Cardiology Consultation Research Articles

Opportunistic screening for atrial fibrillation in hypertensive patients using a mobile application (prospective study of 160 cases)

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia,affecting between 1-4% of the general population and responsible for 10-20% of strokes. New technologies are now available for screening for AF,but their implementation in real clinical settings has not yet been fully investigated. Purpose -evaluate the electrocardiogram recordings on smartphones intended for screening for AF using the KardiaMobile device, with a dedicated mobile application. - Highlight the prevalence of AF in a moroccan hypertensive population -Evaluate the effectiveness of computerized screening for AF in therapeutic management Methods Prospective screening for AF in patients aged 55 or over,known to be hypertensive for at least 5 years, was performed at the cardiology consultation services between June 2019-July 2020.A single lead ECG was acquired by placing the fingers of each hand on the electrodesThe diagnosis of the Kardia app was assessed by the consultation cardiologist,and a baseline ECG was performed for each suspected arrhythmia.CHA2DS2-VASc score was collected from each patient. Results A total of 160 ECGs were performed.The diagnosis of the Kardia app was provided in 93% of cases.A heart rhythm described as normal was detected in 120 consultants,AFwas suspected in 8.1% of the patients described by the device as ‘possible AF’,and confirmed by a baseline ECG in 7.5% of the patients screened. Anti-coagulation was started in 6.2% of patients. Conclusion Mobile Device for screening for atrial fibrillation in a population at risk is a promising, inexpensive tool with significant prognostic benefit for the prevention of cardiovascular complications The Kardia app is able to quickly filter and detect atial fibrillation with high sensitivity and specificity.

A report from the Irish women in cardiology survey, exploring Europe's largest gender gap in cardiology.

AimsIn Ireland, 8% of public cardiology consultants are female; this is the lowest proportion in Europe. We sought to understand perceptions amongst Irish trainees and consultants regarding aspects of working in cardiology in order to identify areas that can be targeted to improve gender equality.Methods and ResultsIn September 2021, the Irish Cardiac Society distributed a questionnaire to trainees and consultants in the Republic and Northern Ireland. Ethical approval was obtained from the University College Dublin, Ireland. There were 94 respondents (50% male, 50% consultants) which equates to ∼30% of all trainees and consultants in all Ireland. Although females were more likely to be single, overall, they had additional child-care responsibilities compared with male counterparts. Despite 53% of the respondents preferring to work less than full time, 64% reported a perceived lack of support from their departments. Males were significantly more likely to go into procedural/high radiation sub-specialities. Bullying was reported by 53% of females. Almost 80% of females experienced sexism and 30% reported being overlooked for professional advancement based on their sex. Females also rated their career prospects lower than males. Key challenges for women were: sexism, maternity leave/child-care responsibilities, cardiology as a ‘boys club’ and lack of flexible training. There was interest from both males and females in a mentorship programme and support for women in leadership positions.ConclusionDiscrimination including sexism, bullying, and equal opportunity for professional advancement are key aspects that need to be addressed to improve gender balance in cardiology within Ireland and Northern Ireland.

Frequency of Thyroid Dysfunction in Heart Failure Patients with Reduced Ejection Fraction

Objective: To look for the frequency of thyroid dysfunction in heart failure patients with reduced ejection fraction at Medicine/Cardiology Department.
 Study Design: Cross-sectional study.
 Place and Duration of Study: Combined Military Hospital Sialkot, from Nov 2019 to Apr 2020.
 Methodology: The sample population comprised of patients diagnosed with the heart failure and ejection fraction of 40% at Medicine/Cardiology unit. Patients underwent thyroid functions test from the laboratory of our hospital and were diagnosed as hypothyroid, hyperthyroid or euthyroid by consultant cardiologist and medical specialist. Age, gender, body mass index and New York heart association (NYHA) class were associated with thyroid dysfunction among the study participants.
 Results: Out of 110 patients with heart failure and low ejection fraction who underwent thyroid function testing during the study period, 92 (83.6%) patients were euthyroid, 14 (12.7%) had thyroid profile parameters showing hypothyroidism, while 04 (3.6%) had laboratory findings of hyperthyroidism. After chi-square, we found that patients with New York heart association class III and IV and high body mass index had a statistically significant relationship with thyroid dysfunction (pvalue 0.017 and <0.001 respectively) among the patients of heart failure with low ejection fraction.
 Conclusion: Thyroid dysfunction, especially hypothyroidism, emerged as a common finding among heart failure patients with low ejection fraction. Patients with New York heart association class III and IV and high body mass index should be considered high-risk and may be screened for thyroid problems if present with heart failure

Lung Ultrasound Characteristics in Neonates With Positive Real Time Polymerase Chain Reaction for SARS-CoV-2 on a Tertiary Level Referral Hospital in Mexico City.

IntroductionAcute respiratory syndrome secondary to SARS-CoV-2 virus infection has been declared a pandemic since December 2019. On neonates, severe presentations are infrequent but possible. Lung ultrasound (LUS) has been shown to be useful in diagnosing lung involvement and following up patients, giving more information, and reducing exposure compared to traditional examination.MethodsLUS was performed after the diagnosis of SARS-CoV-2 infection with respiratory Real Time Polymerase Chain Reaction RT-PCR with portable equipment protected with a silicone sleeve. If hemodynamic or cardiology consultation was necessary, a prepared complete ultrasound machine was used. Ten regions were explored (anterior superior and inferior, lateral, and posterior superior and inferior, right and left), and a semiquantitative score (LUSS) was calculated. Disease severity was determined with a pediatric modified score.ResultsThirty-eight patients with positive RT-PCR were admitted, 32 (81%) of which underwent LUS. Included patients had heterogenous diagnosis and gestational ages as expected on a referral neonatal intensive care unit (NICU) (median, ICR: 36, 30–38). LUS abnormalities found were B-line interstitial pattern 90%, irregular/interrupted/thick pleural line 88%, compact B-lines 65%, small consolidations (≤5 mm) 34%, and extensive consolidations (≥5 mm) 37%. Consolidations showed posterior predominance (70%). LUSS showed a median difference between levels of disease severity and ventilatory support (Kruskal–Wallis, p = 0.001) and decreased with patient improvement (Wilcoxon signed-rank test p = 0.005). There was a positive correlation between LUSS and FiO2 needed (Spearman r = 0.72, p = 0.01). The most common recommendation to the attending team was pronation (41%) and increase in positive end expiratory pressure (34%). Five patients with comorbidities died. A significant rank difference of LUSS and FiO2 needed between survivors and non-survivors was found (Mann–Whitney U-test, p = 0.005).ConclusionLUS patterns found were like the ones described in other series (neonatal and pediatrics). Eighty-eight percent of the studies were performed with handheld affordable equipment. While there is no specific pattern, it varies according to gestational age and baseline diagnosis LUS, which were shown to be useful in assessing lung involvement that correlated with the degree of disease severity and respiratory support.

Lean Management Approach for Reengineering the Hospital Cardiology Consultation Process: A Report from AORN "A. Cardarelli" of Naples.

Background: Consultations with specialists are essential for safe and high-quality care for all patients. Cardiology consultations, due to a progressive increase in cardiology comorbidities, are becoming more common in hospitals prior to any type of treatment. The appropriateness and correctness of the request, the waiting time for delivery and the duration of the visit are just a few of the elements that can affect the quality of the process. Methods: In this work, a Lean approach and Telemedicine are used to optimize the cardiology consultancy process provided by the Cardiology Unit of “Antonio Cardarelli” Hospital of Naples (Italy), the largest hospital in the southern Italy. Results: The application of corrective actions, with the introduction of portable devices and telemedicine, led to a reduction in the percentage of waiting for counseling from 29.6% to 18.3% and an increase in the number of patients treated. Conclusions: The peculiarity of the study is to apply an innovative methodology such as Lean Thinking in optimizing the cardiology consultancy process, currently little studied in literature, with benefits for both patients and medical staff.

Supermarket/Hypermarket Opportunistic Screening for Atrial Fibrillation (SHOPS-AF): A Mixed Methods Feasibility Study Protocol.

Aims: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a key risk factor for ischaemic stroke. Following AF detection, treatment with oral anticoagulation can significantly lower mortality and morbidity rates associated with this risk. The availability of several hand-held devices which can detect AF may enable trained health professionals to adopt AF screening approaches which do not interfere with people’s daily routines. This study aims to investigate the effectiveness of a hand-held device (the MyDiagnostick single-lead Electrocardiogram (ECG) sensor) in screening for AF when embedded into the handles of supermarket trolleys. Methods: A mixed methods two-phase approach will be taken. The quantitative first phase will involve the recruitment of 2000 participants from a convenience sample at four large supermarkets with pharmacies. Prospective participants will be asked to conduct their shopping using a trolley embedded with a MyDiagnostick sensor. If the device identifies a participant with AF, the in-store pharmacist will be dispatched to take a manual pulse measurement and a static control sensor reading and offer a cardiologist consultation referral. When the sensor does not detect AF, a researcher will confirm the reading with a manual pulse measurement. ECGs will be compiled, and the sensitivity, specificity and positive and negative predictive values will be determined. A qualitative second phase will consist of semi-structured interviews carried out with those pharmacists and store managers in-store during the running of the trial period. These will explore the perceptions of staff regarding the merits of embedding sensors in the handles of supermarket trolleys to detect AF. Conclusion: This feasibility study will inform a larger future definitive trial.

Electrocardiography Adverse Effects Systemic Glucantime in a Child With Cutaneous Leishmaniosis: A Case Report and Brief Review

Background: Antimonial compounds are the most common choice for the treatment of cutaneous Leishmaniosis (CL). Antimonial toxicities are common and cardiac toxicity is one of them, which leads to the electrocardiogram (ECG) changes. In this study, ECG changes in a patient with CL, who received systemic glucantime, were evaluated. Objectives: A 7-year-old girl was admitted to Amir-Kabir Hospital with the complaint of skin lesions (CL) on her left leg from ten months ago. The patient had received glucantime (10-20mg/kg/day) as a treatment for two 15-day periods and unfortunately, she had not responded to the treatment. Due to the cardiac side effects of glucantime, cardiology consultation was requested and an ECG was performed for the patients during the administration of treatment for the third time. Several ECG changes were detected, including first-degree block, right bundle branch block (RBBB), and QTc prolongation. The cardiologist stopped the treatment with glucantime to improve the ECG changes, and an ECG was taken every week. Even though prolonged QT interval and RBBB improved after a month, the first-degree block was present for ten months. Conclusions: ECG monitoring is necessary prior to and during the treatment with this drug. Moreover, RBBB has not been commonly reported in other studies. Thus, it should be considered as one of the cardiac side effects of glucantime and needs more attention.

Isolated fetal pericardial effusion follow-up: Should we worry?

Introduction and objectivesFetal pericardial effusion appears in different pathologies such as hydrops fetalis, heart structural or rhythm alterations, however, it can be observed in isolation but an increase in its incidence has been observed in relation to the presence of severe pathologies. MethodsAnalysis of all cases of IFPE detected in Aragon and assessed in a cardiological consultation for prenatal diagnosis of a tertiary hospital collected over ten years, as well as the evolution of the patients to the present. ResultsA sample of 38 fetuses was obtained from 37 pregnant women diagnosed with DPFA with spontaneous resolution in 86.8%. Two abortions (voluntary interruptions after prenatal diagnosis of 22q13 deletion and primary infection by cytomegalovirus) and one spontaneous fetal death were recorded. Pathological alterations were observed in 10/38 newborns: two patients with metabolic disease, two patients with chromosomopathies, one patient with pulmonary hypoplasia and unilateral hydronephrosis, one patient with hypertrophic cardiomyopathy, and four patients studied for alterations in psychomotor development and/or congenital ophthalmological or hearing disorders. The overall morbidity rate was 34.2% and death rate 15.7%. The detection of other ultrasound alterations and the alteration in the first trimester screening were significantly associated with the presence of pathology. ConclusionsIFPE has been classically associated with a good prognosis, although it is sometimes related to clinical entities with high morbidity and mortality: more than a third of the patients in our sample are affected. An exhaustive pre and postnatal follow-up of these cases is recommended in order to perform an early intervention.

Disease burden of cardiovascular conditions complicating pregnancy in Sri Lanka: a protocol

Background Cardiovascular diseases (CVD) are the commonest indirect medical cause of maternal deaths worldwide, both in high-income and low and middle-income countries. To minimize the effects of CVD in pregnancy, proper risk assessment and appropriate referral is required. In Sri Lanka, cardiovascular disease complicating pregnancy is a significant cause of maternal mortality, second only to postpartum hemorrhage. Screening for CVD in pregnancy in Sri Lanka is limited to a routine clinical assessment. Evidence-based guidelines are yet to be developed, and this deficit may have resulted in a substantial underestimation of the CVD burden. This study aims to determine the burden of CVD in early pregnancy and develop a risk prediction model to be used in field pregnancy clinics in Sri Lanka to reduce CVD effects in pregnancy. Methods A prospective cohort study was carried out in the Anuradhapura district, Sri Lanka. Following registration to the antenatal care, pregnant women fulfilling the eligibility criteria were invited to attend a special clinic at their relevant Medical Officer of Health (MOH) area. Risk assessment was done through history and a clinical examination, and suspected/probable cases were referred for an echocardiogram by a consultant cardiologist. All the recruited participants in the first trimester were prospectively followed up and screened again between 24–28 weeks of the period of amenorrhoea (POA). Antenatal ward admissions with CVD complicating pregnancy will be extracted, and a telephone interview will be carried out between 6–12 weeks after the expected delivery date to cover postpartum morbidities. Discussion This proposed study will be the largest of its kind carried out in the local setting. The study's findings will be beneficial for policymakers to develop guidelines to reduce maternal cardiovascular disease morbidities and mortalities in Sri Lanka.

Cardiovascular imaging following perioperative myocardial infarction/injury

Patients developing perioperative myocardial infarction/injury (PMI) have a high mortality. PMI work-up and therapy remain poorly defined. This prospective multicenter study included high-risk patients undergoing major non-cardiac surgery within a systematic PMI screening and clinical response program. The frequency of cardiovascular imaging during PMI work-up and its yield for possible type 1 myocardial infarction (T1MI) was assessed. Automated PMI detection triggered evaluation by the treating physician/cardiologist, who determined selection/timing of cardiovascular imaging. T1M1 was considered with the presence of a new wall motion abnormality within 30 days in transthoracic echocardiography (TTE), a new scar or ischemia within 90 days in myocardial perfusion imaging (MPI), and Ambrose-Type II or complex lesions within 7 days of PMI in coronary angiography (CA). In patients with PMI, 21% (268/1269) underwent at least one cardiac imaging modality. TTE was used in 13% (163/1269), MPI in 3% (37/1269), and CA in 5% (68/1269). Cardiology consultation was associated with higher use of cardiovascular imaging (27% versus 13%). Signs indicative of T1MI were found in 8% of TTE, 46% of MPI, and 63% of CA. Most patients with PMI did not undergo any cardiovascular imaging within their PMI work-up. If performed, MPI and CA showed high yield for signs indicative of T1MI.Trial registration:https://clinicaltrials.gov/ct2/show/NCT02573532.

Prolongation of QTc interval due to increased parity and great grand multiparity

Women are more prone to cardiac arrhythmias. Increased exposure to sex hormones may alter the ventricular repolarisation of the heart as the parity number increases. In this study, we aim to investigate the effect of parity number to electrocardiographic parameters. A total of 205 adult women were included for the study. Nulliparous (NP), primiparous (PP), multiparous (MP), grand multiparous (GMP) and great grand multiparous (GGMP) women constituted the study population. Increased parity has positive correlation with QTc interval (p=.000, r = 0.303). GGMP has significantly higher QTc compared to NP, PP, MP and GMP (p=.001, p=.000, p=.004 and p=.007, respectively). GGMP and parity have explanatory power on QTc (p=.019 and p=.020, respectively). Parity and GGMP affect cardiac repolarisation and prolong the QTc interval most probably due to repeated exposure to sex hormones. This study showed that GGMP and parity are independent risk factors for QTc interval prolongation. Impact Statement What is already known on this subject? Increased exposure to sex hormones may alter the ventricular repolarisation of the heart as the parity number increases. Previous studies showed that increased parity (up to 7) deteriorates ventricular diastolic functions, prolongs QTc interval and these conditions cause cardiovascular diseases. What do the results of this study add? In this study, we added great grand multiparity (10 or more parity) (GGMP) group that have never been studied before. We found that GGMP has much more impact on QTc prolongation than fewer parity groups and this result shows us that GGMP deteriorates ventricular functions more. What are the implications of these findings for clinical practice and/or further research? These results show us that women should be discouraged from having more delivery. Also, women with a pregnancy history of five and more (grand multiparity) should be evaluated with an electrocardiography and a cardiology consultation should be performed before re-conception. In the future, larger prospective studies are needed on this subject. In addition, other electrocardiographic parameters (QRS-T angle and Tpe/QTc in electrocardiography, etc.) that related with diastolic functions should be evaluated for comparison of GGMP and non-GGMP populations in future studies.

Reproducible asystole following vagal nerve stimulator lead replacement: a case report

BackgroundVagal nerve stimulation (VNS) is approved therapy for the treatment of intractable epilepsy. The stimulation of either nerve, left or right, is effective. However, due to the anatomic and physiological effects of cardiac innervation, the right vagus nerve is typically avoided in order to minimize the risk of cardiac bradyarrhythmias. The location of the VNS lead contacts on the nerve can also have an effect, namely, more distally placed contacts have been associated with lower risk of cardiac arrhythmias, presumably by avoiding vagal cervical cardiac branches; however, our case demonstrates reproducible asystole despite left sided, distal VNS lead placement.Case presentationWe report a 28-year-old male patient with pharmacoresistant generalized clonic-tonic seizures. The VNS therapy with 1.5 mA output and 16% duty cycle drastically reduced his seizure burden for several years. The breakthrough seizures along with stabbing pain episodes at the implantable pulse generator (IPG) site have prompted the VNS lead revision surgery with new lead contacts placed more caudally than the old contacts. However, the intraoperative device interrogation with 1 mA output resulted in immediate asystole for the duration of stimulation and it was reproducible until the output was decreased to 0.675 mA.ConclusionsOur case highlights the possibility of new severe cardiac bradyarrhythmias following surgical VNS lead replacements even in patients without preoperatively known clinical side effects. We suggest preoperative electrocardiography and cardiology consultation for detected abnormalities for all patients undergoing new VNS implantations, as well as revision surgeries for VNS malfunctions. Intraoperatively, the surgeon and anesthesia team should be vigilant of cardiac rhythms and prepared for the immediate management.

Bifascicular block in unexplained syncope is underrecognized and under-evaluated: A single-center audit of ESC guidelines adherence.

BackgroundThe presence of bifascicular block on electrocardiography suggests that otherwise-unexplained syncope may be due to complete heart block. European Society of Cardiology (ESC) recommends investigating it with electrophysiology study (EPS). PPM is indicated if high-degree atrioventricular block is inducible. Long term rhythm monitoring with implantable loop recorder (ILR) is recommended if EPS is negative. We evaluated adherence to these guidelines.MethodsThis is a single-center retrospective audit of adult patients with bifascicular block hospitalized for unexplained syncope between January 2018 and August 2019 under general medicine service. Patients with an alternative explanation for syncope were excluded. Guideline adherence was assessed by formal cardiology consult and whether EPS followed by ILR and/or PPM were offered.Results65 out of 580 adult patients (11.2%) admitted to general medicine service for syncope had a bifascicular block; 29 (5%) were identified to have bifascicular block and unexplained syncope. Median age was 77 ±10 years; 9 (31%) were female, and 6 (20.7%) patients had at least one prior hospital visit for syncope at our academic medical center. Cardiology was consulted on 17 (58.6%) patients. Two patients were evaluated by EPS (1 refused) followed by ILR. Overall, 3 out of 29 patients (10.3%) received guideline-directed evaluation during the hospitalization based on ESC guidelines. None of the patients received empiric PPM during the index hospitalization.ConclusionAmong patients admitted to the general medicine service with unexplained syncope and bifascicular block, a minority (10.3%) underwent guideline-directed evaluation per ESC recommendations. Cardiology was consulted in 58.6% of cases.

Frequency of Poor & Good Coronary Collateral Circulation in patients of Non-ST Segment Elevation Myocardial Infarction & to compare mean Platelet –Lymphocyte ratio with good & poor coronary collateral circulation

Background: Coronary collateral circulation (CCC) is a secondary source of blood supply to an ischemic myocardial area in coronary artery disease. One of the most important protective responses of the cardiac against ischemia is the development of CCC. Recently, platelet to lymphocyte ratio has emerged as a major inflammatory marker & a new predictor of serious unfavorable cardiovascular outcomes. Aim: To find the frequency of poor & good coronary collateral circulation in patients of Non-ST Segment Elevation Myocardial Infarction & to compare mean platelet–lymphocyte ratio in patients with poor & good coronary collateral circulation of Non-ST Segment Elevation Myocardial Infarction. Methodology: This cross Sectional study was conducted in Cardiology Department, Mayo Hospital Lahore After taking informed consent 150 patients meeting inclusion criteria was taken in this study. The patients were enrolled from Department Cardiology, Mayo Hospital Lahore. Their basic demographical information like age, gender and contact detail was obtained. Patients were labeled as according to CCC, one with Poor CCC and second with good CCC [as per operational definition]. All procedure was done by consultant cardiologist having more than 5 years of experience after post-graduation. Venous blood was collected from patients in sterilized manners by experienced staff nurse and was sent to hospital laboratory for analysis of PLR. PLR was compared in cases with good and poor CCC. Results:1The average age of cases was 52.41 ± 18.12 years with minimum and maximum age of 20 and 80 years. There were 96(64%) male and 54(36%) female cases in this study. A total of 33 (22%) cases had poor and 117(78%) cases had good CCC. The mean Platelet-to-lymphocyte ratio (PLR) was 122.16 ± 30.10 with minimum and maximum PLR was 80.64 and 201.60. The mean PLR in cases with poor and good CCC was 165.95±21.93 and 109.81 ± 18.21 respectively, the mean PLR was highly significant in cases with Poor CCC when compared with good CCC, p-value < 0.0001. Conclusion: This study concludes that cases with poor CCC have higher PLR when compared to good CCC, so in future cases with higher PLR at admission can be predict for high risk patients for poor CCC. Using PLR (inexpensive and readily available) test we can hence, patients with NSTEMI can be prevented from morbidity & mortality by early and appropriate medications or interventions. Keywords Cardiology, Angiography, coronary artery disease, Low ejection fraction, coronary collateral circulation.

Strength, Weakness, Opportunities, and Threats (SWOT) Analysis of Virtual Outpatient Department Under Telemedicine Department During the COVID-19 Pandemic.

BackgroundCOVID-19 pandemic has challenged all current management tools used for patient care. This study aims to determine strength, weakness, opportunities and threats (SWOT) to virtual OPD and consultants' perceptions of teleconsultation virtual OPD during the COVID-19 pandemic, adapting to newer technologies for successfully handling this situation.Material and methodsA facility-based cross-sectional study was conducted at the Virtual OPD of All India Institute of Medical Sciences Rishikesh among patients availing Telemedicine consultation during the COVID-19 pandemic. All patients availing services from April 2020 to October 2020 were included in this study. Method for SWOT analysis: A checklist was prepared, and investigators assessed SWOT. An external evaluator was invited to evaluate the SWOT analysis conducted by the investigators. For numeric variables, the mean ± SD was used, and for categorical variables, percentages and proportions were used.Results Around 22% of the patients who approached virtual OPDs were ≥ 60 years of age. More than half (55.3%) of the patients or their attendants who consulted Telemedicine OPD were from Uttarakhand, followed by Uttar Pradesh (42.6%). The proportions of male patients were 54.4%. Around 17.6% of teleconsultations were performed for radiotherapy. General medicine and cardiology consultations were (15.2%) and (12.8%), respectively.ConclusionTelemedicine can be effective if certain requirements had been provided. Maintaining privacy of the patient's data was a challenge.

Knowledge and attitudes amongst internal medicine clinicians in referring valvular heart disease patients : a multi-centre survey study

Abstract Funding Acknowledgements Type of funding sources: None. Background With advancement in valvular interventions, outcomes of valvular heart disease (VHD) patients have improved dramatically. However, very little is known regarding levels of knowledge and attitudes amongst non-cardiology clinicians in managing VHD. Purpose To determine the knowledge and attitudes towards VHD management, pertaining specifically to referrals to cardiology services for consideration for intervention, amongst internal medicine clinicians in Malaysia. Methods We conducted a multi-centre survey study. A 20-item survey was distributed amongst internal medicine clinicians within three different institutions. Results A total of 75 responses was obtained (response rate of 35.7%). The mean age of responders was 36.6 years (S.D. 7.9). 57.3% were male. Respondents include medical officers (50.6%), internal medicine consultants (31.9%) and internal medicine specialist (i.e. pre-consultant) (17.5%). Majority had more than 10 years of experience working as medical doctors (46.7%). 69.3% admit to managing patients with VHD regularly (defined as at least one VHD patient per week). Respondents were comfortable using online resources, both formal (95.0%) and informal (75.0%) sources. A large proportion felt that they had ‘insufficient’ or ‘very insufficient’ knowledge and experience managing VHD patients on their own (28.0% and 8.0% respectively) and less than half felt that management of VHD patients within their institutions was ‘adequate’ or ‘very adequate’ (46.7% and 2.7% respectively). However, it is reassuring that most respondents felt comfortable discussing cases of VHD with their senior colleagues or their local cardiology services. Although many were felt to be over-zealous in wanting too frequent an echocardiography monitoring for cases of mild VHD (majority felt that the patient would require it every 1 year (25.3%) or 1-2 years (29.3%)), nevertheless attitudes in referrals to cardiology services for consult and intervention were felt appropriate (majority felt that cardiology consult would be indicated if valvular lesion was at least moderate in severity (56.0%), when there were changes to the heart function or structure (52.0%), when patients became symptomatic (45.3%) or when there were two or more valvular lesions simultaneously (45.3%). However, within a Malaysian context, there may be a need to shift attitudes towards referring much earlier, consistent with changes in recent international guidelines on managing VHD, as valvular surgery waiting times are extremely long. Conclusion The survey highlights the need for education amongst internal medicine clinician to tackle both the over-zealous attitude in monitoring patients with mild valvular disease on one extreme, and in improving early referrals for VHD indicated for intervention in the other. Abstract Figure. Survey items on echocardiography Abstract Figure. Survey items on cardiology referrals

Knowledge and attitudes amongst internal medicine clinicians in referring valvular heart disease patients : a multi-centre survey study

Abstract Funding Acknowledgements Type of funding sources: None. Background With advancement in valvular interventions, outcomes of valvular heart disease (VHD) patients have improved dramatically. However, very little is known regarding levels of knowledge and attitudes amongst non-cardiology clinicians in managing VHD. Purpose To determine the knowledge and attitudes towards VHD management, pertaining specifically to referrals to cardiology services for consideration for intervention, amongst internal medicine clinicians in Malaysia. Methods We conducted a multi-centre survey study. A 20-item survey was distributed amongst internal medicine clinicians within three different institutions. Results A total of 75 responses was obtained (response rate of 35.7%). The mean age of responders was 36.6 years (S.D. 7.9). 57.3% were male. Respondents include medical officers (50.6%), internal medicine consultants (31.9%) and internal medicine specialist (i.e. pre-consultant) (17.5%). Majority had more than 10 years of experience working as medical doctors (46.7%). 69.3% admit to managing patients with VHD regularly (defined as at least one VHD patient per week). Respondents were comfortable using online resources, both formal (95.0%) and informal (75.0%) sources. A large proportion felt that they had ‘insufficient’ or ‘very insufficient’ knowledge and experience managing VHD patients on their own (28.0% and 8.0% respectively) and less than half felt that management of VHD patients within their institutions was ‘adequate’ or ‘very adequate’ (46.7% and 2.7% respectively). However, it is reassuring that most respondents felt comfortable discussing cases of VHD with their senior colleagues or their local cardiology services. Although many were felt to be over-zealous in wanting too frequent an echocardiography monitoring for cases of mild VHD (majority felt that the patient would require it every 1 year (25.3%) or 1-2 years (29.3%)), nevertheless attitudes in referrals to cardiology services for consult and intervention were felt appropriate (majority felt that cardiology consult would be indicated if valvular lesion was at least moderate in severity (56.0%), when there were changes to the heart function or structure (52.0%), when patients became symptomatic (45.3%) or when there were two or more valvular lesions simultaneously (45.3%). However, within a Malaysian context, there may be a need to shift attitudes towards referring much earlier, consistent with changes in recent international guidelines on managing VHD, as valvular surgery waiting times are extremely long. Conclusion The survey highlights the need for education amongst internal medicine clinician to tackle both the over-zealous attitude in monitoring patients with mild valvular disease on one extreme, and in improving early referrals for VHD indicated for intervention in the other. Abstract Figure. Survey item on echocardiography Abstract Figure. Survey item on cardiology referrals

Treatment of tibial shaft nonunion with a retained nail in morbidly obese patients.

Morbid obesity is a rising worldwide health problem. Tibial shaft nonunion with retained intramedullary nail (IMN) in the morbidly obese is a challenging orthopaedic problem. Prolonged immobilization carries a significant risk of complications. This study aimed to investigate whether decortication and cancellous bone grafting with the application of a circular external fixator (CEF) over the preexisting IMN can achieve fracture union and avoid serious complications. We retrospectively reviewed 27 consecutive morbidly obese patients treated for tibial diaphysis aseptic nonunion after failed IMN. All cases were treated with osteoperiosteal decortication, cancellous bone grafting, and fixation with CEF over the IMN. Peri-operative multidisciplinary patient evaluation included internal medicine, cardiology, chest, vascular surgery, and anesthesia consultations. The union rate, bone results, functional results, and complications were recorded. The mean age of the patients was 37.9years. The mean BMI was 45.8. Sixteen cases (59.3%) were treated for hypertrophic nonunion, while 11 cases (40.7%) were treated for atrophic nonunion. Seven cases (25.9%) had open initial injury, 14 cases (51.9%) had associated comorbidities, and seven cases (25.9%) were smokers. Twenty-six cases united. The mean time to union was 5.2months. Bone results and functional results were good to excellent in 96.3% of the cases. We recorded 25 complications in 21 patients. However, most of the complications were minor. Decortication and cancellous bone grafting with the application of CEF over the preexisting nail is a safe and reliable treatment method for aseptic tibial shaft nonunion with retained IMN in morbidly obese patients.

Patient Trying to Tell Something Else: Severe Stress During COVID-19 Pandemic

Identifying mental health illness poses a dilemma, particularly the distinction between heart disease and severe stress. Without early intervention, it can be escalating into psychiatric disorder and suicide. A 44-year-old man sought cardiologist consultation for the "heart disease" symptoms. As a medical laboratory technician in charge, his commitments and extensive responsibility during the COVID-19 pandemic add to his hypertension and dyslipidaemia comorbidities. Despite non-significant investigations related to heart disease, he returned with the same intense unresolved symptoms. His Depression Anxiety Stress Scales 21-item assessment revealed severe stress. Stress management counselling includes detecting the underlying stress impacted by the COVID-19 pandemic, behavioural changes, and stress coping skills was done in 4 sessions. The 1st one-hour session was to instil positive thinking and behavioural changes of the severe underlying stress and to counsel the stress coping skills. Stress coping skill includes relaxation techniques (Deep Breathing Technique and Progressive Relaxation Method) and spiritual empowerment (Islamic Integrated Meditation). The next three counselling sessions of thirty minutes duration to heighten the stress management counselling (positive thinking, stress coping skills, spiritual empowerment) as well as to review his wellbeing and physical diseases control were done at two-week interval. At twelve-week follow-up, reassessment of stress level showed significant improvement with no similar symptoms. This case highlights the clinical complexity and diagnostic challenges in detecting mental health illness. Diagnostic acronym PROMPT with the 'PT' refers to 'Patient Trying to Tell Something Else' demonstrated; without a high index of suspicion, mental health ailment may be overlooked. This case also underlined the integration of behavioural changes, stress coping skills, and spiritual empowerment in stress management counselling.

Feasibility of the cardiac output response to stress test in suspected heart failure patients.

BackgroundDiagnostic tools available to support general practitioners diagnose heart failure (HF) are limited.Objectives(i) Determine the feasibility of the novel cardiac output response to stress (CORS) test in suspected HF patients, and (ii) Identify differences in the CORS results between (a) confirmed HF patients from non-HF patients, and (b) HF reduced (HFrEF) vs HF preserved (HFpEF) ejection fraction.MethodsSingle centre, prospective, observational, feasibility study. Consecutive patients with suspected HF (N = 105; mean age: 72 ± 10 years) were recruited from specialized HF diagnostic clinics in secondary care. The consultant cardiologist confirmed or refuted a HF diagnosis. The patient completed the CORS but the researcher administering the test was blinded from the diagnosis. The CORS assessed cardiac function (stroke volume index, SVI) noninvasively using the bioreactance technology at rest-supine, challenge-standing, and stress-step exercise phases.ResultsA total of 38 patients were newly diagnosed with HF (HFrEF, n = 21) with 79% being able to complete all phases of the CORS (91% of non-HF patients). A 17% lower SVI was found in HF compared with non-HF patients at rest-supine (43 ± 15 vs 51 ± 16 mL/beat/m2, P = 0.02) and stress-step exercise phase (49 ± 16 vs 58 ± 17 mL/beat/m2, P = 0.02). HFrEF patients demonstrated a lower SVI at rest (39 ± 15 vs 48 ± 13 mL/beat/m2, P = 0.02) and challenge-standing phase (34 ± 9 vs 42 ± 12 mL/beat/m2, P = 0.03) than HFpEF patients.ConclusionThe CORS is feasible and patients with HF responded differently to non-HF, and HFrEF from HFpEF. These findings provide further evidence for the potential use of the CORS to improve HF diagnostic and referral accuracy in primary care.