Epidemiology,etiology, and outcomes of in-hospital cardiac arrest in Lebanon

BACKGROUNDIn-hospital cardiac arrest (IHCA) constitutes a significant cause of morbidity and mortality. As data is scarce in the Middle East and Lebanon, we devised this study to shed some light on it to better inform both hospitals and policymakers about the magnitude and quality of IHCA care in Lebanon.METHODSWe analyzed retrospective data from 680 IHCA events at the American University of Beirut Medical Center between July 1, 2016 and May 2, 2019. Sociodemographic variables included age and sex, in addition to the comorbidities listed in the Charlson comorbidity index. IHCA event variables were day, event location, time from activation to arrival, initial cardiac rhythm, and the total number of IHCA events. We also looked at the months and years. We considered the return of spontaneous circulation (ROSC) and survival to discharge (StD) to be our outcomes of interest.RESULTSThe incidence of IHCA was 6.58 per 1,000 hospital admissions (95% CI: 6.09−7.08). Non-shockable rhythms were 90.7% of IHCAs. Most IHCA cases occurred in the closed units (87.9%) (intensive care unit, respiratory care unit, neurology care unit, and cardiology care unit) and on weekdays (76.5%). ROSC followed more than half the IHCA events (56%). However, only 5.4% of IHCA events achieved StD. Both ROSC and StD were higher in cases with a shockable rhythm. Survival outcomes were not significantly different between day, evening, and nightshifts. ROSC was not significantly different between weekdays and weekends; however, StD was higher in events that happened during weekdays than weekends (6.7%vs. 1.9%, P = 0.002). CONCLUSIONSThe incidence of IHCA was high, and its outcomes were lower compared to other developed countries. Survival outcomes were better for patients who had a shockable rhythm and were similar between the time of day and days of the week. These findings may help inform hospitals and policymakers about the magnitude and quality of IHCA care in Lebanon.

In-hospital cardiac arrest (IHCA) constitutes a significant cause of morbidity and mortality.^[1] Based on the American Heart Association’s Get With The Guidelines-Resuscitation (GWTG-R) registry data from 2003 to 2007, the approximated incidence of IHCAs in the United States was 211,000 annually or roughly 6 to 7 cardiac arrests per 1,000 hospital admissions.^[2,3] Data from 2008 to 2017 showed the incidence of IHCA increased to 292,000 annually or 9 to 10 IHCAs per 1,000 hospital admissions.^[1,4] In contrast, data from the United Kingdom National Cardiac Arrest Audit showed an incidence of 1.6 IHCAs per 1,000 hospital admissions in the United Kingdom from 2011 to 2013.^[1] Despite progress in resuscitation technology and care, survival outcomes following IHCA remain low at 15%−25% and vary radically between 0% and 42% worldwide.^[5,6] Sandroni, et al.^[5] showed that various patient and healthcare-related factors are associated with the survival outcomes of IHCA. The main patient-related factors are age, sex, initial cardiac rhythm, underlying medical condition, comorbidities, and the time of the IHCA event. In contrast, major healthcare-related factors are the protocols for IHCA care, duration and method of resuscitation, skills of healthcare professionals, time from code activation and the arrival of the code response team, and the location of the IHCA event.^[5,7] The study by Chen, et al.^[8] suggests that improving the quality of resuscitation care and minimizing other healthcare-related risk factors can markedly increase survival outcomes from IHCAs.^[6,9]Consistent and updated estimates of the magnitude and outcomes of IHCA are fundamental for monitoring and improving the delivery and quality of IHCA care in any healthcare setting. In Lebanon, studies have shown low survival rates (5.5%) from out-of-hospital cardiac arrest.^[10]The reported incidence of IHCA in the United Arab Emirates was 11.7 per 1,000 hospital admissions,^[6] and in Saudi Arabia was 7.76 per 1,000 hospital admissions.^[11] The reported survival to hospital discharge in the United States was only 10.4%,^[12] and it was only 7.9% in the United Kingdom.^[13] However, unlike European countries and the United States, the epidemiology of IHCA is unknown in Lebanon, suggesting the need for research in this area. Therefore, this study aimed to produce the first estimates of the incidence, characteristics, and outcomes of IHCA at a tertiary-care hospital in Lebanon.     

Effect of reperfusion strategy on QT dispersion in patients with acute myocardial infarction: Impact on in-hospital arrhythmia

BACKGROUND Myocardial ischemia and ST-elevation myocardial infarction(STEMI) increase QT dispersion(QTD) and corrected QT dispersion(QTcD), and are also associated with ventricular arrhythmia.AIM To evaluate the effects of reperfusion strategy [primary percutaneous coronary intervention(PPCI) or fibrinolytic therapy] on QTD and QTcD in STEMI patients and assess the impact of the chosen strategy on the occurrence of in-hospital arrhythmia.METHODS This prospective, observational, multicenter study...     

The role of brain magnetic resonance imaging on the timing of antiepileptic drugs withdrawal following mesial temporal lobe epilepsy surgery

Objectives:To assess the influence of magnetic resonance imaging (MRI) brain findings on the timing of antiepileptic drugs (AEDs) withdrawal following anterior temporal lobectomy (ATL) in patients with mesial temporal lobe epilepsy (MTLE).Methods:We conducted a retrospective chart review at King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia from Jan, 2004 – Dec, 2017 of patients with MTLE who underwent ATL and included patients who had a minimum of 2 years of follow-up. We evaluated the association between the time required to start tapering and discontinuing AEDs after ATL in patients with Engel class I outcomes and their preoperative brain MRI.Results:We studied 64 patients who underwent ATL. The majority of patients (63%) had hippocampal sclerosis (HS) on histopathology. Following ATL, the mean time to start tapering AEDs was 10 months and AEDs were discontinued at a mean of 48 months. Abnormal brain MRI was observed in 53 (83%) patients, with findings suggestive of mesial temporal sclerosis (MTS) accounting for 75% of these abnormalities. The presence of any MRI abnormality was associated with a 10-month earlier tapering of AEDs (p<0.01), and an 18-month earlier complete withdrawal of AEDs (p<0.01). The odds of being seizure-free within the first year were higher if MTS was present in the brain MRI (adjusted OR=16). Similarly, this was associated with seizure freedom after the first year (adjusted OR=14.8, p<0.01). The presence of unilateral temporal IEDs on preoperative EEG were also associated with earlier tapering and discontinuation of AEDs as well as a seizure-free state after ATL surgery (OR=8.5 and 4.2, for the first and second year respectively, p<0.01).Conclusion:Patients with abnormal MRI findings and unilateral IEDs had earlier tapering of AEDs with an overall shorter AED discontinuation plan. Moreover, the presence of MTS on MRI, along with unilateral IEDs, were predictors of seizure freedom following ATL.

Anterior temporal lobectomy (ATL) is the standard treatment for medically refractory mesial temporal lobe epilepsy (MTLE), achieving seizure remission in approximately 70% of patients. ^1-3 However, the feasibility and timing of antiepileptic drug (AEDs) withdrawal after ATL are debatable. ⁴ The need for AEDs withdrawal stems from the adverse effects following long-term use, ^5,6 difficulties in maintaining compliance, and their high cost. ^7,8 Moreover, AEDs withdrawal following successful ATL is generally considered safe. ⁴ There are no evidence-based guidelines for managing AEDs withdrawal after resective epilepsy surgery. ^9,10 Moreover, few prospective and retrospective studies have assessed postoperative AEDs management exclusively in patients with MTLE. ^4,11-13 Hence, the timing of AEDs withdrawal after temporal lobectomy is controversial. ^12,14,15 The difficulties faced are how to taper AEDs, how soon it is safe to taper, which clinical profiles favor tapering, and what is the optimal time to start the tapering process. Predicting successful AEDs withdrawal following ATL has been examined in a few studies; however, the results were inconsistent. ^9,12,16-18 In one study, brain magnetic resonance imaging (MRI) findings were associated with seizure outcomes following ATL with successful AEDs discontinuation. ¹² The MRI can detect brain abnormalities, predict postoperative seizure, and AEDs freedom ² Despite this, data are lacking regarding the role of MRI in determining the time to start tapering AEDs postoperatively, as well as the time until AEDs discontinuation in those who do not require postoperative AEDs treatment. These data are essential for establishing guidelines that could assist clinicians with AED management following ATL.We aimed to assess the role of brain MRI in planning the tapering of AEDs and determining when to discontinue AEDs in patients with MTLE following ATL. We also evaluated seizure outcomes in patients with a minimum of 2 years of postoperative follow-up.     

Kienbock's disease: A radiological case report

Kienböck''s disease is a condition characterized by avascular necrosis of the lunate. It is also known as lunatomalacia and aseptic or ischemic necrosis of the lunate.The aim of this work is to summarize and illustrate, through a case diagnosed in our institution, the radiological aspects of this rare entity, which occupy a prominent place in the diagnosis.A better understanding of this recently described nosological entity and a wide dissemination of its diagnostic criteria, especially by radiologists, should facilitate the diagnosis and treatment of patients.     

Breast screening in the emerging world: high prevalence of breast cancer in Cairo

The Cairo Breast Screening Trial (CBST) was designed to evaluate the role of clinical breast examination as a primary screening modality in the context of primary care, as in Egypt breast cancer is usually diagnosed at an advanced stage. A specialised medical centre in Cairo (the Italian Hospital) was selected as the headquarters of the study. The initial target group was women age 35-64 living in a geographically defined area around the Italian Hospital, 4116 being contacted by social workers and invited to attend a Primary Health Centre for clinical breast examination. High rates of breast cancer were observed; 8 per 1000 at the first examination and approximately 2 per thousand among those who attended for re-screening. The initial prevalence suggests that many women in the community with early but palpable breast cancer fail to seek medical attention until their cancer is advanced. The detection rate on re-screening, and after follow-up of those who only received one or no screens, ( approximately 3/1000) is similar to expectation.     

Obstructive Sleep Apnea Syndrome Phenotyping by Cluster Analysis:Typical Sleepy,Obese Middle-aged Men with Desaturating Events are A Minority of Patients in A Multi-ethnic Cohort of 33％ Women

Objective:Several clinical obstructive sleep apnea syndrome(OSAS)phenotypes associated with heterogeneous cardiovascular risk profiles have been recently identi...     

Is Ustekinumab Effective in Refractory Crohn’s Disease of the Pouch and Chronic Pouchitis? A Systematic Review

Digestive Diseases and Sciences - Crohn’s disease (CD) of the pouch and chronic pouchitis represent the most common long-term complications of total proctocolectomy and ileal pouch anal...     

Mycobacterium leprae Infection in a Wild Nine-Banded Armadillo,Nuevo León,Mexico

Nine-banded armadillos (Dasypus novemcinctus) are naturally infected with Mycobacterium leprae and are implicated in the zoonotic transmission of leprosy in the United States. In Mexico, the existence of such a reservoir remains to be characterized. We describe a wild armadillo infected by M. leprae in the state of Nuevo León, Mexico.