Safety and efficacy of REGENDIL™ infused hair growth promoting product in adult human subject having hair fall complaints (alopecia).

BACKGROUND: Hair serum is recommended therapy for the management of hair fall problems. People of all ages suffer from hair fall. AIM: To evaluate safety and efficacy of hair growth promoting product in healthy adult subjects with hair fall complaints (Alopecia). METHODS: In this safety and efficacy clinical study, 32 healthy individuals (aged 18-45 years) experiencing hair loss were enrolled. Participants applied 0.5 mL of the product to the affected scalp area daily for 60 days. The study evaluated various factors, including hair growth rate, thickness, density, scalp condition using CASLite-Nova, anagen-to-telogen ratio, hair fall reduction, overall hair and scalp appearance, hair strength, and participants' subjective perceptions of the product. RESULTS: Highly statistically significant improvement was observed in hair growth rate, thickness, and density at Day 30 and Day 60. Hair growth rate increased (p-value <0.01) by 10.52% in 30 days and 31.62% in 60 days after test product application. Average hair growth increased by 424.21 µm/day and 487.31 µm/day at Day 30 and 60 respectively. The hair growth improved by up to 1.5 times after 60 days of usage in healthy subjects with hair fall complaints. No adverse events or product-related adverse events were reported. CONCLUSION: Hair serum containing REGENDIL™ (Redensyl, AnaGain, Procapil, Capilia longa), and 5 kDa hyaluronic acid was efficacious and well tolerable in reducing hair fall (Alopecia). Hair serum significantly improved hair growth, hair density, hair thickness, and hair strength within 60 days of usage, thereby demonstrating it worth as a beneficial inclusion as a daily haircare product.

Successful percutaneous closure of aortic root-to-right ventricle fistula after transcatheter aortic valve implantation: a valuable option in high-risk surgical patients.

Background: Aortic-to-right ventricle (ARV) fistula is an uncommon complication of transcatheter aortic valve implantation (TAVI). Even though surgical closure is usually the treatment of choice in such communications, percutaneous treatment options are valuable alternatives for these high-risk surgical patients. Case summary: In this article, we present the percutaneous closure of an ARV fistula after TAVI, in a highly symptomatic patient with recurrent episodes of heart failure decompensation with worsening right ventricular function, who failed conservative medical treatment and was deemed inoperable. Successful closure of the fistula with the use of the Amplatzer atrial septal occluder was performed 6 months post-TAVI, under general anaesthesia and transoesophageal echocardiography (TOE). A detailed multi-modality imaging pre-procedural planning was performed utilizing 4D cardiac computed tomography and echocardiography. The patient has remained asymptomatic and in good health 5 months after the ARV fistula closure, with marked improvement in his clinical picture and echocardiographic parameters. Discussion: Aortic-to-right ventricle fistulas with significant shunt post-TAVI could lead to biventricular failure and are associated with increased mortality if left untreated. This case demonstrates that TOE-guided percutaneous closure of a TAVI-related ARV fistula, although technically challenging, is feasible, and can be a valuable option for the treatment of symptomatic high-risk surgical patients.

Impact of COVID-19 pandemic on the management of nonculprit lesions in patients presenting with ST-elevation myocardial infarction: Outcomes from the pan-London heart attack centers.

BACKGROUND: The impact of COVID-19 on the diagnosis and management of nonculprit lesions remains unclear. OBJECTIVES: This study sought to evaluate the management and outcomes of patients with nonculprit lesions during the COVID-19 pandemic. METHODS: We conducted a retrospective observational analysis of consecutive primary percutaneous coronary intervention (PPCI) pathway activations across the heart attack center network in London, UK. Data from the study period in 2020 were compared with prepandemic data in 2019. The primary outcome was the rate of nonculprit lesion percutaneous coronary intervention (PCI) and secondary outcomes included major adverse cardiovascular events. RESULTS: A total of 788 patients undergoing PPCI were identified, 209 (60%) in 2020 cohort and 263 (60%) in 2019 cohort had nonculprit lesions (p = .89). There was less functional assessment of the significance of nonculprit lesions in the 2020 cohort compared to 2019 cohort; in 8% 2020 cohort versus 15% 2019 cohort (p = .01). There was no difference in rates of PCI for nonculprit disease in the 2019 and 2020 cohorts (31% vs 30%, p = .11). Patients in 2020 cohort underwent nonculprit lesion PCI sooner than the 2019 cohort (p < .001). At 6 months there was higher rates of unplanned revascularization (4% vs. 2%, p = .05) and repeat myocardial infarction (4% vs. 1%, p = .02) in the 2019 cohort compared to 2020 cohort. CONCLUSION: Changes to clinical practice during the COVID-19 pandemic were associated with reduced rates of unplanned revascularization and myocardial infarction at 6-months follow-up, and despite the pandemic, there was no difference in mortality, suggesting that it is not only safe but maybe more efficacious.

Antimicrobial and self-crosslinking potential of experimentally developed dioctadecyldimethyl ammonium bromide and riboflavin dentin adhesive.

The aim of the study is to investigate a new formulation, based on dioctadecyldimethyl ammonium-bromide (QA) and riboflavin (RF), combining antimicrobial activities and protease inhibitory properties with collagen crosslinking without interference to bonding capabilities in a rabbit model. Quaternary ammonium riboflavin (QARF) experimental adhesives modified with dioctadecyldimethyl ammonium-bromide and riboflavin were bonded (0.5/1.0/2.0%) to rabbit dentin to investigate for pulpal-histology, interfacial-morphology, transmission electron microscopy, mechanical properties, collagen crosslinking, micro-Raman analysis, antimicrobial, and anti-protease activities. Collagen type-I molecules were generated using molecular-docking. Odontoblasts appeared with normal histology, were seen in controls with no inflammatory cells detected in 0.5% specimens at day 7 and mild inflammatory response at day 30. In QARF 2.0%, inflammatory cells were not detected at day 7 and 30 (p < .05). Dentinal tubules are seen with intact collagen surface in 1% specimens. Resin penetrated inside 1% adhesive specimens with few irregularly funnel-shaped tags. Transmission electron microscopy showed thinner collagen in all specimens except 1% QARF specimens. Biofilms were influenced by QARF adhesives. Elastic moduli were significantly higher in 1.0% and 2.0% QARF adhesive specimens with a significant increase in total crosslinks. Stable amide groups with anti-protease activity was observed in QARF groups. Charged residues were seen in the triple helix hCOL3A1, Gly489-Gly510 after stabilisation with formulation. The 1% QARF modified adhesives improved biochemical and biomechanical properties of rabbit dentin.

COVID-19 pandemic and STEMI: pathway activation and outcomes from the pan-London heart attack group.

OBJECTIVES: To understand the impact of COVID-19 on delivery and outcomes of primary percutaneous coronary intervention (PPCI). Furthermore, to compare clinical presentation and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) with active COVID-19 against those without COVID-19. METHODS: We systematically analysed 348 STEMI cases presenting to the PPCI programme in London during the peak of the pandemic (1 March to 30 April 2020) and compared with 440 cases from the same period in 2019. Outcomes of interest included ambulance response times, timeliness of revascularisation, angiographic and procedural characteristics, and in-hospital clinical outcomes RESULTS: There was a 21% reduction in STEMI admissions and longer ambulance response times (87 (62-118) min in 2020 vs 75 (57-95) min in 2019, p<0.001), but that this was not associated with a delays in achieving revascularisation once in hospital (48 (34-65) min in 2020 vs 48 (35-70) min in 2019, p=0.35) or increased mortality (10.9% (38) in 2020 vs 8.6% (38) in 2019, p=0.28). 46 patients with active COVID-19 were more thrombotic and more likely to have intensive care unit admissions (32.6% (15) vs 9.3% (28), OR 5.74 (95%CI 2.24 to 9.89), p<0.001). They also had increased length of stay (4 (3-9) days vs 3 (2-4) days, p<0.001) and a higher mortality (21.7% (10) vs 9.3% (28), OR 2.72 (95% CI 1.25 to 5.82), p=0.012) compared with patients having PPCI without COVID-19. CONCLUSION: These findings suggest that PPCI pathways can be maintained during unprecedented healthcare emergencies but confirms the high mortality of STEMI in the context of concomitant COVID-19 infection characterised by a heightened state of thrombogenicity.

Experience with Haemorrhoidal artery ligation under direct vision at a tertiary care hospital: A case series.

This study aims to share the results of haemorrhoidal artery ligation under direct vision in the management of symptomatic haemorrhoids. We conducted a case series of 70 patients at Combined Military Hospital Rawalpindi & Quetta, from January 2015 to October 2017. All patients underwent Haemorrhoidal Artery Ligation (HAL) and Recto Anal Repair (RAR). Ligation of superior haemorrhoidal artery was done under direct vision following manual palpation. Patients were followed up postoperatively at 1, 3 and 6 months. At 1 month follow up, all 70 (100%) patients were pain free. Post operative bleeding was observed in 7 (10%) patients but did not require surgical intervention. Sixty two (89%) patients were able to return to their daily activities 1 week after surgery and 57 (81%) resumed military duties or joined their work place at 2 weeks. 70 (100%) patients were asymptomatic and 45 (64%) highly satisfied with their surgery at 3 months. This increased to 53 (75%) at 6 months. 48 (69%) said that they would recommend this procedure to someone else. Prolapse recurrence was observed in 1(1.42%) patient 6 months post operatively which was dealt by band ligation. All patients completed follow-up at 1, 3 and 6 months. HAL is a simple yet safe technique with few complications, acceptable patient satisfaction and early return to work.

Characteristics and Outcomes of Hospitalized Young Adults with Mild Covid -19.

BACKGROUND: Stormy course has been reported among hospitalized adults with COVID-19 in high- and middle-income countries. To assess clinical outcomes in consecutively hospitalized patients with mild covid-19 in India we performed a study. METHODS: We developed a case registry of successive patients admitted with suspected covid-19 infection to our hospital (n=501). Covid-19 was diagnosed using reverse transcriptase polymerase chain reaction (RT-PCR). Demographic, clinical, investigations details and outcomes were recorded. Descriptive statistics are presented. RESULTS: Covid-19 was diagnosed in 234 (46.7%) and data compared with 267 (53.3%) negative controls. Mean age of covid-19 patients was 35.1±16.6y, 59.4% were <40y and 64% men. Symptoms were in less than 10% and comorbidities were in 4-8%. History of BCG vaccination was in 49% cases vs 10% controls. Cases compared to controls had significantly greater white cell (6.96+1.89 vs 6.12+1.69x109 cells/L) and lower lymphocyte count (1.98+0.79 vs 2.32+0.91x109 cells/L). No radiological and electrocardiographic abnormality was observed. All these were isolated or quarantined in the hospital and observed. Covid-19 patients received hydroxychloroquine and azithromycin according to prevalent guidelines. One patient needed oxygen support while hospital course was uncomplicated in the rest. All were discharged alive. Conversion to virus negative status was in 10.2±6.4 days and was significantly lower in age >40y (9.1±5.2) compared to 40-59y (11.3±6.1) and ≥60y (16.4±13.3) (p=0.001). CONCLUSIONS: This hospital-based registry shows that mildly symptomatic or asymptomatic young covid-19 patients have excellent prognosis.

Atrial fibrillation: a leading cause of heart failure-related hospitalizations; a dual epidemic.

BACKGROUND: Atrial fibrillation (AF), and heart failure (HF) are a major cardiovascular epidemic over the last decade. The prevalence and rehospitalization of heart failure are on rising edge, and many factors are responsible for these re-exacerbations of heart failure. In this study, we sought to determine an association of a risk factor for frequent rehospitalization of heart failure at our institute. We aimed to find the re-admission rate, heart rate, and rhythm of heart failure exacerbation. METHODS: We performed a single-center retrospective study at the Abington Hospital - Jefferson health and 418 patients having a history of heart failure, and AF were selected. The heart failure readmission rate (days), heart rate, and rhythm were analyzed. RESULTS: The mean age of the included population was 82.8 years SD ± 9.2. About 53% had AF with a mean heart rate 90 SD ± 21 bpm, and 47% had normal sinus rhythm (NSR) with a mean heart rate of 78 ± 16 bpm on re-admission. This difference was statistically significant (p=0.02). The mean re-admission rate for atrial fibrillation was 27.49 days SD ± 18.97, compared to 32.68 SD ± 20.26 days for NSR, statistically significant (p=0.007) and the Pearson Chi-square was also significant P = 0.006. CONCLUSION: There is a significantly increased rate of re-admission in heart failure patients with atrial fibrillation with a rapid ventricular rate. Efforts should be taken to keep the patient in NSR or controlled AF to minimize the rehospitalization rate, and this, in turn, reduces the financial burden on patients and institutes.

Gitelman Syndrome: A Rare Cause of Seizure Disorder and a Systematic Review.

Gitelman syndrome is one of the few inherited causes of metabolic alkalosis due to salt losing tubulopathy. It is caused by tubular defects at the level of distal convoluted tubules, mimicking a thiazide-like tumor. It usually presents in late childhood or in teenage as nonspecific weakness, fatigability, polyuria, and polydipsia but very rarely with seizures. It is classically associated with hypokalemia, hypomagnesemia, hypocalciuria, hyperreninemia, and hyperaldosteronism. However, less frequently, it can present with normal magnesium levels. It is even rarer to find normomagnesemic patients of GS who develop seizures as the main complication since hypomagnesemia is considered the principal etiology of abnormal foci of seizure-related brain activity in GS cases. Interestingly, patients with GS are oftentimes diagnosed during pregnancy when the classic electrolyte pattern consistent with GS is noticed. Our case presents GS with normal serum magnesium in a patient, with seizures being the main clinical presentation. We also did a comprehensive literature review of 122 reported cases to show the prevalence of normal magnesium in GS cases and an overview of clinical and biochemical variability in GS. We suggest that further studies and in-depth analysis are required to understand the pathophysiology of seizures in GS patients with both normal and low magnesium levels.

Cost-effectiveness of a management strategy based on exercise echocardiography versus exercise electrocardiography in patients presenting with suspected angina during long term follow up: A randomized study.

INTRODUCTION: Exercise ECG (Ex-ECG) is advocated by guidelines for patients with low - intermediate probability of coronary artery disease (CAD). However, there are no randomized studies comparing Ex-ECG with exercise stress echocardiography (ESE) evaluating long term cost-effectiveness of each management strategy. METHODS: Accordingly, 385 patients with no prior CAD and low-intermediate probability of CAD (mean pre-test probability 34%), were randomized to undergo either Ex-ECG (194 patients) or ESE (191 patients). The primary endpoint was clinical effectiveness defined as the positive predictive value (PPV) for the detection of CAD of each test. Cost-effectiveness was derived using the cumulative costs incurred by each diagnostic strategy during a mean of follow up of 3.0 years. RESULTS: The PPV of ESE and Ex-ECG were 100% and 64% (p = 0.04) respectively for the detection of CAD. There were fewer clinic (31 vs 59, p < 0.01) and emergency visits (14 vs 30, p = 0.01) and lower number of hospital bed days (8 vs 29, p < 0.01) in the ESE arm, with fewer patients undergoing coronary angiography (13.4% vs 6.3%, p = 0.02). The overall cumulative mean costs per patient were £796 for Ex-ECG and £631 for ESE respectively (p = 0.04) equating to a >20% reduction in cost with an ESE strategy with no difference in the combined end-point of death, myocardial infarction, unplanned revascularization and hospitalization for chest pain between ESE and Ex-ECG (3.2% vs 3.7%, p = 0.38). CONCLUSION: In patients with low to intermediate pretest probability of CAD and suspected angina, an ESE management strategy is cost-effective when compared with Ex-ECG during long term follow up.

Diagnostic Concordance and Clinical Outcomes in Patients Undergoing Fractional Flow Reserve and Stress Echocardiography for the Assessment of Coronary Stenosis of Intermediate Severity.

BACKGROUND: The ischemic consequences of coronary artery stenosis can be assessed by invasive fractional flow reserve (FFR) or by noninvasive imaging. We sought to determine (1) the concordance between wall thickening assessment during clinically indicated stress echocardiography (SE) and FFR measurements and (2) the factors associated with hard events in these patients. METHODS: Two hundred twenty-three consecutive patients who underwent SE and invasive FFR measurements in close succession were analyzed retrospectively for diagnostic concordance and clinical outcomes. RESULTS: At the vessel level, the sensitivity, specificity, positive predictive value, and negative predictive value of SE for identifying significant disease as assessed by FFR was 68%, 75%, 43%, and 89%, respectively. The greatest discordance was seen in patients with wall thickening abnormalities (WTAs) and negative FFR. During a follow-up of 3.6 ± 2.2 years, there were 23 cardiovascular (CV) events (death and nonfatal myocardial infarction). The number of wall segments with inducible WTAs emerged as the strongest factor associated with CV events (hazard ratio, 1.18 [1.05-1.34]; P = .008). FFR was not associated with outcome. There was a significant increase in event rate in patients with WTA/negative FFR versus no WTA/negative FFR (P = .01), but no significant difference versus WTA/positive FFR (P = .85). CONCLUSIONS: In a patient population with significant CV risk factors, a normal SE had a high negative predictive value for excluding abnormal FFR. WTAs were associated with outcomes regardless of FFR value, suggesting that this is a superior marker of ischemia to FFR.

The Effect of Honey on Radiation-induced Oral Mucositis in Head and Neck Cancer Patients.

AIM: The aim of this study is to evaluate the effect of honey on clinically scoring grades of oral mucositis. MATERIALS AND METHODS: This interventional study was carried out in Radiation Oncology Department of Mayo Hospital, Lahore. In this study, 82 patients of both genders, of head and neck cancer, planned for radiotherapy, were divided into two groups by random sampling numbers. Patients in both groups were treated with a total dose of 60-78 Grays in 4-6 weeks. In treatment group, patients were instructed to take 20 mL of honey. In control group, they were advised to rinse with 0.9% of saline. Patients were evaluated every week to assess the grades of oral mucositis up to 6 weeks. The assessment tool was Radiation Therapy Oncology Group Grading System. The statistical analysis was done by Chi-square test. RESULTS: In honey-treated group, the proportion of mucositis (Grades 3 and 4) was lower and statistically significant as compared to control group at the end of 6 weeks of radiation. CONCLUSION: This study showed that oral intake of honey during radiotherapy is valuable in the reduction of severity of oral mucositis.

Synthesis of novel 5-(aroylhydrazinocarbonyl)escitalopram as cholinesterase inhibitors.

A novel series of 5-(aroylhydrazinocarbonyl)escitalopram (58-84) have been designed, synthesized and tested for their inhibitory potential against cholinesterases. 3-Chlorobenzoyl- (71) was found to be the most potent compound of this series having IC50 1.80 ± 0.11 µM for acetylcholinesterase (AChE) inhibition. For the butyrylcholinesterase (BChE) inhibition, 2-bromobenzoyl- (76) was the most active compound of the series with IC50 2.11 ± 0.31 µM. Structure-activity relationship illustrated that mild electron donating groups enhanced enzyme inhibition while electron withdrawing groups reduced the inhibition except o-NO2. However, size and position of the substituents affected enzyme inhibitions. . In docking study of AChE, the ligands 71, 72 and 76 showed the scores of 5874, 5756 and 5666 and ACE of -64.92,-203.25 and -140.29 kcal/mol, respectively. In case of BChE, ligands 71, 76 and 81 depicted high scores 6016, 6150 and 5994 with ACE values -170.91, -256.84 and -235.97 kcal/mol, respectively.

Relative clinical and economic impact of exercise echocardiography vs. exercise electrocardiography, as first line investigation in patients without known coronary artery disease and new stable angina: a randomized prospective study.

AIMS: Exercise electrocardiography (ExECG) is widely used in suspected stable angina (SA) as the initial test for the evaluation of coronary artery disease (CAD). We hypothesized that exercise stress echo (ESE) would be efficacious with cost advantage over ExECG when utilized as the initial test. METHODS AND RESULTS: Consecutive patients with suspected SA, without known CAD were randomized into ExECG or ESE. Patients with positive tests were offered coronary angiography (CA) and with inconclusive tests were referred for further investigations. All patients were followed-up for cardiac events (death, myocardial infarction, and unplanned revascularization). Cost to diagnosis of CAD was calculated by adding the cost of all investigations, up to and including CA. In the 194 and 191 patients in the ExECG vs. ESE groups, respectively, pre-test probability of CAD was similar (34 ± 23 vs. 35 ± 25%, P = 0.6). Results of ExECG were: 108 (55.7%) negative, 14 (7.2%) positive, 72 (37.1%) inconclusive and of ESE were 181 (94.8%) negative, 9 (4.7%) positive, 1 (0.5%) inconclusive, respectively. Patients with obstructive CAD following positive ESE vs. Ex ECG were 9/9 vs. 9/14, respectively (P = 0.04). Cost to diagnosis of CAD was £266 for ESE vs. £327 for ExECG (P = 0.005). Over a mean follow-up period of 21 ± 5 months, event rates were similar between the two groups. CONCLUSION: In this first randomized study, ESE was more efficacious and demonstrated superior cost-saving, compared with ExECG when used as the initial investigation for the evaluation of CAD in patients with new-onset suspected SA without known CAD.

The clinical efficacy and long-term prognostic value of stress echocardiography in octogenarians.

INTRODUCTION: Although stress echocardiography (SE) is invaluable in younger populations, its prognostic value may be attenuated in the elderly due to shorter life expectancy and the frequent presence of severe comorbidities. This study sought to evaluate the clinical effectiveness of SE in octogenarians, particularly its prognostic value over clinical variables, in predicting hard events. METHODS: A total of 374 consecutive octogenarians who underwent SE for evaluation of coronary artery disease (CAD) were assessed for feasibility, diagnostic accuracy and safety of the test, and followed up for hard outcomes (all-cause mortality, cardiovascular (CV) deaths and non-fatal myocardial infarction (NFMI)). Cox regression analysis was performed to identify predictors of outcome. RESULTS: Of the 374 tests, 360 (96.3%) were diagnostic. Of the 50 patients with inducible ischaemia, 33 patients (66%) proceeded to angiography of which 27 (82%) patients had significant CAD. During long-term follow-up of 4.0±2.0 years, there were 127 deaths and 36 NFMIs. The annualised mortality, NFMI and combined mortality /NFMI rates were 8.1%, 1.8% and 9.4% for patients with a normal SE and 12.1%, 5.5% and 14.1% for those with an abnormal SE, respectively. Predictors of NFMI on multivariate analysis were prior CAD (HR 2.89, CI 1.03 to 8.15, p=0.045), peripheral vascular disease (HR 3.33, CI 1.18 to 9.45, p=0.02), and inducible ischaemia (HR 3.97, CI 1.49 to 10.55, p=0.006). In patients without prior history of CAD, inducible ischaemia was the only independent predictor of NFMI (HR 8.72, CI 1.46 to 52.2, p=0.018). The larger the extent of ischaemia, the greater the incidence of NFMI. The independent predictors of CV events (NFMI or CV mortality) were PAD (HR 2.81, CI 1.21 to 6.52, p=0.016) and peak wall motion score index (HR 5.71, CI 1.67 to 19.6, p=0.006). Although inducible ischaemia predicted all-cause mortality on unadjusted analysis, it did not on multivariate analysis. CONCLUSIONS: In octogenarians, SE demonstrated excellent feasibility, safety and diagnostic accuracy. SE parameters were independent predictors of NFMI and CV events, and the presence of inducible ischaemia was associated with a 50% increase in all-cause mortality.

Relative diagnostic, prognostic and economic value of stress echocardiography versus exercise electrocardiography as initial investigation for the detection of coronary artery disease in patients with new onset suspected angina.

OBJECTIVES: We hypothesised that stress echocardiography (SE), may be superior to exercise ECG (ExECG), for predicting CAD and outcome, and cost-beneficial, when performed as initial investigation in newly suspected angina. METHODS: All patients seen in 2011, with suspected angina, no history of CAD, pre-test likelihood of CAD of > 10% and who underwent SE or ExECG as first line were identified retrospectively. Cost to diagnosis was calculated by adding the cost of all tests, up to and including coronary angiography (CA), on an intention-to-treat basis. Follow-up data on cardiac death and myocardial infarction (MI) were collected, 26 months after the presentation of the last study patient. RESULTS: A total of 456 patients underwent ExECG (224 (49%) negative, 93 (20%) positive, 139 (31%) inconclusive) and 241 underwent SE (200 (83%) negative, 35 (15%) positive, 6 (2%) inconclusive) as first line. In patients subsequently undergoing CA, CAD was present in 46% (37/80) of patients with positive ExECG vs. 72% (23/32) patients with positive SE (p = 0.01). Mean cost to diagnosis was £456 for the ExECG vs. £360 for the SE group (p = 0.002). Over a mean follow-up period of 31 ± 5 months, cardiac events were 2% each in negative SE vs. negative ExECG (p = 0.9). CONCLUSIONS: SE is superior to ExECG for prediction of CAD and is cost-beneficial when used as initial test in patients with no history of CAD presenting with suspected angina.

The benefits of revascularization in chronic heart failure.

Recent efforts have reduced the mortality from coronary artery disease (CAD), with the consequent increase in heart failure with reduced left ventricular function, referred to as ischaemic cardiomyopathy (ICM). As ischemic left ventricular (LV) dysfunction may be partially or completely reversible by revascularization in the presence of viable myocardium, the assessment of myocardial viability is central to the management of ICM. Decades of observational analyses have provided positive evidence for the role of revascularization in hibernating myocardium in improving survival. However, recently the Surgical Treatment for Ischaemic Heart Failure (STICH) trial has challenged this notion, highlighting the noninferiority of optimal medical therapy (OMT) over revascularization and OMT. In this review, we discuss noninvasive imaging modalities to assess myocardial viability and the impact of myocardial viability on revascularization. We critically appraise the STICH trial and suggest an algorithm for viability testing before revascularization in patients with ICM and significant LV dysfunction.

Inequity aversion and the evolution of cooperation.

Evolution of cooperation is a widely studied problem in biology, social science, economics, and artificial intelligence. Most of the existing approaches that explain cooperation rely on some notion of direct or indirect reciprocity. These reciprocity based models assume agents recognize their partner and know their previous interactions, which requires advanced cognitive abilities. In this paper we are interested in developing a model that produces cooperation without requiring any explicit memory of previous game plays. Our model is based on the notion of inequity aversion, a concept introduced within behavioral economics, whereby individuals care about payoff equality in outcomes. Here we explore the effect of using income inequality to guide partner selection and interaction. We study our model by considering both the well-mixed and the spatially structured population and present the conditions under which cooperation becomes dominant. Our results support the hypothesis that inequity aversion promotes cooperative relationship among nonkin.

An unusual case of urinary incontinence in a female child.

We report a case of a 3-year-old female child presenting with continuous urinary incontinence since birth. After relevant investigations, a diagnosis of bilateral single-system ectopic ureters into a vaginalized urogenital sinus was made. We discuss the extreme rarity of the case, importance of an accurate history, along with various treatment options.