Significance of inferior wall ischemia in non-dominant right coronary artery anatomy.

AIM: To investigate the relationship of inferior wall ischemia on myocardial perfusion imaging in patients with non-dominant right coronary artery anatomy. METHODS: This was a retrospective observational analysis of consecutive patients who presented to the emergency department with primary complaint of chest pain. Only patients who underwent single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) were included. Patients who showed a reversible defect on SPECT MPI and had coronary angiography during the same hospitalization was analyzed. Patients with prior history of coronary artery disease (CAD) including history of percutaneous coronary intervention and coronary artery bypass graft surgerys were excluded. True positive and false positive results were identified on the basis of hemodynamically significant CAD on coronary angiography, in the same territory as identified on SPECT MPI. Coronary artery dominance was determined on coronary angiography. Patients were divided into group 1 and group 2. Group 1 included patients with non-dominant right coronary artery (RCA) (left dominant and codominant). Group 2 included patients with dominant RCA anatomy. Demographics, baseline characteristics and positive predictive value (PPV) were analyzed for the two groups. RESULTS: The mean age of the study cohort was 57.6 years. Sixty-one point seven percent of the patients were males. The prevalence of self-reported diabetes mellitus, hypertension and dyslipidemia was 36%, 71.9% and 53.9% respectively. A comparison of baseline characteristics between the two groups showed that patients with a non-dominant RCA were more likely to be men. For inferior wall ischemia on SPECT MPI, patients in study group 2 had a significantly higher PPV, 32/42 (76.1%), compared to patients in group 1, in which only 3 out of the 29 patients (10.3%) had true positive results (P value < 0.001 Z test). The difference remained statistically significant even when only patients with left dominant coronary system (without co-dominant) were compared to patients with right dominant system (32/40, 76.1% in right dominant group, 3/19, 15.8% in left dominant group, P value < 0.001 Z test). There was no significant difference in mean hospital stay, re-hospitalization, and in-hospital mortality between the two groups. CONCLUSION: The positive predictive value of SPECT MPI for inferior wall ischemia is affected by coronary artery dominance. More studies are needed to explain this phenomenon.

ST-segment elevation myocardial infarction, systems of care. An urgent need for policies to co-ordinate care in order to decrease in-hospital mortality.

BACKGROUND: Regional trends for ST-segment elevation myocardial infarction (STEMI) treatment is not known in the state of Nevada. HYPOTHESIS: Great disparity exists for treatment for STEMI in different geographical areas of Nevada. There is a great potential to improve treatment and outcomes of STEMI patients in the State of Nevada. METHODS: Admissions to non-federal hospitals in the state of Nevada, using 2011 to 2013 discharge data from the Nevada State Inpatient Data Base (acquired from Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality), were analyzed. Outpatient-onset STEMI patients were identified. The state of Nevada was divided into three divisions based on population densities, defined as population per square mile. Division A included counties with population density of <50 per square mile, Division B included counties with population density of 50 to 200 per square mile, and Division C included counties with population density of >200 per square mile. Trends in use of STEMI-related therapies and the impact on in-hospital mortality rates were compared. RESULTS: Almost 20% of the patients with outpatient-onset STEMI do not get any STEMI-related therapy and have significantly higher mortality rate. Patients from Division A do not have direct access to percutaneous coronary intervention (PCI) centers. These patients receive less STEMI-related therapies. Low-volume PCI centers had equivalent mortality rates for STEMI patients who got PCI, compared to high-volume PCI centers. CONCLUSIONS: Policies must be created and processes streamlined so all STEMI patients in Nevada receive appropriate treatment.

Comparison of Irrigation versus No Irrigation during Burr Hole Evacuation of Chronic Subdural Hematoma.

Objective To compare the results of the use of irrigation versus no irrigation during burr hole evacuation of chronic subdural hematoma (CSDH). Methodology The study was a retrospective chart review of those patients who underwent burr hole evacuation of CSDH during a period of 5 years. Cases were divided into two groups based on the use of irrigation during surgery. A subdural drain was placed in all patients (i.e., in both the irrigation and no-irrigation groups) and removed 24 to 48 hours postoperatively. Results The total sample size was 56, of which 34 patients were in the irrigation group and 22 in the no-irrigation group. Recurrence rate was 17.6% in the irrigation group and 9.1% in the no-irrigation group (p = 0.46). Systemic complications were predominantly cardiac related in the no-irrigation group compared with respiratory complications in the irrigation group. The irrigation group had a mortality rate of 5.9% compared with 4.5% in the no-irrigation group (p = 0.66). Conclusion No statistically significant difference was found between the two groups in terms of recurrence or mortality.

Burden of chronic kidney disease in an urban city of Pakistan, a cross-sectional study.

OBJECTIVE: To estimate the prevalence of Chronic Kidney Disease in an urban city and to assess the risk factors associated with the condition. METHODS: The cross-sectional study was carried out from June to December 2012 by arranging health camps for asymptomatic population in Karachi at busy shopping areas frequented by people of all socioeconomic classes. The camps provided free screening tests for the general public. Serum creatinine was checked and estimated Glomerular Filtration Rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. SPSS 17 was used for statistical analysis. RESULTS: Of the 301 subjects who came to the camps, 293(97%) had their serum creatinine checked. The age range was 30-80 years. Chronic Kidney Disease was found in 75(25.60%)subjects. A significant relationship was found between the disease and Diabetes Mellitus and Hypertension (p=0.006). There was also a significant relationship between Hypertension and Diabetes with mean Glomerular Filtration Rate (p<0.001). CONCLUSIONS: In view of the prevalence rate of Chronic Kidney Disease, early screening and risk factor stratification is recommended.

Extremely rare case of primary esophageal mucous associated lymphoid tissue lymphoma.

SJ is a 37-year-old male who presented with one year history of dysphagia, odynophagia and 15 pounds weight loss. He underwent endoscopic evaluation which showed mid esophageal ulcers. It was thought that the cause of the ulcer was the multivitamins and the patient was asked to stop them. Furthermore Esomeprazole therapy was also initiated. Patient's symptoms persisted but he did not seek any medical attention until about one year later. Meanwhile the patient reported additional 15 pounds of weight loss. We repeated upper endoscopy again which showed evidence of two chronic non bleeding irregular friable ulcerations seen in the mid esophagus, 31 cm from the incisors. Biopsies and frozen section were taken and sent for assessment to the Pathology lab. Immunoperoxidase studies on frozen sections showed the presence of IgM and for most plasma cells IgG. The microscopic and histologic findings were consistent with mucous associated lymphoid tissue lymphoma with plasmocytic differentiation. Computed tomographic scan done showed no evidence of spread to adjacent structures. The patient was referred to oncology and several cycles of radiation and Rituximab therapy were initiated which cured the disease. Subsequent endoscopies with blind biopsies were done which were negative for any neoplastic process.