Pilot study to evaluate left-to-right ventricular offset in biventricular pacing-comparison of electrocardiographic imaging and ECG.

INTRODUCTION: Biventricular pacing (BiVp) improves outcomes in systolic heart failure patients with electrical dyssynchrony. BiVp is delivered from epicardial left ventricular (LV) and endocardial right ventricular (RV) electrodes. Acute electrical activation changes with different LV-RV stimulation offsets can help guide individually optimized BiVp programming. We sought to study the BiVp ventricular activation with different LV-RV offsets and compare with 12-lead ECG. METHODS: In five patients with BiVp (63 ± 17-year-old, 80% male, LV ejection fraction 27 ± 6%), we evaluated acute ventricular epicardial activation, varying LV-RV offsets in 20 ms increments from -40 to 80 ms, using electrocardiographic imaging (ECGI) to obtain absolute ventricular electrical uncoupling (VEUabs, absolute difference in average LV and average RV activation time) and total activation time (TAT). For each patient, we calculated the correlation between ECGI and corresponding ECG (3D-QRS-area and QRS duration) with different LV-RV offsets. RESULTS: The LV-RV offset to attain minimum VEUabs in individual patients ranged 20-60 ms. In all patients, a larger LV-RV offset was required to achieve minimum VEUabs (36 ± 17 ms) or 3D-QRS-area (40 ± 14 ms) than that for minimum TAT (-4 ± 9 ms) or QRS duration (-8 ± 11 ms). In individual patients, 3D-QRS-area correlated with VEUabs (r 0.65 ± 0.24) and QRS duration correlated with TAT (r 0.95 ± 0.02). Minimum VEUabs and minimum 3D-QRS-area were obtained by LV-RV offset within 20 ms of each other in all five patients. CONCLUSIONS: LV-RV electrical uncoupling, as assessed by ECGI, can be minimized by optimizing LV-RV stimulation offset. 3D-QRS-area is a surrogate to identify LV-RV offset that minimizes LV-RV uncoupling.

Cardiac resynchronization therapy for pacing induced cardiomyopathy: Role of baseline right ventricular pacing burden.

BACKGROUND: Cardiac resynchronization therapy (CRT) is indicated for patients with heart failure with reduced left ventricular ejection fraction (LVEF) and chronic right ventricular (RV) pacing burden ≥40% (pacing-induced cardiomyopathy, PICM). It is uncertain whether baseline RV pacing burden impacts response to CRT. METHODS: We conducted a retrospective study of all CRT upgrades for PICM at our hospital from January 2017 to December 2018. Univariate and multivariable-adjusted changes in LVEF, and echocardiographic response (≥10% improvement in LVEF) at 3-12 months post-CRT upgrade were compared in those with RV pacing burden ≥90% versus <90%. RESULTS: We included 75 patients (age 74 ± 11 years, 71% male) who underwent CRT upgrade for PICM. The baseline RV pacing burden was ≥90% in 56 patients (median 99% [IQR 98%-99%]), and <90% in 19 patients (median 79% [IQR 73%-87%]). Improvement in LVEF was greater in those with baseline RV pacing burden ≥90% versus <90% (15.7 ± 9.3% vs. 7.5 ± 9.6%, p = .003). Baseline RV pacing burden ≥90% was a strong predictor of an improvement in LVEF ≥10% after CRT upgrade both in univariate and multivariate-adjusted models (p = .005 and .02, respectively). CONCLUSION: A higher baseline RV pacing burden predicts a greater improvement in LVEF after CRT upgrade for PICM.

Case of a misleading ECG.

An elderly man with severe chronic obstructive pulmonary disease and a history of complete heart block with pacemaker placement was found to have pacemaker lead infection and required device extraction. He had a standard dual chamber pacemaker in place, however the ECG obtained showed paced QRS complexes with presence of R wave in lead V1 and QS in lead I suggestive of left ventricular pacing. Additional imaging with CT scan obtained for confirmation revealed that the heart was displaced to the left posterior hemithorax secondary to pulmonary disease. Due to significant posterolateral rotation of the heart, a right ventricular paced rhythm can demonstrate Q/S waves in the lateral leads (I, aVL, V5-6) and R waves in the right precordial leads (V1-3). This can be misdiagnosed as a left ventricular paced rhythm.

The impact of Virtual Reality on Anxiety and Functional Capacity in Cardiac Rehabilitation: A Systematic Review and Meta-analysis.

BACKGROUND: The overall utilization of cardiac rehabilitation (CR) is low despite its proven benefits in secondary prevention. Virtual reality (VR), a novel method of rehabilitation, may increase overall compliance. The purpose of this systematic review and meta-analysis is to synthesize evidence and report whether the addition of VR leads to an improvement in anxiety and functional capacity (FC) compared to standard CR. METHODS: A comprehensive search strategy was used to search the online databases for the randomized controlled trials (RCTs) on VR-CR. Statistical analysis was performed using Stata SE version 17.0 (College Station, TX) and RevMan5. RESULTS: A total of 747 study participants were part of 7 studies included in the meta-analysis. Three studies were part of the narrative synthesis. Anxiety showed significant improvement in VR-CR compared to standard CR (SMD -0.32, 95% CI -0.61, -0.03). There was no significant improvement in FC between VR-CR and the standard CR (SMD 0.077, 95% CI -1.24, 1.32). CONCLUSION: VR-CR significantly improved CR-related anxiety compared to standard CR. However, no significant improvement in FC was found in VR-CR compared to the standard CR. Further studies are needed to assess the impact of non-immersive and immersive VR on FC.

Impact of virtual reality on cardiac rehabilitation-related anxiety: a protocol for systematic review and meta-analysis.

INTRODUCTION: Cardiac rehabilitation has proven beneficial in cardiovascular patients and is strongly recommended for secondary prevention after a coronary event. However, overall utilisation of cardiac rehabilitation is often low. The addition of novel methods of rehabilitation may increase overall compliance with cardiac rehabilitation. The use of virtual reality (VR) has been adopted in a variety of therapeutic ways such as physical rehabilitation in neurological diseases, rehabilitation for various psychiatric illnesses and postcancer rehabilitation in breast cancer survivors. In our meta-analysis, we wish to assess whether the addition of VR (fully immersive or non-immersive) leads to an improvement in anxiety and functional capacity compared with standard cardiac rehabilitation at any phase of the rehabilitation process. METHOD AND ANALYSIS: This systematic review and meta-analysis protocol was structured according to the published Preferred Reporting for Systematic Review and Meta-analysis-Protocol guidelines. We will devise a search strategy to use online databases to search for the randomised controlled trials. Inclusion criteria and exclusion criteria will be defined. The articles will be reviewed by two independent reviewers and any conflict will be adjudicated through discussion. The bias in the selected studies will be assessed using Cochrane risk-of-bias tool for randomised trials (RoB 2). The outcome of interest will be anxiety and functional capacity. Effect estimates will be reported as standardised mean difference with 95% CI. Fixed effect model will be used if I2 <60%, otherwise random effect model will be used to estimate the effect size. ETHICS AND DISSEMINATION: There will be no direct involvement of the patient or the public in the conception, design, data collection and analysis of this systematic review and meta-analysis. Results of this systematic review and meta-analysis will be disseminated via journal articles. In accordance with the guidelines, our systematic review protocol is prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 07 August 2022. PROSPERO ID: CRD 42022342736.

Comparison of telecardiac rehabilitation with centre-based cardiac rehabilitation and usual care: a protocol for systematic review including a meta-analysis.

INTRODUCTION: Cardiac diseases are the leading causes of morbidity and mortality. Cardiac rehabilitation is proven to be beneficial in reducing morbidity, mortality and rehospitalisation rates. Recently, more emphasis is given to home-based telemonitored cardiac rehabilitation due to the recent pandemic of SARS-CoV-2. We plan to perform this systematic review and meta-analysis to compare the differences in functional capacity (FC) (measured in peak oxygen uptake (PVO2)) and health-related quality of life (hr-QoL) between telecardiac rehabilitation and both centre-based cardiac rehabilitation (CBCR) and usual care (UC) separately. It will showcase the feasibility of using telemonitored cardiac rehabilitation as an alternative to CBCR considering the ease of performance, safety and limiting unnecessary contact. METHODS AND ANALYSIS: This systematic review and meta-analysis protocol was structured according to the published Preferred Reporting Items for Systematic Review and Meta-analysis-Protocol guidelines. We will devise a search strategy to use online databases to search for the randomised controlled trials (RCTs). Inclusion criteria will include adult population (18 years or older) suffering from at least one cardiac disease referred for cardiac rehabilitation comparing telecardiac rehabilitation with both CBCR and UC. Exclusion criteria will be RCTs in non-English language, hybrid studies, cross-over trials, observational studies and case series. The outcome of interest will be FC measured in PVO2 and hr-QoL. The articles will be reviewed by two independent reviewers and a third reviewer will be available to adjudicate any conflicts. The bias in the selected studies will be assessed using Cochrane risk-of-bias tool for randomised trials. The overall bias of the studies will be assessed. The selected articles will be reviewed and the data will be collected on Microsoft Excel spreadsheet for analysis. These data will include number of subjects in the intervention arm and the comparator arm (which will either be CBCR or UC), measures of FC and hr-QoL and SD. Subgroup analysis and sensitivity analysis will be considered based on heterogeneity among the study effect estimates and the number of available studies for each outcome. Results of the pooled estimates will be reported as standardised mean difference (and 95% CI) with fixed-effect model, if heterogeneity is not significant (I2 <50%). Otherwise, random-effects model will be used for I2 >50%. The data of the subjects who completed the rehabilitation programme of the study period will be used to calculate the effect estimates (per-protocol effect). Publication bias in the meta-analysis will be assessed using Egger's test and funnel plot. The strength of body of evidence of the outcomes will be assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. Data analysis will be performed using Stata SE V.15.0 (College Station, Texas, USA). ETHICS AND DISSEMINATION: There will be no direct involvement of the patient or the public in the conception, design, data collection, and analysis of this systematic review and meta-analysis. Results of this systematic review and meta-analysis will be disseminated via journal articles. PROSPERO REGISTRATION NUMBER: CRD42021245461.

Measurement of age-dependent radiation ingestion doses due to gross alpha and gross beta exposure from medicinal plants.

This article presents the results of a study conducted to measure the gross alpha, gross beta activities in medicinal plant samples collected from different districts of Azad Kashmir, Pakistan. The ASC-950-DP gasless high-speed counter was used for the measurement of gross α/ß activities. Measured activities have been used to assess age-dependent annual effective doses for infants, one-, five-, ten-, and fifteen-year-old and adult people. For a medicinal plant consumption rate (MPCR) of 1.8 kg a-1, the average gross alpha and beta annual committed effective dose (ACED) delivered to one-, five-, ten-, fifteen-year-olds and adults fall below the WHO recommended level (290 µSv a-1) and that reported in the UNSCEAR 2000 (0.3 mSv a-1) report. Results obtained for the current study show that the radiological hazard related to the consumption of natural radionuclides in medicinal plants is inconsequential with exception of the ACED delivered to infants at an MPCR of 1.8 g a-1 and higher values.

Detection and Quantification of Precious Elements in Astrophyllite Mineral by Optical Spectroscopy.

With many advantages over well-established methods, laser induced breakdown spectroscopy (LIBS) has emerged as a useful analytical technique for the compositional analysis of multi-elemental geological materials. In this study, LIBS was employed for qualitative and quantitative analysis of a rare mineral, astrophyllite, bearing precious elements of industrial and technological interest. The experiment was carried out using second harmonic generation of Nd:YAG laser of pulse width 5 ns and repetition rate of 10 Hz. Microplasma was produced by focusing laser beam on an astrophyllite target, and optical emissions from the generated plasma were recorded in the spectral range of 200-720 nm with the help of a LIBS2000+ detection system. On analyzing the optical spectra, existence of 15 elements in astrophyllite target were revealed. These elements include: Ti, W, Ag, Al, Ba, Ca, Cr, Cu, Fe, Li, Mg, Na, Ni, Si and H. For quantification, calibration-free method was used. Only ten elements, namely Ti, W, Fe, Cr, Cu, Ca, Mg, Ni, Si and Al, were quantified with relative weight concentrations of 55.39%, 18.79%, 18.30%, 4.05%, 2.66, 0.43%, 0.18%, 0.12%, 0.06% and 0.02%, respectively. To benchmark these results, XRF analysis was performed, which confirmed the presence of all the elements detected in the optical spectrum of the sample, except for Na, Li, and H. The concentrations of these ten elements as measured by XRF were in reasonable agreement, especially for the major elements. The presence of a significant amount of Ti and W in an astrophyllite sample, found in Pakistan, highlights the economic value of this mineral. This study may be of further interest in commissioning LIBS technology for exploration of minerals in the region.

A Unique Triad of Invasive Sinusitis, Brain Abscess with Focal Cerebritis, and COVID-19.

BACKGROUND We present a case of invasive sinusitis with rhinocerebral infection in a patient who had mild symptoms of COVID-19 infection and did not receive any immunosuppressive therapies. CASE REPORT A 49-year-old man with a history of uncontrolled diabetes presented to the hospital with multiple generalized tonic clonic seizures. He had recently been diagnosed with mild COVID-19 and was treated at home with supportive care only. He was found to have cerebritis in the right frontal lobe along with right fronto-ethmoid sinusitis. He underwent extensive testing with nasal endoscopy with gram stain and culture, cryptococcal studies, 1-3-Beta-D glucan, blood cultures, fungal CSF studies, Lyme disease, HIV, Fungitell assay, and galactomannan studies, which were all negative. He was started on i.v. antibacterial therapy with cefepime, vancomycin, and metronidazole along with amphotericin B. After 2 weeks, his repeat imaging revealed progression of cerebritis along with new early abscess. Given these findings, his antibiotics were changed to meropenem and the amphotericin B dose was increased. He was recommended debridement and sinus surgery but refused. During the course of treatment, he developed acute kidney injury and was switched to Posaconazole. Unfortunately, the patient decided to leave against medical advice 6 weeks into admission. He was advised to continue Posaconazole and levofloxacin but he could only afford levofloxacin. He was then recommended long-term levofloxacin. He has since recovered, with resolution of cerebritis noted in follow-up imaging 1 year later. CONCLUSIONS Our patient had mild COVID-19 infection and presented with secondary infective complications, which are usually associated with an immunocompromised state, despite receiving no immunosuppressives. It is imperative that all clinicians treating COVID-19 be watchful for fungal or bacterial co-infections in patients with active SARS-CoV-2 infection, even if the presenting symptoms are mild, particularly if other risk factors are present.

Atypical pathogens associated with cardiac implantable electronic device infections.

BACKGROUND: Cardiovascular implantable electronic device (CIED) infections are associated with significant morbidity and mortality making the identification of the causative organism critical. The vast majority of CIED infections are caused by Staphylococcal species. CIED infections associated with atypical pathogens are rare and have not been systematically investigated. The objective of this study is to characterize the clinical course, management and outcome in patients with CIED infection secondary to atypical pathogens. METHODS: Medical records of all patients who underwent CIED system extraction at the University of Chicago Medical Center between January 2010 and November 2020 were retrospectively reviewed to identify patients with CIED infection. Demographic, clinical, infection-related and outcome data were collected. CIED infections were divided into typical and atypical groups based on the pathogens isolated. RESULTS: Among 356 CIED extraction procedures, 130 (37%) were performed for CIED infection. Atypical pathogens were found in 5.4% (n = 7) and included Pantoea species (n = 2), Kocuria species (n = 1), Cutibacterium acnes (n = 1), Corynebacterium tuberculostearicum (n = 1), Corynebacterium striatum (n = 1), Stenotrophomonas maltophilia (n = 1), and Pseudozyma ahidis (n = 1). All patients with atypical CIED infections were successfully treated with total system removal and tailored antibiotic therapy. There were no infection-related deaths. CONCLUSIONS: CIED infections with atypical pathogens were rare and associated with good outcome if diagnosed early and treated with total system removal and tailored antimicrobial therapy. Atypical pathogens cultured from blood, tissue or hardware in patients with CIED infection should be considered pathogens and not contaminants.

A new strategy of using dielectric barrier discharge plasma in tubular geometry for surface coating and extension to biomedical application.

There has always been a quest for nanotechnology to develop inexpensive coating methods with the capability of depositing biocompatible nanomaterials on biomedical and surgical tools. In this mini-report, a plasma-based innovative idea of coating a solid surface with antibacterial/antimicrobial nanosilver is floated and experimentally realized. The desired antibacterial nanosilver was obtained from laser ablation and directly entrained in an outflowing plasma jet, excited in the flow of argon at 10 l min-1 using 20 kV/20 kHz. Under these conditions, the jet can protrude 15 mm deeply into ambient air. The quality of the surface coating can be described by sparsely distributed particles or densely agglomerated clusters, controlled by the plasma length and the surface separation. Apart from the coating, plasma interaction leads to the sterilization of the exposed surface. The idea is essentially important to extend and upscale for coating biomedical and surgical devices in a flexible open processing environment.

Calibration-free laser-induced breakdown spectroscopic analysis of copper-rich mineral collected from the Gilgit-Baltistan region of Pakistan.

In this paper, we present the results of compositional analysis of a copper-rich mineral known as malachite, collected from the Gilgit-Baltistan region of Pakistan. A calibration-free laser-induced breakdown spectroscopy (CF-LIBS) technique is employed for determination of elemental composition of the sample. The study aims at the investigation of the presence of precious elements, if any, in minerals of local origin. The laser beam of a 1064 nm wavelength from a nanosecond pulsed $Q$Q-switched Nd:YAG laser was focused on the surface of the sample, and an emission spectrum was obtained with the help of a LIBS2000 spectrometer covering the spectral range between 200 to 700 nm. Results obtained through analyzing the characteristic emission lines of different elements have confirmed the presence of sixteen (16) elements in the investigated sample, viz. Cu, Si, Al, K, Fe, Mn, Ag, Ti, Ba, Sr, Ca, Mg, Na, Li, C, and H. For quantification of the detected elements in the sample, a calibration-free method based on local thermodynamic equilibrium and optically thin plasma model was employed. Plasma parameters, such as electron number density and temperature, were calculated for the purpose of subsequent calculations. Seven elements, viz. Cu, Fe, Si, Ca, Mg, Mn, and Al, were quantified out of 16 initially detected elements, and their concentration in terms of weight percentage was 43.15%, 20.13%, 18.31%, 9.46%, 3.28%, 3.16%, and 2.51%, respectively. The presence of all seven elements quantified by CF-LIBS was confirmed by x-ray fluorescence analysis.

Management of Rapunzel Syndrome in a Four-month Pregnant Female with Twins: The First Reported Case?

A bezoar is a collection of packed indigestible matter that accumulates in the gastrointestinal tract after ingestion by the patient. It may be made of hair (trichobezoar), vegetable or fruit (phytobezoar), or other indigestible materials. Trichobezoars are thought to form due to hair's natural enduring nature, as they get matted and stick together in the gut. We present the case of a young female who was 16-weeks pregnant with twins presenting to the general surgery clinic with abdominal pain, vomiting and a palpable abdominal mass, which eventually turned out to be a massive trichobezoar manifesting as Rapunzel syndrome. Rapunzel syndrome is a large trichobezoar extending from the stomach into the small intestine. This is perhaps the first reported case of Rapunzel syndrome in a patient pregnant with twins.

Determination of trace element levels in patients with burst fractures.

BACKGROUND: This study aimed to determine trace element levels (Zn, Fe, Mn, Mg, Cu, Cd, Co, and Pb) in patients with burst fractures in Van Province, Turkey. METHODS: The study included a total of 44 participants with no additional pathologies, including 22 patients with burst fractures aged over 18 years who were admitted to the neurosurgery departments at two hospitals between June 15, 2015 and January 20, 2016 and 22 healthy volunteers. Serum samples were obtained from all participants to measure the serum levels of trace and heavy elements, including Mn, Cd, Cu, Pb, Fe, Co and Zn, using atomic absorbance spectrophotometry. RESULTS: The trace element levels of Zn, Mn, Cu, Co, and Mg were significantly lower (p<0.001), whereas those of Fe, Cd, and Pb were significantly higher in the patient group than in the control group. In addition, the levels of Zn, Mn, Cu, Co, and Mg were lower and the levels of Fe, Cd, and Pb were higher in the patient group than in the control group. CONCLUSION: The probability of burst fracture and its causes leading to any injury may be considered as an indicator balance for the concentration of trace elements between the patient group and control group and may also be a risk factor associated with the bone exposed to burst fracture Significant changes in serum levels of Zn, Cd, Mn, Mg, Pb, Fe, Cu and Zn elements can be observed in patients with burst fractures.

Acetaminophen induced Steven Johnson syndrome-toxic epidermal necrolysis overlap.

Steven Johnson Syndrome and Toxic Epidermal Necrolysis are rare but severe form of hypersensitivity inflammatory reactions to multiple offending agents including drugs. Acetaminophen is extensively used due to its analgesic and anti-pyretic properties. It is rendered to be relatively safe, with hepatotoxicity considered to be the major adverse effect. However, very few cases of Steven Johnson Syndrome and Toxic Epidermal Necrolysis have been reported with acetaminophen usage in the past. We present the case of a 40 years old lady who developed an overlap of the two condition after taking several doses of acetaminophen for fever. She presented with widespread maculopapular rash, stinging in the eyes, oral mucosal ulcerations and high grade fever. She was successfully treated with corticosteroid therapy along with the supportive treatment. This case addresses the fact, that severe hypersensitivity reactions can occur with acetaminophen which can be potentially life threatening.

Female consensual coital injuries.

OBJECTIVE: To ascertain the pattern and management strategies of coital injuries in married females in Pakistan. DESIGN: An observational, case series. PLACE AND DURATION OF STUDY: Gynaecology and Surgical wings - Fatima Medical Centre, Multan, over a period of seven years from January 1997 to December 2003. SUBJECTS AND METHODS: Records of 33 adult married females sustaining coital injuries were studied. Only married females were included. Injuries raising suspicion of indecent assault, sexual abuse and trauma were excluded. Results were recorded and analyzed. RESULTS: Three vulvar haematomas (9%) settled on conservative management. One labial (3%), 9 posterior fourchette (27%) and 16 vaginal wall lacerations (48%) were stitched. A broad ligament haematoma (3%) and a ruptured ovarian cyst (3%) were laparoscopically dealt with. One posterior fornix perforation (3%) with secondary peritonitis and a ruptured ectopic pregnancy (3%) with life-threatening haemorrhage underwent laparotomy. No mortality occurred in this series. CONCLUSION: Varied presentation of the coital injuries demand careful evaluation to help correct diagnosis, timely management and successful outcome with minimal morbidity.

Lateral internal anal sphincterotomy for anal fissure: with or without associated anorectal procedures.

OBJECTIVE: To confirm or refute the validity of the fear associated with anal sphincterotomy for anal fissure, particularly when performed with other anorectal procedures. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Surgical Wings - Medicare Hospital and Fatima Medical Center, Multan, over a period of 8 years from January 1994 to December 2001. SUBJECTS AND METHODS: Records of 112 anal fissure patients, 46 (41.0%) males and 66 (58.9%) females, ranging in age from 12-95 years (mean 39) were studied. All patients with acute or chronic anal fissures with or without other anorectal pathologies were included. Seventeen patients who had anal dilatation and 2 recurrent fissures were excluded. Open technique of anal sphincterotomy was employed in all cases. Results were recorded and analyzed. RESULTS: Fissures were acute in 16 (14.2 %) and chronic in 96 (85.7 %) patients. Anterior fissure was present in 20 (17.8%), posterior in 80 (71.4%), both in 9 (8.0%) and lateral or multiple fissures in 3 (2.6%) cases. Commonest associated pathology was haemorrhoids; encountered in 64 (57.1%) patients. Minor complications, taken together, occurred in 20 (17.8%) patients. Urinary retention was seen in 3 (2.6%) with lateral internal anal sphincterotomy (LIAS), and in 6 (5.3%) where haemorrhoidectomy was added. Haemorrhage in 2 (1.7%), temporary loss of flatus control in 3(2.6%) and soiling of clothes in 2 (1.7%) patients was encountered. No permanent loss of flatus or faecal control and recurrence has been reported to-date. CONCLUSION: Anal sphincterotomy with or without other anorectal procedures can be safely practiced in properly selected patients. Postoperatively, ablution with mild antiseptic added to plain water is adequate in maintaining hygiene to promote healing.