Echocardiographic Evaluation of Cardiac Changes in Patients with Hypothyroidism and the Response to Treatment

Thyroid hormone acts on heart and peripheral vascular system in multiple ways. Most of the cardiac manifestations are reversible with adequate and timely thyroid therapy. Echocardiographic changes are present in patients with untreated hypothyroidism and the changes are reversible with treatment. Aim of the study was to evaluate the structural and functional changes of the heart in hypothyroid patients and its response to treatment. This prospective observational study was performed in the Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from November 2012 to April 2013. The study included 35 cases and 35 control based on their thyroid hormonal status. The cases were previously untreated for hypothyroidism. By 2D and M-mode echocardiography LV septal wall and posterior wall thickness, LVIDD, LVIDS, LA and Aortic diameter and ejection fraction were measured. Mitral inflow pattern was observed through pulse wave Doppler and peak E velocity, a velocity and E/A ratio were noted. All the observations were noted both in cases and controls and in cases after normalization of hypothyroid status. Echocardiographic variables showed that septal wall and posterior wall thickness, LVIDD and LVIDS were higher in the cases than those in the control group. Left ventricular ejection fraction was lower in case group compared to control group. Of the mitral inflow parameters, a velocity was higher and E/A ratio lower in cases than those in control group. Following treatment of >3 months the septal wall and posterior wall thicknesses were reduced significantly (p<0.001 and p<0.001 respectively) and Left ventricular ejection fraction was also improved significantly (p<0.001) from its baseline status. Of the mitral inflow parameters, E-velocity was significantly increased, A-velocity significantly decreased and E/A ratio significantly increased from their baseline figures (p=0.016, p=0.032 and p<0.001 respectively). Cardiovascular complications of hypothyroidism increase the morbidity of the patients. Results of our study showed importance of early diagnosis and prompt treatment reversed the condition and that will diminish the extent of cardiac complications.

Seroprevalence, associated risk factors and clinico-pathological studies of buffalopox disease in various regions of Punjab province, Pakistan

Buffalopox (BPX) is a highly contagious disease that causes high morbidity and production losses in buffaloes. During this study, seroprevalence, effect of various associated risk factors, and pathological studies of BPX were recorded in the Punjab province. A total of 97 blood samples and 63 scabs were collected from clinically pox suspected buffaloes. Serum was harvested to perform single radial hemolysis to assess the seroprevalence, and scabs were subjected to PCR for BPX virus confirmation. Results revealed that, animal demographics and environmental associated factors showed significant effect (p⟨0.05,1⟨R2⟩0) on BPX occurrence. The overall BPX seroprevalence was recorded 4.18% in the Punjab province. The BPX was recorded 5.48% in Nili Ravi breed during winter (7.42%), aged 5-7 years (7.46%) under loose housing (5.51%) in the Faisalabad region (8.03%). Further, BPX was 5.37% in pregnant, 6.86% pregnant milking buffaloes during the 3rd lactation period (7.28%) in dairy herds (5.20%). The BPX was 5.22% in non-vaccinated buffaloes where multiple animals were reared together (4.99%) in the herds having 21-30 total number of animals. A total of 49 scab samples were found positive for the BPX virus via PCR with C18L gene amplification. Grossly, inflammatory lesions with pits in the center and wart-like nodules were seen on teats and udder of buffaloes. Increased leukocytes, especially neutrophils and lymphocytes, were seen in the blood of the infected animals. These results provide a broader window to understand the effect of associated risk factors, strengthen the diagnostic aid, and to contain the current spread of BPX in Pakistan to safeguard large ruminant-based livelihood.

Prediction of in-hospital mortality by using get with the guideline-heart failure (GWTG-HF) risk scores in patients hospitalized with heart failure

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): University Grants Commission Bangladesh

Background

Prognostic stratification using readily available clinical data can assist clinical decision making in heart failure. Get with the Guideline- Heart Failure (GWTG-HF) score approved by American Heart Association (AHA) can be used to inform hospitals about the expected in-hospital mortality of their patients.

Purpose

This study aims to predict in-hospital mortality of patients with heart failure using GWTG-HF score in order to give evidence based therapy to high risk patients.

Methods

We have included patients who were hospitalized with a diagnosis of heart failure from February 2020 to 15 January 2021. A total of 2038 patients were admitted during this period of which 144 patients were diagnosed with heart failure (7%). The GWTG-HF risk score uses 7 clinical factors collected at admission. These are older age, low systolic blood pressure, elevated heart rate, low serum sodium, elevated BUN, presence of COPD, and ethnicity. The probability of in-hospital mortality is estimated for an individual patient by summing points assigned to the value of each predictor for a total point score within a range of 0-100. These scores were calculated for 144 heart failure patients involved in this study.

Results

Death occurred in 29 heart failure patients (20.13%). Mean age was 59 ±13 years. Male/female ratio was 3.65. All patients were ethnically Bangladeshi Asian. 60% of patients had left ventricular ejection fraction (LVEF) &lt;40%. Overall LVEF was median (IQR) 36% (30-45). Those who died were more likely to have a prior heart failure diagnosis and an LVEF &lt;40%. The observed mortality was 0% for the GWTG-HF score 0-33, 14.14% for 34-50, 42% for 51-57, 40% for 58-61 and 50% with a score of 62-65. The observed mortality of our patients were much higher than expected GWTG-HF score (20% vs 2.8%). The probable reasons for increased mortality in our study could be 1) The number of patients having LVEF &lt;40% is much higher (60%), 2) surgically uncorrected/absence of intervention for underlying valvular disease/advance heart failure/ischaemic cardiomyopathy, 3) different treatment regimens and non-compliance of patients regarding long-term medication. Additionally, those who died had higher serum creatinine and BUN and lower serum sodium and haemoglobin levels at admission. Further multi-centre study involving large population is needed to clarify higher death rate in heart failure patients in our population.

Conclusion

The GWTG-HF risk score can identify patients at high risk of in-hospital death to aid clinical decision making. The risk score could be used to inform hospitals about the expected mortality rates of patients with heart failure admitted to their hospital. Although GWTG-HF risk score is validated in different populations, the mortality rate in this study is greater than expected mortality due to aforementioned reasons. Abstract Figure. GWTG-HF Risk Score (Reference 1)  Abstract Figure. Predicted and Observed Mortality Rates

Observational study of clinico-radiological follow-up of COVID-19 pneumonia: a district general hospital experience in the UK

BACKGROUND

The British Thoracic Society (BTS) recommends that all patients admitted with COVID-19 pneumonia should have a chest X-ray (CXR) and clinical follow-up at 6 or 12 weeks, depending on the disease severity. Little data is available on long-term CXR follow-up for moderate and severe COVID-19 pneumonia. This study aims to evaluate compliance with clinico-radiological follow-up of patients recovering from COVID-19 pneumonia at a local hospital in the UK, as per the BTS guidance, and to analyse radiological changes at clinical follow-up at 12 weeks, in order to risk-stratify and improve patient outcomes.

METHODS

This is a single-centre retrospective audit of 255 consecutive COVID-19 positive patients admitted to a local hospital in the UK over 5 months between May and October 2020. All CXRs and clinic follow-up at 12 ± 8 weeks were checked on an electronic database.

RESULTS

Over one in two (131/255) patients had CXR evidence of COVID-19 pneumonia during the initial hospital admission. Half of the patients (60/131) died before CXR or clinic follow-up. Fifty-eight percent (41/71) of the surviving patients had a follow-up CXR, and only two developed respiratory complications- one had residual lung fibrosis, another a pulmonary embolism. Eighty-eight percent (36/41) of the patients had either resolution or improved radiological changes at follow-up. Most patients who had abnormal follow-up CXR were symptomatic (6/8), and many asymptomatic patients at follow-up had a normal CXR (10/12).

CONCLUSIONS

Although there were concerns about interstitial lung disease (ILD) incidence in patients with COVID-19 pneumonia, most of our patients with COVID-19 pneumonia had no pulmonary complications at follow-up with CXR. This emphasises that CXR, a cost-effective investigation, can be used to risk-stratify patients for long term pulmonary complications following their COVID-19 pneumonia. However, we acknowledge the limitations of a low CXR and clinic follow-up rate in our cohort.

Phytochemical analysis and biological activities of ethanolic extract of Curcuma longa rhizome

Curcuma longa is an important dietary plant which possess several pharmacological activities, including antioxidant, antimicrobial, anti-inflamatory, anticancer and anti clotting etc. The aim of the present study was to determine the phenolic profile of Curcuma longa and in vitro antioxidant and antidiabetic activities. In HPLC chromatogram of Curcuma longa rhizome extract 15 phenolic compounds were identified namely Digalloyl-hexoside, Caffeic acid hexoside, Curdione, Coumaric, Caffeic acid, Sinapic acid, Qurecetin-3-D-galactoside, Casuarinin, Bisdemethoxycurcumin, Curcuminol, Demethoxycurcumin, and Isorhamnetin, Valoneic acid bilactone, Curcumin, Curcumin-O-glucuronide respectively. The ethanolic extract displayed an IC50 value of 37.1±0.3 µg/ml against alpha glucosidase. The IC50 value of DPPH radical scavenging activity was 27.2 ± 1.1 μg/mL. It is concluded that ethanolic extract of Curcuma long is rich source of curcumin and contain several important phenolics. The in vitro antioxidant and alpha glucosidase inhibitory effect of the plant justifies its popular use in traditional medicine.

Portrayal of Punica granatum L. peel extract through High Performance Liquid Chromatography and antimicrobial activity evaluation

Increasing trend in antimicrobial resistance and failure of chemically synthesized antibiotics lead to discover alternative methods for the treatment of bacterial infections. Various medicinal plants are in use traditionally and their active compounds can be further applied for treatment of bacterial diseases. This study was designed to determine the antibacterial activity of Punica granatum (P. granatum L.) (pomegranate) peel extract against Enterobacteriaceae [Escherichia coli (E. coli), Salmonella Typhimurium (S. Typhimurium) and Shigella Dysenteriae (S. Dysenteriae)] and gram-positive bacterium [Staphylococcus aureus (Staph aureus)]. Methanolic extract of P. granatum L. peel was prepared by Soxhlet apparatus method. Total flavonoid and phenolic contents from the extract were determined by High Performance Liquid Chromatography (HPLC). The antibacterial activity of P. granatum L. peel extract was evaluated through agar well diffusion method. HPLC showed the range of phenolics (gallic acid, caffeic acid, benzoic acid, cinnamic acid) and flavonoid compounds. The chemical structures of flavonoid and phenolics found in the methanolic extract of P. granatum L. peel have been reported for the first time. The methanolic peel extract (50 ul) of yellow P. granatum L. showed 26, 10, 10 and 9mm zones of inhibition (ZOI) against S. aureus, S. Typhimurium, S. Dysenteriae and E. coli, respectively. The methanolic extract of red P. granatum L. (100 ul) showed 27, 8, 12 and 15 mm ZOI against Staph. aureus, S. Typhimurium, S. Dysenteriae and E. coli, respectively. Highest ZOI was observed against Staph. aureus. Many of the bacteria studied in the present work may cause serious gastrointestinal infections, which can lead to hemorrhagic diarrhea in children. These infections can be life-threatening to young children and the elderly. There is an incentive to find alternative control measures, such as plant and herbal extracts, especially in lesser-developed countries where traditional antibiotics may not be readily available.

Food habits of indian crested porcupine (Hystrix indica) (Kerr 1792), in district Bagh, Azad Jammu and Kashmir

The Indian Crested Porcupine (Hystrix indica) is classified as an agricultural pest species. It feeds on plants and crops; hence, it is responsible for massive financial losses worldwide. The current study was conducted to assess the diet composition of Indian Crested Porcupine in District Bagh, Azad Jammu and Kashmir (AJ&K). Thus, fecal samples were collected and examined from different sampling sites. Reference slides of the material collected from the study area were prepared for identification of dietary components in fecal pellets. A total of 80 fecal samples were collected and processed. Percent relative frequencies (P.R.F.) were calculated for each plant species recovered from pellets. Data revealed that Indian Crested Porcupine consumed 31 plant species in its diet, among them Zea mays (34.31±7.76) was the most frequently selected species followed by Rumex obtusifolius (15.32±2.57) and Melia azedarach (12.83±4.79). The study revealed that the greatest diversity of (n=20) plant species were consumed in summer season while minimum (n=13) species were used during winter. Among the parts of plants, stem was highly consumed in spring (57.2%) as compared to seed in fall (36.7%) while spikes and leaf were the least recovered parts from the fecal matter. The Berger-Parker diversity index showed highly diversified food (10.92) in the summer time of the year as compared to the autumn season (2.95). This study provides a baseline for the diet preference of this pest in the study area. Based on current findings, a detailed investigation on damage assessment, exploration, habitat use and management of Indian Crested Porcupine in AJ&K has been recommended.

Emergence of dual antiretroviral therapy as a viable regimen option for the treatment of patients with HIV infection

Current antiretroviral therapy is not curative. The need for life-long therapy brings with it concerns regarding long-term toxicity and cost. Thus, investigations into simpler regimens with comparable efficacy and improved safety have been undertaken and continue to be conducted. Various 2-drug combinations have been evaluated with variable results. The combinations of dolutegravir plus lamivudine and dolutegravir plus rilpivirine were found to be comparable in efficacy to conventional 3-drug regimens and have now been approved by the United States Food and Drug Administration (FDA) and have entered into clinical practice. Dolutegravir/rilpivirine was approved for the treatment of adults with HIV-1 infection whose virus has been suppressed on a stable regimen for at least 6 months, with no history of treatment failure and no known substitutions associated with resistance to the individual components of the combination. Dolutegravir/lamivudine was approved for the treatment of HIV infection in adults with no antiretroviral treatment history and with no known or suspected resistance to the individual components of the combination.

Methanol related death in National Institute of Forensic Medicine, Hospital Kuala Lumpur: A case series

INTRODUCTION

Methanol is a widely available chemical with a range of uses including as solvent, as a fuel, in chemical synthesis and anti-freeze preparations. Most of the cases are accidental exposures to drinking beverages contaminated with methanol.

MATERIALS AND METHODS

In mid-September 2018, there was a single outbreak of methanol poisoning in Malaysia especially involving the state of Federal Territory Kuala Lumpur and Selangor. There were 33 reported deaths suspected due to methanol poisoning in this current outbreak where 11 of them were brought in to the Institute of Forensic Medicine (NIFM), Kuala Lumpur. The last outbreak was in the year 2013 with 29 deaths reported out of 44 cases.

RESULTS

There were 3 cases (27.2%) died in hospital and the remaining 8 cases (72.8%) were found dead at home and were later brought in dead to the hospital. A full autopsy was carried out for each case. Autopsy findings, as well as lab results pertaining to cases that survived and directly brought in dead, were of a different spectrum.

CONCLUSION

Methanol related deaths are almost always as a result of greed. The running truism is 'methanol poisoning is a result of deliberate addition/adulteration with industrial methanol'. Prevention of the illegal production of methanol and methylated spirits should be established to curb this matter in the future.

Improvement of Left Ventricular Systolic Function after Percutaneous Coronary Intervention in Diabetic Patients with Non-ST elevated Myocardial Infarction

Long term mortality is higher in Non-ST-segment elevated myocardial infarction (NSTEMI) patients than STEMI paitents. NSTEMI are a high risk factor for ensuing cardiovascular events in diabetic patients. But, use of drug eluting stents (DES) will further improve outcomes in patients with diabetes suffering early percutaneous coronary intervention (PCI). The aim of the study was to determine the changes in left ventricular (LV) systolic activity after successful PCI in NSTEMI diabetic patients was compared with non-diabetic patients. This comparative clinical study was performed in the Department of Cardiology, University Cardiac Center, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2017 to June 2018. Thirty (30) diabetic and 34 non-diabetic patients with NSTEMI undergoing percutaneous coronary intervention were included in the study. In all patients PCI with drug eluting stent was performed successfully. Earlier echocardiography (2-Dimensional) was done, at release subsequent PCI and 3 months afterward to evaluate the LV systolic activity and compare to diabetics and non-diabetics at all levels of evaluation to assess the outcome of intervention. At baseline LVEF was rather lower in diabetic group than non-diabetic group patients. In diabetics patients segments with abnormal wall motion (WMA) was higher than non-diabetics patients. While the LVEDD, LVIDd and LVIDs were significantly larger in the earlier group than those in the latter group, the LVESV was no different in both groups. At release from hospital, no significant enhancement was observed in either group following PCI in terms of LVEF, number of segments with WMA, LVIDd and LVIDs. However, both LVEDV and LVESV reduced successfully in both groups with decrease of LVESV being more marked in non-diabetics compared with diabetics (p=0.018). However, 3 months after PCI, LVEF improved (8.4±1.2%) in diabetics and 7.9±1.2% in non diabetics patients but this improvement between two groups was not statically significant (p=0.631). Similarly baseline to 3 months after PCI LVIDs reduces in diabetics patients (5.7±1.9%) and 4.8±1.1% in non diabetics patients but the difference between both groups was not significant (p=0.201). Diabetic patients more frequently required 2 stents (p=0.30), while stent's diameter and length did not differ between the study groups. This study demonstrated that improvement of the parameters of left ventricular systolic function after using of drug eluting stent in NSTEMI diabetic patients was not lower to the non diabetic group under same condition. So, suggestion of PCI with drug eluting stent may be extended in NSTEMI diabetic patient.

P1731 Multiple floating thrombi in aortic arch leading to acute stroke: A case report and systematic review of literature

Introduction

Around 10-15% of acute cerebrovascular events occur in young adults with age less than 40 years. Trans-oesophageal echocardiogram (TOE) is routinely performed to rule out any cardio-embolic source in patients with ischemic stroke. TOE has shown to significantly change management strategy in up to 16.7% of stroke cases. We report a rare case of recurrent stroke in a young female who was found to have multiple mobile thrombi in aortic arch on TOE. We also report systematic review of literature of similar cases to highlight the management strategies.

Case Presentation

A 38-year-old female presented with one-week history of right upper and lower extremity paresthesia along with headache. Physical examination was unremarkable for any focal neurological deficits at time of initial evaluation. She had pertinent history of acute stroke two years ago associated with non-occlusive left common carotid artery thrombus for which she was previously on anticoagulation with rivaroxaban. The anticoagulation, however, was stopped five months ago after repeat imaging revealed complete resolution of thrombus. Electrocardiogram showed normal sinus rhythm without any other significant abnormality. CT head showed no acute bleeding or infarct. MRI brain showed scattered infarcts in right cerebral hemisphere and left cerebellar hemisphere. CT angiography of head and neck showed multiple small nodular and linear pedunculated thrombi in distal arch of aorta (see Figure 2). TOE was then performed which confirmed two pedunculated and mobile echogenic masses, largest measuring 0.9 x 0.6 cm, in the distal aortic arch (see Figure 1). TOE did not show intracardiac source of embolism. Laboratory testing for thrombophilia was negative for Factor V and Prothrombin gene mutation and heterozygous positive for Methylenetetrahydrofolate reductase (MTHFR)-677T gene. She was also found to have elevated homocysteine levels. She was restarted on anticoagulation with rivaroxaban.

Discussion and Conclusion

Young patients with stroke should undergo detailed investigation to rule out hypercoagulable pathology and cardiovascular embolic source. This should also include multimodality imaging including TOE in the selected patients. During TOE examination, a particular attention should be paid for evaluation of aortic source of thombo-embolism. Our patient was heterozygous for MTHFR-66T gene which is associated with decreassed activity of MTHFR by 35 % with elevated homocysteine levels. Treatment of floating aortic thrombus is still controversial. Anticoagulation is suggested as primary modality by multiple authors who reported complete resolution of thrombus. Other option includes surgical thrombectomy. Our patient was treated with anticoagulation alone due to hypercoagulable state and small size of thrombi.

Abstract P1731 Figure.

Sudden death due to infective endocarditis caused by Streptococcus constellatus: A case report

Infective endocarditis (IE) is a relatively uncommon disease, but has been challenging to diagnose over the years. With the increasing incidence, variety of causative agents and the resistance of microorganisms towards antibiotics, there is still an occurrence of sudden death due to undiagnosed IE. The most common microorganism causing IE is Staphylococcus aureus. However, there is increasing prevalence of other microorganisms causing IE. This case report highlights a case of sudden death due to IE caused by a rare pathogen, Streptococcus constellatus which belongs to the Streptococcus anginosus group (Milleri group). A study noted the crude incidence of IE in 6 world regions ranged between 1.5 and 11.6 cases per 100,000 people. To date, there has been no previous report on sudden death due to IE caused by Streptococcus constellatus in Malaysia, neither in the forensic nor clinical setting. This case report underlined the characteristics and pathological features of this microorganism. The increasing incidence and variety of causative organisms in IE are important public health issues. It is vital for future studies to examine the risk factors of IE related to Streptococcus constellatus, to enhance better understanding, insight and awareness regarding the course of this disease. This in turn may facilitate preventive measures to avoid morbidity and mortality from this condition.

Association of coronary artery calcium score with calcification and degree of stenosis: An autopsy study

INTRODUCTION

Coronary artery disease (CAD) is a known cause of major cardiovascular events and calcium score (CS) has been developed as a marker of coronary atherosclerosis. Yet, the relationship between post mortem computed tomography (PMCT) CS with histologically observed calcification and the severity of coronary artery stenosis has not been widely explored and is still unclear. This study aims to determine the association between coronary artery PMCT CS with histologically observed calcification and degree of stenosis of coronary arteries in post-mortem cases.

MATERIALS & METHODS

This was a cross-sectional study involving 101 subjects recruited from the National Institute of Forensic Medicine (IPFN) Hospital Kuala Lumpur (HKL) over a period of 15 months, from December 2012 until April 2014. PMCT CS of the coronary arteries was calculated using Agatston-Janowitz score. Histological presence of calcification was observed and the degree of stenosis was calculated using an image analysis technique.

RESULTS

PMCT CS increased with increasing severity of stenosis (p<0.001). PMCT CS showed a positive correlation with the presence of calcification (r=-0.82, p<0.001).

CONCLUSION

Calcium score is strongly associated with coronary artery calcification and the degree of luminal stenosis in post mortem subjects. Thus, PMCT may be useful as a non-invasive tool in diagnosing CAD in the event that an autopsy is not possible.

Sudden cardiac death in a young adult man due to spontaneous coronary artery dissection

Spontaneous coronary artery dissection is a rare event and commonly associated with pregnancy and female gender. This condition can reduce or completely obstruct the blood flow to the heart, causing a myocardial ischaemia, abnormalities in heart rhythm or sudden death. We present a case of a 28-year-old Indian male with no previous medical illness who complained sudden onset of chest pain prior to his death. Autopsy revealed a left anterior descending coronary artery dissection associated with plaque rupture. The anterior wall of left ventricle showed contraction band necrosis. There was also atheroma present in the right coronary artery which was insignificant. Histologically, dissection was associated with atherosclerosis. There was no evidence of vasculitis. The cause of death was given as coronary artery dissection due to coronary artery atherosclerosis.

Echocardiographic Assessment of Left Atrial Systolic Function after Percutaneous Mitral Balloon Valvuloplasty Using Tissue Doppler Imaging

Mitral stenosis (MS) affects left atrial (LA) function as a result of hemodynamic and myocardial factors that causes significant symptoms and complications. Conventional echocardiographic methods have been practicing to see the improvement of left atrial function after successful percutaneous mitral balloon valvuloplasty (PMBV). Introduction of tissue doppler imaging allows direct and non-invasive measurement of myocardial velocities. The aim of the study was to evaluate LA functions after PMBV using colour tissue doppler imaging. This cross sectional study was performed in Cardiology department of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from March 2014 to February 2015. Forty six (46) patients (28 females, mean age: 28.96±5.78 years) presenting with mitral valve stenosis who fulfilled the indications for PMBV were included in the study. Within 24 hours before PMBV, all the patients underwent colour tissue doppler study in addition to routine conventional echocardiographic examinations. Late diastolic velocities (A') measured at the septal and lateral annuli were recorded. All the measurements were repeated 24 hours after PMBV. The PMBV was done using the Inoue technique. After PMBV mitral valve areas (MVA) were significantly increased. Maximum and mean gradients, LA diameter, LA area, LA volume, systolic pulmonary arterial pressure and mean LA pressures were decreased while septal and lateral A' were significantly (p<0.001) increased. Lateral and septal A' velocities were correlated with MVA and inversely related to LA pressure measured invasively during PMBV. Tissue doppler velocities illustrated improvement of left atrial systolic function after PMBV in relation to decreased mean left atrial pressure and increased mitral valve area. Therefore, tissue doppler Imaging is a useful tool to detect improvement of left atrial systolic function after PMBV in patients with mitral stenosis.

Interventions to Increase Physician Efficiency and Comfort with an Electronic Health Record System

Objective: To determine comfort when using the Electronic Health Record (EHR) and increase in documentation efficiency after an educational intervention for physicians to improve their transition to a new EHR.

Methods: This study was a single-center randomized, parallel, non-blinded controlled trial of real-time, focused educational interventions by physician peers in addition to usual training in the intervention arm compared with usual training in the control arm. Participants were 44 internal medicine physi cians and residents stratified to groups using a survey of comfort with electronic media during rollout of a system-wide EHR and order entry system. Outcomes were median time to complete a progress note, notes completed after shift, and comfort with EHR at 20 and 40 shifts.

Results: In the intervention group, 73 education sessions averaging 14.4 (SD: 7.7) minutes were completed with intervention group participants, who received an average of 3.47 (SD: 2.1) interventions. Intervention group participants decreased their time to complete a progress note more quickly than controls over 30 shifts (p < 0.001) and recorded significantly fewer progress notes after scheduled duty hours (77 versus 292, p < 0.001). Comfort with EHRs increased significantly in both groups from baseline but did not differ significantly by group. Intervention group participants felt that the intervention was more helpful than their standard training (3.47 versus 1.95 on 4-point scale).

Conclusion: Physicians teaching physicians during clinical work improved physician efficiency but not comfort with EHRs. More study is needed to determine best methods to assist those most challenged with new EHR rollouts.

Immediate & Short Term Outcome of Using Single Bolus Eptifibatide in Percutaneous Coronary Intervention: A Randomized Control Study

The purpose of this study was to assess the immediate and short term outcome of single bolus dose of eptifibatide in elective percutaneous coronary intervention (PCI). We enrolled 146 patients who underwent elective PCI from May 2013 to May 2014 in University Cardiac Centre, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Among 146 patients, seventy four patients received single bolus dose of eptifibatide (10 mg intra coronary single bolus dose) just after crossing the lesion were selected as case. The other 72 patients, who did not receive eptifibatide, were selected as control. All patients of both the groups were treated with aspirin, clopidogrel before and after the procedure and all received a single bolus dose of Clopidogrel (300mg) before the procedure. All patient received weight adjusted doses of heparin during and after the procedure. The outcome measures were 24-hours and 30-day morbidity (complications or adverse events) and mortality. The patients of eptifibatide group experienced significantly lower incidence of QMI lesions and complete absence of NQMI lesion in 24 hours of PCI as compared to 5.6% and 6.9% of the lesions respectively in their control counterparts (p=0.027 and p=0.025 respectively). However, the incidence of bleeding and target vessel revascularization (TVR) were no different between the groups (p=0.255 and p=0.117). There was no incidence of TVR at all in the eptifibatide group as opposed to 5.6% in the control group in 30 days following stenting (p=0.017). Single bolus dose of eptifibatite reduces the Major adverse cardiac events as immediate and short term outcome in elective percutaneous coronary intervention.

A Case Report on Percutaneous Coronary Intervention in Chronic Total Occlusion by Retrograde Visualization

As bilateral approach is paramount in chronic total occlusions with retrograde flow, the use of two radial arteries, two femoral arteries or combination technique using one radial and one femoral artery will probably be increasingly reported in the near future. After puncture of opposite groin, a diagnostic 6 Fr catheter is used to intubate the ostium of the contralateral artery. By visualizing the distal vessel in multiple projections, contralateral injections help to direct the progression of the wire in the occluded segment towards the distal true lumen and confirm the intraluminal position of the wire after the occluded segment. We are reporting a case with chronic total occlusion where we used bilateral femoral access and simultaneous contrast injection to visualize retrograde flow in LAD while opening CTO through ante-grade pathway.

Use of Anticoagulant Warfarin in Patients Presenting With Atrial Fibrillation in a Tertiary Level Hospital

Atrial fibrillation (AF) is the most common sustained arrhythmia in the World, occurring in approximately 0.4% of the general population. The purpose of the present study was to see the trend of use of warfarin in hospital admitted patients with atrial fibrillation. It was conducted in the department of cardiology, University Cardiac Centre, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2008 to January 2009. A total of 150 patients with atrial fibrillation were enrolled in this study. Out of them, male were 60(40%) and female 90(60%); age range 22-79 years. Most common presenting symptoms were palpitation (80%) & dyspnoea (70%). Chronic rheumatic heart disease (Mitral stenosis) (33%) was found in most cases followed by IHD (22%), hypertension (21%). According to CHADS₂ score, most of the patients belonged to moderate risk group (47%) and 32% in low risk group. Anticoagulation with warfarin was used in 40% cases of valvular AF & 25% patients with non valvular AF. Among non valvular AF, it was prescribed for 38% in high risk group, 34% in moderate risk & 3% in low risk group. The study states that warfarin is underused in both valvular & non valvular AF.

MH17: the Malaysian experience

A disaster is a natural or man-made (or technological) hazard resulting in an event of substantial extent causing significant physical damage or destruction, loss of life, or drastic change to the environment. It is a phenomenon that can cause damage to life and property and destroy the economic, social and cultural life of the people; and overwhelms the capacity of the community to cope with the event. The recent tragic aviation accidents in 2014 involving Malaysia Airlines flights MH370 and MH17 shocked the world in an unprecedented manner. This paper focuses on the Malaysian experience in the MH17 mission in Ukraine as well as the first ever international Disaster Victim Identification (DVI) operation for the Malaysian DVI team. The DVI operations in Hilversum, the Netherlands were well described in stages. The Netherlands' Landelijk Team Forensische Opsporing as the lead DVI team in Hilversum operated systematically, ensuring the success of the whole mission. This paper discusses the lessons learned by the Malaysian team on proper DVI structure, inter- and intra-agency cooperation, facilities planning and set up, logistics and health and safety aspects, as well as effective communication and collaboration with other international delegates. Several issues and challenges faced by the Malaysian team were also documented. In addition, the authors shared views, opinions and recommendations for a more comprehensive DVI operation in the future.

Nanodelivery of gambogic acid by functionalized graphene enhances inhibition of cell proliferation and induces G0/G1 cell cycle arrest in cervical, ovarian, and prostate cancer cells

Graphene was used to deliver gambogic acid to cervical, ovarian, and prostate cancer cells and the complex was shown to be more effective at inhibiting cell proliferation, initiating cell cycle arrest and inducing apoptosis compared to the drug alone.

Clostridial aortitis causing ruptured dissecting aneurysm in a young adult female

Ruptured dissecting aortic aneurysm more commonly occur in men in the 40 to 70 age group, and most commonly is associated with atherosclerosis. Uncommon causes are previous heart surgery, connective tissue disorders and aortitis. Despite its rarity, Clostridium spp aortitis progresses very rapidly with a mortality rate of approximately 79% in adults, typically occurring within 48 hours of infection. We present a case of sudden death due to clostridial aortitis causing ruptured aortic dissection in an apparently healthy adult female, 7 weeks post-spontaneous vaginal delivery. This case highlights the pathology of aortic dissection and cystic media necrosis as presentations of clostridium spp infection in young female adult.

Pattern of dyslipidaemia among the Bangladeshi type 2 diabetic patients presented with acute coronary syndrome

Increasing prevalence of diabetes and its complications in the developing communities would pose a threat in respect to their existing health care service. An increased incidence of atherosclerosis in insulin-dependent diabetic patients has long been recognized. Hyperlipidaemia, a common finding in these patients, may be one of the contributing factors. The objective of our study is to find out the patterns of dyslipidaemia among the Bangladeshi patients with type-2 diabetes mellitus presented with acute coronary syndrome. This study was conducted in the department of cardiology of BIRDEM and Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh during the period of January 2009 to December 2009. A total of 100 patients were included in this study, according to the inclusion and exclusion criteria. Diabetes Mellitus and Acute Coronary Syndrome was diagnosed according to the guideline of American Diabetic Association and American College of Cardiology respectively. Among the respondents Mean±SD of fasting blood sugar and 2 hours ABF were 9.23±3.6mmol/L and 12.61±8.52mmol/L respectively. Mean±SD of HbA1C of the respondents was 7.23±2.12. Total cholesterol level <150mg/dl, 150-200mg/dl and >200mg/dl were 27.0%, 42.0% and 31.0% respectively. HDL cholesterol <40mg/dl and >40mg/dl were 76.0% and 24.0% respectively. LDL cholesterol <150mg/dl and >150mg/dl were 43.0% and 57.0% respectively. TG within 40 to 160mg/dl and >160mg/dl were 73.0% and 27.0% respectively, Mean±SD of Total Cholesterol, HDL Cholesterol, LDL Cholesterol and Triglyceride were 162.43±38.62, 37.41±8.59, 137.43±22.73 and 156.43±41.92mg/dl respectively.

Haemorrhagic stroke after thrombolysis with streptokinase

A 54 years old male presented with central chest pain for five hours in a local hospital, Comilla. He was diagnosed as a case of acute STEMI (Extensive Anterior) and was thrombolized with Streptokinase 1.5 million IU. His pain was relieved, ST segment was depressed by >50% after thrombolysis. While in hospital, he developed weakness of his left limbs with gradually deteriorating level of consciousness. A CT scan of brain showed haemorrhage in the right frontoparietal region. This is a rare case of haemorrhagic stroke after thrombolysis with streptokinase.

Cardiovascular complications in patients with end stage renal disease on maintenance haemodialysis

This cross-sectional study was carried out at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka Medical College Hospital (DMCH), National Institute of Kidney Diseases & Urology (NIKDU) and Kidney Foundation from July 2005 to June 2007 to find the cardiovascular complications in end stage renal disease (ESRD) patients on maintenance haemodialysis. Patients of both sexes with age ranging from 18-59 years and getting at least 8 hours of haemodialysis per week for the last 3 months were enrolled in the study. A total of 126 such patients were included in the study. Among 126 patients 77(61.1%) developed some types of cardiovascular complications. In terms of type of complications 63.6% of the patients had LVH, 23.4% had ischemic heart disease (IHD) and 10.4% had congestive heart failure (CCF) and 2.6% cardiomyopathy. Over 96% patients were hypertensive, followed by 46.8% diabetics and 42.1% smokers. Presence of hypertension, diabetes, family history of diabetes and hypertension were observed to be significantly higher in patients who developed cardiovascular complications (p<0.05). It is deserved that cardiovascular complications (CVC) are very common in ESRD patients on maintenance haemodialysis (MHD). Poor control of blood pressure, low Haemoglobin level and poor glycaemic control are higher in ESRD patients on MHD and are possibly related to the development of cardiovascular complications.

Comparative efficacy of subcutaneous versus oral methotrexate in active rheumatoid arthritis

This prospective study was conducted in rheumatology clinic under the department of medicine of Bangabandhu Sheikh Mujib Medical University from December 2004 to December 2005 to asses the efficacy, safety and compliance of subcutaneous methotrexate (MTX) in active rheumatoid arthritis (RA) patients. A total of 92 active rheumatoid arthritis patients according to American College of Rheumatology (ACR) criteria were recruited for the trial for six months. Among them 46 cases belonged to injectable MTX group and 46 cases belonged to oral MTX group. Mean±SD age of patients was 45.54±12.42 vs. 44.63±13.99 years in subcutaneous group and oral group respectively. In the subcutaneous group 41 were female and 5 male; in the oral group 34 were female and 12 male. Mean duration of the disease was 49.74 months in subcutaneous group and 49 months in oral group. RA test was positive in 35 cases in both groups whereas Rose Waaler test was positive in 19 patients in subcutaneous group and 14 patients in oral group. At 24 week, response rate of ACR 20 was significantly higher in subcutaneous MTX than oral MTX group (93% vs. 80%, p=0.02). Similarly ACR 50 response was significantly higher in subcutaneous MTX than in oral group (89% vs. 72%, p=0.03). ACR 70 response was not significantly higher in SCMTX group then oral group (11% vs. 9 %, p=0.72). Adverse effects were relatively less in subcutaneous MTX and most common side effects were nausea (37% vs. 63%), vomiting (11% vs. 30%), dyspepsia (29% vs. 48%), dizziness (4l% vs. 52%) and alopecia (72% vs. 85%). The results of the study demonstrated that subcutaneous MTX was significantly more effective than oral MTX at the same dosage in active Rheumatoid arthritis patients with no increase in side effects.

Aetiology and risk stratification of patients presenting with atrial fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia in the World, occurring in approximately 0.4% of the general population. The purpose of the present study was to see the aetiology, presenting symptoms and risk stratification of hospital admitted patients with atrial fibrillation. It was conducted in the department of cardiology, University Cardiac Centre, Bangabandhu Sheikh Mujib Medical University, Dhaka from January 2008 to January 2009. A total of 100 patients with atrial fibrillation were enrolled in this study. Out of them, male were 40(40%) and female 60(60%); age range 22-79 years. Most common presenting symptoms were palpitation (80%) & dyspnoea (70%). Chronic rheumatic heart disease (CRHD) (63%) was found in most cases followed by IHD (13%), hypertension (11%). Among CRHD, mitral stenosis was 50%, and mixed mitral valve disease was 8%. Risk stratification of patients with AF for future thromboembolism revealed high risk factors were present in 60% cases, moderate in 25% cases, and weaker risk factors in 15% cases. According to CHADS2 score, most of the patients belonged to moderate risk group (47%) and 32% in low risk group. Chronic rheumatic heart disease is one of the major causes of atrial fibrillation in hospital admitted patients & risk stratification revealed that most of the patients were in risk for future stroke.

Carbon nanotubes enhance the internalization of drugs by cancer cells and decrease their chemoresistance to cytostatics

Etoposide is a semisynthetic, chemotherapeutic drug widely recommended to treat an extensive range of human cancers. Our studies indicate that, while etoposide is capable of killing human cancer cells, exposure to single-walled carbon nanotubes (SWCNTs) and etoposide results in enhanced cell death that appears to be synergistic and not merely additive. In this study, we used high pressure liquid chromatography and mass spectrometry to quantify the internal effective dose of etoposide when the human pancreatic cancer cell (PANC-1) was exposed to the combination of these agents. Our results unequivocally indicate that SWCNTs improve etoposide uptake and increase its capacity to kill cancer cells. We suggest that a combination of SWCNTs and etoposide may prove to be a more efficient chemotherapeutic protocol, especially because of the potential to lower toxic drug doses to levels that may be useful in decreasing adverse side effects, as well as in lowering the probability of inducing chemoresistance in exposed cancer cells.

Trimetazidine in the prevention of contrast induced nephropathy after coronary angiogram

This prospective randomized, controlled trial was done to evaluate the efficacy of trimetazidine in the prevention of contrast induced nephropathy in patients with raised serum creatinine levels undergoing coronary angiogram. This study was performed in the Department of Cardiology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from April 2009 to March 2010. Contrast-induced nephropathy (CIN) is a serious complication of coronary angiography that is associated with considerably increased mortality and morbidity, including the need for short-term haemodialysis, extended hospitalisation and permanent impairment of renal function. Trimetazidine (TMZ) has been described as a cellular anti-ischaemic agent. This study was trial with 400 patients. Among them 200 patients treated with trimetazidine plus hydration with normal saline and 200 patients (control) given hydration by normal saline only. It was found that the incidence of CIN was significantly (p<0.05) reduced by trimetazidine administration with saline in comparison with saline alone in patients undergoing coronary angiogram (4% vs. 14%).

Role of ETT to diagnose coronary artery disease

The purpose of the study to predict the coronary arterial disease by exercise treadmill scoring system and to see the correlation of angiographic extent of coronary artery disease by high treadmill score in our country. The present prospective study carried out in the department of cardiology, Bangabandhu Sheikh Mujib Medical University, University Cardiac Centre during the period of January 2006 to July 2006. Based on inclusion and exclusion criteria a total of 80 patient of chronic stable angina or chest pain evaluation having positive ETT who were admitted in university cardiac centre in Bangabandhu Sheikh Mujib Medical University and underwent coronary angiogram within one month were the study population. Among 80 subjects 60(75%) were male and 20(25%) were female and male: female ratio 3:1 Mean age of male subject 51.37±9.08 years and mean age of female subjects were 43.75±7.67 years. Three quarter of the subject had the history of typical anginal pain followed by 21.3% atypical and 3.8% pain of non-anginal origin. All the risk factors like, dyslipidemia (90%), HTN (68.8%) past smoker (45%), current smoker (32.5%), diabetes (36.3%), family history of coronary artery disease (25%) and sudden death of first degree relatives (8.8%); dyslipidemia was the highest percentage. Among 80 subjects more than one third 35% (28) of the subjects were observed to be normal by angiogram, 28.8% (23) had SVD, 16.3% (13) DVD and 20% (16) TVD. Approximately 70% of the significant stenosis was predicted as having high probability of 30.8% as intermediate probability and none as low probability with exercise test scores. Multi-vessel coronary artery disease were predicted by high probability exercise test score 82.8%. Thus high probability score needs urgent coronary angiogram.

Chest pain in children: an update

Chest pain is a common symptom for children and adolescents. It is the second most frequent complaint leading to referral to paediatric cardiologist, murmurs being the largest. The most common cause of chest pain prompting a child to visit a physician is idiopathic chest pain (21-59%). Other disorders are pulmonary (12-24%), psychologic (17-19%), musculoskeletal (7-16%), gastrointestinal (5-7%), cardiac (1-4%) and miscellaneous (2-4%). Most children with chest pain have normal physical findings. Careful physical examination can reveal important clues and save much unnecessary investigations. When an organic cause is found for the pain then specific treatment is commenced. Depending on the circumstances, a therapeutic trial may be warranted, for example use of an inhaled bronchodilator 15-20 minutes before exercise for suspected exercise induced asthma, use of adequate anti-reflux medication for gastro-oesophageal reflux disease or non-steroidal anti-inflammatory medication for musculoskeletal pain. Where an organic cause is not considered to be present, explanation and reassurance can reduce anxiety and decrease the severity of the symptoms. This article specifically deals with problems of chest pain in children and approach to such problems in the form of relevant investigations and management.

Contrast induced nephropathy in diabetic and non-diabetic patients during coronary angiogram and angioplasty

This study was done to assess the incidence of contrast-induced nephropathy (CIN) after coronary angiogram (CAG) and percutaneous transluminal coronary angioplasty (PTCA). Contrast induced nephropathy is the third leading cause of acute renal failure in hospitalized patients. Diabetes mellitus, volume depletion, baseline renal insufficiency, and high volume of contrast agent are a few risk factors. In 245 consecutive patients undergoing CAG or PTCA, we measured serum creatinine at baseline and after 24 and 48 hours of the procedure. CIN was defined as rise in serum creatinine >/=0.5mg/dL or 25% rise from baseline. Two hundred twenty three (91%) subjects were male and 22(9%) were female. Among the 245 subjects 155 (63.3%) were diabetic. Total 59(24.08%) patients developed contrast induced nephropathy. Among these patients, 57(36.8%) were diabetic whereas only 2(2.2%) were non-diabetic. In 59 CIN cases 57(96.6%) were diabetic (p</=0.0001). Among total 59 CIN cases, more than 100 ml of contrast agent used in 51(86.4%) patients (p</=0.0001). Diabetic patients are more prone to develop CIN than non-diabetic. Volume of contrast agent used during procedure is an important predictor for the development of CIN.

Evaluation of left ventricular global function, using Doppler myocardial performance index in patients with systemic hypertension

The study was designed to compare the Doppler myocardial performance index (Tei index) between those patients with systemic hypertension with normal populations. 50 patients with hypertension (16 with left ventricular hypertrophy and 34 without hypertrophy) were taken as cases and 52 age & sex matched healthy individuals were taken as controls. Left ventricular global function was calculated using the echocardiographic Doppler index as described by Tei et al. (Tei index). Left ventricular global function differs significantly between the groups. It does not differ significantly between those with left ventricular hypertrophy and without hypertrophy. Pulmonary venous flow parameters revealed significant increase in atrial reversal velocity and also significant lengthening of atrial reversal duration. All of these parameters signify worsening diastolic properties. The Tei index is not affected by increasing age and therefore, is appropriate for evaluating left ventricular global function in hypertensive patients, most of whom are middle aged or older. This index may be useful for determining treatment strategy and evaluating treatment effects.

Antihypertensive efficacy of indapamide SR in hypertensive patients uncontrolled with a background therapy: the NATIVE study

OBJECTIVES

Antihypertensive monotherapy rarely achieves blood pressure (BP) control. NATIVE (NATrilix SR use in combInation antihypertensiVe thErapy) evaluated indapamide sustained release (SR) in hypertensive patients receiving background therapy.

RESEARCH DESIGN AND METHODS

Patients remaining hypertensive (systolic BP [SBP], 145-180 mmHg; diastolic BP [DBP], 95-105 mmHg) while receiving an angiotensin-converting enzyme (ACE) inhibitor (n = 709), beta-blocker (n = 629), calcium-channel blocker (CCB; n = 493), angiotensin II type 1 receptor blocker (ARB; n = 75), alpha-blocker (n = 29) or other therapy (n = 6) were enrolled, recruited by physicians from 228 centres in Pakistan. Indapamide SR 1.5 mg was administered daily for 3 months with background therapy. BP was assessed every 2 weeks, and blood glucose and total cholesterol were evaluated at baseline and study end in a patient subgroup. Adverse events were also recorded.

MAIN OUTCOME MEASURES AND RESULTS

Of 2073 enrolled patients (49% males; mean age 51 years), 1941 received indapamide SR and background therapy. SBP and DBP decreased significantly (SBP, 166 +/- 16 mmHg at baseline vs. 132 +/- 12 mmHg at 3 months; DBP, 102 +/- 8 mmHg vs. 83 +/- 6 mmHg; both p < 0.0001 vs. baseline). Patients uncontrolled with an ACE inhibitor, beta-blocker, CCB or ARB achieved an SBP/DBP decrease of 34 +/- 15/19 +/- 9, 33 +/- 17/19 +/- 10, 33 +/- 15/18 +/- 8 or 35 +/- 16/20 +/- 12 mmHg, respectively (all p < 0.0001). In all, 84% of patients achieved target SBP (< or = 140 mmHg) and 61% achieved BP normalisation (SBP < 140, DBP < 90 mmHg). The absence of placebo control may lead to an overestimation of the extent of the BP reduction achieved. Glucose and cholesterol levels were unaffected by indapamide SR. Four percent of patients experienced side-effects, which were mild-to-moderate in severity.

CONCLUSIONS

In patients with hypertension despite antihypertensive therapy, indapamide SR significantly reduced BP with a good acceptability profile. Indapamide SR may represent an effective additional therapy for patients who do not achieve BP goals with other antihypertensive agents.

DNA vaccination with VP2 gene of very virulent infectious bursal disease virus (vvIBDV) delivered by transgenic E. coli DH5alpha given orally confers protective immune responses in chickens

The efficacy of different doses of oral DNA vaccines carrying VP2 gene of vvIBDV delivered by E. coli DH5alpha was studied and compared with purified VP2 recombinant expression plasmid DNA vaccine injected intradermally and whole virus vaccine either from homologous virus or from commercial source. The recombinant plasmid pRc-VP2 was transformed in a non-pathogenic strain of E. coli, the DH5alpha and designated as EC/pRC-VP2. Oral immunization of maternal antibody free broiler chickens at 7 and 14-day-old with different dosages of EC/pRc-VP2 elicited specific humoral immune response as measured by ELISA. Protection in different groups was calculated through clinical signs, gross and histopathological lesions, bursa of Fabricius to body weight ratio, humoral and cellular immune responses and mortality in the chickens. Vaccination with EC/pRc-VP2 at the dose rate of 10(9)CFU per chicken conferred 95.4% protection of the chickens against the challenge with homologous virulent field strain of vvIBDV. Protection afforded by attenuated vero cell adapted UAF-06 strain of vvIBDV was comparable (94%) to that by EC/pRc-VP2 and pRc-VP2 vaccines, which was significantly higher (P<0.05) than the protection provided by a commercial attenuated IBDV stain D-78 vaccine (D-78 vaccine was used as positive control due to its frequent use in the field for vaccination of poultry chickens) and other control groups in the study. The results revealed that DNA vaccines against IBDV may be successfully done by adopting bacterial-vectored oral delivery system and vaccination with homologous vvIBDV (UAF-06) conferred significantly higher protection as compared with imported non-homologous commercial IBDV vaccine.

Doppler evaluation of left to right shunt (Qp/Qs) in patients with isolated ventricular septal defect (Vsd)

A prospective observational study was carried out in the department of cardiology, Bangabandhu Sheikh Mujib Medical University (BSMMU) in collaboration with the department of cardiology, Combined Military Hospital (CMH), Dhaka from January 2000 to October 2001. All the patients were clinically evaluated. ECG & Doppler echocardiography were done.All the patients underwent cardiac catheterization. Complex congenital heart disease & cyanotic heart disease patients were excluded from the study. Doppler estimated pulmonary to systemic blood flow ratio (Qp/Qs) was done by conventional (velocity time integral method) method. In cardiac catheterization Qp/Qs ratio derived from oximetric data which has become a well established part of clinical practice. Doppler derived Qp/Qs were compared with catheter derived Qp/Qs. 30 patients with VSD were included. In those patients Doppler derived Qp/Qs ranged from maximum 4.5 to minimum 1.10. Mean (+/-SD) was 1.88+/-0.86 In patients with VSD mean (+/-SD) Qp/Qs at catheterization was 1.80+/-0.80. Qp/Qs ranged from maximum 4.10 to minimum 1.1 In those patients the correlation coefficient for invasively determined Qp/Qs versus Doppler estimated Qp/Qs was .92 (standard error of estimate [SEE] = 0.19) & the line of regression passed close to the origin. The results of this study demonstrate that The Doppler technique allows the noninvasive evaluation of Qp/Qs with a high degree of accuracy & allows determination of the stage of VSD by the consecutive assessment of shunt magnititude.