Spontaneous coronary artery dissection: current evidence from cardiac magnetic resonance and angiography screening

Purpose

To assess the distribution and extent of myocardial infarction, as well as possible clinical significance of peripheral arteriopathy screening in a cohort of patients presented with spontaneous coronary dissection (SCAD) using cardiovascular magnetic resonance (CMR) for cardiac and vascular imaging. The adverse CMR features and predictors of infarction in subgroup analysis were also investigated.

Methods

This is an observational, single centre study of 144 consecutive, angiographically confirmed SCAD survivors >18 years old, based on collected data from Jan 2008-Nov 2020. All scans were performed on a 1.5-Tesla scanner. Cardiac structural and functional indices, myocardial infarct size and distribution were evaluated. In addition, vascular imaging was performed in all patients for thoracic aorta screening as part of the routine protocol, and in 75 patients peripheral arteriopathy screening from Circle of Willis to the iliac arteries was performed using 2D multi-slice and cine imaging, as well as 3D imaging methods.

Results

In the total population, 64% had infarction. Infarct size (%) was predictive of reduced left ventricular ejection fraction (LVEF) (p<0.001) and increased diastolic volumes (p<0.001 for both). Logistic regression showed SCAD in right coronary artery (Odds Ratio (OR): 5.2, p=0.034) predicted the presence of infarction. In the group who also underwent peripheral vascular screening, the overall prevalence of extra-coronary arteriopathy was 27% with fibromuscular dysplasia accounting for one-fourth of the cases (Figure 1). Of note, most positive vascular screening patients (73.3%) exhibited infarction (OR: 7.0, p=0.041), distributed in more than one territory (OR: 4.0, p=0.015) (Figure 2), while infarct size was negatively correlated with LVEF (p<0.001). Right ventricular ejection fraction was significantly reduced in positive screening patients (58.8±7.4 vs. 63.0±8.0, p=0.045). Further subgroup analysis showed pregnancy associated SCAD patients had significantly larger sized infarcts (25.1±6.1 vs. 6.2±0.7%, p<0.001) with reduced LVEF (51.0 vs 63.6±7.6, p<0.001). In logistic regression, this condition also predicted large infarcts >10% (OR: 9.8, p=0.009) in anterior walls (p<0.001).

Conclusions

Patients with SCAD require careful assessment of myocardial structure, function and characterization of infarction which may reflect the underlying pathophysiology. Extra coronary vascular screening, although not established in clinical practice, seems a rational strategy to potentially identify a subgroup with more severe infarction and likely to have vascular pathology.

Funding Acknowledgement

Type of funding sources: None.

An animal tissue simulation assessing three directional displacement forces on five common tracheostomy securing techniques

Introduction Several methods of securing a tracheostomy tube have been described in the literature including using ties or tapes around the neck and suturing the plastic flange to the neck in various ways. However, there are no wet lab-based studies to objectively determine the force required to displace the tracheostomy tube using different securing techniques. Ours is the first animal tissue simulation study published in the literature. Methods A simulated tracheostomy stoma was created on a sheep neck model. A tracheostomy tube was inserted into the stoma and secured using various methods. Tension tests were conducted to significantly displace the tube from the stoma. Each technique was repeated six times on different sheep necks. All results were analysed using SPSS®. Results Repeat measurements indicated that the largest displacement forces come from an oblique direction while the lowest force values were found at the lateral angle. Averages of displacement showed that medially placed sutures required the largest forces in comparison with other securing methods. Wilcoxon signed-rank testing indicated that medial and continuous suture security resists displacement at forces that otherwise displace flange and interrupted sutures. Conclusions This study has shown that any type of securing suture requires a greater displacement force than the strap of the tracheostomy tube holder alone. Medially placed sutures require a greater displacement force than those placed laterally. Displacement in the lateral direction requires the least force in comparison with movement at perpendicular or oblique angles.

International survey and consensus (ICON) on ambulatory surgery in rhinology

OBJECTIVES

Day-case surgery is the gold standard to several surgical procedures in Rhinology. However, few data and guidelines have been published except in the Anglo-Saxon countries and France. The aim of this survey was to propose a list of issues arising during day-case surgery in order to analyze the different constraints encountered around the world.

MATERIAL AND METHOD

It was a prospective multicenter international email survey. The method was based on the formalized expert consensus methodology. A list of 11 issues was based on literature data and was sent by e-mail to 265 key opinion leaders (KOL) who attended the IFOS congress.

RESULTS

The response rate was 20% from 27 countries without statistical difference between continents concerning the score on each item. The mean age of KOL was 50±10 years. Their mean length of experience was 21±10 years. Issues in relation with technical resources and experience showed that the last time at which ambulatory surgery in the day is possible was 4:00 PM but responses varied depending the availability of technical resources. Bleeding or hematoma occurred most frequently between the third and fourth postoperative day whatever the surgical procedure. A strong agreement and consensus was obtained concerning the nasal packing, septal contention and their schedule of removal which were not a contraindication of day-case. Also 75% of participants were agreeing with a therapeutic education program to improve the performance of postoperative care and decrease readmission rates. A relative agreement without consensus were obtained for the distance between the day-case unit and home, the role of surgery duration and the impact of anticoagulant and/or antiplatelet drugs in overnight admission and readmission rates.

CONCLUSION

Practice varies widely owing to local organization constraints and the availability of a dedicated day-case unit seems to be the main limiting factor.

Child abuse and fabricated or induced illness in the ENT setting: a systematic review

BACKGROUND

Child maltreatment is persistently under-recognised. Given that a third of maltreated children may return with serious or fatal injuries, it is imperative that otolaryngologists who are in frequent contact with children are able to detect maltreatment at first presentation.

OBJECTIVE OF REVIEW

This review aims to identify ENT injuries, signs or symptoms that are indicative of physical abuse or fabricated or induced illness (child maltreatment).

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

An all-language search, developed in Medline Ovid and consisting of 76 key words, was conducted of published and grey literature across 10 databases from inception to July 2015, for primary observational studies involving children aged <18 years.

EVALUATION METHOD

Each relevant article underwent two independent reviews with full critical appraisal, applying strict quality standards.

RESULTS

Of the 2448 studies identified and screened, 371 underwent full review, resulting in 38 included studies that detailed 122 maltreated children. Pharyngeal perforations (n = 20) were the most frequent abusive ENT injury, predominantly affecting neonates and infants, presenting with dysphagia, drooling, haemoptysis and surgical emphysema. At least 52% of children with abusive pharyngeal injuries had additional co-existent injuries. The majority of ear injuries were inflicted to the external ear (n = 11) and included auricular deformity, abrasions, petechiae, lacerations and burns. Fabricated or induced illness cases presented most commonly with recurrent, unexplained otorrhoea or ENT lesions that failed to heal despite appropriate therapy.

CONCLUSIONS

All clinicians should be familiar with the signs of child maltreatment. Pharyngeal injuries, or injuries to the external ear, presenting in young children without an explicit history of witnessed injury should prompt a child protection referral for full evaluation. Likewise, children who present with recurrent, or apparently intractable symptoms and signs despite appropriate treatment, should raise the possibility of fabricated or induced illness, and discussion with a child protection specialist is advised. Early recognition of possible child maltreatment and instigation of appropriate safeguarding measures are essential to prevent repetition and escalation of injury. This is of paramount importance to otolaryngologists, who have the potential to identify these children in their practice.

The uptake of day-case septoplasty in England and Wales

Is there a relationship between daycase rates and waiting list times?

An evidence-based approach to the management of snoring in adults

BACKGROUND

Snoring is frequently encountered by the otolaryngologist. Given its significant impact on quality of life and that it is a symptom of sleep-related breathing disorders, diagnosis and treatment are of major importance. In particular, the diagnosis should aim to distinguish between simple snoring and obstructive sleep apnoea. This article aims to provide a systematic, concise and evidence-based method of managing the adult patient with snoring.

METHOD

This review was based on a literature search last undertaken on 30 June 2014. The MEDLINE, EMBASE and Cochrane databases were searched using the subject headings snoring and obstructive sleep apnoea in adults in combination with classification, diagnosis, investigations, management, treatment and surgery. Results were limited to English language articles including case series, clinical trials, randomised controlled trials, meta-analyses, systematic reviews and review articles. Relevant references from selected articles were also reviewed.

RESULTS

The majority of published literature for snoring is of level II/III evidence and that for obstructive sleep apnoea being of level I/II, with 36 relevant randomised controlled trials identified. The diagnosis of obstructive sleep apnoea involves thorough clinical assessment and typically a sleep study. Snoring may be managed with lifestyle modification, intra-oral devices or by surgical intervention, with continuous positive airway pressure being the treatment of choice for moderate-to-severe obstructive sleep apnoea.

CONCLUSIONS

A structured history of snoring and its associated symptoms, comprehensive examination including flexible laryngoscopy and sleep studies where relevant, in addition to targeted investigations, should lead to the correct diagnosis and appropriate management.

Variable degree of liver involvement in siblings with PiZZ alpha-1-antitrypsin deficiency-related liver disease

PiZZ alpha-1-antitrypsin deficiency is the commonest genetic cause of chronic liver disease, but only 10-15% of PiZZ individuals develop liver disease in childhood. Studies have demonstrated varying patterns of disease progression within siblings with the PiZZ phenotype. We retrospectively analysed the case-notes of all patients diagnosed with PiZZ A1ATD between 1978-2002 and compared the pattern of liver disease between affected siblings. We identified 29 families with more than 1 child with the PiZZ phenotype. Twenty-one (72%) PiZZ siblings of the 29 probands had liver disease, which was concordant for severity in 6 (29%), while 8 (28%) had no liver involvement. Five of 7 children requiring liver transplantation had siblings with no persistent liver dysfunction. This study suggests that there is a variable degree of liver involvement in siblings with PiZZ A1ATD-related liver disease and environmental and/or other genetic factors must be involved in determining disease severity.

A case of bilateral ptosis with unsteady gait: suggestibility and culture in conversion disorder

We report a case of a 14-year-old girl who presented, following a sudden onset, with bilateral ptosis, gait disturbance, difficulty swallowing and loss of appetite, right hypochondriacal pain, and frontal headache. Protracted neurological and medical examinations were unremarkable; neither was precipitating psychological stresses evident. The condition, which manifest as typical conversion disorder, lasted for one year. "Treatment" involving electrical stimulation of both eyes muscles and legs with positive reassurance resolved the symptom. This case supports the view that conversion disorder, not only involves a strong element of suggestion, but also incorporates socio-cultural sanctioned prescription.

Psychosocial aspects of epilepsy in Oman: attitude of health personnel

PURPOSE

To assess with a questionnaire the awareness and attitudes of the doctors in Oman toward epilepsy. Attitudes of society toward epilepsy have a wide-ranging influence, affecting issues as diverse as compliance with treatment and doctor--patient communication. Recent studies in both developing and developed countries suggest that within the medical profession, there is a lack of knowledge and negative attitudes toward people with epilepsy (PWE). There are no equivalent studies for Oman or the Arab world.

METHODS

The questionnaire included queries on the backgrounds of the physicians, including their training and qualifications, the main sources of their knowledge of epilepsy, as well as their perceptions of the attributes and care requirements of PWE.

RESULTS

Sixty-two percent (n=121) of those questioned, who were medical personnel working in different regions of Oman, responded. The results suggest that, despite coming from diverse cultural backgrounds and nationalities, the practicing doctors in Oman gained knowledge of epilepsy much earlier than did their counterparts in developed countries. The majority of the respondents thought that PWE have more propensities toward dysfunctional personality and behavioral characteristics than do "normal" people. On questions relating to public image, our respondents opined that, although the general public is negative toward PWE, the realities regarding PWE should be publicized because PWE are capable of having a normal family life and being an integral part of society.

CONCLUSIONS

In spite of having an earlier exposure to seizures and sympathetic acceptance of PWE, negative views still persist on matters related to cognitive and behavior domains. It is concluded that a developing country such as Oman must inculcate more realistic perceptions and attitudes among their doctors toward PWE.

Psychiatric morbidity in Northern Jordan: a ten-year review

OBJECTIVE

To study the psychiatric morbidity in the northern part of Jordan and to determine the frequency distribution of various psychiatric disorders, for planning services.

METHOD

All records of 2,335 psychiatric patients attending the only psychiatric clinic in Northern part of Jordan during a ten-year period from 1984 to 1993 were extensively reviewed and subjected to computerized analysis. Diagnosis was made as per ICD-9.

RESULTS

Out of the 2335 patients who attended the clinic, 55% were males and 45% were females. Those in the age group 25-44 recorded the maximum attendance. Among the male attendees of the clinic, schizophrenia was the commonest diagnosis(19.9%), while among females, affective disorders were the commonest(15.9%).

CONCLUSION

Schizophrenia was found to be the commonest diagnosis in general among attendance of the clinic for the ten-year research period, while anxiety disorders were the commonest diagnosis among attendance of the clinic for the year 1993.