Aim

Prevention of post-operative cardio-respiratory deterioration in cardiac and non-cardiac patients who have undergone non cardiac surgical procedure  due to perioperative fluid overload.

Introduction

Induction in general anesthesia (GA) drives patients in hypotension.

Vasodilation, particularly veno-dilatation, is the primary cause of relative hypovolemia produced by anesthetic drugs. Relative hypovolemia is a consequence of increased venous compliance, decreased venous return and reduced response to vasoactive substances. Maintenance of adequate cardiac output (CO) and arterial blood pressure are vital for preserving tissue perfusion and oxygen delivery (DO2).To preserve CO and adequate organ perfusion, anesthesiologists may chose between liberal perioperative fluid approach and a restrictive one with small dose of vasoactive drugs. Each choice carries its own risks. In general, a liberal perioperative volume replacement strategy  is more common choice. As a consequence of selected therapy,  fluid overload is often seen. The clinically most significant complication of excessive volume is ”Lung -Swelling” respectively - pulmonary edema.

Standard monitoring that includes clinical exam, chest X ray, oxygen saturation of peripheral blood (SpO2) and blood lactate level lacks sensitivity and specificity for pulmonary edema diagnose. Additionally, those are late indicators of tissue and organ hypo-perfusion.

Lung ultrasound provides high diagnostic sensitivities and specificities in detecting various lung pathologies: interstitial syndrome (interstitial sy), pneumothorax and alveolar consolidation. Interstitial sy represents a variety of clinical situations, including pulmonary edema, respiratory distress syndrome,pneumonia and interstitial diseases. Due to the development of pulmonary edema, transition of A-profile (normal lung ultrasound finding) to B-profile (that is specific for interstitial sy) occurs.This findings enable us to act therapeutically  even before the late indicators of cardio-respiratory deterioration appear.

Conclusion

Lung ultrasonography is a helpful, non-invasive method for early detection and treatment of perioperative fluid overload.

Reference

Anthony Mclean,Stephen Huang.Lung and pleural ultrasound. In: Critical Care Ultrasound Manual.Chatswood,NSW:Elsevier Australia, 2012;126-134.

Background.

Echocardiography is a key diagnostic investigation used for many cardiac conditions. Significant delays in the availability of echocardiogram findings and a backlog of echocardiograms requests, were identified as having an impact on clinical decision making in a focused questionnaire delivered to doctors and echocardiographers on a cardiac ward in a district general hospital in London, UK.

Aim. This quality improvement project aimed to expedite delivery of key echocardiogram information to doctors by applying two strategies; 1) introduce a provisional report, and 2) reduce the number of referral requests by implementing a new echocardiogram triage system.

Methods: Baseline data were gathered during a 9-week period aimed at understanding and calculating the median time needed to order, perform and report an echocardiogram, as well as monitoring the total number of echocardiogram requests made. The first intervention (strategy 1), lasting 6 weeks, involved a provisional report (PR) containing key clinical information such as left ventricular function and, if present, any valvular, wall motion or any other relevant abnormalities.   This was then given by echocardiographers to doctors soon after an echocardiogram was completed.  The number of requests, rate of PR uptake and the time from echocardiogram completion to PR availability were monitored during this period.

A second intervention (strategy 2), aimed at reducing unnecessary requests, was implemented 4 weeks after the conclusion of the first intervention and it involved a consultant cardiologist triaging the echocardiogram requests daily, for a 6-week period. The number of requests, procedures and the time from referral to full report availability were again monitored. Semi-structured questionnaires were proposed to doctors (FY2 to consultant level) in cardiac wards at the beginning and end of both cycles to explore participants’ subjective opinion.

We enhanced staff motivation and adherence through visual aids on wards and stakeholder involvement through regular weekly meetings and constant feedback.

Results:

The provisional report (PR) reduced the median time for key information to be available to clinicians from 227 to 48.5 minutes, without negatively affecting the time needed to obtain a full report. However, uptake of the PR varied widely across the intervention window being at best, 40% of the total number of echocardiograms performed.

Triaging resulted in a decrease in the median number of referrals per week, from 47 to 27.5, and a reduction from 2.73 days to 1.87 days in the median time from referral to full report availability. The results were stable across the observation window.

62% of interviewed doctors reported they noticed improvements in speed of echocardiogram information delivery after strategy 1 which increased to 71% after the application of strategy 2.  87% of participants felt strategy 1 and 71% felt strategy 2 improved patient outcomes and timely discharge.

Discussion & Conclusion:

Substantial improvements in reporting times for a key diagnostic procedure can be achieved as shown by the application of strategy 1, while strategy 2 demonstrated how eliminating inappropriate referrals can streamline the process of obtaining investigation results. Furthermore, qualitatively, staff acknowledged significant improvements in the availability of echocardiogram results leading to better support in

clinical decision making and patients’ outcomes. However, sustainability and staff engagement were variable, especially when additional duties, like the formation of a provisional report, are introduced as in the first intervention (strategy 1). Pilot experiences such as this reported experiment and subsequent positive feedback, could become key elements to achieving higher rates of adherence and sustained positive changes.

Declaration of interest: nothing to declare.

This project was exempt from ethical approval as the work was deemed an improvement study; local policy meant that ethical approval was not required

Zebrafish is widely becoming more and more useful model to study heart regeneration due to fast re-growing of both myocardial and epicardial cells. Therefore, the regenerative capacity and such genetic tractability in zebrafish encouraged scientists to use this model for their stud-ies. The cheap supply of zebrafish for laboratories also add another reason to use zebrafish rather other animal models.

A new transgenic zebrafish line model added a new approach to understand the underlying signalling pathways requiring for cardiac regeneration. Therefore, this model also provided an extensive genetic fate map for cardiac cell arrangement during cardiac regeneration.

Here in this review, the attempt has been made to elucidate three major injury models in zebrafish and analysing how zebrafish model can potentially become a permanent solution for establishing a new platform for cardiac regenerative medicine

Introduction:

Increased ratio of Triglyceride (TG)/ High-density Lipoprotein (HDL) has been known as an accompanying finding in conditions like obesity and metabolic syndrome. Therefore, the aim of this study was to assess the utility of TG/HDL ratio as a diagnostic tool for the assessment of coronary artery disease (CAD).

Methods:

This study was conducted at a semi-private hospital Karachi; patients above 15 years of age and undergone angiography or PCI were included. Patients with Congenital Heart Disease and familial hyperlipidmeia were excluded. TG/HDL ratio was obtained for all patients, severity of the disease was classified as normal, mild to moderate, moderate to severe, and very severe based on coronary angiography. Analysis of variance was applied to assess significant differences in mean TG/HDL ratio among severity of disease. P-value<0.05 was considered significant.

Results: 

A total of 2,212 CAD patients were reviewed out of which 1613 (72.9%) were male and 599 (27.1%) were female. Average age of the patients was 55.12 years (±SD=9.93). Of these 2212 patients, 533 (24.1%) had very severe disease, 1213 (54.8%) had moderate to severe disease, 258 (11.7%) had mild to moderate disease, and 208 (9.4%) were normal. A Significant and an increasing trend was observed in TG/HDL ratio with the severity of disease (p=0.0001) Statistically significant difference was observed in the TG/HDL ratio of patients with mild to moderate, moderate to severe and very severe disease from normal patients. However, no statistically significant difference was seen in the TG/HDL ratio between the patients with moderate to severe and very severe disease.

Conclusions:

A positive relationship between Triglyceride to HDL Ratio and severity of coronary artery disease was observed. Therefore, TG/HDL ratio can be used as an indicator of severity of coronary artery disease in addition to other parameters of lipid profile

ThapaKeywords: Tenecteplase, Coronary Angiography, Percutaneous Coronary intervention, Thrombolysis

Corresponding Author: Dr. Shivaji Bikram Silwal, Consultant Cardiologist,

Head, Department of Cardiology , Scheer Memorial Hospital, Banepa, Kavre

BACKGROUND: In the absence of contraindications, fibrinolytic therapy is administered to ST-elevation MI (STEMI) patients with symptom onset within 12 hours after diagnosis of STEMI in partly limited availability of primary percutaneous coronary intervention (PCI) hospital. Reperfusion treatment in acute STEMI represents the main indication for thrombolytic therapy in a community hospital set up.

OBJECTIVE: To study newer fibrin specific thrombolytic agent for the management of acute STEMI.

RESULT: In our study, we had 38 patients presented to the emergency department of Scheer Memorial Hospital and were diagnosed as STEMI presented within the window period. Among 38 patients, 18 were male (37-80 years) and 11 were female (45-82 years). All patients were in killips class I-II. They did not have any contraindications for thrombolysis. Informed consent was obtained. They were thrombolysed with tenecteplase (TNKase) according to body weight. Successful thrombolysis was observed with post TNKase (after 90 minutes). Electrocardiograms were recorded to those patient treated. Successful thrombolysis was observed in both genders. Nine patients underwent coronary angiography (CAG) soon after thrombolysis. Out of nine CAG, three patients had single vessel disease, two normal CAG and four unknown. Three patients with complete heart block were sent to cardiac centre following TNKase. Three died in the hospital ICU. Four patients (> 75 years) had COPD, Pneumonia. Twenty-one patients are still living comfortably with LVEF: > 45%. Two died after two years follow up. Six patients are living with LVEF: <30%. Details of five patients could not be obtained. None of the patients had intracranial bleeding.

CONCLUSION: TNKase appears to be effective and well tolerated in the management of STEMI. TNKase is associated with reduced risk of major bleeding in patient treated for STEMI and has higher thrombolytic potency. TNKase is easy to administer and can be used in community hospital. The entire bolus dose is delivered over five seconds; no second dose is required, and gives very competitive result that can be expected for majority of patients present in first three hours of ACS at community hospital. TNkase offers timely reperfusion in community hospital to prevent the catastrophe in STEMI.

Idiopathic chylopericardium is a rare clinical condition that consist of pericardial effusion composed of high concentrations of triglycerides known as chyle. It may occur as a result of chest trauma, mediastinal neoplasms, mediastinal tuberculosis, mediastinal radiotherapy, and thrombosis of the subclavian vein or can be idiopathic. We hereby present a case that illustrates a healthy female fitness trainer in her 50s who presented with dyspnea that progressively worsened to the point where she was referred to a Cardiologist. Subsequently, chylopericardium was diagnosed with pericardiocentesis. She successfully responded to two and a half weeks of continuous drainage and low fat diet. It has only been a month since discharge. In conclusion, this case demonstrates an rare condition to help elucidate medical literature.

There is increasing evidences that favor the prenatal beginning of schizophrenia. These evidences point toward intra-uterine environmental factors that act specifically during the second pregnancy trimester producing a direct damage of the brain of the fetus. The current available technology doesn't allow observing what is happening at cellular level since the human brain is not exposed  to a direct analysis in that stage of the life in subjects at high risk of developing schizophrenia. Methods. In 1977 we began a direct electron microscopic research of the brain of fetuses at high risk from schizophrenic mothers in order to finding differences at cellular level in relation to controls. Results. In these studies we have observed within the nuclei of neurons the presence of complete and incomplete viral particles that reacted in positive form with antibodies to herpes simplex hominis type I [HSV1] virus, and mitochondria alterations. Conclusion. The importance of these findings can have practical applications in the prevention of the illness keeping in mind its direct relation to the aetiology and physiopathology of schizophrenia. A study of amniotic fluid cells in women at risk of having a schizophrenic offspring is considered. Of being observed the same alterations that those observed previously in the cells of the brain of the studied foetuses, it would intend to these women in risk of having a schizophrenia descendant, previous information of the results, the voluntary medical interruption of the pregnancy or an early anti HSV1 viral treatment as preventive measure of the later development of the illness.

A new systems approach to diseased states and wellness result in a new branch in the healthcare services, namely, personalized and precision medicine (PPM). To achieve the implementation of PPM concept, it is necessary to create a fundamentally new strategy based upon the subclinical recognition of biomarkers of hidden abnormalities long before the disease clinically manifests itself.

Each decision-maker values the impact of their decision to use PPM on their own budget and well-being, which may not necessarily be optimal for society as a whole. It would be extremely useful to integrate data harvesting from different databanks for applications such as prediction and personalization of further treatment to thus provide more tailored measures for the patients resulting in improved patient outcomes, reduced adverse events, and more cost effective use of the latest health care resources including diagnostic (companion ones), preventive and therapeutic (targeted molecular and cellular) etc. A lack of medical guidelines has been identified by responders as the predominant barrier for adoption, indicating a need for the development of best practices and guidelines to support the implementation of PPM! Implementation of PPM requires a lot before the current model “physician-patient” could be gradually displaced by a new model “medical advisor-healthy person-at-risk”. This is the reason for developing global scientific, clinical, social, and educational projects in the area of PPM to elicit the content of the new branch.