Impella-Driven High-Risk Percutaneous Coronary Intervention: A Novel, Single Non-Surgical-Centre Case Report

Complex percutaneous coronary intervention (PCI) procedures have been routinely performed in non-surgical centres in the UK for more than two decades. These procedures follow strict guidelines and recommendations by the British Cardiovascular Intervention Society to ensure a more effective running of PCI programs. Even more so, expected guiding principles necessary for the safe optimisation of complex PCI procedures have also been created.  An 81-year-old male was admitted with non-ST-elevation myocardial infarction (NSTEMI) and severely impaired left ventricle ejection fraction (LVEF; 26% according to the cardiac MRI report). Angiogram findings revealed severe multiple-vessel coronary artery disease affecting the following arteries: right coronary artery (RCA), left anterior descending artery (LAD), left circumflex artery (LCx), and intermediate artery (IM). There was also severe disease in the distal left main stem (LMS) bifurcation extending to the ostia of the LAD, LCx, and IM branches. Following a multidisciplinary meeting, the patient underwent Impella-supported high-risk PCI (complex PCI) using the DK crush technique with no peri- and post-procedure complication and a significant LV function improvement (45-49%). This is the first known case of this procedure performed at the Royal Cornwall Hospital in Treliske (RCHT), Truro, Cornwall. This case report highlights that when the decision to choose between coronary artery bypass graft (CABG) and PCI is not straightforward following an individualised risk-stratification scoring system analysis and in the setting of patient comorbidities, a high-risk PCI supported with the Impella device is a suitable alternative with promising short-term and long-term outcomes.

Consenting practices in interventional cardiology: an analysis from the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Background

Consenting practices in interventional cardiology vary across different procedures, operators, centres and nations.

Purpose

In order to define best practice for obtaining informed patient consent, it is first necessary to understand how consenting practice differs.

Methods

An online survey of 20 questions was sent to all members of the European Association of Percutaneous Cardiovascular Interventions, addressing consenting practices in elective and emergency scenarios.

Results

We received 483 responses from 74 countries. The majority of respondents (77%) were European operators. Responses were received from consultant cardiologists (n=370), fellows in training (n=55), allied health professionals (n=36) and others (n=21).

Across all respondents, in elective practice, 427 (88.4%) operators obtain written consent for every procedure, the remainder (9.5%) obtain verbal consent only. Consent is obtained by the consultant or fellow who directly performs the procedure in 56.9% cases. For coronary angiography, pre-emptive consent for possible additional procedures (pressure wire and PCI) is taken by operators in all cases (58.6%), some cases (30.6%) and never (11.0%). Prior to interventional therapies, written information detailing the risk of the procedure is provided in every case by 63.8% of operators, sometimes by 25.1% of operators, and is never provided by 11.0% of operators.

In emergency settings, where patients are conscious and have capacity to consent, 274 (56.7%) of respondents obtain written consent, 155 (33.1%) obtain verbal consent only and 52 (10.8%) stated that a consent process was not required. Where consciousness and capacity are impaired, 218 (45.1%) always, 118 (24.4%) sometimes and 145 (30%) never document a written capacity and best interests' assessment.

When asked to rate the overall quality of consenting practices in their own institution, 279 (57.8%) stated these were “excellent” or “above average”, 165 (34.2%) were “average” and 39 operators described consenting practices in their institution as “below average” or “poor”.

Conclusions

Diversity in consenting practice spans elective and emergency procedures. These results suggest that there is substantial variation in the understanding of the rationale, legal requirement, and perceived best practices for consent. Further work should consider the merits of standardisation of consent processes across Europe.

Funding Acknowledgement

Type of funding sources: None.

Co-existing sickle cell anaemia and inflammatory bowel disease: case report and review of the literature

Sickle cell anaemia (SCA) is a chronic haemolytic anaemia associated with vaso-occlusive painful crises which may affect several systems including the gastro-intestinal system, resulting in abdominal pain. The concurrence of inflammatory bowel disease and haemoglobinopathy is rare. No previously reported concurrent cases of both SCA and ulcerative colitis (UC) in sub-Saharan Africa were found in the literature. A 16-year-old girl with concurrent SCA and UC is presented. She was admitted to University College Hospital, Ibadan with a 1-year history of recurrent peri-umbilical pain and bloody stools. These symptoms were mainly attributed to SCA at the referring hospital, and she was managed for chronic tropical diarrhoea without a remarkable clinical response. This case illustrates the concurrent presentation of SCA and ulcerative colitis which led to the missed and delayed diagnosis of ulcerative colitis.

Skin cancers in skin types IV-VI: Does the Fitzpatrick scale give a false sense of security?

The Fitzpatrick scale has been in use for skin colour typing according to the tanning potential of skin since its inception in 1975-1976. Thomas Fitzpatrick developed the scale to classify persons with 'white skin' in order to select the correct amount of UVA in Joules/cm² for PUVA treatment for psoriasis. Since then, it has been widely used in Dermatology to gauge the skin's reaction to UV exposure, tanning potential, assessment of sunburn risk and amount of sun protection required for individual patients. However, the use of this scale has been of limited utility because of different self-perception in different areas of the world, particularly among those with skin of colour. Skin cancer risk is loosely inversely correlated with the initial genetic/inherent amount of melanin (most research has focused on eumelanin) present in the skin, although the pattern of exposure and amount of UV radiation required causing DNA damage varies widely according to different cancers. In this review, we have shown that the Fitzpatrick scale is neither correct nor adequate to reflect sunburn and tanning risk for skin of colour. Therefore, it may give both patients and physicians a false sense of security that there is little risk that people of colour can develop skin cancers. We have reviewed the small but not insignificant risk of skin of colour developing skin cancers and emphasise that there remains much research that needs to be done in this field.

Quality of stroke guidelines in low- and middle-income countries: a systematic review

OBJECTIVE

To identify gaps in national stroke guidelines that could be bridged to enhance the quality of stroke care services in low- and middle-income countries.

METHODS

We systematically searched medical databases and websites of medical societies and contacted international organizations. Country-specific guidelines on care and control of stroke in any language published from 2010 to 2020 were eligible for inclusion. We reviewed each included guideline for coverage of four key components of stroke services (surveillance, prevention, acute care and rehabilitation). We also assessed compliance with the eight Institute of Medicine standards for clinical practice guidelines, the ease of implementation of guidelines and plans for dissemination to target audiences.

FINDINGS

We reviewed 108 eligible guidelines from 47 countries, including four low-income, 24 middle-income and 19 high-income countries. Globally, fewer of the guidelines covered primary stroke prevention compared with other components of care, with none recommending surveillance. Guidelines on stroke in low- and middle-income countries fell short of the required standards for guideline development; breadth of target audience; coverage of the four components of stroke services; and adaptation to socioeconomic context. Fewer low- and middle-income country guidelines demonstrated transparency than those from high-income countries. Less than a quarter of guidelines encompassed detailed implementation plans and socioeconomic considerations.

CONCLUSION

Guidelines on stroke in low- and middle-income countries need to be developed in conjunction with a wider category of health-care providers and stakeholders, with a full spectrum of translatable, context-appropriate interventions.

Covid-19 dermatoses: Acral vesicular pattern evolving into bullous pemphigoid

Bullous pemphigoid (BP) appears to be rising in incidence across the Western World, especially in the elderly. Some of the pathogenetic mechanisms involving antigen mimicry and antibody cross‐reactivity have been elucidated for cases associated with neurological disease and certain drugs. There have been reports of cutaneous manifestations of Covid‐19 (SARS‐Cov2 infection) as the pandemic has raged across the world. We report here a case of prolonged Covid‐19, symptomatic with dermatoses only, which was seen to evolve initially from a maculo‐papular exanthema with acral vesicular dermatitis, into classical BP disease. This was confirmed histologically by positive skin autoantibody serology, direct IMF on peri‐lesional skin and also salt‐split IMF. Although possible that the development of BP could be a purely co‐incidental finding during Covid‐19, we suggest that it is more likely that prolonged SARS‐Cov2 infection triggered an autoimmune response to the basement membrane antigens, BP 180 and 230. To our knowledge, this is the first case of BP developing during concurrent Covid‐19 disease. It will be necessary to continue dermatological surveillance as the pandemic continues, to collate data on BP incidence and to test these patients for Covid‐19 disease. As the pandemic continues, even potential and rare associations such as this will be clarified eventually.

What's already known about this topic?

Covid‐19 disease has been associated with a spectrum of dermatoses

Common presentations in up to 20% of patients include exanthema, pseudo‐chilblain like acral lesions ‘Covid toes’, livedo‐/retiform purpuric/necrotic vascular lesions, acute urticarial lesions, and vesicular/varicella‐like lesions

A multi‐system inflammatory syndrome in children akin to Kawasaki syndrome has been described

What does this study add?

To our knowledge, this is the first description of classic Bullous Pemphigoid evolving from vesicular lesions caused by prolonged SARS‐Cov2 induced skin inflammation

Laparoscopic supracervical hysterectomy and uterine morcellation: A case report from Asokoro District Hospital, Abuja, Nigeria

Advanced gynecological laparoscopic surgery is an evolving subspecialty that requires specialized skills, expertise and equipment. This is more challenging and daunting, especially in sub Saharan Africa. Laparoscopic supracervical hysterectomy (LSCH) is an advanced gynecological procedure that has hitherto been seen as difficult because of the big size uteri seen in Nigerian women. We present thefirst LSCH and uterine morcellation done in Nigeria in a 45-year-old multipara on account of symptomatic uterine fibroid of 16 weeks size, at the Asokoro District Hospital, Abuja. Nigeria. She fared well postoperatively and highly satisfied with the procedure at the gynecological clinic review. Our case report has demonstrated clearly that the uterine size is not a limitation to laparoscopic hysterectomy. With proper port placement and adequate skills, LSCH of big size uteri, which is typical in sub Saharan Africa, can be safely achieved. We, therefore, recommend capacity building of Gynaecologists and peri-operative nurses in the field of minimal access surgery and improvement in the equipment in our various facilities to the modern standard.

The effects of treadmill or overground walking training program on gait in Parkinson's disease

BACKGROUND

Gait impairment in Parkinson's disease (PD) patients is characterized by the inability to generate appropriate stride length. Treadmill training has been proposed as a therapeutic tool for PD patients. However, it remains unknown whether treadmill training effects are different from overground walking training. Thus, our goal was to explore the effects of two training programs, walking on a treadmill and walking overground, in PD patients.

METHODS

22 PD patients were randomly assigned to a treadmill or overground training group. The training program consisted of 5 weeks (3 sessions/week). Before and after the program we evaluated gait kinematics during walking at preferred and maximal speed; Timed Up and Go (TUG); static posturography and knee extensors strength. Gait parameters were reevaluated in the treadmill training group one month after the cessation of the training.

RESULTS

Preferred speed walking improved in both groups after the training program. The treadmill training program, but not the overground, led to an improvement in the stride length at the preferred and maximal walking speed in the PD patients. In addition, the treadmill training group showed improvement of the TUG and static posturography tests. The improvement in gait parameters was maintained one month after the cessation of the treadmill training.

CONCLUSIONS

This study provides evidence of a specific therapeutic effect of treadmill training on Parkinsonian gait and balance. Walking on a treadmill may be used as an easy, effective and accessible way to improve the stride length and balance in PD patients.

Effect of nifedipine on reproductive functions in male rats

BACKGROUND

After life itself, fertility is probably the most highly prized human possession. Yet, while medical treatment of the individual naturally demands priority, relatively little attention is paid to the effects of treatment on reproductive function.

OBJECTIVE

To investigate the effect of the calcium channel blocker, nifedipine, on sperm functions and identify the possible mechanism of action.

METHODS

Twenty four (24) male rats weighing 150-170 g were divided into three groups of eight rats each. Group 1 (control) received distilled water; Group 2, received nifedipine 0.57 mg/kg; and Group 3, received 0.57 mg/kg and serve as a recovery group. Treatment was done orally and it lasted for 30 days. Animals in Group 3 were allowed another 30 days after drug withdrawal for recovery. Sperm count, motility, morphology and serum testosterone level were evaluated. The testes were removed, weighed and prepared for histological studies.

RESULTS

The weight of the testis and epididymis were significantly reduced (P < 0.05) with administration of nifedipine. There were significant decreases (P < 0.05) in epididymal sperm count and motility. Serum testosterone levels remained unchanged in treated rats. The histological section of the testis showed no biologically meaningful change compared with control tissue.

CONCLUSION

Nifedipine appears to have a reversible deleterious effect on sperm functions in rats which is not mediated by ta change in testosterone secretion.

Case Report: Acute Limb Ischaemia and Gangrene associated with Peripartum Cardiomyopathy

Thromboembolic complications are frequent in patients with peripartum cardiomyopathy (PPCM). Peripheral artery occlusions are however rare. This case report describes a 30-year-old grand multiparous woman with PPCM complicated by acute lower limb ischaemia and gangrene. This followed left intraventricular thrombi despite maintenance of sinus rhythm. We suspect that the thrombosis is caused by the hypercoagulable state of peripartum period, ventricular dilatation and hypokinesis. The impacts of economic and sociocultural factors in the management of this rare complication of PPCM in a resource depleted nation are highlighted.

KEYWORDS

peripartum cardiomyopathy, limb ischaemia.

Episiotomies in Nigeria--should their use be restricted?

Episiotomy continues to be a frequently used procedure in obstetrics despite little scientific support for its routine use. The incidence of episiotomy and perineal tears and also the indications for episiotomy were therefore investigated in 1007 singleton deliveries between January 1, 1997 and December 31, 1997 at the Lagos University Teaching Hospital. The incidence of episiotomy was 54.9% of all deliveries. Episiotomy was more frequently performed in primipara (90.4%). Perineal tears occurred in only 18.8% of all deliveries, with majority in the multipara (93.6%). Most of the team were of first degree (98.4%). No third degree tear was recorded. The commonest indication for episiotomy was that of protecting the perineum from possible tears (80.7%). All the episiotomies were mediolateral. Episiotomy rate was higher among deliveries conducted by doctors. Performance of episiotomy had a positive correlation with increasing foetal weight. No major complication or maternal death attributable to episiotomy was recorded. The results of our study suggest that the use of episiotomy can be restricted to specified indications like instrumental and big babies delivery. It is also useful for the prevention of maternal morbidity through perineal laceration. Randomized control trials will however be necessary to clarify the controversies relating to restrictive episiotomy.

Hypokalemic paralysis

Hypokalemia that leads to paralysis is extremely rare in children. We report a case of a young child with genetically inherited periodic hypokalemic paralysis. Hypokalemia should be considered in a child with acute onset of muscle weakness.

Galactosylation of endogenous proteins from human platelets

Human platelets have been shown to contain the enzyme glycoprotein:galactosyltransferase that catalyzes the transfer of galactose to an endogenous protein acceptor present in the platelet. Galactosylation of added ovalbumin also occurs. The activity was extracted with 30 mM Tris buffer (pH 7.5). The endogenous activity was enriched 1.4-fold (compared with the crude homogenate) in the fraction, 105,000 g pellet, and the exogenous enzyme was retained in the respective supernatant. The two galactosyltransferase activities showed proportionality to time, protein, and substrate concentration, and were identical in pH dependence and Mn+2 requirement. The effect of Triton X-100 (range 0-1.5%) in the assay system appeared to be different for both activities: with the optimum concentration of detergent (0.15%) the endogenous activity increased by 50% whereas the exogenous activity was augmented 5-fold. From a number of sugar nucleotides tested as glycosyl donor into the endogenous proteins, the optimum substrate was UDP-Glc (100%), followed by UDP-Gal (80%), GDP-Man (24%), UDP-Glc-NAc (21%), UDP-Xyl (19%), and ADP-Glc (5%). An appropriate exogenous acceptor for UDP-Glc as donor was not found. The different solubilization of galactosyl- and glucosyltransferase activities by Triton X-100 suggests that they are distinct enzymes. In addition, the exogenous galactosyltransferase activity achieved after the treatment was much higher (940%) than the endogenous (26%). It is suggested that these differences on both galactosyltransferases could reflect changes in the accessibility of the exogenous substrate to the enzyme.

Glycoprotein biosynthesis by human normal platelets

Incorporation of radioactive Man, Gal, Fuc, Glc-N, and NANA into washed human normal platelets and endogenous glycoproteins has been found. Both parameters were time dependent. Analysis of hydrolyzed labeled glycoproteins by paper chromatography revealed that the radioactive monosaccharide incubated with the platelets had not been converted into other sugars. Acid hydrolysis demonstrates the presence of a glycosidic linkage. All the effort directed to the demonstration of the existence of a lipid-sugar intermediate in intact human platelets yielded negative results for Man and Glc-N used as precursors. The incorporation of these sugars into glycoproteins is insensitive to bacitracin, suggesting no involvement of lipid-linked saccharides in the synthesis of glycoproteins in human blood platelets. The absence of inhibition of the glycosylation process in the presence of cycloheximide suggests that the sugars are added to proteins present in the intact platelets. These results support the contention that glycoprotein biosynthesis in human blood platelets observed under our experimental conditions is effected through direct sugar nucleotide glycosylation.

Enzymatic dephosphorylation of retinyl monophosphate by rat liver

Rat liver has been shown to contain an enzyme that catalyzes the dephosphorylation of retinyl monophosphate. This activity was extracted with 0.1 M Tris buffer (pH 7.5). Maximum reaction rate was observed at a pH range of 7.0-7.5. It did not require metal ions for activity and was sensitive to fluoride ion. The retinyl monophosphate phosphatase activity was proportional to time and protein and substrate concentration. Triton X-100 (range of 0.05-0.10%) increased the activity 100%, whereas other detergents (Tween 80, cholate, and deoxycholate) did not activate the enzyme. A number of phosphorylated compounds tested as inhibitors of retinyl monophosphatase activity, such as glucose 6-phosphate (20 mM), glycerophosphate (20 mM), phosphatidic acid (8 mM), and dolichyl phosphate (3 mM), did not compete with retinyl monophosphate as substrate. However, at 20 mM concentration, ATP, ADP, 5'-AMP, and pyrophosphate were inhibitors of the enzyme. It is not possible at present to give further details about the specificity of the phosphatase activity. The enzyme described could play a regulatory role in retinol-mediated glycosylations, by altering the endogenous level of retinyl monophosphate.