Impaired Functional Status and Echocardiographic Abnormalities Signifying Global Dysfunction Enhance the Prognostic Significance of Previously Unrecognized Myocardial Infarction Detected by Electrocardiography

Background: The relationship between electrocardiographic unrecognized myocardial infarction (UMI), abnormal functional status, echocardiographic abnormalities, and mortality has not been evaluated. Methods: A population‐based random sample of 2042 Olmsted County residents, age ≥45 years, was studied by self‐administered questionnaire, chart review, ECG and echocardiogram, and 5 year follow‐up for all‐cause mortality. UMI (n = 81) was diagnosed if ECG‐MI criteria were met without previous documented myocardial infarction. Functional Status was assessed by the Goldman Specific Activity Scale. Results: UMI subjects had an increased prevalence of abnormal functional status compared to no MI controls (22% vs 11%, P < 0.05). This association was independent of sex, obesity, smoking, diabetes, and pulmonary disease. It became insignificant after stratifying for echocardiographic abnormalities. Compared to no MI controls, UMI subjects with impaired functional status had a higher mortality hazard ratio (HR 7.2; P<0.0001) than those without impaired functional status (HR 2.7; P = 0.02). In UMI subjects with impaired functional status and any echocardiographic abnormality signifying global ventricular dysfunction (systolic or diastolic dysfunction, left atrial or left ventricular enlargement), the mortality risk was even higher (HR 9.5; P<0.001) and persisted in multivariate analyses. This increased mortality risk was unaffected by adjustment for regional wall motion abnormalities. Conclusions: The assessment of impaired functional status and echocardiographic abnormalities improves the prognostic significance of UMI. Even in the absence of regional wall motion abnormalities, structural abnormalities of global dysfunction may play a role in mediating the increased mortality associated with UMI.     

Surgical management of contiguous multilevel thoracolumbar tuberculous spondylitis

Introduction

Tuberculous spondylitis (TBS) is the most common form of extra-pulmonary tuberculosis. The mainstay of TBS management is anti-tuberculous chemotherapy. Most of the patients with TBS are treated conservatively; however in some patients surgery is indicated. Most common indications for surgery include neurological deficit, deformity, instability, large abscesses and necrotic tissue mass or inadequate response to anti-tuberculous chemotherapy. The most common form of TBS involves a single motion segment of spine (two adjoining vertebrae and their intervening disc). Sometimes TBS involves more than two adjoining vertebrae, when it is called multilevel TBS. Indications for correct surgical management of multilevel TBS is not clear from literature.

Materials and methods

We have retrospectively reviewed 87 patients operated in 10 years for multilevel TBS involving the thoracolumbar spine at our spine unit. Two types of surgeries were performed on these patients. In 57 patients, modified Hong Kong operation was performed with radical debridement, strut grafting and anterior instrumentation. In 30 patients this operation was combined with pedicle screw fixation with or without correction of kyphosis by osteotomy. Patients were followed up for correction of kyphosis, improvement in neurological deficit, pain and function. Complications were noted. On long-term follow-up (average 64 months), there was 9.34 % improvement in kyphosis angle in the modified Hong Kong group and 47.58 % improvement in the group with pedicle screw fixation and osteotomy in addition to anterior surgery (p < 0.001). Seven patients had implant failures and revision surgeries in the modified Hong Kong group. Neurological improvement, pain relief and functional outcome were the same in both groups.

Conclusion

We conclude that pedicle screw fixation with or without a correcting osteotomy should be added in all patients with multilevel thoracolumbar tuberculous spondylitis undergoing radical debridement and anterior column reconstruction.

     

Accuracy of diagnosis and relationship with quality of emergency medicine training program

An indicator for emergency room performance is the ability to establish the correct diagnosis within the emergency room over the years. The authors chose to examine the non-congruence of Emergency Room diagnoses to that established after hospital stay for three selected years. A total of 8488 records were reviewed and all disparate diagnosis were recorded and categorized. Retrospective chart reviews were done from July 2008 to February 2009 at the Aga Khan University Hospital, Karachi. A substantial reduction in the percentage of disparate diagnoses was seen over the years from 41% in the initial year to 14% in the last year evaluated. It was concluded that over the years there has been an improvement in the reliability of Emergency Room diagnoses at the Aga Khan University Hospital, Karachi.     

Dual behavior of HCV Core gene in regulation of apoptosis is important in progression of HCC

Hepatitis C virus (HCV) causes acute and chronic hepatitis which can lead to HCC (Hepatocelluar carcinoma) via oxidative stress, steatosis, insulin resistance, fibrosis and liver cirrhosis. Apoptosis is essential for the control and eradication of viral infections. In acute HCV infection, enhanced hepatocyte apoptosis is significant for elimination of viral pathogen. In case of chronic HCV, down regulation of apoptosis and enhanced cell proliferation not only causes HCV infection persistency in the majority of patients. However, the impact of apoptosis in chronic HCV infection is not well understood. It may be harmful by triggering liver fibrosis, or essential in interferon (IFN) induced HCV elimination. Regulation of apoptosis in hepatocytes by HCV Core is so important in progression of HCC. This review focuses on the dual character of HCV Core on regulation of apoptosis and progression of HCC.     

Endoluminal gastroplication in children with significant gastro-oesophageal reflux disease

AIMS: To describe paediatric experience, and to assess complications and therapeutic effectiveness of the use of endoluminal gastroplication in children with gastro-oesophageal reflux disease (GORD) refractory to, or dependent on, proton pump inhibitors. METHODS: Seventeen (five male) consecutive children/adolescents (median (range) age 12.4 (6.1-15.9) years, median (range) weight 46.0 (16.5-87.5) kg) with GORD either dependent for more than 12 months on proton pump inhibitors or non-responsive to medical treatment underwent endoscopic gastroplication using a flexible endoscopic sewing device (EndoCinch). Three plications were placed in gastric tissue below the lower oesophageal sphincter. Drug dose requirement, pH measurements, daily symptom severity and frequency, and validated reflux (QOLRAD) and general gastrointestinal (GSRS) quality of life scores were compared before and after endoscopic gastroplication. RESULTS: All patients showed post-treatment improvement in symptom severity, frequency, and quality of life scores (p<0.0001). Three patients with recurrent symptomatic GORD had a repeat procedure within six weeks and did well subsequently. At up to 33 months of follow up (median 23), 14/17 patients remained off all antireflux medications, and 14/17 had maintained their symptomatic improvement. All pH parameters improved and had returned to normal values in 14/16 patients post-treatment and in 6/9 after one year of follow-up: in particular the reflux index had decreased from a median of 16.6% (0.9-67%) to 2.5% (0.7-15.7%) (p<0.0001) six weeks and 4.3% (2.2-20.6) (p<0.02) 12 months post-procedure. The only complication observed was gastric bleeding in one patient due to previously undiagnosed coagulopathy, which spontaneously resolved. CONCLUSIONS: Endoluminal gastroplication is an effective and safe procedure in children/adolescents with significant GORD refractory to, or dependent on, medical anti-GORD therapy.