Impact of COVID-19 Pandemic on acute cardiac emergencies: ST- Elevation Myocardial Infarction, Acute Aortic Dissection and Ventricular Septal Rupture

Aim: To evaluate the influence of the Covid? 19 pandemic on Acute Cardiac Emergencies, namely, ST-Elevation Myocardial Infarction (STEMI), Acute Aortic dissection (AAD) and Ventricular Septal Rupture (VSR) at a tertiary care hospital in India. Methods: A total of 880 acute cardiac emergencies patients presenting at the emergency department at a tertiary cardiac care centre, diagnosed with STEMI, VSR and AAD were included in the study. Results: A notable reduction in the number of STEMI, VSR and AAD patients presenting to the emergency department was observed coinciding with the COVID-19 pandemic. In STEMI patients the average time from onset of signs and symptoms to first medical contact changed from a central tendency of 5.5 hours pre Covid-19 to 6 hours post Covid-19 ; door to balloon time changed from a central tendency of 90 minutes pre Covid-19 to 82.5 minutes post Covid-19 ; a reduced ejection fraction of less than or equal to 40% was seen in 37.22% of patients pre Covid-19 to 50.7% of patients post Covid-19 ; Percentage of patients in Killip class-1 and Killip class-3 decreased from 84.09% to 69.85% and 1.13% to 0.73% respectively post pandemic. And the percentage of patients in Killip class-2 and Killip class-4 increased from 4.82% to 13.23%, and 9.94% to 16.17% respectively post-pandemic. We observed a sharp fall in acute cardiac emergency patients post Janta Curfew declared on March 22 nd , 2020. There was also a rise in STEMI and VSR patients seen post Unlock 4 declared on September 1 st , 2020. Conclusion: The COVID-19 pandemic has significantly decreased the presentations of acute cardiac emergencies at our tertiary care hospital. There was also a significant delay in time from onset of signs and symptoms to first medical contact. There was no impact on the quality of care given to patients, in fact a decrease in door to balloon time was seen post pandemic at our centre. However, patients presented with a lower ejection fraction and higher Killip’s classification post pandemic. This indicates the possibility of increased mortality and morbidity of such patients, which is a matter of public health concern globally. It is important that we address this by increasing access to immediate healthcare facilities via tele-consultation.

Adverse drug reactions and cost effectiveness of non-steroidal antiinfl ammatory drugs, muscle relaxants, and neurotropic drugs in patients with low back pain.

Background: The objective was to evaluate the adverse drug reactions (ADRs) and cost effectiveness of different classes of drugs in therapy of low back pain. Methods: A prospective observational study was carried out over a period of 12 months (November 2012 to November 2013) in which a total of 300 patients with low back pain were enrolled and divided equally into three groups – Group 1 (nonsteroidal anti-infl ammatory drugs [NSAIDs]), Group 2 (NSAIDs ± muscle relaxant), and Group 3 (NSAIDs ± muscle relaxant ± neurotropic drugs). Any ADR developed after the initiation of treatment at 3 weeks and 6 weeks was noted. Prescription cost per day was also calculated. Results: There was a male predominance in the study population with a mean age of 39.76±9.40 years. A total of 262 ADRs were noted among which most were seen in Group 3 (119 ADRs). Gastritis was the most common ADR in Group 1. Drowsiness was the most common ADR in Group 2 (30%) and 3 (46%). Prescription cost per day was highest in Group 3 (30.28±11.24 Indian Rupee [INR]) followed by Group 2 (25.92±8.66 INR) and Group 1 (12.22±3.38 INR). Conclusion: Patient on combination of three drugs (NSAIDs, muscle relaxants, and neurotropic agents) had maximum ADRs and their prescription cost per day was highest among the three groups.

Ultra low dose aprotinin decreases blood loss and transfusion requirements in high risk two valve replacement surgery.

The efficacy of ultra-low-dose-aprotinin (ULDA) in 'high-risk' two valve replacement surgery, was evaluated in this prospective, randomized, double-blind study. Forty adult high-risk patients undergoing elective two valve replacement surgery, were included. The patients were divided into 2 groups of 20 each. In Group I, aprotinin in a dose of 1,000,000 KIU was administered from the end of anaesthesia induction to the time of sternotomy after a 1 ml of test dose. In Group II (control), 100 ml of normal saline was administered in a similar fashion. Coagulation parameters, blood loss, and amount of transfusion of blood / blood products were measured at specific intervals. The postoperative chest tube drainage in the first 24 hours was significantly less 203+/-35 ml (p<0.05) in Group I as compared with 490+/-104 ml in group II and consequently, Group I patients received significantly less (p<0.05) red cell concentrates and platelet transfusion. There was a significant decrease in the length of postoperative elective ventilation, intensive care unit (ICU) stay and direct costs involved in the hospital expenses with the use of ULDA. We conclude that ULDA is safe and effective in 'high-risk' two-valve replacement surgery to reduce postoperative bleeding, postoperative length of intubation and ICU stay; use of ULDA is associated with significant direct cost savings.

Candida tropicalis causing prosthetic valve endocarditis.

The incidence of endocarditis produced by the so-called "opportunists" as a complication of prosthetic valve surgery is progressively increasing in frequency and gradually transforming the clinical picture habitually associated with this disease. Candida endocarditis is an unusual but severe complication caused by Candida albicans or other fungal species. This case and a review of the literature indicate that Candida endocarditis treated with amphotericin B and prosthetic valve replacement may recur months after treatment, and that late recurrent Candida endocarditis, which is difficult to diagnose and treat, may be best prevented by lifelong antifungal suppressive therapy.

Adult atretic parietal cephalocele.

Atretic parietal cephalocele is a congenital anomaly of childhood with poor prognostic value. The authors report an adult with associated brain malformations (interhemispheric cyst, partial corpus callosum agenesis) - but, interestingly, without any clinical symptoms related to the entity.

Lateral sacral lipomyelomeningocele : a rare anomaly.

Lateral sacral lipomyelomeningocele is a rare spinal developmental anomaly. In the case under report, the fat attached to the neural placode was blending with the gluteal fat externally. The cord was tethered at this level. Multiple bony anomalies and diastematomyelia were associated findings. A case of lateral sacral lipomyelomeningocele with excellent imaging detail provided by the multiplanar magnetic resonance (MR) scan is reported.

Biochemical Markers of Myocardial Injury during Coronary Artery Bypass Grafting with and without Cardiopulmonary Bypass.

Minimally invasive cardiac surgical techniques have been applied recently in the management of variety of cardiac lesions. Between December 1998 and February 1999, fifty patients underwent coronary artery bypass grafting (CABG) under two different techniques. In group A (twenty five patients), CABG was done under cardiopulmonary bypass (CPB) and in group B (twenty three patients), CABG was performed on a 'beating heart' without CPB. Serum concentration of cardiac specific enzymes CPZ-MB and Troponin-T were estimated in all the patients from pre-induction period to 72 hours after the bypass graft. Group A patients exhibited a significant (P<0.05) elevation in the CPK-MB and Troponin-T level as compared to group B. Our results show that the extent of myocardial damage following CABG is significantly less when the procedure is done on a 'beating heart'.

Malignant peritoneal mesothelioma in an inguinal hernial sac: an unusual presentation.

Malignant peritoneal mesothelioma, which is a rare neoplasm, usually presents with abdominal complaints. Though such tumours have been reported from tunica vaginalis testis presenting as para-testicular mass, there is only one documented case of the tumour arising from the inguinal hernial sac. In this paper, we are reporting a rare presentation of this tumour.

Cervico-dorsal spinal enterogenous cyst.

A case of a histologically proven ventrally situated spinal enterogenous cyst of cervico-dorsal region is reported with magnetic resonance (MR) imaging features. A brief review of literature on the subject is discussed.

Basal ganglia calcification.

Basal ganglia calcification (BGC) is now being diagnosed with increasing frequency with widespread application of computed tomography (CT) in clinical practice and is no more considered a rarity. During the period 1987 to 1995, 42 patients were noted to have BGC and it constituted 0.93% of all CT scan of brain carried out during the relevant period. These patients presented with diverse neurological and endocrine disorders i.e., epilepsy (22 patients), mental retardation (five patients), extra-pyramidal syndromes (five patients), abnormal behaviour (three patients), stroke (two patients), raised intracranial tension without localizing signs (one patient), following radiotherapy (one patient), and with hypoparathyroidism (three patients). These patients were noted to have variable degree of calcification in different parts of brain i.e., basal ganglia (42 cases), cerebellum (12 cases) and cerebral cortex (nine cases). Family history of a neurological disorder was available in five patients. This study highlights the fact that calcification of basal ganglia and other parts of the brain is often a nonspecific finding on CT scan and it may not be possible to establish a clinicopathological correlation.

Video-assisted thoracoscopic surgery for closure of patent ductus arteriosus in children.

Video-assisted thoracoscopic surgery (VATS) was recently described as an approach to clip the patent ductus arteriosus (PDA). Between May 1994 and May 1996, we performed this procedure on 34 children below 12 years of age (mean 7 years). Thirty-two had an isolated PDA and two had associated small perimembranous ventricular septal defect (VSD), diagnosed on echocardiography and colour flow mapping. None had pulmonary arterial hypertension. The procedure was successful in 33 (97%) children confirmed by absence of residual shunt on serial echocardiography. Complications in the form of pneumothorax (1) and vocal card paralysis (2) were encountered in three children. The overall hospital stay was reduced to five days. In conclusion, the technique of PDA clipping using VATS is easy to learn and highly successful with acceptable risk of complications.

Significance of exercise induced increase in the diastolic pressure as an indicator of severe coronary artery disease.

A total of 100 patients were studied for the diastolic blood pressure response to treadmill exercise testing. No change in the diastolic pressure or lowering of the pressure was considered normal response. Seventy-four patients had normal and 26 patients had abnormal diastolic blood pressure response. Forty patients underwent coronary angiography. Fifty-five per cent of the patients with normal diastolic pressure response had normal coronaries compared to 20% with abnormal response. Eleven per cent with normal response and 40% with an abnormal response had triple vessel disease whereas 10% with abnormal response had left main coronary artery disease. Exercise induced ST segment depression was almost equal in both groups. Hence it can be concluded that abnormal diastolic pressure response to treadmill exercise testing is a fairly good indicator of coronary artery disease irrespective of ST segment changes.

Significance of exercise induced increase in diastolic pressure as an indicator of severe coronary artery disease.

A total of 100 patients were studied for the diastolic blood pressure response to treadmill exercise testing. No change in the diastolic pressure or lowering of the pressure was considered normal response. Seventy four patients had normal and 26 patients had abnormal diastolic blood pressure response. Out of these, 40 patients underwent coronary angiography. Fifty five percent of the patients with normal diastolic pressure response had normal coronaries compared to 20% with abnormal response (p < 0.03). Fifteen percent with normal response had triple vessel disease or left main coronary artery disease whereas forty percent with an abnormal response had significant disease (p < 0.03). Exercise induced ST segment depression was almost equal in both groups. Hence we can conclude that abnormal diastolic pressure response to treadmill exercise testing is a fairly good indicator of coronary artery disease irrespective of ST segment changes.