Comparative Outcomes of Catheter-Directed Thrombolysis Plus Systemic Anticoagulation Versus Systemic Anticoagulation Alone in the Management of Intermediate-Risk Pulmonary Embolism in a Systematic Review and Meta-Analysis

There are limited and conflicting data on the initial management of intermediate-risk (or submassive) pulmonary embolism (PE). This study sought to compare the outcomes of catheter-directed thrombolysis (CDT) in combination with systemic anticoagulation (SA) to SA alone. A systematic search was conducted in MEDLINE, EMBASE, PubMed, and the Cochrane databases from inception to March 1, 2023 for studies comparing the outcomes of CDT + SA versus SA alone in intermediate-risk PE. The outcomes were in-hospital, 30-day, 90-day, and 1-year mortality; bleeding; blood transfusion; right ventricular recovery; and length of stay. Random-effects models was used to calculate the pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs). A total of 15 (2 randomized and 13 observational) studies with 10,549 (2,310 CDT + SA and 8,239 SA alone) patients were included. Compared with SA, CDT + SA was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p <0.001), 30-day mortality (RR 0.34, 95% CI 0.18 to 0.67, p = 0.002), 90-day mortality (RR 0.34, 95% CI 0.17 to 0.67, p = 0.002), and 1-year mortality (RR 0.58, 95% CI 0.34 to 0.97, p = 0.04). There were no significant differences between the 2 cohorts in the rates of major bleeding (RR 1.39, 95% CI 0.72 to 2.68, p = 0.56), minor bleeding (RR 1.83, 95% CI 0.97 to 3.46, p = 0.06), and blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p = 0.08). In conclusion, CDT + SA is associated with significantly lower short-term and long-term all-cause mortality, without any differences in major/minor bleeding, in patients with intermediate-risk PE.

Saree on Fireside: Fatal Burn in an Elderly Nepalese Female

As winter approaches, people in the land of rural Himalayas commonly use fire as the source of heat. Many accidents occur in the process, and mostly the victims are among unattended children and the elderlies. We present a case from rural Nepal where an elderly female sustained fatal burn injuries. Advanced age, greater surface area, and secondary infection were the complicating factors. In the present case, the victim's clad cloth (Saree) was the harbinger to death. Prevention of infection following burn and control of sepsis still remains the mainstay of treatment in burn victims.

Short-Term Safety of Nicotine Replacement in Smokers Hospitalized With Coronary Heart Disease

Background

Little is known about the safety of nicotine replacement therapy (NRT) in smokers hospitalized with coronary heart disease.

Methods and Results

We examined the short‐term safety of NRT use among smokers hospitalized for coronary heart disease in a geographically and structurally diverse sample of US hospitals in the year 2014. We compared smokers who started NRT in the first 2 days of hospitalization with smokers without any exposure to NRT and adjusted for baseline differences through propensity score matching. Outcomes included inpatient mortality, hospital length of stay, and 1‐month readmission. From 270 hospitals, we included 27 459 smokers (mean age, 58 years; 69% men; 56.9% in intensive care unit), of whom 4885 (17.8%) received NRT (97.2% used the nicotine patch, at a median dose of 21 mg/d for 3 days). After propensity matching, covariates were well balanced within each patient group. Among patients with myocardial infarction, compared with patients who did not receive NRT, those who received NRT showed no difference in mortality (2.1% versus 2.3%; P=0.98), mean length of stay (4.4±3.5 versus 4.3±3.3 days; P=0.60), or 1‐month readmission (15.8% versus 14.6%; P=0.31). Results were similar for patients undergoing percutaneous coronary intervention or coronary artery bypass surgery.

Conclusions

Among smokers hospitalized for treatment of coronary heart disease, use of NRT was not associated with any differences in short‐term outcomes. Given the known beneficial effects of NRT in treating nicotine withdrawal, reducing cravings, and promoting smoking cessation after discharge, our findings suggest that NRT is a safe and reasonable treatment option.

Study on Hanging with Brief Discussion upon Ambiguity in Method of Choice and Gender Differences for Completed Suicide in Existing Literatures in Nepalese Scenario

Background Hanging is one of the common forms of violent mechanical asphyxial deaths. When compared to other forms of unnatural death all over the world this method stands on top as death is instantaneous. Death due to hanging is always suicidal until and unless otherwise specified. Objective To explore the socio-demographic characteristics in cases of death due to completed hanging in Nepal. Method This prospective study of death due to hanging was conducted during the period of July 2011 to July 2013. Meticulous autopsy of the body was done in all cases with bloodless dissection of the neck was carried out. Result During the study period medico legal autopsy of 91 cases of death due to hanging was conducted, out of which 57 (63%) were males and 34 (37%) were females. Majority of the deceased were suspended at their own house or peri-domestic settings. Based upon the circumstantial evidences 95.61% (n=87) cases attributed to suicide in nature. Conclusion Hanging undoubtedly is one of the most preferred methods to commit suicide, popular for its lethality. Lack of suicide surveillance system and national data bank in Nepal has resulted into equivocal findings. More studies should be encouraged based upon autopsy findings to get a clear picture on mortality rates.

Obligate Myiasis: A Case Series From Nepal

Although maggots are unanonymously linked to carcass or dead tissues, there are reports of its infestation into living tissues as well. Myiasis denotes maggot infestation in living tissue. There are two forms of myiasis namely obligate and facultative. Obligate myiasis denotes maggots feeding on living tissue whereas facultative myiasis represents the opportunistic behaviour of the fly taking advantage of wound or necrotic tissue, laying by eggs which hatch into maggots. Decreased physical activity and poor hygiene leads to maggot infestation. Maggot invasion of living tissues is undesirable occurrence which can best be avoided by improving hygiene. People with low living standards in the developing nations are the occasional victims for maggot infestations. We present cases of obligate myiasis for their uniqueness and rarity.

Comparision of Extramucosal Enucleation and Submucosal Excision Technique for the Treatment of Oral Mucocele at Birat Medical College & Teaching Hospital, Morang, Nepal

IntroductionMucocele is a painless swelling in the oral cavity usually confined to the lower lip. Of the various treatment techniques surgery remains the best modality.ObjectivesThe present study is aimed to observe the prevalence of mucocele in Eastern Region of Nepal and to compare the results of extramucosal enucleation and submucosal excision as the treatment of mucocele.MethodologyThis prospective study was conducted on patients diagnosed with mucocele in Birat Medical College Teaching Hospital; a tertiary centre in Eastern Nepal during the period between June 2014 to April 2017. Out of total 37 cases two groups were divided based upon size of mucocele. Patients underwent extramucosal enucleation in cases where the size of mucocele was less than 1 cm and submucosal excision was done in patients whose size of the mucocele exceeded 1 cm. The data was entered and analyzed using Statistical Package for the Social Sciences (SPSS) vs 21. Different parameters like wound infection, scar formation, recurrence, healing time, follow up were compared for both the methods.ResultThe mean age of the patient in extramucosal enucleation was 9.90±2.807 while in submucosal excision was 11.22±3.068 years. The most common location for mucocele in both the groups was the lower lip; who underwent either extramucosal enucleation (90%) or submucosal excision (70.4%). Recurrence was not observed in submucosal excision whereas one patient with extramucosal enucleation had recurrence.ConclusionMucocele in comparison to extramucosal enucleation as it usually healed within a week with fewer incidences of wound infection and without any recurrence.Birat Journal of Health Sciences Vol.2/No.1/Issue 2/ Jan - April 2017, Page: 215-218

Awareness and Perceptions of Medical Students towards Health Care Ethics - A Study from Nepal

Background Medical practitioners are the men of science who treat patients based on their knowledge and skill. Unethical and immoral conduct in the practice of medicine pertains to human right issues and litigation. Objective The present study is conducted to understand the perceptions and awareness of the moral and ethical responsibilities of future medical doctors in Nepalese scenario. Method This cross sectional study was carried out among the undergraduate medical students of Manipal College of Medical Sciences, Pokhara, Nepal who were administered a pre-tested, semi-structured questionnaire relating to various aspects of health care ethics. A total of 202 students (116 girls and 86 boys) voluntarily participated in the study. Based upon the criteria whether a student had attended forensic medicine lecture the study participants were thus divided into two groups Group I and Group II. The responses of the participants were obtained on a 5 point Likert scale and analyzed. Result The study observed that the overall awareness on issues regarding consent was proportionately higher than for issues dealing with patient's right to treatment. The awareness levels were similar among the students of both groups for most of the issues with exception of a few issues where awareness levels were higher among the Group II students when compared to the Group I students. Conclusion This present study attempts to present the assessment of students on issues relating to ethics and moral reasoning. The present study also emphasizes on the importance of ethics in the practice of medicine.

Pressure Cooker-A Potential Hazard in Domestic Setting

Pressure cooker is an integral part of Asian kitchen, and is frequently used in Nepal. Steam under pressure generated while cooking has high boiling point and great penetrating power. The use of pressure cooker in kitchen is associated with unintentional injuries that mostly include pressure cooker burns. In rare instances the pressure cooker may accidently explode and may cause serious injuries. The same mechanism is used in making explosive device for mass homicides. An unusual case of penetrating facial injury sustained in a pressure cooker explosion in a domestic setting is reported along with a brief review of literature on pressure cooker explosions.

Abstract 319: Development and Validation of a Mortality Prediction Model for Hospitalized Heart Failure Patients

Background: Clinical predication models for hospitalized patients with heart failure have good performance characteristics but require medical record review, which is both costly and time-consuming. In contrast, administrative claims data are readily available for research but have limited clinical detail.

Methods: We used highly detailed billing data to derive a multivariable in-hospital mortality prediction model for patients with heart failure. We validated the model in a separate multi-hospital dataset derived from electronic health record (EHR) data. For the derivation, we included patients aged ≥18 years admitted to one of 433 hospitals that participate in the Premier, Inc. Data Warehouse (PDW) between January 2009 and June 2011. Patients with a principal ICD-9-CM diagnosis of heart failure or principal diagnosis of respiratory failure with secondary diagnosis of heart failure were included. After dividing the dataset into derivation and validation sets, we used generalized estimating equations to estimate the parameters of a generalized linear model that adjusted for clustering within hospitals. The model included selected patient demographics, comorbidities, history of prior heart failure admissions, and initial medications and therapies (e.g., inotropes, mechanical ventilation) administered in the first 2 hospital days. We applied the models to the validation set. Finally, we applied the coefficients from the model to a novel multi-hospital dataset, HealthFacts (Cerner Corp), which contains information about hospitalizations and is derived from the electronic health record of 76 participating sites (years 2010-2012).

Results: In PDW, we identified 200,832 patients ≥18 years old with a diagnosis of heart failure. Of these, 80% (160,839) were randomly assigned to the derivation cohort and the remaining 20% (39,993) were assigned to the validation cohort. Mortality was 4.0%. In the derivation cohort, the model showed a c-statistic of 0.79 Factors that were most strongly associated with mortality included age over 80 years, early inotropes, early vasopressors, and diagnosis of acute kidney injury that was present on admission. In the validation cohort, the c-statistic was 0.79. We then validated the model in the HealthFacts dataset, which had a higher percentage of African American patients (28% vs. 17%). In this cohort, the c-statistic was 0.82.

Conclusions: A heart failure mortality model based on detailed administrative data available in the first 2 hospital days had excellent performance characteristics in a derivation and an external, EHR-based validation dataset. When clinical data are not available, this model may be useful for severity adjustment in comparative effectiveness studies of heart failure patients.

Abstract 238: Validation of In-hospital Mortality Prediction Models for Patients with Heart Failure

Background: Mortality prediction models, developed with the goal of improving risk stratification in hospitalized heart failure (HF) patients, show good performance characteristics in the datasets in which they were developed but have not been validated in external populations.

Methods: We used a novel multi-hospital dataset [HealthFacts (Cerner Corp)] derived from the electronic health record (years 2010-2012). We examined the performance of four published HF inpatient mortality prediction models developed using data from: the Acute Decompensated Heart Failure National Registry (ADHERE), the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study, and the Get With the Guidelines-Heart Failure (GWTG-HF) registry. We compared to an administrative HF mortality prediction model (Premier model) that includes selected patient demographics, comorbidities, prior heart failure admissions, and therapies administered (e.g., inotropes, mechanical ventilation) in the first 2 hospital days. We also compared to a model that uses clinical data but is not heart failure-specific: the Laboratory-Based Acute Physiology Score (LAPS2). We included patients aged ≥18 years admitted with HF to one of 62 hospitals in the database. We applied all 6 models to the data and calculated the c-statistics.

Results: We identified 13,163 patients ≥18 years old with a diagnosis of heart failure. Median age was 74 years; approximately half were women; 65% of patients were white and 27% were black. In-hospital mortality was 4.3%. Bland-Altman plots revealed that, at higher predicted mortality, the Premier model outperformed the clinical models. Discrimination of the models varied: ADHERE model (0.68); EFFECT (0.70); GWTG-HF, Peterson (0.69); GWTG-HF, Eapen (0.70); LAPS2 (0.74); Premier (0.81) (Figure).

Conclusions: Clinically-derived inpatient heart failure mortality models exhibited similar performance with c statistics hovering around 0.70. A generic clinical mortality prediction model (LAPS2) had slightly better performance, as did a detailed administrative model. Any of these models may be useful for severity adjustment in comparative effectiveness studies of heart failure patients. When clinical data are not available, the administrative model performs similarly to clinical models.

Abstract 362: Presentation, Management, and Outcomes of Infective Endocarditis at a Tertiary Medical Center

Background: Infective endocarditis (IE) has historically caused significant morbidity and mortality, but there are few descriptions of contemporary cohorts of IE patients.

Methods: We conducted a retrospective cohort study of adult patients admitted to a single tertiary medical center with diagnosis of IE between 2007-2011. Using medical record abstraction and administrative databases, we collected demographic data, comorbidities and clinical data indicating IE severity, management and outcome.

Results: We identified 180 hospitalizations with a primary or secondary discharge diagnosis of IE and clinical criteria confirming IE diagnosis; 66% were male and 79% were white. Mean patient age was 60 years (SD=18 years) and 29% (52 of 180) of patients were admitted to critical care or step down unit. Risk factors for IE were common: 9% (17 of 180) had previous history of IE, 25% (45 of 180) had prosthetic valve IE, 17% (30 of 180) had intra cardiac devices, 12% (21 of 180) had long term central lines and 14% (25 of 180) were intravenous drug users.

Half of the sample had an infected native mitral valve (90 of 180) and 40% had an infected native aortic valve (72 of 180). Nearly all patients (93%: 173 of 180) had at least 2 sets of blood cultures drawn before starting antibiotics. The most common microorganism detected in blood culture was Staphylococcus aureus (41%: 69 of 180), followed by Streptococcus.viridans (17%: 29 of 180). Cultures were negative for 4% (7 of 180). Infectious disease consultation was completed in 83% (150 of 180) and cardiac surgery consultation in 45% (81 of 180) of patients.

Echocardiography was performed in 89% (161 of 180) of patients, transthoracic in 69% (125 of 180), and transesophageal in 56% (100 of 180). Among patient who had echocardiography, 17% (28 of 180) had a left ventricular ejection fraction of <50%; 52% (94 of 180) had insufficiency of the infected valve. Perivalvular abscess was reported in 8.9% (16 of 180) and valve perforation in 11% (19 of 180).

The median length of stay was 13 days (interquartile range 9-21days), inpatient mortality rate was 15% (27 of 180; 95% CI: 11.2%-21.2%), and 6-month readmission rate was 10.5% (19 of 180; 95% CI: 6.0%-15.1%).

Conclusions: In a single academic medical center, IE patients presented with high degree of acuity and found to have frequent complications in echocardiogram. Despite recent advances in medical, surgical, and critical care, many patients had a long hospitalization with relatively high inpatient mortality and readmission rate.

Acute regional left atrial ischemia causes acceleration of atrial drivers during atrial fibrillation

BACKGROUND

The mechanisms by which acute left atrial ischemia (LAI) leads to atrial fibrillation (AF) initiation and perpetuation remain unclear.

OBJECTIVE

To investigate the electrophysiological mechanisms of AF perpetuation in the presence of regional atrial ischemia.

METHODS

LAI (90-minute ischemia) was obtained in isolated sheep hearts by selectively perfusing microspheres into the left anterior atrial artery. Two charge-coupled device cameras and several bipolar electrodes enabled recording from multiple atrial locations: with a dual-camera setup (protocol 1, n = 10, and protocol 1', n = 4, for biatrial or atrioventricular camera setups, respectively), in the presence of propranolol/atropine (1 μM) added to the perfusate after LAI (protocol 2, n = 3) and after a pretreatment with glibenclamide (10 μM; protocol 3, n = 4).

RESULTS

Spontaneous AF occurred in 41.2% (7 of 17) of the hearts that were in sinus rhythm before LAI. LAI caused action potential duration shortening in both the ischemic (IZ) and nonischemic (NIZ) zones by 21% ± 8% and 34% ± 13%, respectively (pacing, 5 Hz; P<.05 compared to baseline). Apparent impulse velocity was significantly reduced in the IZ but not in the NIZ (-65% ± 19% and 9% ± 18%; P = .001 and NS, respectively). During LAI-related AF, a significant NIZ maximal dominant frequency increase from 7.4 ± 2.5 to 14.0 ± 5.5 Hz (P<.05) was observed. Glibenclamide, an ATP-sensitive potassium current (IKATP) channel blocker, averted LAI-related maximal dominant frequency increase (NIZ: LAI vs glibenclamide 14.0 ± 5.5 Hz vs 5.9 ± 1.3 Hz; P<.05). An interplay between spontaneous focal discharges and rotors, locating at the IZ-NIZ border zone, maintained LAI-related AF.

CONCLUSIONS

LAI leads to an IKATP conductance-dependent action potential duration shortening and spontaneous AF maintained by both spontaneous focal discharges and reentrant circuits locating at the IZ border zone.