Workers: Findings From the MultiTex Pilot Study in Karachi, Pakistan

We piloted the development and implementation of a multifaceted intervention package for improving respiratory health among textile workers using a pre-post design at six mills in Karachi. The intervention, implemented following a baseline survey (n = 498), included health and safety training of workers and managers, promotion of cotton dust control measures, and the provision of facemasks. Follow-up surveys were conducted at 1, 6, and 12 months post-intervention. Knowledge, attitude, and practice (KAP) scores and respiratory symptoms were assessed through a questionnaire and spirometry was conducted. The intervention was provided to 230 workers and led to an improvement in KAP scores that was more likely among workers with a higher educational status, spinners, smokers, those with a permanent employment status, working in morning shifts, and with ⩾5 years of textile experience. We found the intervention acceptable and feasible in these textile mills henceforth, trials are required to determine its effectiveness.

Which curve is better? A comparative analysis of trauma scoring systems in a South Asian country

Objectives

A diverse set of trauma scoring systems are used globally to predict outcomes and benchmark trauma systems. There is a significant potential benefit of using these scores in low and middle-income countries (LMICs); however, its standardized use based on type of injury is still limited. Our objective is to compare trauma scoring systems between neurotrauma and polytrauma patients to identify the better predictor of mortality in low-resource settings.

Methods

Data were extracted from a digital, multicenter trauma registry implemented in South Asia for a secondary analysis. Adult patients (≥18 years) presenting with a traumatic injury from December 2021 to December 2022 were included in this study. Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Revised Trauma Score (RTS), Mechanism/GCS/Age/Pressure score and GCS/Age/Pressure score were calculated for each patient to predict in-hospital mortality. We used receiver operating characteristic curves to derive sensitivity, specificity and area under the curve (AUC) for each score, including Glasgow Coma Scale (GCS).

Results

The mean age of 2007 patients included in this study was 41.2±17.8 years, with 49.1% patients presenting with neurotrauma. The overall in-hospital mortality rate was 17.2%. GCS and RTS proved to be the best predictors of in-hospital mortality for neurotrauma (AUC: 0.885 and 0.874, respectively), while TRISS and ISS were better predictors for polytrauma patients (AUC: 0.729 and 0.722, respectively).

Conclusion

Trauma scoring systems show differing predictability for in-hospital mortality depending on the type of trauma. Therefore, it is vital to take into account the region of body injury for provision of quality trauma care. Furthermore, context-specific and injury-specific use of these scores in LMICs can enable strengthening of their trauma systems.

Level of evidence

Level III.

Lifesaving skills training in schools - A qualitative study to explore students, teachers, and parent's perceived opportunities and challenges

OBJECTIVE

The objective of this study is to explore the perception of teachers, parents and students' regarding implementation of a school-based lifesaving skills program and help predict potential barriers and solutions.

METHODS

This qualitative exploratory study was conducted in Karachi, Pakistan, from December 2020- to October 2021. We included students, teachers, and parents of secondary (grades VIII, IX, and X) and higher secondary level students (grades XI and XII) in Karachi, Pakistan's public and private schools and colleges. We selected one public, two semi-private, and two private schools. We recruited students, teachers, and parents through convenience sampling. We conducted fifteen focus group discussions (FGDs) with the students, six FGDs with the teachers, and eighteen in-depth interviews (IDIs) with parents. We transcribed the data from audio recordings and translated it into the English language. Finally, we manually analyzed the data using thematic analyses.

RESULTS

This study found that bystanders' main barriers to performing lifesaving skills are lack of knowledge, fear of legal involvement, fear of hurting the patient by incorrect technique, lack of empathy among community stakeholders, and gender bias. However, the participants had a positive and supportive attitude toward implementing lifesaving skills training in schools. They suggested starting student training in the early teenage years, preferred medical staff as trainers, and suggested frequent small sessions in English/Urdu both or Urdu language and training via theory and practical hands-on drills. Furthermore, the training was proposed to be integrated into the school curriculum to make it sustainable. Finally, the government needs to support the program and make the legal environment more conducive for bystanders.

CONCLUSION

This study identified the significant barriers to performing lifesaving skills in an emergency in a low- and middle-income country (LMIC). The participants supported implementing a national lifesaving skills program in schools and colleges. However, the participants expressed that support is needed by the government for sustainability, integrating lifesaving skills into the school curriculum, providing legal support to the bystanders, and creating awareness among the general public.

Three-Dimensional Semantic Segmentation of Diabetic Retinopathy Lesions and Grading Using Transfer Learning

Diabetic retinopathy (DR) is a drastic disease. DR embarks on vision impairment when it is left undetected. In this article, learning-based techniques are presented for the segmentation and classification of DR lesions. The pre-trained Xception model is utilized for deep feature extraction in the segmentation phase. The extracted features are fed to Deeplabv3 for semantic segmentation. For the training of the segmentation model, an experiment is performed for the selection of the optimal hyperparameters that provided effective segmentation results in the testing phase. The multi-classification model is developed for feature extraction using the fully connected (FC) MatMul layer of efficient-net-b0 and pool-10 of the squeeze-net. The extracted features from both models are fused serially, having the dimension of N × 2020, amidst the best N × 1032 features chosen by applying the marine predictor algorithm (MPA). The multi-classification of the DR lesions into grades 0, 1, 2, and 3 is performed using neural network and KNN classifiers. The proposed method performance is validated on open access datasets such as DIARETDB1, e-ophtha-EX, IDRiD, and Messidor. The obtained results are better compared to those of the latest published works.

Documenting response to COVID-individual and systems successes and challenges: a longitudinal qualitative study

Background

This study aimed to document the evolution of perceptions of frontline healthcare workers (FHCW) regarding their well-being and the quality of health systems' response to the COVID-19 pandemic over four months in Pakistan.

Methods

We conducted this prospective longitudinal qualitative study during the four months (June–September 2020) coinciding with the peak and trough of the first wave of Pakistan's COVID-19 pandemic. We approached frontline healthcare workers (physicians and nurses) working in emergency departments (ED) in two hospitals using the WhatsApp group of the Pakistan Society of Emergency Physicians (PSEM). Participants were asked to self-record their perception of their wellness and their level of satisfaction with the quality of their hospitals' response to the pandemic. We transcribed, translated, and analysed manually using MAXQDA 2020 software and conducted the thematic analysis to identify themes and sub-themes.

Results

We invited approximately 200 FHCWs associated with PSEM to participate in the study. Of the 61 who agreed to participate, 27 completed the study. A total of 149 audio recordings were received and transcribed. Three themes and eight sub-themes have emerged from the data. The themes were individual-level challenges, health system-level challenges, and hope for the future. Sub-themes for individual-level challenges were: fear of getting or transmitting infection, feeling demotivated and unappreciated, disappointment due to people’s lack of compliance with COVID-19 protocols, physical exhaustion, and fatigue. For the healthcare system, sub-themes were: Infrastructure, logistics, management, and communications response of the hospital/healthcare system and financial stressors. For sub-themes under hope for the future were the improved disease knowledge and vaccine development. The overall perceptions and experiences of FHCWs evolved from fear, grief, and negativity to hope and positivity as the curve of COVID-19 went down.

Conclusion

This study shows that the individuals and systems were not prepared to deal with the challenges of the COVID-19 pandemic. The findings highlight the challenges faced by individuals and health systems during the wake of the Covid-19 pandemic. The healthcare workers were emotionally and physically taxed, while the health systems were overwhelmed by COVID-19. The overall perceptions of FHCWs evolved with time and became negative to positive as the curve of COVID-19 went down during the first wave of COVID-19 in Pakistan.

Changing Perceptions of Rural Frontline Workers and Caregivers About Management of Childhood Diarrhea and Pneumonia Despite Several Inequities: The Nigraan Plus Trial in Pakistan

Purpose

Diarrhea and pneumonia greatly contribute to high childhood mortality in Pakistan. Frontline community health workers or the Lady Health Workers (LHWs) provide care at the doorstep of over 60% of Pakistan’s rural residents. Difficult terrain, lack of supplies, and inadequate supervision put these LHWs at an added disadvantage in the timely diagnosis and delivery of known treatment options to community caregivers (CCGs). This study aims to assess whether a supportive supervision intervention through Lady Health Supervisors (LHSs) using enhanced mentorship and written feedback cards have the potential to improve case management of childhood diarrhea and pneumonia.

Study Setting and Design

This perception-based qualitative inquiry nested within the Nigraan Plus trial included LHSs, LHWs, and CCGs as the participants. Twenty-two in-depth interviews (IDIs) and 16 focus group discussions (FGDs) were conducted before a supportive supervision intervention in 2017, and 10 FGDs were conducted in 2019 once the intervention concluded. Data were analyzed using manual content analysis.

Results

The perceived ability of LHWs and LHSs to describe the danger signs of diarrhea and pneumonia, classify dehydration and relate respiratory rate to the severity of pneumonia improved over time. Appropriate prescription of zinc in diarrhea and antibiotics in pneumonia was noted. Furthermore, CCGs’ trust in LHWs increased following the intervention, and they reported a growing inclination to contact LHWs as their first point of care. LHWs in the intervention arm were more satisfied with their job due to frequent supervisory visits and continuous feedback by LHSs.

Conclusion

Despite geographic, social, and economic inequities, supportive supervision has the potential to improve knowledge, practice, and skills of frontline health workers related to CCM of childhood diarrhea and pneumonia in disadvantaged rural communities. Additionally, the trust of CCGs in the health workers’ ability to manage such cases is also enhanced.

Cardiopulmonary resuscitation (CPR) training strategies in the times of COVID-19: a systematic literature review comparing different training methodologies

BACKGROUND

Traditional, instructor led, in-person training of CPR skills has become more challenging due to COVID-19 pandemic. We compared the learning outcomes of standard in-person CPR training (ST) with alternative methods of training such as hybrid or online-only training (AT) on CPR performance, quality, and knowledge among laypersons with no previous CPR training.

METHODS

We searched PubMed and Google Scholar for relevant articles from January 1995 to May 2020. Covidence was used to review articles by two independent researchers. Effective Public Health Practice Project (EPHPP) Quality Assessment Tool was used to assess quality of the manuscripts.

RESULTS

Of the 978 articles screened, twenty met the final inclusion criteria. All included studies had an experimental design and moderate to strong global quality rating. The trainees in ST group performed better on calling 911, time to initiate chest compressions, hand placement and chest compression depth. Trainees in AT group performed better in assessing scene safety, calling for help, response time including initiating first rescue breathing, adequate ventilation volume, compression rates, shorter hands-off time, confidence, willingness to perform CPR, ability to follow CPR algorithm, and equivalent or better knowledge retention than standard teaching methodology.

CONCLUSION

AT methods of CPR training provide an effective alternative to the standard in-person CPR for large scale public training.

Determinants of occupational hazards knowledge and safety practices among textile workers in Karachi, Pakistan: a cross sectional study

OBJECTIVE

To determine the factors associated with good knowledge and safe practices regarding occupational hazards among textile workers.

METHODS

The cross-sectional study was conducted in Karachi from September 2015 to February 2016, and comprised male workers from seven textile mills. A 45-item structured questionnaire was developed and pretested in Urdu, the local language. One part of the questionnaire comprised 31 items related to good knowledge, and the other part comprised 14 items related to safe practices. Data was analysed using SPSS 19.

RESULTS

Of the 300 subjects, 123(41%) were aged 18-27 years, 183(63%) were educated, 184(61.3%) worked more than eight hours daily, 170(57%) were employed in the weaving section and 164(55%) as machine operators. Besides, 231(77%) had good knowledge, and 62(21%) reported safe practices. Educated workers were more likely (p<0.05), and machine operators were less likely (p<0.05) to have good knowledge, while educated workers, those in the spinning section and those working less than 8-hours daily (p<0.05) were more likely to report safe practices.

CONCLUSIONS

There was a high knowledge level, but a wide gap in adopting safety practices, which indicates need for focused interventions targeting high-risk workers and regulation of working hours.

Physical and mental health impacts of COVID-19 on healthcare workers: a scoping review

BACKGROUND

Coronavirus disease (COVID-19) pandemic has spread to 198 countries, with approximately 2.4 million confirmed cases and 150,000 deaths globally as of April 18. Frontline healthcare workers (HCWs) face a substantially higher risk of infection and death due to excessive COVID-19 exposure. This review aimed at summarizing the evidence of the physical and mental health impacts of COVID-19 pandemic on health-care workers (HCWs).

METHODS

We used the Arksey O'Malley framework to conduct a scoping review. A systematic literature search was conducted using two databases: PubMed and Google Scholar. We found 154 studies, and out of which 10 met our criteria. We collected information on the date of publication, first author's country, the title of the article, study design, study population, intervention and outcome, and key findings, and divided all research articles into two domains: physical and mental health impact.

RESULTS

We reviewed a total of 154 articles from PubMed (126) and Google Scholar (28), of which 58 were found to be duplicate articles and were excluded. Of the remaining 96 articles, 82 were excluded after screening for eligibility, and 4 articles did not have available full texts. Ten full-text articles were reviewed and included in this study. Our findings identified the following risk factors for COVID-19-related health impact: working in a high-risk department, diagnosed family member, inadequate hand hygiene, suboptimal hand hygiene before and after contact with patients, improper PPE use, close contact with patients (≥ 12 times/day), long daily contact hours (≥ 15 h), and unprotected exposure. The most common symptoms identified amongst HCWs were fever (85%), cough (70%), and weakness (70%). Prolonged PPE usage led to cutaneous manifestations and skin damage (97%), with the nasal bridge (83%) most commonly affected site. HCWs experienced high levels of depression, anxiety, insomnia, and distress. Female HCWs and nurses were disproportionately affected.

CONCLUSION

The frontline healthcare workers are at risk of physical and mental consequences directly as the result of providing care to patients with COVID-19. Even though there are few intervention studies, early data suggest implementation strategies to reduce the chances of infections, shorter shift lengths, and mechanisms for mental health support could reduce the morbidity and mortality amongst HCWs.

P245 Acute ST segment elevation MI in a patient following negative dobuatmine stress echocardiography: Possible mechanisms and lessons to learn

Funding Acknowledgements

No Funding

Background

Dobutamine stress echocardiography (DSE) has been used as a safe stress modality for assessing myocardial ischemia. Acute myocardial infarction is one of the rare complications of DSE. In this report, we will discuss a case of a 60 year old lady who developed anterior ST-segment elevation myocardial infarction(STEMI) after a negative DSE.

Case report

60 year old lady with a background of PCI to LAD in 2009 presented with angina , a repeat angiogram showed mild to moderate in stent restenosis (ISR) within the LAD but instant wave-free ratio (IFR ) was 0.94 , Fractional Flow Reserve(FFR) 0.84 and negative IVUS studies. Despite that, the patient continued to have chest pain with effort and therefore a DSE was requested. The patient was stressed with intravenous Dobutamine with a maximum dose of 40mcg/kg/min plus 600mcg of atropine. There was no evidence of ischemia. The Patient developed chest pain 15 minutes later. ECG was done and showed ST elevation in anterior leads. Urgent angiography was undertaken which showed acute thrombotic occlusion in the mid LAD with TIMI 0 flow (within the area where ISR had been seen previously) (fig1) . Percutaneous intervention was undertaken and TIMI III flow was restored.

Discussion

Acute STEMI within a few hours after normal DSE is very rare with an incidence of 0.02% (range 0.00% to 0.10%) Plaque destabilisation and rupture are the possible underlying mechanisms behind coronary occlusion. Interestingly, most of the cases happen within 30 mins after the test.

The activation of sympathetic nervous system leads to increased catecholamines, blood viscosity, arterial pressure and heart rate, which are accompanied by detectable increase in platelet aggregation and decrease in fibrinolytic activity that both tend to favour thrombosis. This could lead to propagation of mural thrombus overlying a small plaque erosion that might otherwise have been harmless.

Another interesting learning point is the correlation between chronotropic incompetence (CI) and myocardial ischaemia. Low basal heart rate is one of the predictors of CI (baseline average heart rate of 60 bpm in our case, and she managed to achieve only 81% of target Heart rate (THR) despite the maximum dose of dobutamine and atropine). Many studies examined the significance of CI. Impaired Chronotropic response is associated with an increased risk of mortality and MI. Possible explanation is that patients with CI fail to demonstrate or underestimate extent of ischemia.

With the experience of our case and similar cases from the literature, we suggest symptoms of chest pain should be seriously attended even after a normal DSE. The risk of life-threatening complication should be informed to patients and enough time should be taken for observation post stress test.

More research is needed to clarify the role of DSE in CI patients on account of its potential normal result with submaximal THR and risk of life threatening cardiac event.

Abstract P245 Figure. Coronary Angiogram fig1

Spontaneous coronary artery dissection presenting as an ischaemic stroke in a middle-aged man with anti-cardiolipin antibodies: a case report

Introduction

Cerebrovascular disease is a major cause of mortality and morbidity worldwide. Ischemic stroke is the most common manifestation, encompassing a wide variety of causative mechanisms. We present the case of a middle-aged male patient with spontaneous coronary artery dissection in the presence of anti-cardiolipin antibodies, leading to left ventricular thrombus and presenting with stroke.

Case presentation

A 56-year-old Caucasian man presented with dysarthria and right-sided weakness. There was a history of chest pain with autonomic symptoms four days earlier. Examination revealed right-sided hemiparesis. Electrocardiogram showed sinus rhythm with anterior Q waves. Magnetic resonance imaging of the brain showed large left parietal and smaller multiple cerebral infarcts. Echocardiogram showed anterior wall and apical akinesis with a large mural thrombus. Anti-cardiolipin antibodies immunoglobulin G and immunoglobulin M were strongly positive. Coronary angiography showed dissection of the mid left anterior descending artery with normal flow down the distal vessel. He was treated conservatively with anticoagulation and secondary prevention. He was in good health when seen in clinic four months later.

Conclusion

We highlight the importance of a comprehensive approach at obtaining the correct diagnosis, input of different specialities and the fact that the presence of anti-cardiolipin antibodies is associated with coronary artery dissection in a middle-aged male patient whose presentation was stroke.

First myocardial infarction in patients of Indian subcontinent and European origin: comparison of risk factors, management, and long term outcome

OBJECTIVE

To compare long term outcome after first myocardial infarction among British patients originating from the Indian subcontinent and from Europe.

DESIGN

Matched pairs study.

SETTING

Coronary care unit in central Leicester.

SUBJECTS

238 pairs of patients admitted during 1987-93 matched for age (within 2 years), sex, date of admission (within 3 months), type of infarction (Q/non-Q), and site of infarction.

MAIN OUTCOME MEASURES

Incidence of angina, reinfarction, or death during follow up of 1-7 years.

RESULTS

Patients of Indian subcontinent origin had a higher prevalence of diabetes (35% v 9% in patients of European origin, P < 0.001), lower prevalence of smoking (39% v 63%, P < 0.001), longer median delay from symptom onset to admission (5 hours v 3 hours, P < 0.01), and lower use of thrombolysis (50% v 66%, P < 0.001). During long term follow up (median 39 months), mortality was higher in patients of Indian subcontinent origin (unadjusted hazard ratio = 2.1, 95% confidence interval 1.3 to 3.4, P = 0.002). After adjustment for smoking, history of diabetes, and thrombolysis the estimated hazard ratio fell slightly to 2.0 (1.1 to 3.6, P = 0.02). Patients of Indian subcontinent origin had almost twice the incidence of angina (54% v 29%; P < 0.001) and almost three times the risk of reinfarction during follow up (34% v 12.5% at 3 years, P < 0.001). The unadjusted hazard ratio for reinfarction in patients of Indian subcontinent origin was 2.8 (1.8 to 4.4, P < 0.001). Adjustment for smoking, history of diabetes, and thrombolysis made little difference to the hazard ratio. Coronary angiography was performed with similar frequency in the two groups; triple vessel disease was the commonest finding in patients of Indian subcontinent origin and single vessel disease the commonest in Europeans (P < 0.001).

CONCLUSIONS

Patients of Indian subcontinent origin are at substantially higher risk of mortality and of further coronary events than Europeans after first myocardial infarction. This is probably due to their higher prevalence of diffuse coronary atheroma. Their need for investigation with a view to coronary revascularisation is therefore greater. History of diabetes is an inadequate surrogate for ethnic origin as a prognostic indicator.

Like father like son? Sons of patients of European or Indian origin with coronary artery disease reflect their parents' risk factor patterns

OBJECTIVE

To investigate the extent to which risk factor patterns associated with coronary artery disease (CAD) in patients of Indian origin and in those of North European origin undergoing coronary angiography for suspected angina were reflected in their apparently healthy sons aged 15-30 years.

DESIGN

Prospective study in which risk markers were measured in patients of Indian origin and in matched European patients undergoing angiography and in their sons.

SETTING

Patients attending a regional cardiac centre and their families.

PATIENTS

102 consecutive male patients of Indian origin undergoing diagnostic coronary angiography for suspected angina and 89 of their sons aged between 15 and 30 years; 102 age matched male European patients and 82 sons.

MAIN OUTCOME MEASURES

Father son correlations for risk markers predicting the severity of parental CAD; differences in mean levels of these markers between young males of Indian origin and those of North European origin.

RESULTS

Lp(a) lipoprotein, total cholesterol, and serum insulin were independent predictors of the severity of CAD in patients of Indian origin and in those of North European origin. In both groups, there was strong correlation between paternal and filial serum insulin (r = 0.41 Indian origin, r = 0.49 North European, P < 0.001), Lp(a) lipoprotein (r = 0.44 Indian origin, r = 0.48 North European, P < 0.001), and total cholesterol (r = 0.39 Indian origin, r = 0.45 North European, P < 0.001) concentrations, and the risk factor profiles of the sons were predictive of CAD severity in their fathers. Sons of patients of Indian origin had significantly higher serum insulin (Indian origin 14.3 mU/l v North European 8.4 mU/l, P = 0.002) and Lp(a) lipoprotein (Indian origin 19.1 mmol/l v North European 10.5 mmol/l, P = 0.001) concentrations than sons of patients of North European origin.

CONCLUSIONS

Apparently healthy young men aged 15-30 years from either ethnic community already reflect risk marker patterns associated with coronary artery disease in their parents, both for genetically determined factors such as Lp(a) lipoprotein and environmentally influenced factors such as insulin and cholesterol. Health promotion measures aimed at reducing the prevalence of CAD should include the adolescent and young adult populations, particularly those with a family history of CAD, or who are from ethnic communities in which this diagnosis is prevalent.

Determinants of early and late mortality in patients with end-stage renal disease undergoing cardiac surgery

To determine factors influencing early and late mortality associated with cardiovascular surgery in end-stage renal disease, 48 consecutive patients (mean age 56.3 years) were reviewed: 30 underwent coronary and 18 valvular surgery. There were eight early deaths, three in the former and five in the latter group. Factors significantly related to early mortality in univariate testing included infective valvular disease, emergency vs elective surgery (both p = 0.02) poor left ventricular function and prolonged clamping and bypass times (all p = 0.001). When these factors were included in a stepwise logistic regression analysis, infective valvular disease (p = 0.02), poor left ventricular function (p = 0.01) and long cross-clamping (p = 0.01) were independently associated with early mortality. There were six late deaths. Survival for the whole cohort at 1, 5 and 7 years was 95%, 60.4% and 42.6%, respectively. Related to late mortality at univariate testing were age (p = 0.03), smoking (p = 0.04), diabetes (p = 0.03) and poor left ventricular function (p = 0.02), and stepwise logistic regression analysis showed independent association with age, diabetes and impaired left ventricular function. Mortality associated with cardiac surgery in patients with end-stage nephropathy can be reduced by better patient selection, early operation in patients with infective endocarditis, and minimized cross-clamping and bypass times.

A comparison of early mortality and morbidity after single and bilateral internal mammary artery grafting with the free right internal mammary artery

OBJECTIVE

To compare differences in early mortality and morbidity in patients receiving a single internal mammary artery graft (SIMA) with those receiving bilateral internal mammary artery grafts (BIMA) with a free right internal mammary artery (RIMA).

DESIGN

Retrospective analysis of 150 patients undergoing BIMA grafting between 1989-1992 who were carefully matched with 150 patients undergoing SIMA grafting between 1987-1992 for known cardiovascular risk factors, extent of coronary disease, left ventricular function, and number of coronary grafts. Operative variables noted included aortic cross clamp time and bypass time. Postoperative cardiac, respiratory, and wound complications were also noted.

RESULTS

Operative mortality was 2% in the SIMA group and 1.3% in the BIMA group (NS). Other than the prevalence of ventricular arrhythmias (P = 0.025), which were more common in the BIMA group, there were no significant differences between the two groups in terms of postoperative morbidity. At median (interquartile range) follow up of 27.94(0.86) and 23.94(0.74) months for the SIMA and BIMA groups respectively there were no deaths. 87% of the SIMA group and 91% of the BIMA group were free of symptoms at follow up.

CONCLUSIONS

The earlier fears regarding increased early mortality and morbidity after BIMA surgery were not confirmed by this study. All patients receiving both mammary arteries had a free rather than pedicle right internal mammary graft. The early mortality and morbidity reported here compares favourably with previous reports on the use of a pedicle graft.

A prospective study of serum lipoproteins after coronary artery bypass surgery

We examined the acute and long-term effects of coronary artery bypass (CABG) surgery on serum lipid, lipoprotein and apolipoprotein levels. One series of 34 patients having CABG surgery was studied pre-operatively and for six weeks afterwards, and another 22 patients were investigated before and two years after CABG surgery. None of the patients studied received any lipid-lowering drug therapy or specific dietary advice. In both groups, pre-operative serum lipoprotein (a) (Lp(a)) and serum triglyceride concentrations were raised and serum high-density lipoprotein (HDL) cholesterol and apolipoprotein AI (apo AI) were low compared to healthy people. Acutely, there were profound decreases of 40-60% in the serum levels of cholesterol (p < 0.001), low-density lipoprotein cholesterol (p < 0.05), triglycerides (p < 0.01), Lp(a) (p < 0.05) and apolipoprotein B (apo B) (p < 0.05). There was a small decrease in serum apo A1 (p < 0.05), and serum HDL cholesterol showed no change. All these variables regained their pre-operative values within six weeks. Two years postoperatively, serum Lpa was 40% less than its pre-operative concentration (p < 0.001) and HDL cholesterol had increased (p < 0.001). Triglyceride levels decreased (p < 0.02) when beta-blockade was withdrawn. The long-term decrease in Lp(a) following surgery is unlikely to be due either to stopping beta-blockers or to life-style changes. Myocardial ischaemia relieved by the operation may have been partially responsible for its previously raised concentration.

Bicoronary-pulmonary fistulae with coexistent mitral valve prolapse: a case report and literature review of coronary-pulmonary fistula

Bicoronary-pulmonary artery fistulae are rare congenital coronary artery fistulae. We report the case of a 57-year-old man who presented with biventricular failure and angina pectoris. At angiography the coronary arteries were normal, but bicoronary-pulmonary fistulae were noted; severe mitral regurgitation secondary to mitral valve prolapse was also present. At right heart catheterization the calculated left to right shunt was 2.1. Fistula ligation and repair of both mitral and tricuspid valves was undertaken. The literature regarding coronary-pulmonary fistula is also reviewed.

Early and late results following combined coronary bypass surgery and mitral valve replacement

To study the effect of various perioperative and operative variables, we analysed the results of 66 consecutive patients undergoing mitral valve replacement (MVR) and coronary artery bypass grafting (CABG). The mean age was 61.2 years (34 males and 32 females), the mean follow-up 54.71 +/- 7.8 months. The hospital mortality rate was 7.6% (5/66). New York Heart Association (NYHA) functional class (P < 0.01), left ventricular global wall motion score (increased scores indicating impaired function, P = 0.005) and cross-clamp time (P < 0.05) were associated with hospital mortality. There was no significant relationship of age (certainly up to the age of 70), cause of mitral valve disease, severity of mitral regurgitation, number of grafts, presence of angina, or previous myocardial infarction with hospital mortality. There were eight late deaths, survival at 1, 3 and 5 years was 92.4%, 83.2% and 80.2%, respectively. Although there was a trend for pulmonary vascular resistance (P = 0.15), NYHA class (P = 0.18) and aortic cross-clamp time (P = 0.09) to be associated with late survival, the only factor significantly related to late survival was global wall motion score (P = 0.001), i.e. those with scores of more than 10. Severity of mitral regurgitation and cause of mitral valve disease have been reported as being related to late survival in patients undergoing combined CABG and MVR, but we have found no such relationship. Our results indicate that both hospital and late mortality after this operation are strongly correlated with left ventricular function.

Myocardial infarction in a young adult due to Kawasaki disease. A case report and review of the late cardiological sequelae of Kawasaki disease

Although Kawasaki disease is generally self-limiting, 15-25% of children with Kawasaki disease may develop significant cardiovascular sequelae, presentation may occur acutely or late (death has been reported up to 14 years after the acute illness). The most common late complication is the persistence of coronary artery aneurysms, these may produce myocardial ischaemia and even myocardial infarction, valvular dysfunction has also been reported. However the occurrence of late abnormalities of myocardial function is controversial. We describe a 24-year-old man who presented with myocardial infarction as a result of coronary artery aneurysms caused by Kawasaki disease, he gave no recent or childhood history of prodromal illness compatible with Kawasaki disease. The diagnosis was confirmed at post mortem.

Type I aortic dissection in a patient with osteogenesis imperfecta

The previously undescribed association between aortic dissection and osteogenesis imperfecta is reported in a 39-year-old man with known osteogenesis imperfecta, who presented with a type I aortic dissection. His ascending aorta was repaired using a Dacron tube graft under hypothermic circulatory arrest but the patient died 12 h later, following re-dissection around the left coronary ostium resulting in massive myocardial infarction of the left ventricle.