Analytical assessment of clinical sensitivity and specificities of pharmaceutical rapid SARS-CoV-2 detection nasopharyngeal swab testing kits in Pakistan

Despite of the global unity against COVID-19 pandemic, the threat of SARS-CoV-2 variants on the lives of human being is still not over. SARS-CoV-2 pandemic has urged the need of rapid viral detection at earliest. To cope with gradually expanding scenario of SARS-CoV-2, accurate diagnosis is extremely crucial factor which should be noticed by international health organizations. Limited research followed by sporadic marketing of SARS-CoV-2 rapid pharmaceutical detection kits raises critical questions against quality assurance and quality control measures. Herein we aimed to interrogate effectivity and specificity analysis of SARS-CoV-2 pharmaceutical rapid detection kits (nasopharyngeal swab based) using conventional gold standard triple target real-time polymerase chain reaction (USFDA approved). A cross-sectional study was conducted over 1500 suspected SARS-CoV-2 patients. 100 real time-PCR confirmed patients were evaluated for pharmaceutical RDT kits based upon nasopharyngeal swab based kits. The SARS-CoV-2 nasopharyngeal swab based rapid diagnostic kit (NSP RDTs) analysis showed 78% reactivity. Among real time PCR confirmed negative subjects, 49.3% represented false positivity. The positive predictive analysis revealed 67.82%, while negative predictive values were 64.40%. The NSP RDTs showed limited sensitivities and specificities as compared to gold standard real time PCR. Valid and authentic detection of SARS-CoV-2 is deemed necessary for accurate COVID-19 surveillance across the globe. Current study highlights the potential consequences of inadequate detection of SARS-CoV-2 and emerging novel mutants, compromising vaccine preventable diseases. Current study emphasizes need to wake higher authorities including strategic organizations for designing adequate measures to prevent future SARS-CoV-2 epidemics.

Hepatitis C virus associated ALT, AST, GGT, Bili T, HB, HBA1C, CREAT, PT, aPPT, AFP, CEA, CA 125, CA 19-9, iPTH biomarkers, computed tomography and HCV burden of disease during pre COVID-19 era (2018-2019) and post COVID-19 era (2020-2022) in Pakistan

The national burden of HCV has significantly mounted over the period of last few decades placing Pakistan at the worst placement of second largest burden of HCV globally. Herein for the first time from Pakistan, we examined clinical correlation of potential biomarkers with HCV. Nation-wide study was conducted on 13,348 suspected HCV patients during 2018-2022. During pre-COVID-19 era of 2018-2019, prevalence of HCV remained 30%. During 2018, among HCV positive patients, 91% of ALT, 63% of AST, 67% of GGT, 28% of Bili T, 62% of HB, 15% of HBA1C, 25% of CREAT, 15% of PT, 15% of aPTT and 64% of AFP were abnormal. During 2019, among HCV infected 74.47% of ALT, 63.54% of AST, 70.24% of GGT, 24.71% of Bili T, 8.77% of HB and 75% of AFP were raised. CT/CAT scan revealed 4.65% liver complications (mild 13.04%, moderate 30.43% and severe 56.52%). During 2020, HCV prevalence remained 25%. 65.17% of ALT, 64.20% of AST, 68.75% of GGT, 31.25% of Bili T, 20.97% of HB, 4.65% of CREAT and 73.68% of AFP levels were raised. CAT analysis revealed liver complications among 4.41% (14.81% mild, 40.74% moderate, and 44.44% sever). 85.71% of participants diabetes was out of control. During 2021, HCV prevalence remained 27.1%. ALT (73.86%), AST (50.6%), GGT (67.95%), Bili T (28.21%), HB (20%), CREAT (5.8%) and AFP (82.14%) levels were abnormal. During 2022, the levels of ALT (56.06%), AST (56.36%), GGT (56.6%), Bili T (19.23%), HB (43.48%), HBA1C (14.81), CREAT (18.92%), AFP (93.75%) were abnormal. CAT analysis revealed 7.46% liver complications (25% mild, 30.36% moderate, and 42.86% sever). During 2021-2022, 83.33% of subject's diabetes was not controlled.

Spectrum of fetal limb anomalies

PURPOSE

Antenatal detection of limb anomalies is not uncommon, and pregnancies are usually terminated in view of the expected physical handicap. The aim of this retrospective observational study is to delineate the spectrum of fetal limb anomalies and provide evidence in support of complete postnatal evaluation in establishing recurrence risk.

METHODS

We present 54 cases of limb malformations detected antenatally and discuss the spectrum of abnormalities, the utility of fetal autopsy, and genetic testing to establish recurrence risk in subsequent pregnancies.

RESULTS

16/54 cases were isolated radial ray anomalies. There were five cases of amniotic band syndrome, five limb body wall complex cases, three VACTERL (vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities) associations, one case of sirenomelia, two cases of limb pelvis hypoplasia, and one case of OEIS (Omphalocele Exstrophy Imperforate anus and spinal defects). Four fetuses with non-isolated radial ray anomaly had trisomy 18. One case with bilateral radial ray defect had a mutation in the FANC-E gene confirming fanconi anemia. Twelve cases were unclassified.

CONCLUSION

Autopsy is the most important investigation in fetuses with limb anomalies. We suggest chromosomal microarray (CMA) as a first-tier test after autopsy. However, in cases of bilaterally symmetrical limb anomalies, in case of previous similarly affected child, or history of consanguinity, whole exome sequencing (WES) can be offered as the primary investigation, followed by CMA if WES is normal.

1638 Decade-Long Trends in Surgery for Acute Type A Aortic Dissection

Background

Little is known about unwarranted variations in care and outcomes of patients who undergo surgical repair for type A acute aortic dissection(TAAD). We aim to investigate decade-long trends in TAAD surgical repair in England.

Method

Retrospective review of the National Institute for Cardiovascular Outcomes Research (NICOR) National Adult Cardiac Surgery Audit (NACSA) registry from January 2009 to December 2018 , which prospectively collects demographic and peri-operative clinical information for all adult cardiac surgery procedures in the UK.

Results

Over the 10-year period,3,686 TAAD patients underwent surgical repair in England. A steady doubling in the overall number of operations conducted in England was observed from 237 cases recorded in 2009 to 510 in 2018. Number of procedures per hospital per year also doubled, from 10 in 2009 to 21 in 2018. The risk profile of the operated patients remained unchanged. Overall, in-hospital mortality was 17.4% with a trend toward lower mortality in the most recent years (from 22.8% in 2009 to 14.7% in 2018). There was a significant variation in operative mortality across regions with a trend towards lower mortality in regions with a high-volume hospital.

Conclusions

Surgery is the only treatment for acute TAAD but is associated with high mortality. Prompt diagnosis and referral to a specialist center is paramount. The number of operations conducted in England has doubled in 10 years and the associated survival following surgery has improved. Regional variations exist in service provision with a trend towards better survival in high volume centers.

18F-FDGPET/CT improves diagnostic certainty over the modified Duke Criteria in blood culture negative infective endocarditis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Diagnosis of blood culture negative infective endocarditis (BCNIE) is challenging, with positive microbiology key in the modified Duke Criteria (mDC). ESC IE Guidelines (2015) recommend the use of 18F-FDG PET/CT (PET) in cases where transoesophageal echocardiography (TOE) is equivocal and where cardiac implantable device-related IE (CIDRE) is suspected. We explored the role of PET to improve diagnostic certainty in the challenging cohort of BCNIE.

Methods

Retrospective review of all suspected BCNIE patients undergoing PET (10/2015 to 01/2021). Myocardial suppression technique was used in all cases, and studies were assessed for valve/device avidity. Patients were classified as definite/possible/rejected IE by mDC pre- and post-PET, with incremental benefit assessed by net reclassification index (NRI) versus actual diagnosis. Actual diagnosis was defined by Endocarditis Team consensus or surgical specimen (where available) at a minimum of 2-months following index admission.

Results

PET was performed in 110/807 (13.6%) cases overall. BCNIE prevalence was 18% across the total cohort, with 25/110 (22.7%) PET studies in BCNIE patients (male = 17, mean age 65). (p = 0.16 for PET in BCNIE compared to overall). PET was undertaken in 8 CIDRE, 9 native IE (NVE) and 10 prosthetic IE (PVE); 2-patients had suspected CIDRE + PVE. TOE was performed in all cases, and surgery was required in 8/25 patients. IE was confirmed in 44% of cases.

PET sensitivity, specificity, positive and negative predictive values were 73%, 93%, 89% and 81%, respectively. Addition of PET to the mDC improved re-classification to definite or rejected IE, with NRI 0.633 (positive NRI 0.3; negative 0.333), and added weight to the original mDC classification in 14/25 (56%) of cases.

Conclusion

PET improves diagnostic certainty when combined with mDC in the evaluation of patients with BCNIE across NVE, PVE and CIDRE.

The impact of frailty in an endocarditis cohort: association with length of stay and mortality

Introduction

Predictors of poor outcome are well established in Endocarditis (IE). “Frailty” refers to a syndrome of physiological decline associated with adverse health outcomes. Gilbert et al.(Lancet, 2018) developed a Hospital Frailty Risk Score (HFRS) that predicts 30-day mortality and length of stay (LOS).

Aim

Identify impact of an abbreviated HFRS (aHFRS) on in-hospital survival and LOS in IE given high morbidity and mortality.

Methods

Retrospective analysis of prospectively collected cases (Jan 2018–date). aHFRS score was calculated with key IE, cardiac, respiratory, oncology & frailty diagnoses. Univariate regression was applied overall and in key “cohorts” (native & prosthetic IE, medical & surgical management) for survival and LOS.

Results

Of 334 cases, LOS data were available in 317; mean age 57.8y (range 17–91, male 74%). Table 1 describes key cohorts. Mortality was 10.1% (medical, 11.9%; surgical, 8.3%). Mean LOS was 31.2 days (range 0–224).

Mean aHFRS was 5.38diagnoses (SD 2.61, range 0–14); 1.65 pre-IE and 3.73 attributed to IE alone, consistent across cohorts. Regression analyses highlight increasing LOS with increasing aHFRS (r2=0.06, Figure 1). Table 1 summarises the modest impact of aHFRS on LOS, and a trend to worse outcome in medical management (r2=0.02).

Discussion

Higher aHFRS is associated with longer LOS and a trend to higher mortality in medically managed IE. IE itself is associated with a number of frailty diagnoses. To improve outlook and provide holistic care, the IE Team may need to include experts in frailty. Satisfactory outcomes may require intensive post-IE rehabilitation.

Funding Acknowledgement

Type of funding source: None

P2764Medical management of Staphylococcus aureus infective endocarditis: unexpectedly favourable outcomes in an aggressive disease

Introduction

Early surgical intervention (ESI) for infective endocarditis (IE) is associated with improved outcomes. Staphylococcus aureus endocarditis (SAE) is associated with particularly high rates of tissue destruction, morbidity and mortality. However, the question as to whether ESI is mandated in all SAE continues to be debated, in both native (NVE) and prosthetic (PVE) endocarditis.

Methods

Retrospective review of all IE cases presenting to our institution from October 2015 to January 2019. IE was diagnosed following imaging and microbiological protocols as per ESC guidance, and data were extracted for those with SAE. Patients with isolated cardiac implantable electronic device IE or bacteraemia secondary to indwelling long-term venous catheter infection were excluded (non-valvular IE).

Results

Valvular IE was diagnosed in 411 patients overall; NVE in 286 (69.6%) and PVE in 125 (30.4%). S aureus was isolated in 111 patients (28.1%), of whom 5 had a Methicillin-resistant strain. SAE was confirmed in a similar proportion of NVE and PVE cases [83/111 (74.8%) and 28/111 (25.2%), respectively]. Surgical intervention was mandated in 35/83 with NVE (42.2%) and 11/28 (39.3%) with PVE, lower than in our overall cohort (55.9% and 48.8%, respectively).

In-hospital SAE mortality was 16.2% overall (18.4% medical vs 13.0% surgical), and contributes a significant proportion to overall mortality (29% to medical & 26% to surgical mortality). Figure 1 identifies the cause of death per mode of treatment, highlighting the aggressive nature of S aureus infection (abscess, disseminated infection and septic shock; n=8), the importance of advanced non-cardiac comorbidity precluding intervention (n=3) and ongoing intravenous drug use in those with PVE (n=4). However, medical management was successful in 57.8% (38/83) of NVE and 60.7% (17/28) of PVE cases, both in hospital and to a minimum follow-up of 3-months.

Conclusion

Staphylococcus aureus is virulent and highly pathogenic, driving severe sepsis and advanced tissue destruction in SAE. Despite this, medical management can be successful when following international guidance, but requires co-ordinated care driven by a multidisciplinary IE team at a cardiothoracic centre.

P2569Self-adhesive bi-layered dressing incorporating amnion-derived mesenchymal stromal cells for the treatment of heart failure: a pre-clinical proof of concept study

Introduction

Mesenchymal stromal cell (MSC) transplantation is a promising treatment to promote myocardial repair. Among various sources, the amnion has an advantage in mass production of high-quality MSCs due to its large initial cell-yield and prenatal nature of isolated cells. In addition to the powerful tissue-repair potential, amnion-derived MSCs (AMSCs) exhibit a robust immunomodulative ability, enabling allogeneic transplantation without immunosuppressive reagents. We here report a novel bioengineering technique to deliver AMSCs for myocardial repair by epicardial placement of self-adhesive, bi-layered, AMSC-incorporating dressings (AMSC-dressing), which is fabricable on-site (Figure A).

Methods and results

AMSC-dressing was fabricated by spreading AMSC suspension on the inner layer of a fibrin sealant film, composed of fibrinogen and thrombin. Due to the resulting adhesive AMSC-fibrin complex, the AMSC-dressing firmly adhered to the heart surface without the need for suture or additional glue. The outer collagen layer of the film facilitated the easy handling and also protected the AMSC-fibrin complex from external damage. We applied a 1 cm2 dressing containing 0, 1, 2 or 4 millions of rat AMSCs to a rat ischemic cardiomyopathy model (4 weeks post coronary artery ligation). Intramyocardial (IM) injection of 4 millions of AMSCs and sham treatment were also conducted. Echocardiography and catheterization consistently demonstrated that AMSC-dressing therapy improved cardiac function and reduced heart dilatation in a dose-dependent manner compared to the sham control. Furthermore, this therapeutic effect exceeded that of IM injection (Figure B). Histological analyses revealed that AMSC-dressing therapy resulted in augmented myocardial tissue repair (increased neovascularization, attenuated pathological fibrosis and reduced cardiomyocyte hypertrophy) compared to IM injection and sham groups. These effects were associated with increased upregulation of a range of tissue repair-related genes including Il10, Cxcl12, Igf1, Timp1, Hif1a, Tgfb, Mmp2, Hgf, Fgf2 and Vegf. Of note, it was elucidated that both initial retention and subsequent survival of donor AMSCs were enhanced by the dressing technique compared to IM injection. In addition, in vitro studies demonstrated that culturing in a fibrin glue not only enhanced upregulation of tissue-repair genes of AMSCs but also improved their survival against environmental stress through activating the Akt/PI3K cell-survival pathway.

Conclusion

AMSC-dressing therapy enhanced both quantity and quality of donor cell engraftment, leading to the augmented therapeutic efficacy, compared to the current method. Furthermore, this technique is user-friendly and requires no specialized equipment at the treating hospital, highlighting its great potential to be a widely-adopted, standard treatment for heart failure. Further development of this advanced cell therapy towards clinical application is justified.

Acknowledgement/Funding

British Heart Foundation, Heart Research UK, Japan Agency for Medical Research and Development, Kaneka Corporation

Living with Amputation: Anxiety and Depression Correlates

INTRODUCTION

Trauma accounts for 16% of the total burden of disease in the world, making it a leading cause of morbidity and mortality especially in the developing nations. India represents about 10% (225million) of the total world workforce in agriculture. With the evolution of new machinery and better techniques of agriculture, there has been a substantial increase in the associated injuries. Depression, anxiety and post-traumatic stress are among the predictors of poor quality of life (QOL).

AIM

This study was aimed to assess and correlate of traumatic amputation on the patient's mental health in the Northern Indian rural setting.

MATERIALS AND METHODS

This cross-sectional study included subjects who had undergone traumatic amputations. A pre-tested, semi-structured questionnaire was administered to each study participant after an informed verbal consent. The questionnaire had two parts. The first part gathered socio-personal and the disability related information from the patient and the second part included a Hospital Anxiety and Depression Scale (HADS).

RESULTS

The mean anxiety and depression scores were 9.10±5.7 and 3.44±3.42, respectively. The length of original inpatient stay, people at hand for help, number of hospitalizations, number of follow ups per year, type of family (nuclear versus joint), pain perception, optimism, rehabilitation satisfaction and lower limb amputations correlated significantly with anxiety levels in the patients. The depression levels correlated significantly only with perception of pain.

CONCLUSION

The amputees have a large number of psychosocial concerns which need to be addressed to provide a holistic care and a better QOL. It is essential to sensitize the community, the health care providers and the patient's family to the additional psychosocial needs of the amputee.

Telemedicine for multidisciplinary lung cancer meetings

According to recent UK guidelines on the management of lung cancer, all cases should be reviewed prospectively by a lung cancer multidisciplinary team (MDT) and a thoracic surgeon should be readily available to liaise with the MDT. However, there is a shortage of thoracic surgeons in the UK. Over a one-year period, 28 MDT meetings were held at a district general hospital in Southend, at which 62 patients were presented to a tertiary cardiothoracic centre in London, 80 km away, via ISDN videoconferencing at 384 kbit/s. The annual resection rate increased by 30% following the introduction of the telemedicine MDT meetings, and the mean time from first being seen in the clinic to surgery was reduced from 69 to 54 days. We estimate that the telemedicine meetings saved over three working weeks of thoracic surgical time during the year.

Revised guidelines on management of antenatal hydronephrosis

Widespread antenatal screening has resulted in increased detection of anomalies of the kidneys and urinary tract. The present guidelines update the recommendations published in 2000. Antenatal hydronephrosis (ANH) is transient and resolves by the third trimester in almost one-half cases. The presence of oligohydramnios and additional renal or extrarenal anomalies suggests significant pathology. All patients with ANH should undergo postnatal ultrasonography; the intensity of subsequent evaluation depends on anteroposterior diameter (APD) of the renal pelvis and/or Society for Fetal Urology (SFU) grading. Patients with postnatal APD exceeding 10 mm and/or SFU grade 3-4 should be screened for upper or lower urinary tract obstruction and vesicoureteric reflux (VUR). Infants with VUR should receive antibiotic prophylaxis through the first year of life, and their parents counseled regarding the risk of urinary tract infections. The management of patients with pelviureteric junction or vesicoureteric junction obstruction depends on clinical features and results of sequential ultrasonography and radionuclide renography. Surgery is considered in patients with increasing renal pelvic APD and/or an obstructed renogram with differential renal function <35-40% or its subsequent decline. Further studies are necessary to clarify the role of prenatal intervention, frequency of follow-up investigations and indications for surgery in these patients.

Clinical and biomarker profile of trauma-induced secondary cardiac injury

BACKGROUND

Secondary cardiac injury has been demonstrated in critical illness and is associated with worse outcomes. The aim of this study was to establish the existence of trauma-induced secondary cardiac injury, and investigate its impact on outcomes in injured patients.

METHODS

Injured adult patients eligible for enrolment in the Activation of Coagulation and Inflammation in Trauma 2 study, and admitted to the intensive care unit between January 2008 and January 2010, were selected retrospectively for the study. Markers of cardiac injury (brain natriuretic peptide (BNP), heart-type fatty acid binding protein (H-FABP) and troponin I) were measured on admission, and after 24 and 72 h in blood samples from injured patients. Individual records were reviewed for adverse cardiac events and death.

RESULTS

During the study period, 135 patients were enrolled (106 male, 78·5 per cent) with a median age of 40 (range 16-89) years. Eighteen patients (13·3 per cent) had an adverse cardiac event during admission and these events were not associated with direct thoracic injury. The in-hospital mortality rate was higher among the adverse cardiac event cohort: 44 per cent (8 of 18) versus 17·1 per cent (20 of 117) (P = 0·008). Raised levels of H-FABP and BNP at 0, 24 and 72 h, and troponin I at 24 and 72 h, were associated with increased adverse cardiac events. BNP levels were higher in non-survivors on admission (median 550 versus 403 fmol/ml; P = 0·022), after 24 h (794 versus 567 fmol/ml; P = 0·033) and after 72 h (1043 versus 753 fmol/ml; P = 0·036), as were admission troponin I levels.

CONCLUSION

Clinical and cardiac biomarker characteristics support the existence of trauma-induced secondary cardiac injury, which is associated with death, and unrelated to direct thoracic injury.

Case fatality rates for South Asian and Caucasian patients show no difference 2.5 years after percutaneous coronary intervention

OBJECTIVE

To compare short and medium-term prognosis in South Asian and Caucasian patients undergoing percutaneous coronary intervention (PCI) to determine if there are ethnic differences in case death rates.

DESIGN

Retrospective cohort study.

SETTING

A cardiology referral centre in east London.

PATIENTS

9771 patients who underwent PCI from October 2003 to December 2007 of whom 7966 (81.5%) were Caucasian and 1805 (18.5%) were South Asian.

MAIN OUTCOME MEASURES

In-hospital major adverse cardiac events (MACE; death, myocardial infarction, stroke and target vessel revascularisation), subsequent revascularisation rates (PCI and coronary artery bypass grafting; CABG) and all-cause mortality during a median follow-up of 2.5 years (range 1.5-3.6 years).

RESULTS

South Asian patients were younger than Caucasian patients (59.69±0.27 vs 64.69±0.13 years, p<0.0001), and more burdened by cardiovascular risk factors, particularly type II diabetes mellitus (45.9%±1.2% vs 15.7%±0.4%, p<0.0001). The in-hospital rates of MACE were similar for South Asians and Caucasians (3.5% vs 2.8%, p=0.40). South Asians had higher rates of clinically driven PCI for restenosis and subsequent CABG, although Kaplan-Meier estimates of all-cause mortality showed no significant differences; this was regardless of whether PCI was performed post-acute coronary syndrome or as an elective procedure. The adjusted hazard of death for South Asians compared with Caucasians was 1.00 (95% CI 0.81 to 1.23).

CONCLUSION

In this large PCI cohort, the in-hospital and longer-term mortality of South Asians appeared no worse than that of Caucasians. South Asians had higher rates of restenosis and CABG during follow-up. Data suggest that the excess coronary mortality for South Asians compared with Caucasians is not explained by differences in case-fatality rates.

Partial cardiomyectomy--an animal model of gastro-oesophageal reflux

Various procedures have been adopted to provide experimental models of gastro-oesophageal reflux. Although some procedures have produced better results than others, previous literature does not assert that experimental gastro-oesophageal reflux can be produced reliably in all animals. This study attempts to compare two procedures to produce a working model of gastro-oesophageal reflux in the rabbit: (i) cardiomyotomy and (ii) cardiomyectomy. The animals underwent intraoesophageal pH monitoring one week before and one week following surgery. The mean changes in % reflux time from preoperative to one week postoperative were compared. The cardiomyotomy group did not demonstrate significant gastro-oesophageal reflux (p > 0.2, p < 0.5), the mean change in % reflux time was 10.5 +/- 14.11%, whereas the cardiomyectomy group did demonstrate significant reflux (p < 0.001) with a mean change in % reflux time of 22.35 +/- 3.05%. A further study investigated the cardiomyectomy procedure in ten rabbits. Animals underwent preoperative, one-week and four-week postoperative intraoesophageal manometry and pH studies. The mean change in values from preoperative to four weeks postoperative were compared. There was a significant increase in mean % reflux time from a preoperative value of 3.05 +/- 2.29% to 42.08 +/- 12.05% at four weeks after surgery (p < 0.001). There was also a significant decrease in mean basal LOS pressure from a preoperative value of 15.00 +/- 5.49 mmHg to 4.45 +/- 1.90 mmHg four weeks following surgery (p < 0.001). This study showed that cardiomyectomy alone produces effective gastro-oesophageal reflux in the rabbit, and thus provides an experimental model to test the effectiveness of antireflux procedures.

Concomitant off-pump myocardial revascularization and pheochromocytoma resection

Surgical management of patients with coexisting ischemic heart disease and pheochromocytoma remains challenging. We present one such case in which hybrid myocardial revascularization (angioplasty with stenting and off-pump coronary artery bypass grafting) and resection of pheochromocytoma were undertaken. Unusual features included simultaneous coronary artery surgery and tumor resection and, in particular, coronary artery surgery being performed without cardiopulmonary bypass.

Do oral flora colonize the nasal floor of patients with oronasal fistulae?

OBJECTIVE

To determine if oral bacteria colonize the cleft nasal floor in patients with unilateral oronasal fistula when compared with the unaffected nasal floor and whether the results obtained would be of benefit in assessing oronasal fistulae in the clinic.

DESIGN

Prospective study of 26 patients with cleft palate and unilateral oronasal fistula. Microbiological culture swabs were taken from the mouth and nasal floors of patients. The unaffected nasal floor was used as a control. Bacterial isolates were identified and compared in the laboratory by a senior microbiologist.

MAIN OUTCOMES MEASURE

A significant growth of oral bacteria from the cleft nasal floor when compared with the unaffected nasal floor.

RESULTS

Four patients were excluded because no growth was found on any culture plate. In the remaining 22 cases, a light growth of oral flora was found in the cleft nasal floor in only 3 patients. No statistical correlation between culture of oral bacteria and the cleft nasal floor could be found (p =.12).

CONCLUSIONS

The relative lack of colonization of the cleft nasal floor by oral bacteria may reflect poor transmission of bacteria through the fistula, competition with commensal nasal flora, or an inability of oral bacteria to survive in a saliva-depleted area. The investigation is not helpful in the assessment of oronasal fistulae in the clinic.

Use of cold medications for upper respiratory tract infections in children

Prescribing practices in the treatment of upper respiratory tract infections (URTI) in children were studied, with particular emphasis on overuse of antibiotics, combination cold medications, and off-label use of medicines in children. Prescriptions with the diagnosis of URTI were studied over a period of 5 months in a general pediatric clinic. Out of 224 prescriptions scrutinized, a cold medication was prescribed in 88.4% of cases and 50.9% prescriptions contained a combination preparation. Antihistamines (50.9%), alpha-adrenoceptor agonist decongestants (50.0%) and opioid anti-tussives (24.5%) were the common ingredients of cold medications. Antihistamines (35.7%) were also used alone. Of the children 18.2% were receiving a drug contraindicated or not recommended in their age group. Antibiotics were prescribed in only 8.5% of cases, and for appropriate indications, reflecting a more restrained use of antibiotics.

Cleft lip and palate management by U.K. consultant oral and maxillofacial surgeons: a national survey

OBJECTIVE

Following the report of the Clinical Standards Advisory Group (CSAG), a national survey of U.K. consultant oral and maxillofacial surgeons was performed to determine the current cleft lip and palate practice of this group prior to the implementation of proposed radical changes in the delivery of cleft services. The views of these surgeons regarding the proposed changes was also sought.

DESIGN

An anonymous postal questionnaire sent to all 266 consultants in the U.K., which requested information on the practice of cleft surgery during a defined 1-year period (March 1997 through February 1998). It included the numbers and types of procedures performed, the involvement of multidisciplinary care, research and audit activity, and questions regarding the implementation of CSAG.

RESULTS

One hundred ninety-one replies (72% response rate). Seventy-three surgeons were actively involved with mainly secondary cleft surgery. A varied number and range of procedures were undertaken, with most surgeons performing less than five of each procedure per year. Audit and research activity was 26%. The majority of both noncleft and cleft surgeons agreed with proposals made by CSAG (except for cleft osteotomy procedures).

CONCLUSIONS

In the U.K. at present, there are many oral and maxillofacial surgeons performing mainly secondary cleft surgery; overall, the number of procedures performed by these surgeons per year is small. Intraspecialty referral is suggested to further improve patient outcome.

Effect of oral magnesium supplementation on blood pressure, platelet aggregation and calcium handling in deoxycorticosterone acetate induced hypertension in rats

OBJECTIVE

To study the effect of oral magnesium supplementation on blood pressure, platelet aggregation and platelet calcium handling in deoxycorticosterone acetate (DOCA)-induced hypertension in rats.

DESIGN AND METHODS

Rats were divided into four groups of 20 each. Drug treatments were given for a 6-week period. Control rats were vehicle treated. In the second group, DOCA, 15 mg/kg, was injected subcutaneously twice weekly with 1% NaCl used instead of drinking water. The third group was given magnesium oxide (MgO), 1 g/kg daily, orally by gavage. The fourth group was given MgO along with DOCA and 1% NaCl. Blood pressure and heart rate were measured weekly. Platelet aggregation, intracellular calcium, calcium uptake and calcium efflux studies were performed at the end of sixth week. Serum magnesium concentration, plasma levels of reactive nitrogen intermediates (RNI) and citrulline were also measured

RESULTS

There was a significant rise in blood pressure in the DOCA-treated rats. Magnesium prevented the gradual rise in blood pressure when given along with DOCA, but had no effect in normotensive rats. Heart rate did not show any significant change. Platelet aggregation was significantly reduced in all the treatment groups compared to the control group. DOCA treatment produced a significant increase in the intracellular calcium concentration as well as the calcium uptake compared to the control group. Magnesium supplementation inhibited the increased intracellular calcium concentration and calcium uptake in DOCA-treated rats. RNI and citrulline levels were elevated in all the treatment groups. Serum magnesium levels were significantly higher in the magnesium-treated and DOCA plus magnesium-treated rats.

CONCLUSIONS

Magnesium supplementation prevents blood pressure elevation in DOCA hypertensive rats. These effects are associated with inhibition of platelet calcium uptake and decreased intracellular free calcium concentration.

Adverse drug reactions among inpatients in a north Indian referral hospital

BACKGROUND

Monitoring spontaneous adverse drug reactions is one of the epidemiological methods for assessing the safety of drugs in a hospital setting.

METHODS

Data on adverse drug reactions (ADRs) were collected over a 3-year period among inpatients in a north Indian referral hospital using the spontaneous ADR monitoring system.

RESULTS

A total of 317 ADRs were reported. Cutaneous reactions (38.8%) and gastrointestinal disturbances (28.4%) made up a large proportion of reported ADRs. Antimicrobial agents, including those used for antituberculosis therapy, were responsible for 47.3% of the events. Radiocontrast dyes, and antineoplastic and psychoactive agents were the other important drugs causing ADRs. No age- or sex-related differences were found in the overall rate of ADRs, though toxic epidermal necrolysis was more frequent in the elderly.

CONCLUSION

The pattern of ADRs and drugs involved were largely similar to those reported in the western literature.

Term twin pregnancy with hydatidiform mole and a normal fetus

A term twin pregnancy with a complete hydatidiform mole and a normal live fetus is reported.

Cutaneous adverse reactions in in-patients in a tertiary care hospital

Cutaneous reactions were monitored by spontaneous adverse reaction monitoring system among inpatients in Nehru Hospital, over a period of 3 1/2 years. A total of 379 adverse drug reactions were reported during this period, of which 144 (40%) were cutaneous reactions. Maculopapular rashes (50% of cutaneous reactions), and urticaria (21.5%) were the most common eruption. Stevens-Johnson syndrome (13.9%) and toxic epidermal necrolysis (TEN 4.9%) were the serious cutaneous reactions. There were 4 fatal cutaneous reactions (all due to TEN). Antimicrobials (caused 56.9% reactions), radiocontrast dyes (14.6% reactions) and antiepileptics (15.3% reactions) were the most prominent drugs responsible for these eruptions.

Adverse drug reactions to fluoroquinolones at a tertiary care hospital in northern India

Use of fluoroquinolones has increased considerably in the last 5-6 years in our hospitals. With a view to ascertain their safety and the type of adverse drug reactions (ADRs) in our population, spontaneous reports were collected and analysed to ciprofloxacin (the most prescribed fluoroquinolone in our hospital) over a period of three and a half years. The pattern of reactions were rash in 18, severe reactions like Steven Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in 4, gastritis and diarrhoea in 3, shivering and rigors in 2, hemorrhagic purpuric spots in 2 and oedema of eye and lids with topical application in 1 patient. Most cases recovered on stoppage of the drug and symptomatic treatment. However, one case of SJS and one of TEN proved fatal. Care needs to be exercised in their use and they do not appear to be innocuous to severe and disturbing ADRs.

Re-do cardiac surgery in patients over 70 years old

OBJECTIVE

This study was conducted in order to determine the outcome of cardiac re-operations in patients over the age of 70.

METHODS

All patients who underwent 're-do' cardiac surgery at our institution, between January 1987 and October 1995 were identified. The case notes of patients over the age of 70 were reviewed retrospectively and follow-up was by telephone.

RESULTS

A total of 687 re-do operations were performed during this 8 years and 9 months period. Operations, 110 (16%) were on patients aged 70 years and over (CABG 54, MVR 32, AVR 9, AVR + MVR 5, MVR + CABG 4, AVR + CABG 3, repair of paraprosthetic leak 2 and closure of VSD 1). Operations, 63 (57%) were elective and 42 (38%) were urgent. The median age was 73 years (range 70-82) and 64 patients (58%) were male. Pre-operatively, 78 patients (72%) were NYHA functional class III/IV and 55 (50%) had angiographically impaired left ventricular function (ejection fraction < 50%). The overall operative mortality was 7% (8/110). Median ITU stay was one night (range 1-21) and hospital stay was 7 days (range 5-35). Major in-hospital complications included resternotomy in five patients (5%), permanent stroke in three (3%), renal failure requiring haemodialysis in two (2%) and heart block requiring permanent pacing in two (2%). At a median follow-up of 34 months (range 2-101), 69 of the 77 patients alive at follow-up (90%) were NYHA functional class I/II.

CONCLUSIONS

'Re-do' cardiac surgery in patients over the age of 70 carries an acceptable operative morbidity and mortality with a good functional improvement at medium term follow-up.

A surgical approach to coexistent coronary and carotid artery disease

OBJECTIVE

To assess the early results of combined coronary artery bypass graft surgery and carotid endarterectomy.

DESIGN

Retrospective and ongoing analysis of patients who underwent combined coronary artery bypass graft surgery and carotid endarterectomy.

SETTING

Cardiothoracic unit in a London teaching hospital.

PATIENTS

From June 1987 to March 1995, 64 patients were identified. They were patients who were scheduled to have coronary artery bypass graft surgery or required urgent coronary revascularisation and who were found to have significant coexistent carotid disease. (Unilateral carotid stenosis > 70%, bilateral carotid stenosis > 50%, or unilateral carotid stenosis > 50% with contralateral occlusion.)

INTERVENTIONS

Both procedures were performed during one anaesthesia: the carotid endarterectomy was performed first without cardiopulmonary bypass. After completion of carotid endarterectomy, coronary artery bypass graft surgery was performed.

MAIN OUTCOME MEASURES

The incidence of stroke, transient ischaemic attack, and myocardial infarction in the early postoperative period was analysed.

RESULTS

Myocardial revascularisation was successful in all 64 patients. There were no perioperative infarcts. In three patients (4.7%) a new neurological deficit developed postoperatively: two recovered fully before hospital discharge.

CONCLUSIONS

Combined coronary artery bypass graft surgery and carotid endarterectomy were performed safely and with good results.