Complete Heparin Reversal by Protamine during Off-Pump Coronary Artery Bypass Surgery (OPCAB): A Necessity or Myth?

In our country majority of the coronary artery bypass surgery (CABG) are done off-pump and was reported having excellent clinical outcome along with cost efficiency by various investigators. Heparin is commonly used as most effective anticoagulant, and protamine sulfate is now generally used to reverse the anticoagulant action of heparin. While under dosing of protamine may result in incomplete heparin reversal and prolonged anticoagulation, protamine overdosing is associated with impaired clot formation exerted by the intrinsic anti-coagulation properties of protamine itself, moreover protamine administration is associated with mild to severe cardiovascular and pulmonary complications. Apart from traditional full neutralization of heparin now-a-days, half dose protamine was also introduced showing good outcome regarding lower activated clotting time (ACT), overall, less surgical bleeding with less transfusion. This comparative study was designed to detect differences between traditional and decreased protamine dosing in Off-Pump Coronary Artery Bypass (OPCAB) surgery. Four hundred (400) patients who underwent Off-Pump Coronary Artery Bypass Surgery (OPCAB) surgery at our institution over a period of 12 months were analyzed and were divided into two groups. Group A- received 0.5mg of protamine per 100 unit of heparin; Group B-received 1.0mg of protamine per 100 unit of heparin. ACT, blood loss, hemoglobin and platelet count units of blood and blood product transfusion requirements, clinical outcome and hospital stay were assessed in each patient. This study showed that 0.5mg of protamine per 100 unit of heparin was always able to reverse the anticoagulant effect of heparin with no significant difference in hemodynamic parameters, amount of blood loss and requirements of blood transfusion in between the groups. A standard protamine dosing formula (protamine-heparin at ratio of 1:1) adequate for on-pump cardiac surgical procedures significantly overestimates protamine requirements for OPCAB. Patients treated with decreased protamine do not appear to have adverse outcomes in terms of post-operative bleeding.

Coronary Artery Revascularization with the Left Internal Mammary Artery (LIMA) to Diagonal (D) & Left Anterior Descending (LAD) Sequential and LIMA-LIMA "Y" Graft, Our Experiences at National Heart Foundation Hospital and Research Institute.

The Left internal mammary artery (LIMA) is considered the conduit of choice for the surgical treatment (CABG, coronary artery bypass grafting) of Coronary artery disease (CAD) due to its superior long term potency than the other conduits. Sequential anastomosis with the LIMA in CABG increases the number of arterial graft and more completeness the arterial revascularization. To increase the number of arterial graft and improved long term potency, an alternative technique is sequential anastomosis of LIMA to Diagonal (D) & left anterior descending artery (LAD) and LIMA-LIMA "Y" Graft play a vital role in patients with tight proximal lesion. Perioperative data were prospectively collected from all patients with isolated CAD with tight proximal LAD lesion, who underwent off-pump CABG from November 2013 to October 2015 at a single Centre. A total of 321 patients had LIMA to D & LAD sequential and LIMA-LIMA "Y" grafts pattern with severe proximal LAD lesion. The mean age was 54.7±8.4 years, male & female ratio was 29.7:7.5. Left main involvement was in 25% & triple vessel disease was 89% with LVEF 53.6±8.6%. Sequential LIMA to diagonal (side to side) & LAD (end to side) done in all 294 cases and LIMA-LIMA"Y" grafts in 27 cases. Thirty days mortality was 0.935% (3 patients). Postoperative myocardial infarction (MI) occurred in 2 patients (0.623%). Two sequential LIMA graft failed and both the diagonal & LAD bypassed coronary arteries were very narrow, about 1mm in diameter. All the patients underwent postoperative NYHA class evaluation at 3-6 months follow up & found normal and none of the patients suffered for angina. Revascularization with skeletonized sequential LIMA anastomosis to D, LAD & LIMA-LIMA "Y" graft is a safe, feasible with improve overall long-term potency and reproducible alternative in the presence of severe proximal LAD lesion to the complete revascularization of the anterior& lateral myocardial wall. Long term follow-up with coronary angiogram is essential to recommend this technique as standard one.

Significant Left Main Coronary Artery Disease Does Not Incur Any Additional Risk to the Short Term Outcome of Off Pump Coronary Artery Bypass Grafting Surgery.

Coronary artery disease is the most common form of heart disease and single most important cause of premature death in developed countries. Off pump coronary artery bypass grafting surgery has recently became widespread internationally and has produced good clinical outcome even in left main coronary artery disease following off pump coronary artery bypass grafting surgery. A prospective observational study was conducted in the department of Cardiac Surgery, National Heart Foundation Hospital and Research Institute, Dhaka, Bangladesh from January 2015 to September 2016 after fulfillment of enrollment criteria, 428 patients were studied for the purpose of the study and they were grouped in two, significant left main coronary artery disease in group A and non left main coronary artery disease requiring surgery in group B. Comparison of risk factors between groups demonstrates that diabetes mellitus and smoking habit between two groups were almost identical. 69.2% of patient with significant left main coronary artery group were hypertensive and 25.2% were dyslipidaemic in comparison to non left main coronary artery disease group which were 50.9% and 6.5% respectively. Requirement of per operative inotropic support was significantly higher in left main coronary artery group. 33.6% of patient of left main coronary artery group required per operative inotropic support whereas non left main coronary artery group require 24.8%. Postoperative inotropic support, mechanical ventilation time, ICU stay, hospital stay and complication were similar in both these groups. So, we can say that off pump coronary artery bypass grafting surgery for significant left main coronary artery disease is as safe as non left main coronary artery disease.

Overview evidence on interventions for population suicide with an eye to identifying best-supported strategies for LMICs.

Globally, over 800 000 people died by suicide in 2012 and there are indications that for each adult who died of suicide there were likely to be many more attempting suicide. There are many millions of people every year who are affected by suicide and suicide attempts, taking into consideration the family members, friends, work colleagues and communities, who are bereaved by suicide. In the WHO Mental Health Action Plan 2013-2020, Member States committed themselves to work towards the global target of reducing the suicide rate in countries by 10% by 2020. Hence, the first-ever WHO report on suicide prevention, Preventing suicide: a global imperative, published in September 2014, is a timely call to take action using effective evidence-based interventions. Their relevance for low- and middle-income countries is discussed in this paper, highlighting restricting access to means, responsible media reporting, introducing mental health and alcohol policies, early identification and treatment, training of health workers, and follow-up care and community support following a suicide attempt.

Randomised trial of 0.2% chlorhexidine gluconate and 2.5% natamycin for fungal keratitis in Bangladesh.

AIM: The management of suppurative keratitis due to filamentous fungi presents severe problems in tropical countries. The aim was to demonstrate the efficacy of chlorhexidine 0.2% drops as an inexpensive antimicrobial agent, which could be widely distributed for fungal keratitis. METHODS: Successive patients presenting to the Chittagong Eye Institute and Training Complex with corneal ulcers were admitted to the trial when fungal hyphae had been seen on microscopy. They were randomised to drop treatment with chlorhexidine gluconate 0.2% or the standard local treatment natamycin 2.5%. The diameters, depths, and other features of the ulcers were measured and photographed at regular intervals. The outcome measures were healing at 21 days and presence or absence of toxicity. If there was not a favourable response at 5 days, "treatment failure" was recorded and the treatment was changed to one or more of three options, which included econazole 1% in the latter part of the trial. RESULTS: 71 patients were recruited to the trial, of which 35 were randomised to chlorhexidine and 36 to natamycin. One allocated to natamycin grew bacteria and therefore was excluded from the analysis. None of the severe ulcers was fully healed at 21 days of treatment, but three of those allocated to chlorhexidine eventually healed in times up to 60 days. Of the nonsevere ulcers, 66.7% were healed at 21 days with chlorhexidine and 36.0% with natamycin, a relative efficacy (RE) of 1.85 (CL 1.01-3.39, p = 0.04). If those ulcers were excluded where fungi were seen in the scraping but did not grow on culture, the estimated efficacy ratio does not change but becomes less precise because of smaller numbers. Equal numbers of Aspergillus (22) and Fusarium (22) were grown. The Aspergillus were the most resistant to either primary treatment. CONCLUSIONS: Chlorhexidine may have potential as an inexpensive topical agent for fungal keratitis and warrants further assessment as a first line treatment in situations where microbiological facilities and a range of antifungal agents are not available.

Suppurative corneal ulceration in Bangladesh. A study of 142 cases examining the microbiological diagnosis, clinical and epidemiological features of bacterial and fungal keratitis.

Suppurative keratitis is an important preventable cause of blindness, particularly in the developing world. This study analyses 142 cases of suppurative keratitis referred to Chittagong Eye Infirmary Bangladesh. Some 53.5% of cases were bacterial and 35.9% were fungal. The five most common pathogens were: Pseudomonas sp. 24%, Streptococcus pneumoniae 17%, Aspergillus sp. 13%, Fusarium sp. 7% and Curvularia sp. 6%. Gram stain and culture results were consistent in 62.6% of cases. Previous antibiotic treatment was a significant factor for failure of culture isolation and less so for Gram stain failure. On Gram stain, 55.9% of pseudomonal cases were missed, but only 2% of fungal cases were missed. Over all, Gram stain had a sensitivity of 62% and positive predictive value of 84% for bacterial cases, and 98% and 94% for fungal cases, respectively. Fungal ulcers were typically filamentous, but an antecedent history of trauma was not common. The most frequent injury was due to rice grains, but the inoculum appeared to be introduced during eye washing with contaminated water. Pseudomonal ulcers occurred most frequently in the monsoon season, and Fusarium cases were seen only in the hot, dry season.

Microbiological diagnosis of suppurative keratitis in Bangladesh.

Experience in setting up an inexpensive microbiology laboratory in the Bangladesh National Society for the Blind Eye Hospital and Training Complex at Chittagong is presented, together with the results of a pilot study to identify organisms responsible in 33 consecutive cases of suppurative keratitis in the Chittagong area of Bangladesh. Of the 33 cases 21 were positively identified by means of Gram stain and/or culture. Two-thirds of the responsible organisms were bacteria, and one-third were fungi. The bacterial causes included Streptococcus pneumoniae and Pseudomonas aeruginosa. The fungi isolated were Aspergillus fumigatus, Aspergillus ochraceus, and Fusarium solani. Among the causes of failure to diagnose the organism was chronicity of infection and previous treatment. The value of the study in the planning of future treatment regimens, and the implications of setting up similar relatively cheap microbiology laboratory facilities in developing countries, are discussed.