Additional complex fractionated atrial electrogram ablation does not improve the outcomes of non-paroxysmal atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials

BackgroundNon-paroxysmal atrial fibrillation (AF) has a complex pathophysiological process. The standard catheter ablation approach is pulmonary vein isolation (PVI). The additional value of complex fractionated electrogram (CFAE) ablation is still unclear. We aimed to investigate the additional value of CFAE ablation for non-paroxysmal AF.MethodsWe performed a systematic review and meta-analysis of randomized controlled studies up to May 2020. Articles comparing pulmonary vein isolation (PVI) plus CFAE ablation and PVI alone for AF were obtained from the electronic scientific databases. The pooled mean difference (MD) and pooled risk ratio (RR) were assessed.ResultsA total of 8 randomized controlled trials (RCTs) including 1034 patients were involved. Following a single catheter ablation procedure, the presence of any atrial tachyarrhythmia (ATA) with or without the use of antiarrhythmic drugs (AADs) between both groups were not significantly different (RR = 1.1; 95% confidence interval [CI] = 0.97–1.24; p = 0.13). Similar results were also obtained for the presence of any ATA without the use of AADs (RR = 1.08; 95% CI = 0.96–1.22; p = 0.2). The additional CFAE ablation took longer procedure times (MD = 46.95 min; 95% CI = 38.27–55.63; p = < 0.01) and fluoroscopy times (MD = 11.69 min; 95% CI = 8.54–14.83; p = < 0.01).ConclusionAdditional CFAE ablation failed to improve the outcomes of non-paroxysmal AF patients. It also requires a longer duration of procedure times and fluoroscopy times.     

Effectiveness and safety profiling of zolpidem and acupressure in CKD associated pruritus: An interventional study

Background:Chronic kidney disease (CKD)-associated pruritus (CKD-aP) contributes to poor quality of life, including reduced sleep quality and poor sleep quality is a source of patient stress and is linked to lower health-related quality of life. This study aimed to investigate the effectiveness of zolpidem 10 mg and acupressure therapy on foot acupoints to improve the sleep quality and overall quality of life among hemodialysis patients suffering from CKD-aP.Method:A multicenter, prospective, randomized, parallel-design, open label interventional study to estimate the effectiveness of zolpidem (10 mg) oral tablets versus acupressure on sleep quality and quality of life in patients with CKD-aP on hemodialysis. A total of 58 hemodialysis patients having sleep disturbance due to CKD-aP completed the entire 8-week follow-up. The patients were divided into a control (acupressure) group of 28 patients and an intervention (zolpidem) group of 30 patients.Results:A total of 58 patients having CKD-aP and sleep disturbance were recruited. In the control group there was a reduction in the PSQI score with a mean ± SD from 12.28 ± 3.59 to 9.25 ± 3.99, while in the intervention group the reduction in PSQI score with a mean ± SD was from 14.73 ± 4.14 to 10.03 ± 4.04 from baseline to endpoint. However, the EQ5D index score and EQ-visual analogue scale (VAS) at baseline for the control group with a mean ± SD was 0.49 ± 0.30 and 50.17 ± 8.65, respectively, while for the intervention group the values were 0.62 ± 0.26 and 47.17 ± 5.82, respectively. The mean EQ5D index score in the control group improved from 0.49 ± 0.30 to 0.53 ± 0.30, but in the intervention group there was no statistical improvement in mean EQ5D index score from 0.62 ± 0.26 to 0.62 ± 0.27 from baseline to week 8. The EQ 5D improved in both groups and the EQ-VAS score was 2.67 points higher at week 8 as compared to baseline in the control group, while in the intervention group the score was 3.33 points higher at week 8 as compared to baseline. Comparing with baseline, the PSQI scores were significantly reduced after week 4 and week 8 (P =  < .001). Furthermore, at the end of the study, the PSQI scores were significantly higher in the control as compared to the intervention group (P = .012).Conclusion:An improvement in sleep quality and quality of life among CKD-aP patients on hemodialysis has been observed in both the control and intervention groups. Zolpidem and acupressure safety profiling showed no severe adverse effect other that drowsiness, nausea and daytime sleeping already reported in literature of zolpidem.     

Human papillomavirus subtype 16 is common in Pakistani women with cervical carcinoma.

INTRODUCTION: Human papillomavirus (HPV) is recognized as a major causative agent for cervical carcinomas. Based on their oncogenic potential, HPV subtypes have been divided into high- and low-risk. In Pakistan, screening for HPV in female patients is not commonly practiced, and as a consequence, the degree of HPV prevalence and its correlation with cervical cancer is unknown. OBJECTIVE: In this study, we have attempted to estimate the prevalence of HPV infection, and also the HPV subtype profile, among Pakistani women with cervical cancer from varied geographical, racial, and social backgrounds within Pakistan. METHODOLOGY: Women visiting two tertiary care hospitals in Karachi, diagnosed with carcinoma of the cervix within the past 15 years, were analyzed for HPV subtypes in their cancer specimens. Retrospectively, 60 paraffin-embedded cervical cancer biopsies were examined for the presence of HPV DNA. After DNA extraction from these samples, polymerase chain reaction (PCR) was used to amplify the HPV L1 gene using the consensus (general) primers, and primers specific for subtypes 16 and 18. RESULTS: Of the 60 samples analyzed, only one sample was HPV negative; the rest of the samples were positive for the presence of HPV. Of the 59 HPV positive samples, 56 showed the presence of HPV16 and one sample was positive for HPV18; HPV subtype could not be determined in two samples. CONCLUSION: Our results show a strong relationship between HPV infection and cervical cancer among Pakistani women. These results underscore the need to implement regular HPV screening for Pakistani women. An early diagnosis of HPV infection will allow better health management to reduce the risk of developing cervical cancer.     

Who is excluded and how? An analysis of community spaces for maternal and child health in Pakistan

Background

The maternal, newborn, and child health (MNCH) indicators of Pakistan depict the deplorable state of the poor and rural women and children. Many MNCH programmes stress the need to engage the poor in community spaces. However, caste and class based hierarchies and gendered social norms exclude the lower caste poor women from accessing healthcare. To find pathways for improving the lives of the excluded, this study considers the social system as a whole and describes the mechanisms of exclusion in the externally created formal community spaces and their interaction with the indigenous informal spaces.

Methods

The study used a qualitative case study design to identify the formal and informal community spaces in three purposively selected villages of Thatta, Rajanpur, and Ghizer districts. Community perspectives were gathered by conducting 37 focus group discussions, based on participatory rural appraisal tools, with separate groups of women and men. Relevant documents of six MNCH programmes were reviewed and 25 key informant interviews were conducted with programme staff.

Results

We found that lower caste poor tenants and nomadic peasants were excluded from formal and informal spaces. The formal community spaces formed by MNCH programmes across Pakistan included fixed, small transitory, large transitory, and emerging institutional spaces. Programme guidelines mandated selection of community notables in groups/committees and used criteria that prevented registration of nomadic groups as eligible clients. The selection criteria and adverse attitude of healthcare workers, along with inadequacy of programmatic resources to sustain outreach activities also contributed to exclusion of the lower caste poor women from formal spaces. The informal community spaces were mostly gender segregated. Infrequently, MNCH information trickled down from the better-off to the lower caste poor women through transitory interactions in the informal domestic sphere.

Conclusion

A revision of the purpose and implementation mechanisms for MNCH programmes is mandated to transform formal health spaces into sites of equitable healthcare.