The role of aspirin, statins, colchicine, and IL-1 inhibitors in prevention of cardiovascular events: a systematic integrative review.

CONTEXT: Cardiovascular disease (CVD) is the leading cause of death in the United States. As such, an unmet need exists in the primary and secondary prevention of adverse cardiovascular events (CVEs). Specifically, identifying drugs that can reduce the progression of CVD and serious adverse events is much needed. Drugs that work by reducing platelet aggregation, blocking cholesterol formation (3-hydroxy-3-methyl-glutaryl-coenzyme A [HMG-CoA] reductase inhibitors), and/or blocking inflammation pathways (mainly interleukin-1b [IL-1b]) have been linked to preventing adverse CVEs, including acetylsalicylic acid (ASA, aspirin), statins, colchicine, and IL-1 inhibitors (interleukin-1 receptor antagonists). This systematic review aims to provide insight into utilizing these four agents for the primary and/or secondary prevention of CVD. OBJECTIVES: In this systematic review, we opted to review the efficacy of aspirin, statins, colchicine, and IL-1 inhibitors in the primary and secondary prevention of CVE to provide clinical practitioners with evidence-based practice approaches and determine any unmet needs in their utilization. METHODS: Between October 1 and 12, 2021, a search was conducted and completed on five databases: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Biomedical Reference Collection: Comprehensive. A total of 13 researchers (V.A., A.H., S.B., V.G., D.C., C.C., C.B., C.A., S.K., J.H., A.K., S.F., and S.E.) were involved in the search and screening of the articles. Search terms included "aspirin, statins, colchicine, IL-1 inhibitors, and primary, secondary, myocardial infarction (MI)." Inclusion criteria included clinical study design, English language articles, all genders older than 50 years old, and established patient history of CVD, including MI. In addition, articles were excluded if they were animal models, in vitro studies, pharmacokinetic studies, systematic reviews, literature reviews, and studies exploring therapies other than those listed in the inclusion criteria. First, five individuals independently sorted through abstracts or articles based on the inclusion and exclusion criteria. Then, a team of 13 individuals sorted through full-text articles of selected abstracts based on the same criteria. A separate researcher resolved conflicts between the team. RESULTS: A total of 725 articles were identified from all databases, from which 256 duplicated articles were removed. Thus, a total of 469 articles abstracts were screened, of which 425 articles either did not meet the inclusion criteria or met the exclusion criteria. A total of 42 articles were retrieved and assessed for full-text review, from which 15 articles were retrieved for analysis. CONCLUSIONS: Statins may prevent primary CVEs based on their role in preventing cholesterol formation. Aspirin, canakinumab, and colchicine may be helpful in the secondary prevention of CVEs due to their blocking of various steps in the inflammation pathway leading to CVD. Future research should primarily focus on the use of canakinumab and colchicine in preventing CVD due to the limited number of studies on these drugs.

Quantitative determination of creatinine from serum of prostate cancer patients by N-doped porous carbon antimony (Sb/NPC) nanoparticles.

Creatinine is an indicator of hindrance in urination and renal insufficiency. Creatinine levels are the marker of the late stages of prostate cancer. Early and sensitive detection of creatinine can reduce deaths associated with prostate cancer. In this work, nitrogen-doped porous carbon antimony (Sb/NPC) nanoparticles are fabricated to be employed as a non-enzymatic biosensor. Sb/NPC has promising redox activity and is synthesized by a two-step reaction using low-cost precursors. Electrochemical sensing by Sb/NPC is conducted for standard creatinine solutions on a three-electrodes system. Cyclic voltammetry, amperometry, and electrochemical impedance spectroscopy are used to sense creatinine. LOD and LOQ of the Sb/NPC modified electrode are 0.74 µM and 2.4 µM, respectively. This electrode system analyzes creatinine in the serum of prostate cancer patients who have elevated PSA levels. More than 90% creatinine is recovered from a spiked serum sample of a prostate cancer patient. A direct relation is observed between PSA levels and creatinine levels in prostate cancer. The developed cyclic voltammetric setup detects trace concentrations of creatinine in serum.

Leiomyomatosis peritonealis disseminata: An exceptional case.

Leiomyomatosis peritonealis disseminata is a rare clinical disorder characterised by proliferation of smooth muscles spread all over the peritoneal cavity. History and examination do not help in establishing a proper diagnosis, which is possible only by histopathology. Although LPD is a benign disease which regresses spontaneously, it may degenerate to malignancy, so proper follow up is mandatory. A 38-year-old lady presented with lower abdominal pain on 27th day of her menstrual cycle. Due to suspicion of ovarian cyst accident, laparotomy was performed during which innumerable nodules were found scattered all over the peritoneal cavity. Histopathology revealed leiomyomatosis peritonealis disseminata. The patient was followed up for two years without any treatment and she remained asymptomatic.

Intraperitoneal Bupivacaine as Post-laparoscopic Cholecystectomy Analgesia.

OBJECTIVE: To assess the efficacy of large volumes of diluted intraperitoneal bupivacaine in post-laparoscopic cholecystectomy analgesia. STUDY DESIGN: A randomised controlled trial. PLACE AND DURATION OF STUDY: Department of General Surgery, Nishtar Hospital, Multan, from August 2018 to June, 2019. METHODOLOGY: Two equal groups with 55 patients each were formed. Normal saline 500 ml in group A, and mixture of 20 ml 0.5% bupivacaine in 480 ml normal saline in group B, was used to irrigate peritoneal cavity. Final outcome of the study was the comparison of pain-free duration. Postoperatively, numerical rating scale (NRS) score at various intervals and total analgesics requirement within 24 hours after the procedure were included in the secondary outcomes. Student's t-test was applied on continuous data and Pearson's Chi-square test on nominal variables. P >0.05 was considered of no statistical significance. RESULTS: Both groups were comparable for age, weight, gender, duration of surgery. Postoperative analgesia duration was 0.99 ± 0.51 hours in group A and 16.53 ±2.65 hours in group-B (p<0.001). On average, 124.80 ±26.68 mg and 31.00 ±14.98 mg tramadol was given to group A and B patients, respectively (p<0.001). There was statistically significant difference in NRS score at 30 minutes, 1, 3, 6 and 12 hours postoperatively (p<0.05). NRS score at ETT extubation and at 24 hours was statistically not different (p >0.05). CONCLUSION: Large volume of diluted bupivacaine when injected intraperitoneally during laparoscopic cholecystectomy provides prolonged time pain relief.

Overnight Caloric Restriction Prior to Cardiac Arrest and Resuscitation Leads to Improved Survival and Neurological Outcome in a Rodent Model.

While interest toward caloric restriction (CR) in various models of brain injury has increased in recent decades, studies have predominantly focused on the benefits of chronic or intermittent CR. The effects of ultra-short, including overnight, CR on acute ischemic brain injury are not well studied. Here, we show that overnight caloric restriction (75% over 14 h) prior to asphyxial cardiac arrest and resuscitation (CA) improves survival and neurological recovery as measured by, behavioral testing on neurological deficit scores, faster recovery of quantitative electroencephalography (EEG) burst suppression ratio, and complete prevention of neurodegeneration in multiple regions of the brain. We also show that overnight CR normalizes stress-induced hyperglycemia, while significantly decreasing insulin and glucagon production and increasing corticosterone and ketone body production. The benefits seen with ultra-short CR appear independent of Sirtuin 1 (SIRT-1) and brain-derived neurotrophic factor (BDNF) expression, which have been strongly linked to neuroprotective benefits seen in chronic CR. Mechanisms underlying neuroprotective effects remain to be defined, and may reveal targets for providing protection pre-CA or therapeutic interventions post-CA. These findings are also of high importance to basic sciences research as we demonstrate that minor, often-overlooked alterations to pre-experimental dietary procedures can significantly affect results, and by extension, research homogeneity and reproducibility, especially in acute ischemic brain injury models.

Trends and repetition of non-fatal suicidal behaviour: analyses of the Gold Coast University Hospital's Emergency Department.

Objective The aim of the current paper is to analyse time trends of non-fatal suicidal behaviour (NFSB) and its repetition at the Gold Coast in 2005-2015. Methods Data on presentations for NFSB were obtained from the Emergency Department (ED) Information System. Potential cases were identified through keyword searches, which were further scrutinised and coded. Annual person-based age-standardised rates for NFSB were calculated. Chi-square test, Poisson regression and Cox proportional hazards regression were used. RESULTS: There was a significant increase in the age-standardised rates of NFSB for males (incidence Rate Ratio = 1.05; 95% confidence interval (CI): 1.04-1.07) and females (iRR = 1.06; 95% CI: 1.04-1.07). Age-specific rates showed significant increases for all age groups, except 25-34 and 55+ for females. Different types of poisoning were the predominant method of NFSB (poisoning only - 61.7% of episodes), followed by cutting (23%). Within the first year after the index episode, 13.4% of subjects repeated NFSB. Multivariate Cox regression model showed that sex, age and method predicted repetition. CONCLUSION: The increasing trends of NFSB and relatively high repetition rates emphasise the need for preventative actions. Monitoring of NFSB at the ED level should be further extended in Australia.

A Study of Prehospital Delay Patterns in Acute Myocardial Infarction in an Urban Tertiary Care Institute in Mumbai.

OBJECTIVE: There is now increasing awareness about the need for early diagnosis in patients presenting with chest pain. Pre-hospital delay remains a major hurdle in the institution of early reperfusion therapy, which is crucial in salvaging 'at-risk' myocardium and reducing adverse cardiovascular events following ST elevation myocardial infarction (STEMI). This study aims to determine the incidence and the determinants of delayed presentation STEMI and the potential impact of such delay on adverse cardiovascular outcomes. METHODS: We prospectively evaluated all patients who were admitted in the emergency department of our hospital with STEMI from March 2014 to February 2016. Data was collected sequentially at the time of admission, discharge and during follow-up. Patients were evaluated with serial ECGs, continuous ECG monitoring and echocardiography. RESULTS: Out of 1386 patients with STEMI, delayed presentation was seen in 1148 (> 2 hrs) and 805 (> 4 hrs) patients. The duration from onset of symptoms to the presentation in the emergency room (pre-hospital delay) was 228 ± 341minutes.The door to needle time was 34 ± 24 minutes. The major factors for pre-hospital delay were misinterpretation of symptoms (45%) and transportation problems (27%). CONCLUSIONS: The problem of pre-hospital delay continues to remain a major hurdle in initiating timely reperfusion therapy in patients with acute STEMI. Lack of awareness and poor transportation facilities are the major contributors. It should be the goal of STEMI care programmes of the future to make a concerted effort to addressing these factors, in order to optimize the benefit of reperfusion therapy for this high risk group of patients.

Is accelerated idioventricular rhythm a good marker for reperfusion after streptokinase?

BACKGROUND: Accelerated idioventricular rhythm (AIVR) is a common arrhythmia observed in patients with ST segment elevation myocardial infarction (MI). It is not clear how much value AIVR has in predicting successful reperfusion, since there have been conflicting data regarding this in the past. Streptokinase (STK) even today is the commonest thrombolytic agent used in the public health care set-up in India.(1) Most data for the use of STK are from the 1990s, which had showed that at best it is effective in only 50% of patients in restoring adequate flow.(2) It is probable that with the current dual-antiplatelet loading dose regimen and other newer medications, this figure could be higher. Also, rescue angioplasty for failed thrombolysis is the standard of care now, unlike before. Hence, we need reliable non-invasive markers to judge successful reperfusion in the present era. While ST segment resolution is the standard marker for reperfusion used in thrombolytic trials, in several instances it is not definitive. An additional marker would thus be very useful, especially in such cases. METHODS: This was a prospective observational study carried out at a public teaching hospital. 200 consecutive patients with a diagnosis of acute MI who were given STK within 12h of index pain were included. The STK dose was 1.5 million units, infused over 30min; the ECG was again recorded after 90min of completion of the infusion. Continuous ECG monitoring for the first 24h of ICCU stay was performed and AIVRs during this period were documented. Early AIVR was defined as that occurring within 2h of completing the STK infusion. Echocardiography was performed 24h after presentation. The time course of AIVR was studied vis-a-vis the outcome of thrombolysis. RESULTS: AIVR was seen in 41% of the patients. Though AIVR was found to have low sensitivity (45%) and specificity (64%) as a predictor of successful thrombolysis, early AIVR was a reliable sign of successful thrombolysis (p<0.05). The sensitivity (45%) of early AIVR was low; however, the specificity (94%) and positive predictive value (94%) were very good. CONCLUSION: AIVR is a common arrhythmia in the setting of STEMI receiving thrombolytic therapy. Early AIVR is more common with successful thrombolysis, with an excellent positive predictive value. Thus, early AIVR can be used as an additive criterion to ST segment resolution as a non-invasive marker of successful thrombolysis with STK.

Incessant fascicular VT presenting as cardiogenic shock with multi-organ dysfunction syndrome.

We report a rare clinical presentation of incessant idiopathic fascicular ventricular tachycardia (FVT), presenting as multi-organ dysfunction (MOD) syndrome with cardiogenic shock. Our patient was a 19-year-old male who presented with slowly progressive dyspnea from New York Heart Association (NYHA) II to NYHA IV at the time of presentation, palpitations, and dilated cardiomyopathy due to drug-refractory FVT. The patient was in cardiogenic shock with raised central venous pressures and required inotropic support for maintaining systolic blood pressure above 90 mmHg. The MOD was seen in the form of deranged liver and kidney parameters. Echocardiography showed a dilated left ventricle (LV, 58 mm at end-diastole, 52 mm at end-systole) and decreased ejection fraction (20%). Electrocardiography showed a wide-QRS tachycardia (QRS 140 ms, cycle length 440 ms), with RsR' in lead V1 and a QRS axis of -60°. After stabilization with ventilation, inotropic support, and cautious use of diuretics, an electrophysiologic study was performed. A Purkinje potential with early local ventricular activation was recorded from the LV inferoseptal region. The tachycardia was ablated at this site with radiofrequency (RF) energy (40 W for 35 sec). Over a 3-month follow-up, the patient remained asymptomatic and the LV size and function returned to normal. .

Role of honey in wound dressing in diabetic foot ulcer.

BACKGROUND: Honey has antibacterial and antimicrobial properties. This study was conducted to evaluate the efficacy and role of honey as local wound dressing agent in the management of diabetic foot and its effect on rate of amputation. METHOD: This prospective observational study was done in the general surgery department, Al- Noor Specialist hospital, Holly Makkah, KSA from 1st March, 2007 to 31st May, 2008 (15 months). This study includes 172 patients of either gender, above 18 years of age, belonging to different nationalities admitted to A1- Noor specialist hospital, Holly Makkah, KSA. RESULTS: A total of 172 patients with male to female ratio 1.54:1 were admitted from 1st March, 2007 to 31st May, 2008 with complicated and non-healing diabetic foot ulcers. Out of these 172 patients, 135 (78.48%) were Saudi and 37 (21.52%) were non Saudi residents with ratio of 3.6:1. After admission and resuscitation, all the patients under went early surgical debridement and dressing with the thick layer of honey locally available. Wounds became healthy within 7-35 days. Three patients (1.75%) underwent big toe amputation and 2 (1.16%) patients under.went below knee amputations. Twenty (11.6%) patients under went split skin grafting to cover the wound while in other patients wound healed by secondary intention. CONCLUSION: Use of honey significantly reduced rate of amputation and improve wound healing when used for wound dressing in chronic diabetic foot ulcers.

Role of ultrasonography in early diagnosis of infantile hypertrophic pyloric stenosis.

BACKGROUND: Infantile hypertrophic pyloric stenosis (IHPS) is a common cause of gastric outlet obstruction in infants. This study was conducted to identify the accuracy of ultrasonography in the diagnosis of infantile Hypertrophic pyloric Stenosis. METHODS: This cross-sectional descriptive study was conducted in Department of Paediatric Surgery, Children Hospital Complex & the Institute of Child Health, Multan during two year period from 1st July, 2010 to 30t of June, 2012. Fifty patients <8 weeks of age who presented with complaints of non-bilious vomiting were included in the study. Abdominal ultrasound was performed in all the cases. On ultrasonography pyloric canal length, diameter and pyloric muscle wall thickness was measured. Open surgery was performed as per indications and after informed consent. The pre-operative findings were compared with ultrasongraphic findings. Study variable were male to female ratio, percentage of - cases in which pyloric mass was palpable. We also compare the duration of onset of symptorms with pyloric canal length, diameter and muscle thickness. RESULTS: In this study, out of 50 patients, 46 (92%) were male and 4 (8%) were females. Gastric peristalsis was visible in 100% patients and mass was palpable in 14 (28%) patients. Pyloric canal length was more than standard in 98% cases; canal diameter was more than the standard in 87% cases and pyloric muscle thickness in 60% of cases. Ultrasonographic findings remained 98% accurate in this study. CONCLUSION: Ultrasonography is an investigation of choice for early diagnosis of IHPS before significant fluid and electrolyte imbalance occur. It is cost effective, harmless, freely available and easier to perform. Pyloric canal length and diameter are more specific for the diagnosis of IHPS than pyloric muscle thickness.

Single versus 3-dose antibiotic prophylaxis in clean and clean contaminated operations.

BACKGROUND: Infection is a great problem in surgery and is encountered by all surgeons by nature of their craft; they invariably impair the first line of host defence. Bacteria may enter the wound during or after the operation and may be of endogenous or exogenous origin. The objective of this study was to determine the effectiveness of preoperative antibiotic prophylaxis in reduction of postoperative wound infection in clean and clean contaminated procedures and to compare the cost of antibiotic prophylaxis in both groups. METHOD: This was a prospective study done on patients in General Surgery Department, Al-Noor Specialist Hospital, Holly Makkah, Saudi Arabia from 1st April 2006 to 30th March 2007. Total 400 patients were divided into 2 groups of 200 patients each: Group-A received single dose antibiotic prophylaxis, and Group-B received 3 doses of antibiotic therapy. Only clean and clean contaminated procedures were included and results were compared. RESULTS: In Group A, clean procedures (Group-Al) were 110, and clean contaminated (Group-A2) were 90 patients. In clean procedure, rate of infection was 5 out of 110 (4.54%) and in clean contaminated procedures it was 3 out of 90 (3.33%). In Group B, in clean procedures (Group-B1), rate of infection was 7 out of 90 (7.77%), while in clean contaminated procedures (Group-B2) it was 9 out of 110 (8.18%) patients. Over all wound infection rate after single dose antibiotic prophylaxis was 4% in both procedures and 8% after 3-dose antibiotic therapy. CONCLUSION: Single dose antibiotic prophylaxis is as effective as 3-dose therapy in clean and clean contaminated procedures to prevent wound infection and is cost-effective.

Prevalence of necrotizing fasciitis during Ramadan and Hajj 1427-H.

BACKGROUND: Necrotizing Fasciitis is a rare progressive disease which results in significant rate of mortality and morbidity if there is any delay in diagnosis and treatment. Objectives of this Prospective observational study were to share our experience of dealing necrotizing fasciitis in terms of different presentations, diagnosis, treatment and outcome during Ramadan and Hajj. It was conducted in the Department of General Surgery, Al-Noor Specialist Hospital, Holly Makkah, KSA during Ramadan and Hajj period from 1-8-1427 to 30-1-1428. METHODS: Total 35 patients > 12 years of age, irrespective of the gender belonging to different nationalities admitted to Al-Noor specialist hospital, Makkah, KSA were included in this study to evaluate the different causative factors, presentations, response to medical/surgical treatment and outcome. RESULTS: Total 35 patients with male to female ratio of 6:1 were admitted during Ramadan and Hajj period from 1-8-1427 to 30-1-1428 (six months) with the features of necrotizing Fasciitis. Out of these 35 patients, 23 (65.7%) were Hajji and 12 (34.28%) were residents (Both Saudi and non Saudi) with a ratio of 2:1. Major co-morbid factors were old age, diabetes mellitus, hypertension and renal failure. Among systemic manifestations, 4 (11.42%) developed septic shock and admitted to ICU, 4 (11.42%) needed ventilator support for respiratory failure, and 5 (14.28%) patients developed Myocardial infarction. After resuscitation, 33 patients under went aggressive surgical debridement and two patients died before surgery. Microbiology revealed, 15 (42.85%) Streptococcus Group-A infection, 13 (8.51%) Polymicrobial and 4 (11.42%) MRSA. Diagnosis was conformed by histopathology. Mortality rate was 11.5%. CONCLUSION: Better outcome in necrotizing fasciitis depends upon early presentation, prompt diagnosis and aggressive surgical debridement. There was strong correlation between severity of necrotizing fasciitis and co morbid factors, general condition at presentation, systemic toxicity and raised WBC count.

Spontaneous cholecystocutaneous fistula.

We report a case of cholecystocutaneous fistula in a 90 years old female as a complication of gallstone disease. Patient presented with necrotizing fasciitis of anterior abdominal wall and cholecystocutaneous fistula. She was bedridden for the last 3 years due to cerebral vascular accident. She was a known case of chronic cholecystitis and 2 years back common bile duct stenting was done, in Jeddah, for obstructive jaundice but cholecystectomy was not done because patient was not fit for surgery.

Assessment following deliberate self-harm: who are we seeing and are we following the guidelines?

OBJECTIVES: To determine whether assessments of patients admitted to a general hospital following deliberate self-harm (DSH) were in line with the Royal College of Psychiatrists guidelines. To examine the profile of cases and presentations and to make recommendations for improvements to the service. METHOD: Clinical and demographic data recorded on 70 admissions after DSH during 1997-98 were analysed retrospectively. A checklist was also developed, using factors shown by previous research to be associated with future risk of suicide, to determine the quality of assessments. RESULTS: The majority (70%) of assessments took place within 24 hours of admission thereby meeting College recommendations. Medical personnel performed all adult assessments. Circumstances of the overdose, recent stresses, psychiatric diagnosis, immediate risk and follow-up arrangements were documented in the majority of cases. Family psychiatric history, past suicidal behaviour, alcohol and drug abuse history, and previous violence, were frequently not documented. A copy of a discharge summary to the GP was found in 41% of charts. Overdoses accounted for 93% of cases of DSH. The most frequently recorded problem (37.5%) was adjustment disorder. CONCLUSIONS: Despite evidence showing that non-psychiatric medical staff are competent in assessing DSH and guidelines encouraging multidisciplinary involvement, DSH assessments remain the preserve of the medical psychiatric team. Closer attention should be paid to all the risk factors associated with suicide by assessors; a checklist could prove helpful. There is room for improved communication between psychiatric services and GPs following DSH. The setting up of a self-harm service planning group could improve the co-ordination and efficiency of delivery of general hospital services to this patient group.