Beyond biventricular pacing: Exploring the advantages of his-bundle pacing and left bundle branch pacing in heart failure-A systematic review and meta-analysis

BACKGROUND

This meta-analysis compares His-Purkinje system pacing (HPSP), a novel cardiac resynchronization therapy (CRT) technique that targets the intrinsic conduction system of the heart, with conventional biventricular pacing (BiVP) in heart failure (HF) patients with left ventricular (LV) dysfunction and dyssynchrony.

METHODS

We searched multiple databases up to May 2023 and identified 18 studies (five randomized controlled trials and 13 observational studies) involving 1291 patients. The outcome measures were QRS duration, left ventricular ejection fraction (LVEF) improvement, left ventricular end-diastolic diameter (LVEDD) change, HF hospitalization, and New York Heart Association (NYHA) functional class improvement. We used a random-effects model to calculate odds ratios (OR), and mean differences (MD) with 95% confidence intervals (CI). We also assessed the methodological quality of the studies.

RESULTS

The mean LVEF was 30.7% and the mean follow-up duration was 8.1 months. Among LBBP, HBP, and BiVP, HBP provided the shortest QRS duration [MD: -18.84 ms, 95% CI: -28.74 to -8.94; p = 0.0002], while LBBP showed the greatest improvement in LVEF [MD: 5.74, 95% CI: 2.74 to 7.46; p < 0.0001], LVEDD [MD: -5.55 mm, 95% CI: -7.51 to -3.59; p < 0.00001], and NYHA functional class [MD: -0.58, 95% CI: -0.80 to --0.35; p < 0.00001]. However, there was no significant difference in HF hospitalization between HPSP and BiVP.

CONCLUSION

LBBP as modality of HPSP demonstrated superior outcomes in achieving electrical ventricular synchrony and systolic function, as well as alleviating HF symptoms, compared to other pacing techniques.

Risk Perception and Willingness to Work Among Doctors and Medical Students of Karachi, Pakistan During the COVID-19 Pandemic: A Web-Based Cross-Sectional Survey

Purpose

During the timeline of twenty years, several epidemics and pandemics have occurred. Yet, a consistent feature of these public health crises is the surge in the demand for healthcare services exceeds the availability.

Materials and Methods

A cross-sectional web-based survey was conducted in the month of June and July 2020 in Karachi, Pakistan. The study participants included doctors and medical students residing in Karachi.

Results

Out of 187 doctors, 74.3% were working during the COVID-19 pandemic, of which 58.3% were willing to work. Out of 200 medical students, 93.5% were not volunteering during the COVID-19 pandemic, of which 46% were willing to volunteer. Doctors strongly agreed that they would be willing to work during the COVID-19 pandemic if they were healthy and able to do so (57.2%), if they were provided personal protective equipment (PPE) (51.3%), and if they were guaranteed coverage of treatment cost if they get infected while working (57.8%). Medical students strongly agreed that they would be willing to volunteer during the COVID-19 pandemic if they were provided PPE (49.0%), and if their parents were supportive of their decision to volunteer (44.5%). Most doctors (54.5%) felt that they were extremely likely to get infected while working during the COVID-19 pandemic and 59.4% felt that in turn, they were extremely likely to infect their families as well. Most medical students (40.5%) felt that they were somewhat likely to get infected while volunteering during the COVID-19 pandemic and 55.5% felt that in turn, they were extremely likely to infect their family as well. In the event of infection with COVID-19, 51.3% doctors and 42.0% medical students felt that they would recover without hospitalization.

Conclusion

Since future pandemics are likely, we encourage health-care policymakers to utilize the findings of this study to create a sustainable pandemic response.

Knowledge, attitude and perception survey of doctors regarding antibiotic use and resistance in Karachi, Pakistan

OBJECTIVE

To establish a better understanding of physicians' knowledge and beliefs, and to compare distinctions in knowledge, attitude and perception of junior and senior doctors regarding rational use of antibiotics.

METHODS

The cross-sectional study was conducted at a tertiary care hospital in Karachi, from June 1 to July 31, 2016, and comprised senior and junior doctors. A 26-item questionnaire divided in three sections was used to test knowledge, attitude and perception of the subjects regarding rational use of antibiotics. Data was analysed using SPSS 23.

RESULTS

Of the 200 subjects, 132(66%) were senior doctors; 68(34%) were junior; 116(58%) were females; 84(42%) were males; and the highest number of respondents were from General Medicine 65(32.5%). While 182(91%) doctors realised that antibiotic resistance was a pressing issue, only 131(65.5%) felt confident about their prescriptions and 94(47%) admitted that they over-prescribed antibiotics. Among young physicians, 13(19.1%) believed that antibiotics did not cause side effects even when prescribed unnecesarily. Also, 47(69.1%) junior doctors felt that patients' demands influenced their prescriptions compared to 66(50%) senior doctors (p=0.01).

CONCLUSIONS

Although physicians were found to be knowledgeable about rational use of antibiotics, there were gaps in knowledge and perception.

Vitamin D and COVID-19: Does a Deficiency Point Towards an Unfavorable Outcome?

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Clinical aspects of Ebola virus disease: a review

Ebola Virus Disease (EVD), also known as Ebola Hemorrhagic Fever (EHF), initially emerged over 40 years ago in the Democratic Republic of Congo. Endemic to Africa, outbreaks have been recorded in six African countries since its detection in 1976. Fruit bats are believed to be the natural hosts of Ebola viruses (EBoV), with humans and other mammals serving as accidental hosts. Transmission of EBoV has been reported in various ways, including human to human transmission through close contact with blood and bodily fluids. The virus has an incubation period ranging from two to twenty-one days, followed by a multitude of clinical manifestations such as the sudden onset of high fever, chills and myalgia depicting a flu-like syndrome. It is usually diagnosed based on several clinical symptoms such as the sudden onset of illness, high fevers for less than three weeks, and at least two hemorrhagic symptoms despite no predisposing factors. This generally provides enough evidence for clinicians to consider EHF and begin supportive treatment until the virus is confirmed through laboratory findings. Management of patients involves supportive care such as maintaining fluid along with electrolyte balance, blood pressure and oxygen saturation. This also includes treating complications arising from secondary infections. The main options include: prophylactic strategies, anti-viral therapy for EVD, immunotherapies, vaccines, and ZMapp. Finally, the key to managing EBoV epidemics is to stop the transmission of disease in the most severely affected population, as prevention has become of utmost importance to alleviate the significant physical and economic burden.

Relationship between Night Eating Syndrome and Self-esteem: A Cross-sectional Population-based Study in Karachi, Pakistan

Background

The amount of literature shedding light upon eating disorders in developing countries, such as Pakistan, is scarce. This is partially because talking about such matters is considered taboo in the general population. Night Eating Syndrome’s (NES) link with depression and obesity has been established; however, presently, no study has been conducted which solely focuses on NES’s correlation with self-esteem. Therefore, to bridge this knowledge gap, we conducted this study to assess the prevalence of NES in Karachi and its association with self-esteem.

Methods

We conducted a cross-sectional study in August 2018 using convenience sampling in 395 individuals, out of which 197 belonged to the age group 18-24 and 198 to 25-30. The participants were interviewed for their gender, body mass index (BMI), and their level of education. The participants were asked to complete a structured, standardized questionnaire assessment, which comprised of questions from the Night Eating Questionnaire (NEQ) and Rosenberg Self-Esteem scale (RSE). The eating habits of the participants and the level of self-esteem were assessed using four- and five-point Likert scales. Kruskal-Wallis and chi-square tests were used as the primary statistical tests.

Results

Out of the 395 respondents, more than half of the respondents were females (n = 235/395, 59.5%). About one-fourth (n = 92/395, 23.3%) of the participants had a BMI of greater than 25.0 kg/m². More than one-third of the underweight (n = 20/55, 36.4%) and overweight population (n = 33/92, 35.9%) had low self-esteem, while more than one-fourth (n = 25/92, 27.2%) of the overweight participants fulfilled the criteria of NES. The final outcomes showed that 14.4% of the participants had NES, and 4.6% of the participants had low self-esteem.

Conclusion

Our results pointed out to a significant relationship between NES and self-esteem. Furthermore, NES and self-esteem also had a significant association with age, gender, and BMI. Additionally, awareness regarding eating and mental disorders should be done in countries like Pakistan, where talking in regard to such matters is considered taboo. Given the various factors that further strengthen the positive relationship between NES and low self-esteem, these factors can be the targets on which the treatment can be focused.

Cerebral infarct in patients with hemorrhagic shock and encephalopathy syndrome

The syndrome of hemorrhagic shock and encephalopathy (HSE) was first described by Levin et al. in 1983 but not until recently has it been considered to be a newly identified devastating disorder. The main features of this syndrome consist of sudden onset of shock, coma, convulsions, coagulopathy, renal and hepatic dysfunction. The mortality rate is very high with surviving patients suffering from severe neurologic sequelae. In review of the literature, we did not find any reports of cerebral infarcts. Recently we managed two patients with this syndrome, both of whom had CT scan findings consistent with cerebral infarctions.

Computed tomography of temporal bone pneumatization: 1. Normal pattern and morphology

The pneumatization of 141 "normal" temporal bones on computed tomography (CT) was evaluated in 100 patients (age range, 6-85 years). Because of the controversy surrounding the sclerotic squamomastoid (mastoid), temporal bones with this finding were discarded. A CT index of pneumatization was based on the pneumatized area and the number of cells seen within a representative scanning section. Results suggest that squamomastoid pneumatization follows the classic normal distribution and does not correlate with age, gender, or laterality. A high degree of symmetry was found in 41 patients who had both ears examined. In 35% of all temporal bones, the petrous apex was pneumatized, concordant with the findings of other investigators. Pneumatization extending into other regions of the temporal bone corresponded linearly with squamomastoid pneumatization. Air-cell configuration was variable. Air-cell size tended to increase progressively from the mastoid antrum. The scutum "pseudotumor" appearance caused by incomplete pneumatization was seen frequently, and should not be mistaken for mastoiditis or an osteoma. Thick sections producing partial-volume effect may also produce this spurious finding. Therefore, when searching for mucosal thickening due to mastoiditis, large air cells should preferably be analyzed.

Computed tomography of cerebrovascular calcifications in postsurgical hypoparathyroidism

Despite the extensive literature on the radiographic appearance of basal ganglia calcification in hypoparathyroidism, the vascular and perivascular deposits that are the hallmark of this disease have not been described radiographically. We report two patients with postsurgical hypoparathyroidism in whom such vascular calcification was observed on CT and was confirmed pathologically in one. The metabolic disturbance leading to the vascular deposits is discussed.

Computed tomography in the study of the development of the skull base: 1. Normal morphology

We examined 11 human fetuses (18 to 30 weeks' gestation) with high resolution CT to study the developmental ossification of the two main component structures of the skull base, the temporal and sphenoid bones. Computed tomography, with its excellent contrast discrimination, allowed clear visualization of the morphology of ossifying centers. Skull base growth during this gestational period was found to be a dynamic event with rapid changes in morphology and interosseous relationships. The growth of the sphenoid body on CT corroborates the studies done by Kodama, who used dehydrated skulls. The temporal bone proceeded in a stepwise fashion; complete encapsulation of the membranous labyrinth occurred before it grew anteroposteriorly to form the apex and mastoid.

Intracerebral pneumatocele: CT findings

Two cases of intracerebral pneumatocele following trauma are presented. One to two months after initial treatment both patients had deteriorating neurologic status. The diagnosis was made by radiography. When a pneumatocele is suspected clinically, computed tomography can play a vital role in determining the precise location of the gas collection, its relationship to the fracture site, and the amount of mass effect on the brain.

Intracranial teratoma associated with agenesis of the corpus callosum

Several intracranial tumors are known to occur in conjunction with agenesis of the corpus callosum. We report the occurrence of a teratoma with callosal agenesis, an association not previously described, and suggest that the tumor's ventral location may serve to differentiate it from other lesions.

Computed tomography in the study of the development of the skull base: 2. Anencephaly, the aberrant skull form

The application of various radiographic modalities in the analysis of the paradigm aberrant skull of anencephalics is reported. Again, we found high resolution CT to be the most valuable modality. A detailed description of the skull base changes in anencephaly is presented, and the appropriate embryologic explanation is offered.

Computed tomography of temporal bone pneumatization: 2. Petrosquamosal suture and septum

The degree of visualization of the petrosquamosal (Körner's) septum on high-resolution axial computed tomography (CT) in 141 temporal bones (100 subjects) was analyzed. The superior and inferior parts of the septum were assessed separately and were seen in 75% and 41% of cases, respectively. There was no relation between the size of Körner's septum and pneumatization. The clinical relevance of this finding is discussed. The CT features of the ventral petrosquamosal suture also were investigated. The crista tegmentalis, a contribution of the petrosal tegmen to the mandibular fossa, was seen on CT as a polypoid excrescence projecting from the ventrolateral petrous pyramid. This knowledge is useful in the radiographic analysis of the course of longitudinal fractures of the petrous bone.

Interhemispheric fissure sign of dysgenesis of the corpus callosum

Failure to develop of the corpus callosum and the neighboring midline structures results in abnormal proximity between the interhemispheric fissure (IHF) and the third ventricle. We have called this finding the IHF sign of dysgenesis of the corpus callosum (DCC). In a retrospective study of 39 cases the presence of the IHF sign was assessed in conjunction with the other well recognized CT manifestations of the disorder. These are: (a) lateral ventricles: pointing of the frontal horns, disproportionate enlargement of the occipital horns and separation of bodies of the lateral ventricles; (b) third ventricle: enlargement, elevation and anterior displacement; and (c) interventricular foramen: enlargement. We found that the IHF sign was present concurrently with the other CT signs of DCC in all 35 cases (100%) where the quality of the CT scans permitted its satisfactory evaluation; in the remaining four the sign could not be assessed because of the unsatisfactory quality of the CT scans. Our study confirms that the IHF sign is an additional reliable CT feature of DCC.

Prolactin-secreting pituitary adenomas: CT appearance in diffuse invasion

The authors describe 2 diffusely invasive prolactin-secreting pituitary adenomas which produced marked destruction of the base of the skull thought to be diagnostic of chordoma on computed tomography (CT). Failure to recognize this pattern led to biopsy, which was diagnostic. The authors emphasize the need to recognize this rare growth pattern of diffusely invasive pituitary adenoma on CT.

Computed tomography in penetrating injury to the eye

We used computed tomography to detect and localize foreign bodies in two unusual cases of penetrating injury to the eyes. In one case, a large broken twig appeared to have penetrated the globe and the inferior rectus muscle; in the other, the globe was ruptured by many glass shards . In the first case surgery showed the computed tomographic impression to be incorrect. The globe and the inferior rectus muscle were intact and vision and motility were normal postoperatively. In the second case, swelling made direct visualization impossible, and computed tomography was used to locate the foreign bodies.

Primary tethered cord syndrome: a new hypothesis of its origin

Primary tethered cord syndrome is defined as low placement of the spinal cord and thickened filum terminale with associated anomalies. This definition excludes anomalies concomitant with overt myelomeningocele and spinal cord tethering secondary to myelomeningocele repair. Embryologically, the primary tethered cord syndrome is an entirely different entity from overt myelomeningocele and associated Arnold-Chiari type II malformation, but its origins have not been satisfactorily explained. The authors postulate that primary tethered cord syndrome is a manifestation of local dysmorphogenesis of all three germ layers at the lumbosacral area, possibly triggered by a hemorrhagic, inflammatory, or some other local lesion occurring in embryogenesis.

High-resolution computed tomographic appearance of normal cochlear aqueduct

Computed tomographic (CT) scans of 37 patients with normal adult cochlear aqueducts were selected for retrospective analysis. Usually, only the inferomedial part of the cochlear aqueduct could be seen on axial CT. The sizes of the external cochlear aqueduct opening were tabulated, and they did not vary significantly with age or gender. The average width was 2.9 mm. Of the configurations found, the most common was the funnel (22 cases).

Skull phylogeny: an investigation using radiography and high-resolution computed tomography

To demonstrate the phylogenetic changes that have led to the current form of the human skull, dried skulls of various representative vertebrates were examined using plain radiography and high-resolution computed tomography. The latter was chosen rather than pluridirectional tomography in anticipation of its future role as the major method for imaging the skull base. The phylogenetic history of the human skull is reviewed by considering separately the evolution of the calvarium, zygomatic arch, palate, jaw, and skull base.

CT findings in a nasopharyngeal extramedullary plasmacytoma

We report a case of an extramedullary plasmacytoma arising from the nasopharynx. The computed tomographic appearance of this rare tumor is discussed.

CT appearance of cerebellar glioblastoma multiforme

We report a case of cerebellar glioblastoma multiforme in a young adult. The rarity of this tumor in this location is discussed along with its computed tomographic appearance.