Teachable moments in ECG: The physiology behind the pattern

@#The electrocardiographic analysis of heart blocks provides great opportunities for the discussion of mechanisms of electrical cardiac conduction, serving as “teachable moments” in medicine. Recognition of heart blocks can sometimes be a challenge as they can present in many forms, different severities and levels of blocks that present as varied patterns on electrocardiographic tracing. The ultimate key to correct diagnosis rests on adequate understanding of normal electrophysiology of the electrical system of the heart. While it is vital to recognize the pattern, we should always know and understand the physiology behind the pattern. This article presents a detailed analysis of a case of heart block which can easily be misinterpreted on first look. The case is featured not for its rarity but for the interesting concepts in cardiac electrophysiology that are highlighted. Navigation of the different elements of tracing can be an adventure and a great learning experience enjoyed by both students and experts.

The typology of physicians according to perspectives on telemedicine during and beyond the COVID-19 pandemic

Introduction@#The coronavirus (CoVid-19) pandemic brought about a massive impact to the healthcare system, including disruption of patient follow-ups and consultations. Subsequently, an increase in physicians’ use of telemedicine was seen. While this technology has been documented to improve delivery of care, it has encountered varied acceptance among physicians. Gaps in specific national legislation, lack of established rules and accreditation standards, and ethical/legal implications add to the concerns. Anchored on the Unified Theory of Acceptance and Use of Technology model, this study aimed to segment physicians according to their perspectives regarding telemedicine during the pandemic. @*Methods@#A mixed methods sequential explanatory design using Q-methodology was applied to identify distinct patterns and perceptions of physicians on the use of telemedicine during the pandemic. A Q-sample of 25 statements on perceptions of telemedicine was developed through literature review, and 24 physicians were purposively selected. Participants were instructed to sort statements into a distribution grid according to their degree of agreement/disagreement. Post-sorting interview was conducted to expound on their response. Data were analyzed using by-person factor analysis through the PQMethod software version 2.35.

Hearing screening through frequency analysis of auditory brainstem response using PhysioNet Data

Objectives@#Responding to the reality of neonate patients with delayed childhood development due to late diagnosis of and intervention on hearing impairment, this study aims to determine the features based on time-frequency domain of auditory brainstem response (ABR) signals and to test the protocol on ABR signals from PhysioNet. @*Methods@#This is done by pre-processing, performing time-frequency analysis, and characterizing hearing impairment using the dominant features of the ABR. In this study, normal (N) and hearing impaired (HI) ABR adult human signals were acquired from Physionet.org, a publicly available database. Considering its high signal-to-noise ratio, numerous filters and transformations were applied to extract the ABR. Consequently, the features acquired — dominant frequency and bigrams, were used as data classifiers. @*Results@#Initial results using only N classifiers, that is features from the Normal dataset, and bandpass Chebyshev filter with a lower cut-off frequency of 60 Hz show that the tests yielded low to middle sensitivity. Further tests were done to improve the sensitivity that incorporated the HI classifiers, used data filtered with a low cut-off frequency of 300 Hz, and data divided per stimulus intensity level. @*Conclusion@#Conclusions made are 1) data with both N and HI classifiers have higher sensitivity than those using only N classifiers, 2) data with a Chebyshev cut-off frequency of 300 Hz have a higher sensitivity than those with 60 Hz, and 3) data divided per intensity level have a higher sensitivity than data analyzed as a whole, and that features with stimulus intensity in middle ranges have a better distinction between HI and N patients.

Effects of training volume on lower-body muscle strength in untrained young men: a contralateral control study

The purpose of this study was to examine the effects of training volume (1 vs. 3 sets) on lower-body muscle strength in untrained young men. Methodsː Eighteen untrained young men were recruited and their legs were trained with 1 or 3 sets (in a contralateral design) for 6 weeks, using a knee extension machine. Isokinetic peak torque and one repetition maximum (1RM) were assessed at pre- and post-training. Resultsː There was a similar improvement in the 1RM strength (1SET: +14.8% vs. 3SET: 16.3%, P > 0.05) and peak torque (1SET: +8.1% vs. 3SET: 9.3%, P > 0.05) for both conditions from pre- to post-training. The effect size (ES) for the change in 1RM was moderate for both conditions (1SET: 1.39 vs. 3SET: 1.41), and peak torque was trivial and small for 1SET (0.47) and 3SET (0.55), respectively. Additionally, there were no significant (P > 0.05) differences in the dietary intakes from pre- to post-training. Conclusionsː Our results indicate that 1 set is as effective as 3 sets for increasing lower-body muscle strength after a short-term RT period (6 weeks) in untrained young men.(AU)

Health-related quality of life in patients with permanent pacemaker at the University of Santo Tomas Hospital: A cross-sectional correlational study

Introduction@#The evolution of cardiac pacing is expected to decrease the cardiovascular morbidity and mortality but this type of intervention might affect the health-related quality of life (HRQOL) and eventually the overall prognosis of the patient. This study assessed the HRQOL in patients with permanent pacemaker using Philippines (Tagalog) Short Form (SF)-36v2 health survey.Introduction:The evolution of cardiac pacing is expected to decrease the cardiovascular morbidity and mortality but this type of intervention might affect the health-related quality of life (HRQOL) and eventually the overall prognosis of the patient. This study assessed the HRQOL in patients with permanent pacemaker using Philippines (Tagalog) Short Form (SF)-36v2 health survey.@*Methods@#A cross-sectional correlation study was conducted. Philippines (Tagalog) SF-36v2 health survey was administered among patients with permanent pacemaker who had their pacemaker analysis at the University of Santo Tomas Hospital from October to December 2015. The higher the score the better HRQOL and many studies used a cut-off point of 50. Pearson Correlation and Non-Parametric Mann-Whitney Tests were used in this study. @*Results@#Forty-two patients were enrolled in this study. There were 24 male and 18 females with mean interval of age 71.48+12.3. Most of the HRQOL scores were lower than 50. The highest HRQOL scores were vitality and mental health aspect while the worst were role emotional and physical functional aspect. Age, educational attainment, type of permanent pacemaker, pacemaker dependency, NYHA (New York Heart Association) functional capacity and presence of co-morbidities particularly diabetes mellitus type 2 were significant factors for poor HRQOL. @*Conclusion@#This study showed that overall the HRQOL in patients with permanent pacemaker was below average. A comprehensive management in order to improve the HRQOL should be considered among patients with permanent pacemaker.

Incidence of Contrast-induced Nephropathy in Patients Undergoing Coronary Angiography: An Annual Review in A University Hospital

Introduction@#The rapidly growing number of percutaneous coronary interventions has led to a considerable improvement in the outcome of patients with acute coronary syndromes, yet concurrently exposing patients to enormous volumes of contrast media with the inherent risk of renal function impairment.@*Objective@#To determine the incidence of contrast induced nephropathy of patients admitted at University of Santo Tomas Hospital (USTH) who underwent coronary angiography with or without Percutaneous Transluminal Coronary Angioplasty (PTCA).@*Methodology@#This is a retrospective, descriptive study including patients aged 18 years and above, of any gender, admitted at the USTH from January 1, 2016 to December 31, 2016, who underwent coronary angiography with or without PTCA with baseline and follow up creatinine levels 48-72 hours after the procedure. Data were retrieved by review of medical records of these patients. @*Results@#Three out of 78 patients (3.8%) had elevated creatinine but all three patients also underwent major surgery within 48 hours after coronary angiography which could explain the renal impairment.@*Conclusion@#Although contrast induced nephropathy was described as the third most common cause of new Acute Kidney Injury in hospitalized patients, it was accordingly nil among those who underwent coronary angiography at USTH from January to December 2016. Benefi ts and risks of undergoing coronary angiography should always be weighed individually. Risk stratifi cation scores should only serve as a guide in managing patients and proper preventive measures should be applied.

Comparação dos efeitos da ventilação mecânica não invasiva contínua e intermitente sobre parâmetros cardiorrespiratórios e modulação autonômica de indivíduos saudáveis / Comparison of the effects of continuous and intermittent non invasive mechanical ventilation on cardiorespiratory parameters and autonomic modulation of healthy individuals

Modelo do estudo: Estudo transversal. Objetivo: Avaliar a influência da Ventilação Mecânica não Invasiva (VMNI) de forma contínua e intermitente sobre a modulação autonômica cardíaca e parâmetros cardiorrespiratórios em mulheres saudáveis. Métodos: Vinte voluntárias realizaram duas modalidades de VMNI: contínua por meio do CPAP e intermitente por meio do Reanimador de Muller. Inicialmente permaneceram em repouso em respiração espontânea por 20 minutos. Em seguida foram submetidas a 20 minutos de aplicação de VMNI com a técnica selecionada e por fim permaneceram 20 minutos em repouso em respiração espontânea. Os parâmetros cardiorrespiratórios e variabilidade da frequência cardíaca (VFC) foram mensurados em todos estes momentos. Resultados: Não houve diferenças significantes quando comparadas as duas técnicas. Observaram-se diferenças nos parâmetros cardiorrespiratórios e VFC quando analisadas individualmente. Menores valores de frequência cardíaca e frequência respiratória foram observados na modalidade contínua quando comparado os valores durante a ventilação com respiração espontânea (p<0,005). Em ambas técnicas observaram-se aumentos significantes de SpO2 durante a ventilação em comparação a respiração espontânea. Observou-se aumento da modulação parassimpática (RMSSD, HF ms2 e SD1) e da variabilidade global (SDNN, RR triangular e SD2) em ambas as técnicas quando comparado ventilação e respiração espontânea (p<0,005). Conclusão: Não houve diferença quando comparadas as duas modalidades de VMNI. Contudo, quando analisadas individualmente observam-se comportamento diferentes dos parâmetros cardiorrespiratórios e na modulação autonômica.

Study design: Cross-sectional study. Objective: To evaluate the influence of continuous and intermittent non invasive mechanical ventilation (NIV) on cardiac autonomic modulation and cardiorespiratory parameters in healthy women. Methods: Twenty subjects performed two types of NIV: continuous through CPAP and intermittent through Müller Reanimator. Initially they remained at rest for 20 minutes in spontaneous breathing. Then volunteers were subjected to 20 minutes of NIV application with the selected technique and finally remained at rest for 20 minutes in spontaneous breathing. Cardiorespiratory parameters and heart rate variability (HRV) were measured in all these moments. Results: Therewere no significant differences when comparing the two techniques. Differences were observed in HRVand cardiorespiratory parameters when analyzed individually. Lower values of heart rate and respiratory rate were observed in continuous ventilation when compared to values during ventilation with spontaneous breathing (p <0.005). In both techniques we observed significant increases in SpO2 during ventilation compared to spontaneous breathing. We observed an increase in parasympathetic modulation (RMSSD, HF ms2 and SD1) and overall variability (SDNN, RR triangular and SD2) in both techniques when compared ventilation to spontaneous breathing (p <0.005). Conclusion: There was no difference comparing the two types of NIV. However, when analyzed individually we observe different behavior of cardiorespiratory parameters and autonomic modulation.

Outcomes in Malnourished Children at a Tertiary Hospital in Swaziland after Implementation of the World Health Organization Treatment Guidelines

Background. Swaziland adopted the World Health Organization (WHO) guidelines for the inpatient treatment of severely malnourished children in 2007; with the aim of reducing high case fatality rates for childhood malnutrition. However; no follow-up studies have been conducted to determine the reduction in these rates after implementation of the guidelines.Objectives. To determine the case fatality rate for childhood malnutrition after implementation of the WHO treatment guidelines.Methods. A retrospective observational study was undertaken. Demographic; anthropometric and clinical characteristics and outcomes for all children aged under 5 years admitted for inpatient treatment of malnutrition between January 2010 and December 2011 were recorded and analysed. Results. Of the 227 children who met the study inclusion criteria; 179 (64.6) were severely malnourished and 98 (35.4) had moderate malnutrition; 111 children died during admission; giving an overall case fatality rate of 40.1. Mortality was significantly higher among severely malnourished children than among those with moderate malnutrition (46.9 v. 27.6) (odds ratio (OR) 3.0; 95 confidence interval (CI) 1.7 - 5.3). Co-morbid pneumonia and gastroenteritis were significant predictors of mortality (OR 2.0; 95 CI 1.2 - 3.4 and OR 1.9; 95 CI 1.1 - 3.2; respectively). Conclusion. Case fatality rates for childhood malnutrition remain high despite adoption of the WHO treatment guidelines. There is a need for periodic clinical audits and mortality review meetings to reduce deaths from childhood malnutrition so as to meet the WHO mortality target of less than 5 and improve child survival

Intravitreal chemotherapy for vitreous seeding in retinoblastoma Recent advances and perspectives

For decades intravitreal chemotherapy [IViC] remained virtually banished from the therapeutic armamentarium against retinoblastoma, except as a heroic attempt of salvage before enucleation in only eyes with refractory vitreous seeding. Very recently, we have initiated a reappraisal of this route of administration by [1] profiling eligibility criteria, [2] describing a safety-enhanced injection procedure, [3] adjusting the tumoricidal dose of melphalan, and [4] reporting an unprecedented efficacy in terms of tumor control of vitreous seeding. Since then, intravitreal chemotherapy is being progressively implemented worldwide with great success, but still awaits formal validation by the ongoing prospective phase II clinical trial. As far as preliminary results are concerned, IViC appears to achieve complete vitreous response in 100% of the 35 newly recruited patients irrespective of the previous treatment regimen, including external beam radiotherapy and/or intra-arterial melphalan. In other words, vitreous seeding, still considered as the major cause of primary and secondary enucleation, can now be controlled by IViC. However, sterilization of vitreous seeding does not necessarily translate into eye survival, unless the retinal source of the seeds receives concomitant therapy. In conclusion, IViC, an unsophisticated and cost-effective treatment, is about to revolutionize the eye survival prognosis of vitreous disease in advanced retinoblastoma

Expression of ERα, its ERαΔ3 Splice Variant and γ-SYNUCLEIN in Ovarian Cancer: A Pilot Study.

Aims: Ovarian cancer has the highest mortality of any gynaecological malignancy; this is due to rapid peritoneal spread of tumour cells and neovascularization. Understanding the mechanisms underlying this is critical to developing early diagnostic or treatment strategies. We devised a pilot study to examine the role of g-SYNUCLEIN (g-SYN), oestrogen receptor (ER)a, and the splice variant ERaΔ3. Methodology: With ethical approval, ovarian tissue was collected from patients (n=24) undergoing oopherectomy for non-ovarian pathology or primary surgery for suspected ovarian cancer. Quantitative gene expression analysis was employed for g-SYN, ERa, and ERaΔ3. To identify the in situ localization, immunofluorescence for g-syn was carried out. Results: Ovarian tumour tissue exhibited an elevated expression of g-SYN and high-grade tumours had an elevated ERaΔ3:ERa ratio compared with benign tissue. The majority of previous studies point to the g-syn protein being present in epithelial cells of high-grade disease. Our study supports this, but additionally we conclusively identify its presence in the endothelial cells of vasculature surrounding low-grade disease; immunofluorescence was strongest in the apical cells surrounding the lumen. Conclusion: Our results demonstrate for the first time that there are readily-expressed levels of g-SYN and ERaΔ3 in normal ovarian tissue and ovarian tumours. In high-grade disease, g-syn and an elevated ERaΔ3:ERa ratio might confer metastatic potential to the tumourigenic cells and promote neoangiogenesis. Future in vitro studies might be necessary to delineate such a mechanism, which could potentially be the basis of early intervention.

Relação bidirecional entre a doença periodontal e a diabetes mellitus / Bidirectional relationship between periodontal disease and diabetes mellitus

O diabetes mellitus é uma doença de natureza crônica, que resulta de uma perturbação no metabolismo dos carboidratos em virtude de a insulina não exercer seus efeitos metabólicos. A doença periodontal pode ser definida como um processo de infecção e inflamação que destrói os tecidos de proteção e sustentação dos elementos dentários. O diabetes tem sido amplamente considerado como um importante fator de risco para doenças periodontais, por sua vez, a periodontite dificulta o controle do diabetes, sendo considerada a complicação oral mais importante do diabetes. Essas doenças apresentam uma relação bidirecional, na qual o diabetes favorece o desenvolvimento da doença periodontal, e esta, quando não tratada, piora o controle metabólico do diabetes. Portanto, o objetivo deste trabalho é o de realizar uma revisão de literatura acerca dessa relação e as condutas possíveis para o tratamento odontológico do paciente.

Diabetes mellitus is a disease of chronic nature, which results from a disturbance in the metabolism of carbohydrates because the insulin does not exert its metabolic eff ects. Periodontal disease can be defined as a process of infection and inflammation that destroys tissue protection and support of the teeth. Diabetes has been widely regarded as an important risk factor for periodontal disease, in turn, periodontitis difficult to control diabetes, is considered the most important oral complication of diabetes. These diseases have a bidirectional relationship in which diabetes promotes the development of periodontal disease. If this disease is not going to be treat, worst is going to be the metabolic control of diabetes. It is, therefore, aim of this study the review of the literature about this relationship and the possible behaviors of the dental patient.

Hypoglycaemic complications with diabetes mellitus management: the predominant adverse drug reaction presenting to the accident and emergency department of the University Hospital of the West Indies / Complicaciones hipoglicémicas en el tratamiento de la diabetes mellitus: las reacciones adversas a los medicamentos que de manera predominante se presentan en la división de accidentes y emergencias del Hospital Universitario de West Indies

Evaluation of adverse drug reactions (ADRs) is important to the assessment of risk factors in an aim to ensure maximum benefits of drug therapy. This study was done to assess the types of ADRs presenting to the Accident and Emergency department (A&E) of the University Hospital of the West Indies. Admissions to the A&E associated with drugs were followed on a weekly basis for 19 weeks from October 2007 to February 2008 using the patient logbook. Medical records of patients with suspected ADRs were collected and evaluated by an Emergency Medicine Consultant of A&E to confirm the occurrence of ADRs and the suspected drug. Of the 8170 admissions to A&E, 48 (0.6%) were related to ADRs, with most occurring in females and the mean age (± standard error) was 58.9 (± 3.4) years. Drug induced hypoglycaemia accounted for 28 (56.3%) cases of ADRs and included mainly patients on insulin, with or without a sulphonylurea therapy. Most of these diabetic patients also had co-morbidities and were on multi-drug therapy (18). Allergic reactions accounted for 10 (21%) of the ADR outcomes. Other drugs accounting for ADRs included cardiovascular drugs (10.4%), analgesic/anti-inflammatory medications (8.3%), drugs acting on the central nervous system (8.3%) and anti-infectives (8.3%). It is concluded that drug-induced hypoglycaemia is the major ADR presenting to the A&E of the University Hospital of the West Indies; it is a preventable ADR and therefore further investigation should evaluate possible factors attributed to the occurrences.

La evaluación de reacciones adversas a los medicamentos (RAMs) es importante a la hora de evaluar los factores de riesgo con el objeto de asegurar beneficios máximos con la terapia medicamentosa. Este estudio fue realizado con el propósito de evaluar los tipos de RAMs que se presentan en la División de Accidentes y Emergencias (DAE) del Hospital Universitario de West Indies. Los ingresos al DAE asociados con medicamentos, fueron seguidos de forma hebdomadaria por un período de 19 semanas, desde octubre de 2007 hasta febrero de 2008, usando el libro de registro de pacientes. Las historias clínicas de los pacientes sospechosos de RAMs fueron recogidas y evaluadas por un Consultante de Medicina de Emergencia del DAE con el fin de confirmar que se trataba en efecto de un caso de RAM y verificar el medicamento de sospecha. De los 8170 ingresos al DAE, 48 (0.6%) guardaban relación con RAMs, siendo el caso que la mayor parte ocurrió con hembras y la edad promedio (± error estándar) fue 58.9 (± 3.4) años. La hipoglicemia inducida por medicamento representó 28 (56.3%) casos de RAMs e incluyó principalmente a pacientes bajo el uso de insulina, con o sin una terapia sulfonilurea. La mayoría de estos pacientes diabéticos también presentaban co-morbosidades y estaban bajo terapia multi-medicamentosa (18). Las reacciones alérgicas representan 10 (21%) de los resultados de ADR. Otros medicamentos causantes de RAMs incluyeron los medicamentos cardiovasculares (10.4%), los analgésicos/anti-inflamatorios (8.3%), los medicamentos que actúan sobre el sistema nervioso central (8.3%) y los anti-infecciosos (8.3%). Se concluye que la hipoglicemia inducida por medicamento es la RAM mayor que se presenta al DAE del Hospital Universitario de West Indies. Se trata de una RAM prevenible, y por ende las investigaciones ulteriores deben evaluar los posibles factores responsables de estas ocurrencias.

Isquemia miocárdica na síndrome cardíaca X investigada com ecocardiografia sob estresse físico / Myocardial ischemia in cardiac syndrome X evaluated by exercise echocardiography

Objetivo: Avaliar o significado da evidência da isquemia miocárdica e a ocorrência de eventos cardiovasculares na Síndrome Cardíca X (SCX), comparando com doença coronária obstrutiva inicial (DAC <- 50 por cento). Métodos: Estudo observacional de coorte, em, amostra de 605 pacientes (população fonte de 5.137 indivíduos), com ecocardiografia sob estresse físico (EEF) positiva para isquemia miocárdica, os quais foram submetidos à cineangiocoronariografia, e divididos, posteriormente, em 2 grupos: G1 (SCX, n=64) e G2 (DAC<- 50 por cento, n=84). Os pacientes foram comparados quanto às características clínicas, parâmetros ergométricos e ecocardiográficos, e seguidos po +- 43,8 meses (mínimo de 12 meses e máximo de 85 meses), quanto ao surgimento de ngina típica, infarto agudo do miocárdico...

Oral hypoglycaemic agents for diabetes in pregnancy - an appraisal of the current evidence for oral anti-diabetic drug use in pregnancy

<p><b>INTRODUCTION</b>The use of oral hypoglycaemic drugs in pregnancy is not recommended because of reports of foetal anomalies and other adverse outcomes in animal studies and in some human cases. However, recent studies have suggested that some oral hypoglycaemic drugs may be used in pregnancy. This review will examine these studies critically.</p><p><b>METHODS</b>Literature review of articles obtained from a PubMed search of peer-reviewed journals on oral hypoglycaemic drug use in pregnancy.</p><p><b>RESULTS</b>In two prospective studies, one of which was a randomised controlled trial, glibenclamide was as effective and safe as insulin in gestational diabetes. In several studies, metformin did not increase foetal anomalies or malformations when used during pregnancy in women with polycystic ovary syndrome (PCOS). In one prospective study on infants born to mothers who used metformin in pregnancy, follow-up for 18 months showed no adverse effects. In several prospective and retrospective studies on women with PCOS, metformin was shown to prevent early pregnancy loss, decrease insulin resistance, reduce insulin and testosterone levels, and decrease the incidence of gestational diabetes when these women got pregnant while on metformin and continued to take it throughout their pregnancy. In a single small study, acarbose did not cause any adverse effects during pregnancy.</p><p><b>CONCLUSIONS</b>Recent evidence shows promising findings in the safety and efficacy of some oral hypoglycaemic agents in treating pregnant diabetics. However, larger clinical studies will be needed to ensure the safety and efficacy of these drugs in pregnancy.</p>