Echocardiographic RV-E/e' for predicting right atrial pressure: a review.

Right atrial pressure (RAP) is a key cardiac parameter of diagnostic and prognostic significance, yet current two-dimensional echocardiographic methods are inadequate for the accurate estimation of this haemodynamic marker. Right-heart trans-tricuspid Doppler and tissue Doppler echocardiographic techniques can be combined to calculate the right ventricular (RV) E/e' ratio - a reflection of RV filling pressure which is a surrogate of RAP. A systematic search was undertaken which found seventeen articles that compared invasively measured RAP with RV-E/e' estimated RAP. Results commonly concerned pulmonary hypertension or advanced heart failure/transplantation populations. Reported receiver operating characteristic analyses showed reasonable diagnostic ability of RV-E/e' for estimating RAP in patients with coronary artery disease and RV systolic dysfunction. The diagnostic ability of RV-E/e' was generally poor in studies of paediatrics, heart failure and mitral stenosis, whilst results were equivocal in other diseases. Bland-Altman analyses showed good accuracy but poor precision of RV-E/e' for estimating RAP, but were limited by only being reported in seven out of seventeen articles. This suggests that RV-E/e' may be useful at a population level but not at an individual level for clinical decision making. Very little evidence was found about how atrial fibrillation may affect the estimation of RAP from RV-E/e', nor about the independent prognostic ability of RV-E/e' . Recommended areas for future research concerning RV-E/e' include; non-sinus rhythm, valvular heart disease, short and long term prognostic ability, and validation over a wide range of RAP.

Prolonged QT dispersion in Subclinical Hypothyroid Females: A Study in University Teaching Hospital in Central Nepal.

Background QT dispersion is a simple index derived from 12 lead ECG; its prolongation has been shown to be associated with increased arrhythmia risk. Increased cardiovascular risks, particularly occurrence of the malignant arrhythmias are a common finding in patients with subclinical hypothyroidism. This increased arrhythmia risk is found to be higher mainly in patients with TSH level more than 10 milli international unit per liter. Objective To assess QT dispersion among subclinical hypothyroid and euthyroid Nepalese females aged 20-59 years attending general practice out patient department of centrally located University Teaching Hospital from November 2016 to April 2017. Method Forty-three newly detected subclinical hypothyroid females and forty-one euthyroid females were enrolled. Resting electrocardiogram (ECG) was performed. QT dispersion was analyzed from ECG and corrected for heart rate using Framingham correction formula. Independent sample t-test was applied to compare mean QT dispersion between two groups. Pearson correlation test was used to examine the association between QT dispersion and TSH level. Result Mean QT dispersion for sub-clinical hypothyroid group was 75.35 ± 43.82 whereas mean QT dispersion for euthyroid group was 59.51 ± 22.13, with p value 0.041. A weak association between QT dispersion and TSH level was seen with correlation factor of 0.23. Conclusion The result showed prolongation of QT dispersion in sub-clinical hypothyroid group and weak positive correlation between TSH level and QT dispersion suggesting arrhythmia risk in subclinical hypothyroid females.

Pulmonary Functions are Impaired among Carpet Factory Workers: A Spirometric Evaluation.

INTRODUCTION: Carpet factory produces various types of dusts and workers occupationally get exposed to them continuously. It has adverse health effects and most notably to the pulmonary functions. Nepal is one of the carpet exporter developing countries and still does have many factories within Kathmandu valley. However, the health hazards especially the status of pulmonary function of carpet factory workers from Nepal has not been studied. METHODS: A cross-sectional comparative study was designed to recruit carpet factory workers and healthy controls to assess their pulmonary functions. A total of 118 subjects (59 males and 59 females) were recruited (60 carpet factory workers and 58 controls). Pulmonary function tests were carried out using Medical International Research Spirolab II portable spirometer. RESULTS: The carpet factory workers had significantly less FEV1 (90.37 ±16.6 % vs. 103.89±9.79%, p<0.001), FVC (87.78 ± 15.48 % vs. 102.81 ± 8.41 %, p < 0.001) and PEFR (66.19 ± 20.29 % vs. 102.81 ± 11.09 %, p < 0.001) as compared to control group. Similarly the carpet factory workers had significantly higher FEV1/FVC ratio (89.96 ± 6.42 % vs. 87.12 ± 4.58 %, p = 0.007) as compared to control. CONCLUSIONS: Carpet industry dusts exposure adversely affects pulmonary functions among its workers. The findings significant increase in the FEV1/FVC ratio and decrease in FEV1, FVC, and PEFR suggest that the effects are both restrictive and obstructive patterns of lung disease.

Real-time three-dimensional myocardial contrast echocardiography: is it clinically feasible?

AIMS: Real-time 3D echocardiography (RT3DE) and 2D low mechanical index (LMI), contrast specific, myocardial perfusion imaging are now both accepted techniques. We evaluated the feasibility of an RT3DE LMI implementation in unselected patients. METHODS AND RESULTS: Forty-six patients undergoing contrast enhanced dobutamine stress echo were imaged with novel 3D LMI power modulation software. All patients underwent contrast enhanced 2D and RT3DE acquisitions, in left ventricular opacification (LVO), and LMI perfusion modes. The data sets were evaluated segmentally for wall motion (WM) and myocardial contrast enhancement. Of the 736 evaluated segments, WM could be assessed in 726 (98.6%) of the 2D and 708 (96.2%) 3D segments (P = 0.007). Perfusion could be assessed in 721 (98%) of 2D and 701 (95.2%) of 3D segments (P = 0.006). Six hundred and sixty-one segments had normal WM and thickening in 2D and of these RT3DE demonstrated normal myocardial opacification in 77.2% of basal, 85% of mid, and 91.8% of apical segments. Thirty-four segments were akinetic, with no evidence of perfusion in 2D, and of these RT3DE revealed a perfusion defect in 31 (91%, P = NS). CONCLUSION: LMI RT3DE evaluation of myocardial perfusion is feasible in most segments. It has the potential to accurately locate and possibly quantify perfusion defects.

Massive haemorrhage after a low-energy pubic ramus fracture in a 71-year-old woman.

We describe a case of a patient receiving warfarin who presented with a superior pubic ramus fracture after a trivial fall at home. She developed a massive retroperitoneal haematoma as a result of vascular injury and subsequently died. This case emphasises the importance of admitting and observing patients with pubic rami fractures who are receiving antithrombotic treatment, and haemorrhage should be considered if they become haemodynamically compromised.

B-type natriuretic peptide can detect silent myocardial ischaemia in asymptomatic type 2 diabetes.

OBJECTIVE: To find out whether B-type natriuretic peptide (BNP) detects silent myocardial ischaemia in patients with type 2 diabetes, since many of these patients have silent ischaemia leading to unexpected cardiac deaths. DESIGN: Prospective cross-sectional study with consecutive recruitment of patients. SETTING: Outpatient, single centre. PATIENTS: 219 patients with type 2 diabetes. Patients were excluded if they had a history or evidence of cardiac failure. OUTCOME MEASURES: BNP, echocardiography and exercise tolerance test (ETT). BNP was compared with the ETT result in all patients and specifically in those who had no apparent ischaemic heart disease (IHD). RESULTS: 121 patients had no history of IHD or cardiac failure and of these patients 85 had a clearly abnormal or normal ETT result. BNP was higher in patients with an abnormal than with a normal ETT (mean 58.2 (SD 46.3) v 24.4 (SD 15.7) pg/ml, p < 0.001). In univariate analysis BNP was an independent predictor of an abnormal ETT (p < 0.001). In multivariate analysis BNP remained an independent predictor of the ETT result. BNP concentration over 20 pg/ml predicted an abnormal ETT result with a sensitivity of 87% and specificity of 37%, and BNP over 40 pg/ml had a sensitivity of 63% and a specificity of 81%. CONCLUSION: BNP is of value in predicting silent ischaemia on exercise testing in asymptomatic patients with type 2 diabetes.

QT interval abnormalities are often present at diagnosis in diabetes and are better predictors of cardiac death than ankle brachial pressure index and autonomic function tests.

OBJECTIVES: To study serial measures of maximum QT interval corrected for heart rate (QTc) and QT dispersion (QTD) and their association with cardiac mortality patients with non-insulin dependent diabetes and to compare QT abnormalities with other mortality predictors (ankle brachial pressure index (ABPI) and autonomic function tests) in their ability to predict cardiac death. SETTING: Teaching hospital. METHODS AND PATIENTS: QT interval analysis, heart rate (RR) variation in response to deep breathing and standing, and ABPI were analysed in 192 patients with non-insulin dependent diabetes. Cardiac death was the primary end point. RESULTS: Mean (SD) follow up was 12.7 (3.2) years (range 1.2-17.1 years). There were 48 deaths, of which 26 were cardiac. QTc and QTD were individually significant predictors of cardiac mortality throughout the follow up period (p < 0.001). The predictability of QT parameters was superior to the predictability of ABPI and RR interval analysis. Temporal changes in QT parameters showed that the mean absolute QT parameter was a significant predictor of cardiac death (p < 0.001), whereas an intraindividual change in QT parameter over time was not predictive. CONCLUSION: QT abnormalities seem to exist at the point of diagnosis of diabetes and do not appear to change between then and the subsequent cardiac death. Furthermore, the analysis of QT interval is superior to ABPI and the RR interval in identifying diabetic patients at high risk of cardiac death.

Exercise blood pressure correlates with the maximum heart rate corrected QT interval in hypertension.

Submaximal exercise systolic blood pressure (ExSBP) is a recognised predictor of cardiac mortality. This study examined the possibility that this might be related to increased QT dispersion or prolonged maximum QT(c) interval (QTcmax). Twenty-nine untreated hypertensive subjects were assessed. Each subject underwent an echocardiographic examination and a 24-h ambulatory blood pressure (ABP). ExSBP was measured during a 3-min lightweight submaximal Dundee step test. In multiple regressional analyses, only left ventricular mass index significantly predicted QT dispersion (R2 = 22.4%, P = 0.018) and QT(c) dispersion (R(2) = 25.3%, P = 0.012). However, with respect to QTcmax, ExSBP (R2 = 21.6%, P = 0.02) emerged as the sole significant predictor of this index. Five (17.2%) out of the 29 subjects had prolonged QTcmax > or = 430 ms and these subjects were not differentiated by 24-h ABP (146 (s.d. 21)/83 (16) vs 140 (14)/88 (11) mm Hg, P = Ns) but by ExSBP (226 (15) vs 188 (24) mm Hg, P = 0.002). In conclusion, systolic blood pressure measured during exercise correlated with QT(c) max in hypertension. This finding may partly explain the prognostic value of exercise blood pressure.

Recurrent pericardial effusion: the value of polymerase chain reaction in the diagnosis of tuberculosis.

A 23 year old army man presented with progressive dyspnoea and was found to have a massive pericardial effusion. Despite extensive investigations the cause remained elusive, until samples were sent for polymerase chain reaction (PCR). This case was unusual for several reasons and is a reminder of the atypical way in which tuberculosis infection can present and how a high index of suspicion should be maintained. It shows the importance of molecular biological advances in providing simple and rapid methods for arriving at the correct diagnosis, by way of nucleic acid probes and polymerase chain reaction.

Role of ultrasound in the evaluation of blunt abdominal trauma.

Twenty nine cases of intra abdominal injuries who became stable after initial shock were selected for ultrasound examination. Ultrasound detected intra-abdominal hematomas in 19/29 (65.51%). These cases were managed conservatively. The different types of hematomas encountered were renal, hepatic, splenic, retroperitoneal and parietal.

Endometrioma of the kidney: case report.

A case of endometrioma of the right kidney with extensive involvement is presented. The patient complained of vague pain in the right lumbar region with no specific symptom relating to the kidney. An excretory urogram revealed a hydronephrotic kidney and diagnosis was a renal hydatid cyst. The 7 cases reported previously in the medical literature are reviewed briefly.

Heterosis and components of genetic variation for protein and lysine content in some grain sorghums.

Twelve varieties representing six geographical regions and nine taxonomic groups from a World Collection ofSorghum were used in a diallel and line X tester analysis of the nature of genetic variation for protein and lysine content. In a majority of crosses, heterosis was negative for protein, and positive for lysine.Analysis of combining ability indicated that both additive and non-additive variation were important for protein, while the non-additive component was predominant for lysine. Heterosis inlow Xlow andmedium Xlow crosses also indicated the presence of substantial non-allelic gene interactions for both the characters.Associations between protein, lysine and yield in parents were significantly different from those in the hybrids indicating considerable scope for genetic manipulation. Negative correlations between protein and lysine (% protein) and between protein and grain yield were very low. The results indicated that a high level of protein and moderately high lysine may be incorporated in high yielding varieties of sorghum, by using Caudatum kaura, Roxburghii shallu and durra from Nigeria and Sudan in the hybridisation programme.