Development of an interview-based warfarin nomogram predicting the time spent in the therapeutic INR range: A cost-effective, and non-invasive strategy building from a cross sectional study in a low resource setting

A cross-sectional study was conducted to predict time in therapeutic range (TTR) using clinical history, examination, and socioeconomic data. Study included warfarin-receiving patients from outpatient-clinic. In 203 patients studied, mean warfarin start-dose was 2.55 mg/day and maintenance-dose/week was 30.79 mg. Body mass index (BMI) (p ¼ 0.03), warfarin maintenance dose/day (p ¼ 0.02), and comorbidity presence (p ¼ 0.04) were significantly associated with TTR. Occupation (p ¼ 0.53), income (p ¼ 0.83), education (p ¼ 0.55), and socioeconomic score (p ¼ 0.73) showed non-significant association with TTR. A TTR predicting nomogram was built from clinical history and examination findings.

Objective-structured clinical examination in cardiovascular system for the assessment of internal medicine postgraduates amidst the Covid-19 pandemic

BACKGROUND The Covid-19 pandemic has posed a challenge to organizing a safe clinical assessment for postgraduate degree candidates completing the residency programmes in various specialties. Although minimizing the risk of Covid-19 transmission is a priority, fulfilling the objectives of the assessment is equally important. METHODS We conducted this study in the Department of Internal Medicine at our institute. Instead of physically examining patients, case scenarios that included history, clinical and investigational data of the cardiovascular system (CVS) were presented to the candidates. Performance was scored by both the conventional and the CVS objective-structured clinical examination (CVS-OSCE) method and compared. RESULTS Clinical assessment examination of 27 candidates for the degree of Doctor of Medicine showed that the median cumulative score gained in narrating and analysing various differential diagnoses was lower compared to the mean cumulative score gained in arriving at a single correct diagnosis (50% [interquartile range—IQR 39%–64%] v. 79% [IQR 64%–100%], p<0.01). Most of the candidates agreed that case scenarios were good alternatives to the conventional physical examination amidst the pandemic. CONCLUSION CVS-OSCE-based assessment using structured case scenarios is a feasible and effective alternative for clinical skill assessment in high-stake examinations.

Retroperitoneal iliac conduits as an alternative access site for endovascular aortic repair: a tertiary care center experience / Condutos ilíacos retroperitoneais como local de acesso alternativo para reparo endovascular de aneurisma: experiência em centro de atenção terciária

Abstract Background Retroperitoneal open iliac conduits (ROIC) are used in patients with hostile iliac anatomy undergoing endovascular aortic repair (EVAR). Objectives We hereby report our experience of ROIC in patients subjected to EVAR. Methods This was a retrospective evaluation of 8 patients out of a total of 75 patients (11%) who underwent EVAR in the last 10 years. Pre-procedure computed tomography angiography was used to assess the dimensions of iliac and femoral arteries. Patients who had small arterial dimensions (i.e. smaller than the recommended access size for the aortic endograft device) were subjected to ROIC. Results The mean age of the 3 males and 5 females studied was 45.7 ± 15.2 years. The indication for ROIC was the small caliber ilio-femoral access site in 7 patients and atherosclerotic disease in 1 patient. All external grafts were anastomosed to the right common iliac artery except one which was anastomosed to the aortic bifurcation site because of a small common iliac artery. The procedural success rate was 100%. Local access site complications included infection (n=1), retroperitoneal hematoma (n=1), and need for blood transfusion (n=3). The median post-intervention hospital stay was 10 days. All patients had favorable long-term outcomes at a median follow-up of 18 months. Conclusions Female patients require ROIC during EVAR more frequently. Adjunctive use of iliac conduit for EVAR was associated with favorable perioperative and short-term outcomes.

Resumo Contexto Os condutos ilíacos abertos retroperitoneais são utilizados em pacientes submetidos a reparo endovascular de aneurisma (REVA) com anatomia ilíaca hostil. Objetivos Relatamos a nossa experiência com os condutos ilíacos em pacientes submetidos a REVA. Métodos Trata-se de uma avaliação retrospectiva de oito pacientes, de um total de 75 (11%), os quais foram submetidos a REVA nos últimos 10 anos. Foi realizada angiotomografia computadorizada antes do procedimento para avaliar as dimensões das artérias ilíaca e femoral. Os pacientes com dimensões arteriais menores, abaixo do tamanho de acesso recomendado para o dispositivo de endoprótese aórtica, foram submetidos a condutos ilíacos. Resultados A média de idade dos participantes foi de 45,7±15,2 anos, sendo três do sexo masculino e cinco do sexo feminino. As indicações para condutos ilíacos foram local de acesso ilíaco femoral de pequeno calibre, para sete pacientes, e doença aterosclerótica, para um paciente. Todas as próteses externas foram anastomosadas na artéria ilíaca comum direita, com exceção de uma, que foi anastomosada no local da bifurcação aórtica por apresentar artéria ilíaca comum menor. A taxa de sucesso do procedimento foi de 100%. As complicações no local de acesso incluíram infecção (n = 1), hematoma retroperitoneal (n = 1) e necessidade de transfusão de sangue (n = 3). O tempo mediano de internação hospitalar pós-intervenção foi de 10 dias. Todos os pacientes apresentaram desfechos de longo prazo favoráveis no seguimento mediano de 18 meses. Conclusões As pacientes do sexo feminino necessitaram de condutos ilíacos durante REVA com maior frequência. O uso adjuvante de condutos ilíacos com REVA foi associado a desfechos perioperatórios e de curto prazo favoráveis.

Simultaneous endovascular revascularization of external iliac artery dissection and transplant renal artery stenosis in a recent renal allograft recipient / Revascularização endovascular simultânea de dissecção da artéria ilíaca externa e de estenose da artéria renal transplantada em receptor recente de aloenxerto renal

Abstract Various vascular complications following renal transplantation include renal artery and vein thrombosis, renal artery stenosis, pseudoaneurysm, and iliac artery dissection. Transplant renal artery stenosis (TRAS) is the most common, while iliac artery dissection is the rarest of these various vascular complications. We describe an elderly male, who had both external iliac artery dissection and TRAS at 2 months following renal transplantation. He underwent successful percutaneous endovascular intervention of both complications. The post-intervention course was uneventful, with improvement in graft renal functions and left lower limb perfusion.

Resumo As diversas complicações vasculares possíveis após um transplante renal incluem trombose da veia e artéria renais, estenose da artéria renal, pseudoaneurisma e dissecção da artéria ilíaca. Entre essas diversas complicações, a estenose da artéria renal transplantada é a mais comum, enquanto a dissecção da artéria ilíaca é a mais rara. Relatamos o caso de um homem idoso que desenvolveu tanto dissecção da artéria ilíaca quanto estenose da artéria renal transplantada 2 meses após transplante renal. As intervenções endovasculares percutâneas foram bem-sucedidas em ambas as complicações. O período pós-intervenção cursou sem complicações, com melhora na função renal do enxerto e na perfusão do membro inferior esquerdo.

Endovascular stenting with a drug-eluting stent of transplanted renal artery stenosis in a dual kidney transplanted patient / Tratamento endovascular com stent farmacológico em estenose de artéria renal transplantada de paciente com transplante renal duplo

Abstract Renal transplant remains the preferred therapy for end-stage renal disease (ESRD). Given the shortage of suitable donor kidneys, use of an expanded criteria donor (ECD) allows marginal kidneys to be transplanted; albeit at risk of increased graft failure due to lower nephron mass. To reduce the risk of graft failure, double kidney transplant (DKT) is advocated, with favorable outcomes. Transplant renal artery stenosis (TRAS) is one of the most common vascular complications following renal transplant. Unlike single kidney transplants, where TRAS usually presents with fluid overload, uncontrolled hypertension, and worsening kidney functions; it may be clinically silent in DKT patients since they have two functional transplanted kidneys. We hereby report a case of TRAS in a DKT patient who had 2 years of favorable clinical outcomes following successful endovascular stenting. He however recently died of COVID-19 associated pneumonitis.

Resumo O transplante renal continua sendo a terapia preferida para doenças renais em fase terminal. Dada a escassez de rins de doadores adequados, o doador com critérios expandidos permite que rins marginais sejam transplantados, embora haja um maior risco de falha do enxerto devido à diminuição da massa nefrótica. Para diminuir o risco de falha do enxerto, recomenda-se o transplante renal duplo (TRD), com resultados favoráveis. A estenose de artéria renal transplantada (EART) é uma das complicações vasculares mais comuns após o transplante renal. Ao contrário dos transplantes de rim simples, nos quais a EART geralmente se manifesta como sobrecarga de fluido, hipertensão descontrolada e piora das funções renais, ela pode ser clinicamente silenciosa em pacientes com TRD, pois eles têm dois rins funcionais transplantados. Relatamos aqui um caso de EART em um paciente com TRD que teve resultados clínicos favoráveis por dois anos após o sucesso do implante de stent endovascular. No entanto, ele morreu recentemente de pneumonite associada à covid-19.

IVC filter: Review.

Thrombo-embolic disease continues to be the paramount cause of morbidity as well as mortality in those afflicted despite amelioration in diagnostic imaging and anticoagulation regimens. Sometimes, standard medical therapy for thrombo-embolism is contraindicated, for it results in complications, or fails to adequately protect patients from pulmonary embolism (PE). These patients are treated by insertion of inferior vena cava (IVC) filters. Although IVC filters diminish long-term risk of pulmonary embolism (PE), they are associated with increased risk of IVC thrombosis and lower-extremity deep venous thrombosis (DVT) as compared to anticoagulation alone. Despite their prolonged use for more than 40 years, there are limited randomized clinical trials, comparing oral anticoagulation with IVC filters. Also, data on long term use of IVC filter is scarce. This article will address traits of an ideal IVC filter, different types of filters available and complications involved in the use of the diffrent IVC filter.

Prenatal management with digoxin and sotalol combination for fetal supraventricular tachycardia : Case report and review of literature.

Sustained fetal supraventricular tachycardia (SVT) with a heart rate of approximately 210 bpm may lead to increased atrial and venous pressures and congestive heart failure. There is no clear consensus regarding the best drug-treatment regimens for fetal SVT. However, considerable nonrandomized experience in the transmaternal treatment of fetal SVT is available with a number of antiarrhythmic agents. We report a case of fetal supraventricular tachyarrhythmia with hydrops detected at 32 weeks that was managed with combination of oral digoxin and sotalol and review management guidelines available in the literature.

Utilization of Telefax System for Early Detection, Interpretation and Management of Acute ST-Elevation Myocardial Infarction: An Initial Experience from Rural Punjab Telecardiology Rapid Access Project.

OBJECTIVES: The aim of this study was to assess the feasibility, safety and efficacy of telecardiology-guided initiation of therapy and management of acute coronary syndrome at primary care hospitals before the transfer of the patient to a tertiary care center. METHODS: This study covered 25 of 41 patients diagnosed with acute coronary syndrome at the Kharar Civil Hospital over a period of 15 months. These 25 patients (group A) had ST-elevation myocardial infarction. The remaining 16, with non- ST-elevation acute coronary syndrome, were excluded from the study. The group A patients were thrombolyzed at the Kharar Civil Hospital under telecardiology guidance (transmission of the electrocardiograms by fax to the coronary care unit of the PGIMER, where they were analyzed by a cardiologist). The patients were later sent to the PGIMER for further treatment. The group A patients were compared with two control groups (B and C) of 25 patients each with similar problems. The group B patients were referred for thrombolysis to the emergency ward of the PGIMER from local hospitals (situated at a distance of about 15 km), after acute myocardial infarction had been confirmed by electrocardiograms. The group C patients had come directly to the PGIMER emergency ward for thrombolysis. The patients in all groups were evaluated in terms of door-to-needle time saved, improvement in left ventricular systolic function and adverse events during hospitalization, as well as at three months' follow-up. RESULTS: For patients in group A, the mean door-to-needle time was 67.08 +/- 18.21 minutes. It was 121.8 +/- 48.71 minutes for those in group B and 22.68 +/- 9.24 minutes for those in group C. Thus, the differences among the groups were significant (p < 0.0001). Complications were rare and none occurred during transfer from the Kharar Civil Hospital to the PGIMER. The ejection fraction of all the patients showed an improvement between the time of admission and at three months' follow-up (p < 0.0001). CONCLUSIONS: Utilizing telecardiology advances, district hospital physicians, in collaboration with cardiologists at the tertiary center, can provide adequate standard diagnosis at the pre-coronary care unit level and also provide adequate therapy for acute myocardial infarction. Early administration of streptokinase in the civil hospital brought about a significant reduction in door-to-needle time and considerable improvement in left ventricular function.

Acquired atrioventricular block in a patient with sinus node disease on single-chamber atrial pacing.

Single-chamber atrial pacing is the most physiological and yet economical modality of treatment in patients with symptomatic sinus node disease with normal atrioventricular conduction. However, because of the possibility of future development of a high-degree atrioventricular block and atrial fibrillation, most patients are implanted either dual- or single-chamber right ventricular pacemakers. We report a patient with symptomatic sinus node disease on single-chamber atrial pacing for the past 7 years who developed a progressive increase in the PR interval and ultimately presented with symptomatic high-degree atrioventricular block requiring pacemaker upgradation. The pacemaker was upgraded to the single-chamber ventricular mode with one additional ventricular lead introduced from the same side percutaneously.