Did child obesity decline after 2016 food regulations in Chile? / ¿Disminuyó la obesidad infantil en Chile después de la introducción de las regulaciones alimentarias en el 2016? / A obesidade infantil diminuiu após a regulamentação de alimentos de 2016 no Chile?

ABSTRACT We estimated trends in the prevalence of obesity and overweight among Chilean primary and secondary students before and after Chile's 2016 regulations on the marketing and availability of foods high in energy, total sugars, sodium, or saturated fat. We used data from Chile's Survey of Nutrition, which measured the body mass index (BMI) of students in government-funded schools. Using BMI thresholds defined by the World Health Organization, we calculated the prevalence of overweight and obesity for each year from 2013 to 2019 among students attending pre-kindergarten (age 4 years), kindergarten (age 5 years), first grade (6 years), and ninth grade (14 years). In ninth grade students, overweight and obesity prevalence rose by 2 percentage points over the 3 years after introduction of the 2016 regulations. In pre-kindergarten, kindergarten, and first grade, overweight and obesity fell 1 to 3 percentage points 1 year after the regulations were introduced, but rebounded to previous levels the next year. Chile's food regulations were not followed by a sustained decline in obesity in primary- and secondary-school students. Future research should examine whether and how children in Chile and other countries maintain high levels of overweight and obesity despite food regulations designed to reduce consumption of obesogenic foods and beverages.

RESUMEN Se estimaron las tendencias en la prevalencia de la obesidad y el sobrepeso en estudiantes chilenos de educación primaria y secundaria, antes y después de las regulaciones introducidas en Chile en el 2016 sobre la comercialización y disponibilidad de productos hipercalóricos, con un alto contenido de azúcares, sodio o grasas saturadas. Se utilizaron datos del Mapa Nutricional de Chile, una encuesta en la que se midió el índice de masa corporal (IMC) de la población estudiantil de las escuelas públicas. Tomando los umbrales de IMC definidos por la Organización Mundial de la Salud, se calculó la prevalencia del sobrepeso y la obesidad para cada año entre el 2013 y el 2019 en estudiantes de jardín de infancia (4 años), preescolar (5 años), primer grado (6 años) y noveno grado (14 años). En los estudiantes de noveno grado, la prevalencia del sobrepeso y la obesidad aumentó en 2 puntos porcentuales durante los 3 años posteriores a la introducción de las regulaciones del 2016. En el caso de los grupos de jardín de infancia, preescolar y primer grado, el sobrepeso y la obesidad disminuyeron entre 1 y 3 puntos porcentuales un año después de la introducción de las regulaciones, pero al año siguiente volvieron a los niveles anteriores. La introducción de las regulaciones alimentarias de Chile no estuvo seguida de una disminución continua de la obesidad en la población estudiantil de primaria y secundaria. En las investigaciones futuras se deberá examinar si la población infantil de Chile y otros países mantiene niveles altos de sobrepeso y obesidad a pesar de las regulaciones alimentarias diseñadas para reducir el consumo de productos y bebidas obesogénicos, así como las características específicas que adopta este problema de salud.

RESUMO Foram estimadas tendências de prevalência da obesidade e do sobrepeso em alunos chilenos do ensino fundamental e médio antes e depois da regulamentação de 2016 da propaganda e disponibilidade de alimentos com alto teor calórico ou ricos em açúcares totais, sódio ou gorduras saturadas no Chile. Foram utilizados dados obtidos da Pesquisa em Nutrição do Chile, que aferiu o índice de massa corporal (IMC) de escolares da rede pública. Com base nos limiares de IMC definidos pela Organização Mundial da Saúde (OMS), calculou-se a prevalência anual de sobrepeso e obesidade em crianças na pré-escola (4 anos), no jardim da infância (5 anos), no primeiro ano (6 anos) e no nono ano (14 anos) em cada ano no período entre 2013 e 2019. Entre os alunos do nono ano, a prevalência de sobrepeso e obesidade aumentou 2 pontos percentuais nos 3 anos que se seguiram à introdução da regulamentação de 2016. Entre os alunos da pré-escola, do jardim de infância e do primeiro ano, ocorreu uma redução de 1 a 3 pontos percentuais na prevalência de sobrepeso e obesidade um ano após a introdução da regulamentação, mas os níveis voltaram a subir no ano seguinte. A regulamentação de alimentos não resultou em um declínio sustentado da obesidade nos alunos do ensino fundamental e médio do Chile. Pesquisas futuras devem ser realizadas para avaliar se, e como, a prevalência de sobrepeso e obesidade nas crianças chilenas e de outros países se mantém alta a despeito da regulamentação de alimentos visando à redução do consumo de alimentos e bebidas obesogênicos.

Choroidal metastasis: Radiation and bevacizumab at presentation

Purpose: To reveal early intervention outcomes for patients describing with choroidal metastasis. Methods: A retrospective interventional case series on 27 eyes of 22 patients treated for choroidal metastasis with external beam radiation therapy (EBRT) With and without intravitreal injections. The prescribed radiation dose was a mean and median 30 Gy (range of 30–40 Gy in 180–200 cGy daily fractions). Outcome measures included change in tumor thickness, subretinal fluid, visual acuity, radiation oculopathy, and survival. Results: Decreased vision was the most common presenting symptom (n = 20/27, 74%). Pre?treatment vision for subfoveal lesions was a mean 20/400, median 20/200, and range 20/40 to hand motions (HM). Pre?treatment vision for extrafoveal tumors were a mean 20/40, median 20/25, range 20/20 to counting fingers (CF) which improved to a mean 20/32, median 20/20, range 20/12.5 to 20/200. Local control, with ultrasonographic height regression (44.5%; mean: 2.7–1.5 mm), was observed in all eyes at mean follow?up of 16 months (range: 1–72 months). Intravitreal anti?vascular endothelial growth factor (anti?VEGF) was given in nine cases (n = 9/27, 33%) to slow the growth of the metastasis and suppress their exudative detachments and to treat radiation maculopathy in 10 cases (n = 10/27, 37%). Late radiation complications included keratoconjunctivitis sicca in four cases (n = 4/27, 15%), exposure keratopathy in two cases (n = 2/27, 7%), and radiation retinopathy in 10 cases (n = 10/27, 37%). Of the 23 phakic eyes, four (n = 4, 17%) developed cataract. Conclusion: Radiation therapy with or without intravitreal anti?VEGF injections was a safe and effective treatment for choroidal metastasis. It was associated with local tumor control, reduction of secondary retinal detachments, and vision preservation.

Prevalence of Overlap Syndrome in Patients with Obstructive Sleep Apnea in a Quaternary Care Center of Kerala

Background: The coexistence of obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) is termed “Overlap syndrome (OS).” Objectives: The present study aimed at estimating the prevalence of OS among patients diagnosed with OSA. Methods: It was a prospective observational study conducted on patients presenting to respiratory medicine outpatient department (sleep clinic) with symptoms of sleep-disordered breathing and was found to have OSA by overnight polysomnography. These patients were then subjected to spirometry to diagnose COPD. Results: The prevalence of OS in the study population was found to be 41.3%. Excessive daytime sleepiness was found to be higher in overlap group patients (P = 0.033), the difference was statistically significant. The mean age (59.9 ± 9.6 years) was found to be high in the OS group compared to those without the same. The mean forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC (pre? and postbronchodilator) spirometry parameters were found to be lower in patients with OS. Conclusion: The study showed that the prevalence of OS in the present study was 41.3%. Excessive daytime sleepiness and age >60 years were risk factors for OS in a patient with OSA. OS patients had lower pulmonary function values.

Patients presenting with stage IV uveal melanoma: Lessons learned

Challenges persist in identifying patients with stage IV uveal melanoma. While clinical, histopathologic, and genetic features of the primary tumor have been shown to provide prognostic value for assessing metastatic risk, biopsy?related genetic analyses are expensive and not universally available. Therefore, this review will focus on clinical characteristics. Initial staging and follow?up screening protocols have evolved for patients with uveal melanoma. The Collaborative Ocular Melanoma Study (COMS) required a physical examination, chest X?ray, and hematologic survey (primarily liver function tests). Though these studies were found to have a high specificity, COMS investigators typically found late?stage metastases. More recently, protocols have concentrated on liver imaging (abdominal ultrasound, computed tomography, and magnetic resonance imaging). Though hepatic radiographic imaging has been found more likely to reveal earlier metastatic uveal melanoma, by definition it cannot detect most extrahepatic and multiorgan metastases. An international multicenter registry study recently focused on patients who were diagnosed with stage IV uveal melanoma simultaneously with their primary intraocular melanoma. Therein, utilizing center?specific diagnostic methods, stage IV was found to occur in about 2% of patients. However, subgroup analysis found that a disproportionate number of multi?organ metastases were discovered when whole?body positron emission tomography/computed tomography was used for staging. Herein, we review the literature on patients who present with stage IV uveal melanoma, how they were detected, and their outcomes.

Confocal Laser Endomicroscopy in the Diagnosis of Biliary and Pancreatic Disorders: A Systematic Analysis

Background/Aims@#Endoscopic visualization of the microscopic anatomy can facilitate the real-time diagnosis of pancreatobiliary disorders and provide guidance for its treatment. This study aimed to review the technique, image classification, and diagnostic performance of confocal laser endomicroscopy (CLE). @*Methods@#We conducted a systematic review of CLE in pancreatic and biliary ducts of humans, and have provided a narrative of the technique, image classification, diagnostic performance, ongoing research, and limitations. @*Results@#Probe-based CLE differentiates malignant from benign biliary strictures (sensitivity, ≥89%; specificity, ≥61%). Needlebased CLE differentiates mucinous from non-mucinous pancreatic cysts (sensitivity, 59%; specificity, ≥94%) and identifies dysplasia. Pancreatitis may develop in 2-7% of pancreatic cyst cases. Needle-based CLE has potential applications in adenocarcinoma, neuroendocrine tumors, and pancreatitis (chronic or autoimmune). Costs, catheter lifespan, endoscopist training, and interobserver variability are challenges for routine utilization. @*Conclusions@#CLE reveals microscopic pancreatobiliary system anatomy with adequate specificity and sensitivity. Reducing costs and simplifying image interpretation will promote utilization by advanced endoscopists.

Assessment Of Drug Utilization Among Pediatric Patients In Private Clinic And Public Hospital Of Bangladesh

Objective: Aim of the study was to assess drug utilization among pediatric patients in both private practice and hospital settings in Rajshahi city, Bangladesh. Methods: This observational study was conducted during a period of two months (March to April) in 2017. Prescriptions were randomly collected from patients and recorded in a predesigned questionnaire form. The data analysis was carried out by using a statistical software package GraphPad Prism. Results: The study involved a total of 185 patients, of which 62.70% were male and 37.30% were female. The patient’s age ranges from 1 mo-12 y and highest number of patients visited physicians belong to group 1 mo-1 y (47.57%). Most commonly occurring disease conditions were pneumonia (24%), the leading cause of hospitalizations among the children's age group of 1 mo-1 y. The results indicated that physician’s handwriting was not clear and legible in 50 (27.03%) prescriptions. A total of 468 drugs were prescribed with an average of 2.53 per prescription. However, none of the drugs were prescribed by generic name. The most commonly prescribed drugs were antibiotics 173 (93.5%). About 78% patients were exposed to antibiotics, of which single antibiotic was prescribed in 116 (62.70%) and two antibiotics in 23 (12.43%) prescriptions. Among the drugs, NSAIDS 65 (35.14%), anti-histamine 57 (30.81%), anti-asthmatic 49 (26.49%) drugs were assigned in prescriptions followed by vitamin and minerals 51 (27.57%). Steroids 57 (30.81%) and hypnotics 26 (14.05%) were also accounted in many prescriptions. Interestingly, antibiotics were indiscriminately prescribed in private practices without any bacteriological examinations, whereas in hospital settings, most of the treatment was initiated after culture and sensitivity tests. Conclusion: Children were highly exposed to antibiotics, steroids and hypnotics in both private practice and hospital settings.  So Medical practitioners should be aware of current guidelines for prescriptions of antibiotics and drugs in child.

A Very Rare Case of Pancreatic Acinar Variant of Gastric Adenocarcinoma with Review of the Literature

A pancreatic acinar variant of gastric adenocarcinoma is a very rare presentation, and only six cases have been reported worldwide.A 55-year-old male came with complaints of vomiting and weight loss. By PET-CT, a growth was found in the gastric antrum.Distal gastrectomy was done and a histopathology report of a pancreatic acinar variant of gastric adenocarcinoma was done.

Tecnologías de la información y comunicación en el desarrollo de modelos estocásticos aplicados al sector de la salud / Information and communication technologies in the development of stochastic models applied to the health sector

Un modelo estocástico de simulación permite estudiar y represen tar de manera simplificada el comportamiento de variables complejas en términos de probabilidad. En este contexto, el objetivo de este trabajo es presentar, a través del uso de herramientas de tecnologías de la información y comunicación, la aplicabilidad de modelos y métodos de simulación, en estudios de indicadores dentro del sector de la salud. A través del desarrollo de un caso de estudio, este trabajo demuestra el potencial de las herramientas tecnológicas @Risk y Excel en la construcción de modelos estocásticos que permiten a los profesionales de la salud predecir, monitorizar y dar soporte en la toma de decisiones en el tratamiento y seguimiento de indicadores e índices de una población.

A stochastic simulation model allows to study and represents in a simplified manner the behavior of complex variables in terms of probability. In this context, the objective of this work is to present, through the use of information and communication technology tools, the applicability of simulation models and methods, in studies of indicators within the health sector. Through the development of a case study, this work demonstrates the potential of the @Risk and Excel technological tools in the construction of stochastic models that allow health professionals to predict, monitor and support decision making in the treatment and monitoring of indicators and indices of a population.

Evaluation of a community based yoga training programme in Ernakulam

Background: Mental health concern is escalating globally and current therapeutic approach is insufficient to bring people towards the state of mental well-being. There is a compelling need for effective population mental health promotion approaches. Yoga is a universally acclaimed method for promoting mental and physical well-being, but very much underutilised. The objective of the present study is to evaluate a community-based yoga training program which was conducted in the field practice area of a medical college in Ernakulam.Methods: A sequential mixed method-quantitative and qualitative-study was done among the participants who attended the yoga training. The perceived benefits of yoga and adherence to yoga were assessed using an investigator administered semi-structured questionnaire. Subsequently a focus group discussion was conducted among the study participants.Results: 20 subjects who attended the training participated in the study. Mean age was 48 years (SD±14.663) and 85% were females. Mean duration of yoga practice was 6 months. Among the participants, 95% continued yoga practice at home after the training. The main benefits reported were: a feeling of increased energy (75%), relaxed/happy feeling (55%), relief from body pain (40%) and stress reduction (35%). The subjects reported that the increased energy they felt from yoga increased their work productivity and eased tiredness and stress.Conclusions: The study shows that yoga offers considerable benefits on mental health, with a large proportion of participants feeling energised and happier. Community based yoga training is a low cost and feasible approach for better mental health.

Impact of Periampullary Diverticulum on ERCP Performance: A Matched Case-Control Study

BACKGROUND/AIMS: Periampullary diverticulum (PAD) is frequently encountered during endoscopic retrograde cholangiopancreatography (ERCP) and has been associated with stone formation in the bile duct. The effects of PAD on the ERCP procedure have been often debated. We aimed to compare the therapeutic success of ERCP between patients with PAD and matched controls. METHODS: We reviewed all ERCPs with findings of PAD in a national database (n=1,089) and compared them with age- and gendermatched controls in a 1:3 fashion (n=3,267). Demographics, endoscopic findings, visualization of main structures, and therapeutic success rates were compared between groups. Secondary analysis compared PAD cases and controls who had gallstone disease. RESULTS: The average cohort age was 68.4±14.3 years and 55.1% were male. ERCP success was similar in both groups, and no significant inter-group differences were found in the multivariate analysis. The presence of PAD did not affect the rates of sphincterotomy or visualization of main biliary structures. Secondary analysis showed similar success rates for gallstone removal between patients with PAD and controls. CONCLUSIONS: PAD may not be considered a hinderance to ERCP success. Further research is needed to determine the best approach to cannulate the ampulla and provide endoscopic therapy for different subtypes of PAD.

Comparison of incidence of ptosis after combined phacotrabeculectomy with mitomycin C and phacoemulsification.

Objective: To compare the incidence of upper eyelid blepharoptosis after combined phacotrabeculectomy with mitomycin C and phacoemulsification surgeries and the relationship of bleb morphology to the incidence of ptosis. Design: Retrospective observation study. Participants: We included 46 patients after combined phacotrabeculectomy and 44 patients with phacoemulsification in the former group, and all eyes underwent a standardized two‑site surgery with intra‑operative mitomycin C. Materials and Methods: Postoperative ptosis was defined as a reduction of upper marginal reflex distance 2 mm in the operated eye compared to the fellow eye. Trabeculectomy bleb measurements were carried out using anterior segment optical coherence tomography (VisanteTM, Carl Zeiss Meditec, Dublin, CA, USA) which included bleb height and total area of the bleb. Results: There were 8 eyes (17.4%) and 5 eyes (11.4%) with postoperative ptosis in the phacotrabeculectomy and phacoemulsification groups, respectively (P = 0.342). In multivariate regression analysis, reduced total bleb area was significantly associated with upper eyelid ptosis after adjusting for age, gender, and type of anesthesia. The trend seemed to show that increased bleb height was also associated with ptosis, but this did not reach statistical significance. Conclusions: Incidence of persistent ptosis after phacoemulsification combined with trabeculectomy and mitomycin C is similar compared to stand alone phacoemulsification surgery in a multiethnic Asian population. Bleb morphology may play an important role in postoperative ptosis development and should be considered in the evaluation of upper eyelid blepharoptosis.

Spectrum of malignancies in human immunodeficiency virus – positive patients at a tertiary care centre in South India.

CONTEXT: India has a very large number of patients living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome. Opportunistic infections in these patients are commonly encountered. However, malignancies in such patients also do occur. AIM: The aim was to study the spectrum of malignancies in HIV‑positive patients at a tertiary health care center. SETTINGS AND DESIGN: Retrospective study. MATERIALS AND METHODS: The cases were retrieved from pathology record files at our Institute from January 2003 to December 2008. The follow‑up was obtained from Medical oncology records. The morphology of each case was reviewed along with immunohistochemistry wherever done. RESULTS: There were 61 such cases (51 males, 10 females). The age range was 7–78 years with a median of 35 years. The clinical presentation varied according to the malignancy. The largest group was non‑Hodgkin lymphoma (18 nodal, 23 extra‑nodal). The others included carcinoma breast (4), chronic myeloid leukemia (3), Burkitt Leukemia (2), squamous cell carcinoma anal region (2), multiple myeloma (2) and one each of miscellaneous malignancies (7). CONCLUSION: Malignancies in HIV positive individual occurred in younger individuals. Non‑Hodgkin lymphomas, especially extra‑nodal lymphomas, were the most common malignancy. There were no cases of proven Kaposi’s sarcoma or invasive cervical carcinomas. There were two cases of multiple myeloma which are infrequently reported.

Anti-fungal and anti-bacterial activities of ethanol extracts of selected traditional Chinese medicinal herbs

OBJECTIVE@#To evaluate in vitro antimicrobial activities of selected 58 ethno-medicinal plant extracts with a view to assess their therapeutic potential.@*METHODS@#A total of 58 traditional Chinese medicinal plants were carefully selected based on the literature review and their traditional use. The antimicrobial activities of ethanol extracts of these medicinal plants were tested against fungi (Aspergillus fumigatus), yeast (Candida albicans), gram-negative (Acinetobacter baumannii and Pseudomonas aeruginosa) and gram-positive bacteria (Staphylococcus aureus). The activities were tested at three different concentrations of 1.00, 0.10 and 0.01 mg/mL. The data was analysed using Gene data Screener program.@*RESULTS@#The measured antimicrobial activities indicated that out of the 58 plant extracts, 15 extracts showed anti-fungal activity and 23 extracts exhibited anti-bacterial activity. Eight plant extracts have exhibited both anti-bacterial and anti-fungal activities. For instance, Eucommia ulmoides, Polygonum cuspidatum, Poria cocos and Uncaria rhyncophylla showed activity against both bacterial and fungal strains, indicating their broad spectrum of activity.@*CONCLUSIONS@#The results revealed that the ethanol extracts of 30 plants out of the selected 58 possess significant antimicrobial activities. It is interesting to note that the findings from the current study are consistent with the traditional use. A clear correlation has also been found between the antimicrobial activity and the flavonoid content of the plant extracts which is in agreement with the literature. Hence, the results presented here can be used to guide the selection of potential plant species for the isolation and structure elucidation of novel antimicrobial compounds in order to establish the structure-activity relationship. This in turn is expected to lead the way to the discovery of novel antimicrobial agents for therapeutic use.

A prospective comparison of chronic primary angle-closure glaucoma versus primary open-angle glaucoma in Singapore

<p><b>INTRODUCTION</b>To describe the optic disc, visual field and ocular characteristics of a consecutive cohort of Asian patients with chronic primary angle-closure glaucoma (CPACG), and compare them with those having primary open-angle glaucoma (POAG).</p><p><b>METHODS</b>In a prospective comparative case series of new patients with POAG or CPACG in Singapore, all patients underwent visual acuity assessment, slit-lamp examination, tonometry, gonioscopy, refraction, Heidelberg Retina Tomograph (HRT) and Humphrey visual field (HVF) assessment.</p><p><b>RESULTS</b>98 patients were enrolled (POAG n = 48; CPACG n = 50). CPACG patients were significantly older (66.5 ± 9.2 years vs. 64.1 ± 13.5 years; p = 0.027) and mostly female (p = 0.004). CPACG eyes had significantly higher intraocular pressure (26.9 ± 6.9 mmHg vs. 24.5 ± 3.3 mmHg; p = 0.03), shorter axial length (22.89 ± 0.97 mm vs. 24.26 ± 1.79 mm; p < 0.001) and shallower anterior chamber depth (2.60 ± 0.25 mm vs. 3.16 ± 0.48 mm; p < 0.001). HVF mean deviation or pattern standard deviation (PSD) did not differ significantly between POAG and CPACG eyes, but the latter had a lower PSD for a given mean deviation. HRT parameters between the two groups were not significantly different.</p><p><b>CONCLUSION</b>In this study, CPACG eyes had significantly higher presenting intraocular pressure than POAG eyes, but there were no significant differences in optic disc topography. A majority of the patients in both groups had moderate field defects at the time of presentation, followed by severe and then mild defects. The field loss in CPACG eyes was more diffuse than that in POAG eyes.</p>

Availability and suitability of rapid diagnostic kits for screening donated blood in Afghanistan

As health infrastructure is being rebuilt in Afghanistan, military, public, and private facilities offer donor blood collection/ transfusion services. This study aims to measure availability and type of blood screening test kits in the military, public and private facilities in Afghanistan. This national cross-sectional assessment targeted all facilities providing donor blood collection/transfusion services across all sectors. Descriptive statistics were generated with screening test availability compared by setting [urban vs. rural], province/region, and facility type [private vs public] using Chi-square test. A total of 243 facilities were assessed, with all 34 provinces represented with urban settings containing 63% of the facilities. Screening rapid tests were widely present for most pathogens, including HIV [87.7% of facilities], hepatitis B surface antigen [HB[s]Ag] [93.8%], hepatitis [HCV] antibody [90.5%], and syphilis [70.0%]. Private facilities were less likely to have syphilis tests available [51.4% vs. 84.1% [public], p<0.01]. Nineteen percent of facilities use the WHO evaluated test kit for HIV, 2.1% for HB[s]Ag, and none for HCV Ab. Of sites with available test kits, 7.5% of HIV, 0.9% of HB[s]Ag, 2.3% of HCV, and 6.5% of syphilis tests were expired at time of assessment. For expired tests, private facilities were more likely to have expired HIV and syphilis tests [p=0.07 and p=0.02, respectively] than other facility types. Blood collection/transfusion is a multisectoral service in Afghanistan, with substantial differences in test availability and type between sectors. Mechanisms are needed that ensure availability of quality test kits at all levels where blood collection/transfusion is performed. Test kits that have been evaluated by the WHO should be used for blood screening in all facility types

Management of angle closure glaucoma.

Primary angle closure glaucoma (PACG) is equally prevalent in Indian in Asian population as the primary open angle glaucoma. Eighty-six percent of people with PACG are in Asia, with approximately 48.0% in China, 23.9% in India and 14.1% in southeast Asia. To understand PACG, it is mandatory to understand its classification and type of presentation with the underlying pathophysiology. The treatment options are medical, laser and/or surgical. The present article provides an overview of PACG.

Adjunctive pharmacologic agents and mechanical devices in primary percutaneous coronary intervention

Primary percutaneous coronary intervention (PPCI) has been shown to be superior to thrombolysis in patients presenting with ST-segment elevation acute myocardial infarction (STEMI) in reducing death, stroke and re-infarction. However, bleeding and thrombotic complications can occur despite successful PPCI and slow fl ow/no-reflow or poor microvascular reperfusion can occur in a significant minority despite a technically successful procedure. Bleeding or need for peri-procedural transfusion has been shown to increase short- and long-term mortality. Newer anticoagulants appear to reduce the bleeding risk and improve overall clinical outcomes. A novel combination of antiplatelet agents also appears to further improve the outcomes after PPCI. Although PPCI can achieve high rates of epicardial artery patency, some patients experience suboptimal microvascular perfusion, which affects long-term prognosis. Several pharmacologic agents have been shown to improve microvascular perfusion and left ventricular function, although none impacts on clinical outcomes. Of the mechanical devices available to reduce distal embolisation, the simple aspiration catheter holds the most promise in reducing clinical adverse events. Additional research and well designed studies are needed to further enhance the outcomes after PPCI.

Risk stratification for sudden cardiac death after acute myocardial infarction

Many patients who survive an acute myocardial infarction (AMI) remain at risk of recurrent cardiac events and sudden cardiac death after discharge, despite optimal medical treatment. Assessment of the degree of left ventricular dysfunction and residual myocardial ischaemia is useful to identify the patients at greatest risk. In addition, there is increasing evidence that a number of other cardiovascular tests can be used to detect autonomic dysfunction and myocardial substrate abnormalities postAMI that increase the risk of life-threatening ventricular arrhythmias. These investigations include ECG-based tests (signal averaged ECG and T-wave alternans), Holter-based recordings (heart rate variability and heart rate turbulence) and imaging techniques (echocardiography and cardiac magnetic resonance), as well as invasive electrophysiological testing. This article reviews the current evidence for the use of these additional cardiac investigations among survivors of AMI to aid in their risk stratification for malignant ventricular arrhythmias and sudden cardiac death.