Hours Of Symptom Onset Research Articles

EGS SO01 - A retrospective study on understanding the dangers of delaying emergency laparoscopic cholecystectomies in patients with acute cholecystitis

Abstract Background Gallstone related diseases account for approximately one-third of emergency general surgery admissions and referrals. Acute cholecystitis (AC), a major complication of gallstones, is typically treated with laparoscopic cholecystectomies (LC), the gold standard for treating symptomatic gallstone disease. According to NICE guidelines patients with AC should preferably undergo a LC within 72 hours. Similarly, SAGES recommends that patients who can tolerate the procedure should have a LC within 24-72 hours of diagnosis. This study aimed to determine if surgical outcomes differ among patients managed within 24 hours, between 25-72 hours, and more than 72 hours from onset of symptoms. Method This retrospective analysis evaluates wait times between onset of symptoms and surgery, as well as subsequent surgical outcomes for patients booked for emergency LC over a twelve-month period from September 2022 to September 2023. The data assessed included demographics, indications, imaging results, alkaline phosphate (ALP) levels, alanine transaminase (ALT) levels, total bilirubin levels, C-reactive protein (CRP) levels, white cell count levels, american society of anaesthesiologists (ASA) grade, type of intraoperative complications, time of day operated, length of hospital stay, duration of symptoms prior to decision for surgery and wait until surgery. This data was compared against NICE and SAGES standards. Results Sixty-one patients underwent emergency LC in the twelve-month period reviewed, mean age was 49.7 years. The sample was approximately 70% (n=43) female and 28% (n=17) male. 62% (n=38) of patients were booked for a LC within 72 hours of symptom onset. 5% (n=3) of patients had their surgery within 24 hours of presenting to hospital with symptoms, 41% (n=25) had their surgery within 24-72 hours and 54% (n=33) waited more than 72 hours for their LC. 84% (n=51) of the total patients had no adverse intraoperative findings. The 16% (n=10) patients who had complications were part of all three groups. Conclusion This study found that 46% of the patients presenting with symptoms of AC undergo emergency LC within 72 hours as per NICE and SAGES guidelines. Intraoperative complications were found in all groups of patients, waiting from 0 to 72 hours for their surgery. 80% of the complications seen were in patients waiting more than 24 hours for their LC. Increasing local awareness on the importance of not delaying emergency LC by creating pathways, such as dedicated LC lists, to allow same-admission LC will enable us to adhere more closely to current guidelines and reduce morbidity from gallstone disease.

Factors affecting treatment delays among malaria patients presenting at health facilities in Guinea, 2022–2023

BackgroundEarly identification and management of cases are key for controlling and eliminating malaria. This study aimed to assess the factors associated with the delay malaria treatment in Guinea.MethodsCross-sectional study was conducted at 60 health facilities in eight administrative regions from December 2022 to March 2023. Patients with a diagnosis of malaria through either microscopy or a rapid diagnostic test (RDT), were interviewed using a standardized questionnaire. Treatment delays were defined as seeking care 48 hours after the onset of symptoms. Logistic regression was performed to assess factors associated with treatment delay. Adjusted odds ratio (OR) and confidence interval (CI) were used to explain the associated factors.Results3,300 malaria patients were included and the findings showed a median time of symptoms onset and access of malaria treatment was 3.04 days. Alarmingly, only 800 (24.24%) of all cases sought and received treatment within 48 hours of symptom onset. The multivariate logistic regression indicated that children under 5 years of age who attempted self-medication for fever were 4.32 times more likely to experience a delay in treatment than those who sought immediate medical care in health facilities (OR:4.32, 95% CI: 2.96–6.36). Children whose parents had no formal education were 3.05 times more likely to experience a delay in treatment (OR:3.05, 95% CI: 1.66–5.60). Moreover, when the disease was considered non-severe the first time by caregivers, OR = 1.71 (95% CI: 1.26–2.33). For those 5 years old and above, using university hospital OR = 4.01, (95% CI: 2.01–8.44), living in Forest Guinea OR = 3.14, (95% CI 1.93–5.10) and Middle Guinea OR = 1.46 (95% CI: 1.09–1.95) were more likely to experience delay treatment.ConclusionsThe proportion of malaria patients with treatment within 48 is low, significantly falling short of the national targets. This substantial delay in treatment was attributed to factors such the lack of formal education, self-medication practices, and failure to recognize the illness severity. These findings underscore the urgent need for NMCP to enhance awareness regarding the importance of early presentation at health facilities, with targeted interventions.

The Relationship between Raised Mean Platelet Volume and Severity of Newly Diagnosed Acute Ischaemic Stroke

Introduction and Objective: Stroke is one of the leading causes of mortality and long-term disability throughout the world. Mean platelet volume (MPV), a marker of platelet activation, is calculated and provided by automatic blood cell count equipment during routine complete blood count analysis is a surrogate marker of platelet function and a potential mediator of the association between inflammation and thrombosis. So, to investigate MPV in ischaemic stroke and its role to discriminating more severe stroke from mild one the current study was done. Methods: This observational case control study was carried out in Department of Medicine, Dhaka Medical College Hospital (DMCH) from July 2015 to June 2016. 100 patients with attack of ischaemic stroke who presented within 24 hours of symptoms onset were divided into 2 groups (group-1: mRS score 0-2, and group-2: mRS score 3 or more) based on severity. Severity of ischaemic stroke was assessed by the modified Rankin Scale. At the same time 100 age and sex matched controls were taken. Blood samples were collected from both groups and MPV was measured. The results were statistically compared by SPSS 22.0. Statistical significance was accepted at <0.05. Results: The MPV values were more in case group in comparison to control group (10.88±1.23 vs 10.03±1.03; z score-5.31; p value <0.01). Comparison between the 2 groups revealed that MPV value was higher and more significant in group 2 of cases than group 1(10.15± 0.739 in group 1 versus 11.63± 1.04 in group having 2; z score-7.7, p value <0.001). 6 patients of group 2, who could not overcome the situation and died within 24 hours of admission had MPV value of 12.92±0.30. After controlling the risk profiles associated with ischaemic stroke by means of binary logistic regression model, the effect of MPV in ischaemic stroke remained statistically significant (OR: 4.418, 95% CI 2.468-7.908, p= 0.000). ROC curve was 0.85 and standard error 0.039 (95% CI: 0.779-0.932; p<0.01), ...

Endovascular Treatment of Patients With Acute Ischemic Stroke With Tandem Lesions Presenting With Low Alberta Stroke Program Early Computed Tomography Score.

Recent trials confirmed the efficacy and safety of endovascular thrombectomy in patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS); however, evidence in tandem lesions is limited. This study evaluates endovascular thrombectomy safety and efficacy in patients with acute large-vessel occlusion with tandem lesions, stratified by baseline ASPECTS. We conducted a retrospective analysis of data from 16 centers. Inclusion criteria included the following: age ≥18 years, anterior circulation tandem lesions, endovascular thrombectomy <24 hours of symptom onset, and ≥70% internal carotid artery stenosis/occlusion. Patients were categorized into low (0-5) and high (6-10) ASPECTS. Inverse probability of treatment weighting matching was used to balance the groups. Primary outcomes included the following: 90-day modified Rankin Scale (mRS) score 0 to 2 and symptomatic intracranial hemorrhage. Secondary outcomes included the following: ordinal mRS, mRS 0 to 3, modified Thrombolysis in Cerebral Infarction ≥2b and 2c-3, petechial hemorrhage, parenchymal hematoma (1/2), early neurologic improvement, and mortality. Of 691 patients, 44 had ASPECTS 0 to 5 and 505 had ASPECTS 6 to 10. Patients with low ASPECTS had lower odds of 90-day mRS 0 to 2 (adjusted odds ratio [OR], 0.48; P=0.036) and higher odds of symptomatic intracranial hemorrhage (adjusted OR, 3.78; P=0.014). Additional significant differences were found in mRS shift, mRS 0 to 3, parenchymal hematoma 2, and mortality. In interaction analysis, the association between low ASPECTS and functional outcome persisted only in the internal carotid artery occlusion subgroup, with no significant interaction indicating no reason to suppose a difference between the effect of both subgroups. Endovascular thrombectomy in patients with tandem lesions with low ASPECTS is associated with reduced odds of functional recovery and increased symptomatic intracranial hemorrhage risk, when compared with patients with high ASPECTS. However, 30% of patients with low ASPECTS achieved 90-day functional independence, suggesting potential benefit for a nonnegligible proportion of patients.

A PROSPECTIVE STUDY ON MANAGEMENT OF CARDIOGENIC SHOCK WITH PERCUTANEOUS CORONARY INTERVENTION

Cardiogenic shock following acute myocardial infarction (AMI) is a critical condition with high mortality rates. Percutaneous coronary intervention (PCI) has emerged as a key intervention, but the outcomes and associated risk factors, including comorbidities such as hypertension, diabetes, and smoking, remain essential to understand for optimizing treatment and improving prognosis. Objective: To evaluate outcomes and identify risk factors in patients with cardiogenic shock secondary to acute myocardial infarction managed with percutaneous coronary intervention. Methods: A prospective observational study was conducted at a tertiary care hospital involving 70 patients aged 60 years and above who presented with cardiogenic shock due to AMI within 24 hours of symptom onset. Data were collected on demographics, clinical indicators of shock severity, and mechanical complications, including pump failure, papillary muscle rupture, ventricular septal rupture (VSR), and free wall rupture. The incidence of comorbidities, such as hypertension, diabetes, and smoking status, was documented. Mortality and recovery patterns were assessed during hospitalization and post-discharge. Statistical analysis was performed to examine associations between comorbidities and adverse outcomes. Results: The mean age of the cohort was 68.8 ± 4.5 years, with a male predominance of 57.1%. Key complications included pump failure in 31.4%, papillary muscle rupture in 11.4%, papillary muscle dysfunction in 34.3%, VSR in 7.1%, and free wall rupture in 4.3% of patients. Overall mortality was 12.9%. Hypertension was present in 67.1% of patients, diabetes in 61.4%, and smoking in 21.4%, all of which correlated with higher complication rates and adverse outcomes. Conclusion: Early PCI management in patients with cardiogenic shock secondary to AMI is associated with favorable survival rates. However, comorbidities such as hypertension and diabetes significantly increase complication rates. These findings underscore the importance of timely intervention and risk-targeted management to improve survival outcomes in high-risk patients.

A Hybrid Simulation‐Based Workshop Improves Knowledge and Confidence in the Management of Hemorrhagic Conversion of Stroke Among Interventional Neurology Trainees

Background Mechanical thrombectomy is the standard of care in acute ischemic stroke with anterior large vessel occlusion presenting within 6 hours of symptom onset, but complications do exist. We assessed the feasibility of a hybrid simulation‐based workshop at a national meeting for interventional neurology trainees focused on the management of acute ischemic stroke and tissue‐plasminogen activator‐related hemorrhage. Methods In this prospective, observational, hybrid simulation‐based study at a fellows’ workshop at a national conference, participants were asked to manage a patient with acute ischemic stroke in the neurointerventional suite followed by thrombolytic‐related hemorrhage leading to cerebral herniation during mechanical thrombectomy. We evaluated the participants’ ability to complete critical actions that were developed based on best practices and relevant American Heart Association guidelines and the Neurocritical Care Society's Emergency Neurological Life Support protocols. The primary outcome was the improvement in knowledge from a precourse to postcourse test. Secondary outcomes included participant reactions. Results Sixty trainees completed the simulation session in 8 groups. The mean sum of critical actions completed by trainees was 9.75/14 (70%). There was a moderate effect of the intervention on trainees’ knowledge from pretest (mean 3.8, SD = 0.3) to posttest (mean 4.3, SD = 0.3). The simulation scenario was described as moderately realistic, very engaging, and extremely satisfactory. Following the workshop, all fellows endorsed an increase in proficiency and confidence in neurological emergency management. Conclusion Simulation‐based workshops at national conferences are feasible and a potentially useful tool for safely educating a large audience of trainees who may not have access to high‐fidelity simulation platforms at their institutions.

Stratifying by Blood Glucose Levels to Predict Hemorrhagic Transformation Risk Post-Rt-PA in Acute Ischemic Stroke.

Stroke is a leading cause of disability and mortality worldwide, posing a significant public health challenge. While treatment of acute ischemic stroke (AIS) with recombinant tissue plasminogen activator (rt-PA) is effective but increases the risk of hemorrhagic transformation (HT). This study aimed to explore the determinants of HT in AIS patients treated with rt-PA and investigate the association between blood glucose levels and HT risk. We conducted a prospective cohort study at the First Affiliated Hospital of Harbin Medical University from January 2018 to December 2021. Patients with AIS and who received rt-PA within 4.5hours of symptom onset were included. Demographic, clinical, laboratory, and imaging data were collected. Of the 426 patients, 15% experienced HT post-rt-PA, occurred more frequently in patients with a history of cardiac embolism, higher prethrombolysis NIHSS scores, and elevated fasting blood glucose (FBG) levels. The frequency of HT was higher in non-diabetic patients with FBG levels ≥7.0mmol/L compared to diabetic patients. Elevated blood glucose levels were significantly associated with HT, regardless of diabetes history. The findings suggest importance of precise glycemic control during AIS management to improve patient outcomes, particularly in non-diabetic patients. Future protocols for AIS treatment should incorporate these findings to reduce HT risks. Further large-scale studies are needed to confirm these associations and guide clinical practices.

To bridge or not to bridge: the role of intravenous thrombolysis in mechanical thrombectomy for large cerebral infarctions through a two-center cohort study and meta-analysis

BackgroundThe effectiveness and safety of intravenous thrombolysis before mechanical thrombectomy (MT) in large cerebral infarctions remains uncertain. This study compares bridging MT, which includes intravenous thrombolysis, to direct MT without it. MethodsData from 298 patients with anterior circulation large cerebral infarctions, assessed via non-enhanced CT (ASPECTS 0-5), who underwent MT in two-center cohort studies, were analyzed. Primary outcomes focused on independent ambulation (modified Rankin Scale scores 0-3) at 90 days post-stroke. Safety outcomes included parenchymal hemorrhage (PH) rates and mortality. We conducted a sensitivity analysis considering the timing from symptom onset to imaging within 4.5 hours. Additionally, a meta-analysis of 17 studies involving 3527 patients assessed the interventions' effectiveness and safety, with further scrutiny of high-quality studies (Newcastle-Ottawa Scale ratings 7-9) to increase robustness of results. ResultsNo significant differences were found in 90-day independent ambulation between the bridging MT and the direct MT group (adjusted odds ratio [aOR] 1.15, 95% CI 0.68-1.94). Rates of PH and mortality were also similar across groups. These outcomes were consistent in the subgroup imaged within 4.5 hours of symptom onset. The meta-analysis supported these outcomes, showing no improvement in ambulation (aOR 1.16, 95% CI 0.82-1.64) or reduction in PH with bridging MT. Further analysis of high-quality studies supported these results. ConclusionsThe cohort study and meta-analysis provide Class II evidence indicating no significant differences in functional outcomes or hemorrhagic risks between bridging and direct MT for large cerebral infarctions. This suggests that direct MT might be a viable alternative to bridging MT.

Association between Asymptomatic Cerebrovascular Stenosis and Early Neurological Deterioration in Single Subcortical Infarction Patients

Background: Patients with ischemic stroke may experience early neurological deterioration (END) during the acute phase. This study aimed to identify association between asymptomatic vascular stenosis and END in single subcortical infarction patients.Methods: The study included 562 patients admitted within 48 hours of symptom onset between January 2015 and August 2022. END was defined as a decrease of ≥1 point in the National Institutes of Health stroke scale (NIHSS) motor score or ≥2 points in the total NIHSS score within the first 48 hours after stroke onset. Clinical characteristics, including age, sex, smoking habits, underlying vascular risk factors, initial NIHSS score, trial of Org 10172 in acute stroke treatment classification, laboratory parameters, and presence of vascular stenosis or occlusion, were analyzed to identify predictors of END.Results: END occurred in 115 patients (20%) with single subcortical infarction. Age (odds ratio [OR], 1.0; &lt;i&gt;p&lt;/i&gt;=0.011), female sex (OR, 1.7; &lt;i&gt;p&lt;/i&gt;=0.042), location of cerebral infarction at corona radiata (OR, 3.0; &lt;i&gt;p&lt;/i&gt;=0.023), systolic blood pressure (OR, 1.0; &lt;i&gt;p&lt;/i&gt;=0.011) and presence of asymptomatic vascular stenosis (OR, 2.2; &lt;i&gt;p&lt;/i&gt;=0.019) were independently associated with END in multivariable logistic regression.Conclusions: This study suggests that age, sex, location of cerebral infarction, systolic blood pressure and the presence of asymptomatic vascular stenosis are independent predictors of END.

Effect of primary pci in asymptomatic stemi patients presenting 12 to 48 hours of symptom onset, on myocardial viability assessed by spect tc 99m sestamibi scan epitome99

Abstract Background Guidelines on revascularization of asymptomatic stable STEMI patients presenting 12-48 hours of symptom onset are limited. We utilized TC-99mSestaMIBI scan to study the impact of primary PCI on myocardial viability by deriving myocardial salvage index (MSI) from area at risk (AAR), prior to revascularization and final infarct size (FIS) at follow up, in asymptomatic stable STEMI patients presenting between 12-48 hours of symptom onset to PCI. Purpose Evidence contributing lack of symptoms to a non-viable myocardium is lacking and it would be unethical to randomize patients with myocardial infarction (&amp;lt; 48 hours old) to a control arm or a non-intervention arm without evaluating the possibility of salvageable myocardium. Our study aims to inculcate evidence based management of late presenting stable asymptomatic STEMI patients. Methods We enrolled 141 patients presenting with STEMI (12-48 hours), from January 2021 to December 2023, who then underwent TC-99mSestaMIBI scan, followed by revascularization of IRA with 138 patients completing the designed study with follow-up scan at 3 months. Subjects were subcategorised into cohort A(12-24 hrs.), B(25-36 hrs.), and C(37-48 hrs.) according to the duration of symptom onset. Results A substantial MSI of &amp;gt; 0.50 was achieved by 36 %, 8% and 5 % of patients from cohort A, cohort B, and cohort C respectively. Although the AAR was comparable throughout cohorts, on post HOC analysis a statistically significant reduction in the final infarct size was seen among patients in cohort A vs C [Q = 4.72 (p = .00309)], while a reduction of FIS in cohort B and cohort C were obvious but statistically insignificant. Myocardial salvage index was smaller in late presenters, with no statistically significant difference among cohort B &amp; cohort C [Q = 0.96 (p = .77697)]. Delaying the timing of Primary PCI from symptom onset was associated with larger AAR (R= - 0.01) &amp; FIS (R= 0.35) although with a lower correlation coefficient. While evaluating MSI against timing of Primary PCI, a moderately negative (R= - 0.41) relation exists, indicating a linear correlation to reduced myocardial salvage Index with delay in the timing of primary PCI to symptom onset. Conclusion Asymptomatic stable STEMI patients presenting 12-24 hours of symptom onset to PCI, benefited from primary PCI with lesser final infarct size and larger MSI. Despite a comparable AAR across cohorts, MSI fell sharply among patients undergoing primary PCI 24-48 hours of symptom onset with a larger final infarct size, warranting viability guided revascularization. Although primary PCI improved final LVEF and MSI in patients with ischemic heart failure, parameter gain alone was insufficient in endeavoring a positive clinical impact.

Impact of late reperfusion therapy in patients with inferior ST-segment elevation myocardial infarction and right ventricular dysfunction: one size never fits all

Abstract Background A significant proportion of ST-segment elevation myocardial infarction (STEMI) patients present late to the emergency room with limited evidence of benefit of reperfusion after 12 hours of symptom onset. Inferior myocardial infarction (MI) with right ventricle (RV) dysfunction is associated with high morbidity and mortality, however, the RV has a unique physiology that allows it to withstand ischemia better and recover faster. Purpose To compare adverse in-hospital cardiovascular events in latecomers with inferior STEMI and RV dysfunction admitted to a cardiovascular intensive care unit (CICU) from a low-to-middle-income country, who underwent late reperfusion treatment versus conservative treatment. Methods A retrospective cohort study was conducted from March 2022 to April 2023. Patients with inferior STEMI and RV dysfunction who received late reperfusion treatment were included. RV dysfunction was defined as a TAPSE &amp;lt;17 mm, tricuspid annular systolic velocity on TDI &amp;lt;9.5 cm/s, or a fractional area change &amp;lt;35%. Late reperfusion was defined as primary percutaneous coronary intervention (PCI) performed after 12 hours of symptom onset or rescue PCI after 12 hours of failed fibrinolysis. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were cardiovascular death, reinfarction, stroke, cardiogenic shock, and mechanical complications. Results During the specified period, a total of 106 patients met the inclusion criteria from a total of 1,786 patients admitted to the CICU in our center. Only 60 patients underwent late PCI, accounting for 56% of the cases, with a median time of onset of symptoms to reperfusion of 19.4 hours (IQR: 15.7, 30.2). The average age was 66.5 ± 10.4 years, and 28% were women. Although the all-cause death rate was lower among late PCI group (13.3% vs 26.1%; p=0.096), this difference did not reach statistical significance in the bivariate analysis. Stratified by cardiogenic shock, a lower rate of all-cause mortality was also observed (33% vs 55%, p=0.15). The incidence of reinfarction was significantly lower in the late PCI group (0% vs 13%, p=0.004). In the multivariate analysis, adjusting for those who underwent PCI between 12-48 hours, revascularization of latecomers was independently associated with a significant reduction of mortality (adjusted OR 0.22; 95% CI 0.05-0.92; p=0.038). In a post-hoc analysis, late PCI showed a lower association with the composite outcome of all-cause mortality and reinfarction (adjusted OR 0.16, 95% CI 0.04-0.56; P=0.004). Conclusion(s) Our study demonstrates that implementing a reperfusion strategy in latecomers with inferior STEMI and RV dysfunction significantly reduces the risk of in-hospital mortality and reinfarction. This suggests a potential benefit of expanding the therapeutic window for PCI in this high-risk population. However, prospective studies are needed to conclude these preliminary findings.

Effect of empagliflozin on no-reflow in patients with st elevation myocardial infarction undergoing primary percutaneous coronary intervention

Abstract Background Primary percutaneous coronary intervention (PPCI) restores myocardial tissue perfusion successfully in over 90 % of ST-elevation myocardial infarction (STEMI) patients .However there remains a small proportion of patients who exhibit no-reflow.(1) Empagliflozin is a sodium glucose co-transporter 2 (SGLT2) inhibitor that acts as a powerful anti-oxidant and has beneficial effects on endothelial function and reducing burden of ischemia in-vitro.(2) Aim and Objectives: To Assess the effect of Empagliflozin preloading in non-diabetic STEMI patients before PPCI on procedural, in-hospital outcomes and short-term Major Adverse Cardiovascular events (MACE) in a single tertiary center. Patients and Methods: The study was carried out on 200 non-diabetic STEMI patients presenting to our university hospital within the first 8 hours of symptom onset. Patients were randomised into 2 groups , the intervention group received 10mg Empagliflozin before PPCI with the standard medical therapy while the control group received only the standard medical therapy. Patients were assessed for demographic data, risk factors, procedural outcomes, clinical and in-hospital outcomes, and short-term MACE up to 1 month. Results: Our study found a significant difference between the intervention and control groups regarding contrast volume with a mean of 131 ml in the intervention group and 144 ml in control group with a p value of 0.009, incidence of no-reflow with 34.5% in the control group and only 18.2% in the intervention group and a p value of 0.014 and myocardial blush grade (MBG) were 84.1% of the patients in intervention group had MBG III after PCI while only 65.5% of the patients in the control group showed the same results with a p value of 0.019. Also, there was a significant difference in St-segment resolution post PCI as 59.1% of patients in the intervention group had complete ST segment resolution and only 39.1% of the patients in the control group had complete resolution with a p-value of 0.027, and total MACE in the first month which affected 44.8% of the patients in the control group and only 28.4% of those in the intervention group with a p-value of 0.024. Conclusion Our study showed that pre-loading of STEMI patients with Empagliflozin resulted in improvement in procedural outcomes, decreasing the incidence of coronary no-reflow, improvement in patient’s course during hospital stay and short-term MACE. Improvement in MACE was mainly due to reduced HF hospitalisations and anginal symptoms.

Percutaneous revascularization in late-presenting STEMI with absence of viability: effects on left ventricular remodeling and scar

Abstract Introduction In patients with ST-elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) should be conducted within 12 hours of symptom onset. The potential benefits attributable to late reperfusion in STEMI fall under the "open artery hypothesis" where the stunned peri-infarction zone after revascularization would restore blood supply and contractility. Purpose To estimate the differences on the LV ejection fraction (LVEF), indexed LV end-systolic volume (iLVESV) and scar in patients with STEMI without viabilitity randomized to optimal medical therapy (OMT) alone or OMT and a late percutaneous coronary intervention (PCI) performed between 24 hours and 30 days after the event. Methods Patients with non-reperfused STEMI were evaluated from September 2021 to June 2022 at a tertiary cardiology hospital. The patients underwent Cardiac Magnetic Resonance (CMR) to assess myocardial viability and were classified as non-viable if they had only 1 wall segment with less than fifty percent thickness of the affected wall with late gadolinium enhancement. The patients were randomized to PCI or OMT alone. CMR was repeated at 6 months to evaluate LVEF, iLVESV and fibrosis. This summary presents a planned partial analysis of the 6-month results (N=51). Descriptive statistics analysis included central and dispersion estimators, or absolute and relative frequencies. To explore the differences between groups and time, Mann-Whitney and Wilcoxon tests were run, and results were given as point-estimates and confidence intervals at 95% (95% CI). A significance level of 5% was adopted for inferential analysis. Results 51 patients (60±11 years, 71% male) were included in the analysis. Of this total, 24 were randomized to PCI + OMT, and 27 to isolated OMT. The groups showed balanced distribution regarding clinical characteristics and initial CMR parameters (LVEF, iLVESV, and fibrosis). The difference in LVEF at the end of 6 months between the OMT and PCI groups was 2.07%, favoring the OMT group; however, this difference was not significant (p= 0.677, 95% CI: -5 to 10). Between the groups, the difference at the end of 6 months in iLVESV was -6.82 ml/m², also without statistical significance (p= 0.858, 95% CI: -19 to 11). There was a significant reduction in the amount of fibrosis in both PCI group with -14.68g (p= 0.011) and in the OMT group with -12.57g (p= 0.009). Detailed results are presented in Table 1. Conclusion Despite a significant reduction in fibrosis in both groups, there was no superiority observed in late PCI compared to isolated OMT in reducing reverse remodeling and fibrosis in patients with non-viable STEMI when compared to isolated OMT.Remodeling changes.

The effectiveness of optic nerve sheath diameter in predicting large vessel occlusion in ischemic stroke patients

Aim: This study assessed the effectiveness of ultrasonography-measured optic nerve sheath diameter (ONSD) in predicting large vessel occlusion (LVO) in ischemic stroke patients.Materials and methods: This single-center, prospective observational study involved patients presenting to the emergency department within 24 hours of symptom onset with moderate to severe stroke, and healthy volunteers.Results: The study included 133 ischemic stroke patients and 63 healthy volunteers. The patient group had significantly higher right [5.8 (0.9)] and left [5.9 (0.8)] ONSD values compared to controls (right [5.7 (0.6)], left [5.7 (0.8)], p&lt;0.001 for both). LVO was present in 58.6% (n = 78) of patients. Median right ONSD was 6.1 mm (0.8) in LVO patients vs. 5.7 mm (0.65) in non-LVO patients (p=0.002). Median left ONSD was 5.9 mm (0.9) in LVO patients vs. 5.7 mm (0.7) in non-LVO patients (p=0.002). A right ONSD ≥6 mm had 51.28% sensitivity and 78.18% specificity for LVO. A left ONSD ≥5.5 mm had 83.33% sensitivity and 40% specificity for LVO.Conclusion: Elevated ONSD values measured by ultrasonography can effectively indicate LVO in stroke patients.

Study on Heparin-Induced Thrombocytopenia and Blood Group among Individuals Suffering from Acute Coronary Syndrome

Background: Clinicians confront heparin-induced thrombocytopenia (HIT) as the most pertinent pathological relationship. Antibodies directed against complexes of heparin molecules and platelet factor 4 (PF4) are the cause of this immune-mediated phenomena. HIT is a significant adverse event that affects individuals with acute coronary syndromes (ACS). Objective: To assess the frequency of HIT in patients presenting with ACS. Materials and Methods: This study was carried out the Northeast Medical College's Department of Cardiology in Sylhet from June 2021 to December 2022. A total of 234 individuals aged 40 to 70 years old presented with ACS within 24 hours of symptom onset. This study excluded patients with idiopathic thrombocytopenic purpura (ITP), aplastic anemia, myeloproliferative diseases, or pre-existing thrombocytopenia. Thrombocytopenia was evaluated using medical records and a full blood count (CBC), with isolated thrombocytopenia (platelets &lt;150 x109/L) prior to heparin administration. Results: Diabetes mellitus, hypertension, a history of ACS, and obesity were the most frequent comorbidities, accounting for 41.03%, 33.76%, 43.16%, and 14.96%, respectively. The incidence of HIT in NSTEMI and STEMI was higher than in unstable angina, although still comparable. The delayed presentation of ACS &gt; 12 hours was also strongly correlated with the occurrence of HIT (p&lt;0.05). Unstable angina and middle age (50–60 years) were found to have a significant relationship with HIT (p&lt;0.05). Conclusion: HIT is more common in patients who have had a myocardial infarction or who have had symptoms for more than 12 hours at the time of hospitalization. Cardiologists and internal medicine experts must take extra precautions when administering heparin to high-risk patients to prevent problems.

IN-HOSPITAL OUTCOMES AMONG PATIENTS PRESENTED WITH ST-ELEVATION MYOCARDIAL INFARCTION TREATED WITH PRIMARY PERCUTANEOUS CORONARY INTERVENTION

Primary Percutaneous Coronary Intervention (PCI) is considered the gold standard treatment for patients with ST-elevation myocardial Infarction (STEMI). Prompt intervention, aimed at restoring blood flow, plays a critical role in improving survival and minimizing complications in these patients. Objective: The objective of this study was to evaluate in-hospital outcomes among patients diagnosed with STEMI and treated with Primary PCI. Methods: This cross-sectional study was conducted in the Cardiology Department over one year. The study included patients aged 50 years and older who were diagnosed with STEMI based on electrocardiographic criteria and presented within 12 hours of symptom onset. Demographic information, clinical characteristics, comorbidities, and in-hospital outcomes were recorded. Statistical analyses were performed using relevant descriptive measures. Results: A total of 150 patients were included in the study. The mean age of patients was 60.89 ± 5.65 years, with 64.4% being male. The average door-to-balloon time was 89.93 ± 18.12 minutes. Successful reperfusion, defined as achieving a TIMI grade 3 flow, was observed in 87.8% of the patients. In-hospital mortality was recorded at 4.4%, while 3.3% of patients developed infections during their hospital stay. Conclusion: The study demonstrated favourable in-hospital outcomes for STEMI patients treated with Primary PCI, with a high success rate in achieving TIMI grade 3 flow and a relatively low in-hospital mortality rate. These findings underscore the efficacy of timely PCI in improving survival and procedural outcomes in STEMI patients, particularly when door-to-balloon time is minimized.

EARLY SUCCESSFUL PRIMARY PERCUTANEOUS CORONARY INTERVENTION ON LEFT VENTRICULAR EJECTION FRACTION IN PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION

Early intervention in patients with ST-elevation myocardial infarction (STEMI) is crucial for preserving left ventricular function and improving patient outcomes. Primary percutaneous coronary intervention (PPCI) has become the standard of care, and the timing of intervention significantly influences recovery and long-term prognosis. Objective: This study aimed to evaluate the impact of early successful primary percutaneous coronary intervention (PPCI) on left ventricular ejection fraction (LVEF) in patients presenting with STEMI. Methods: A prospective cohort study was conducted on 116 STEMI patients undergoing PPCI at a tertiary care hospital. The patients were categorized into two cohorts: early presenters (n=67) who received PPCI within 6 hours of symptom onset and late presenters (n=49) who received PPCI after 6 hours. Baseline characteristics, procedural outcomes, Thrombolysis in Myocardial Infarction (TIMI) flow grades, and LVEF measurements were assessed at presentation and two months post-PPCI using transthoracic echocardiography. The primary outcome was the change in LVEF from baseline to follow-up, and the secondary outcome was the distribution of TIMI flow grades achieved during PPCI. Statistical analysis was performed using appropriate tests to compare outcomes between the two groups. Results: Early presenters demonstrated significantly better outcomes compared to late presenters. At presentation, the mean LVEF in the early group was higher (45.67 ± 1.73%) compared to the late group (36.94 ± 1.25%) (p = 0.0001). At the two-month follow-up, the LVEF improved significantly in both groups, with early presenters achieving an LVEF of 56.24 ± 1.73%, which was notably higher than the LVEF of late presenters (45.12 ± 1.42%) (p = 0.0001). In terms of coronary reperfusion, 62.7% of early presenters achieved TIMI grade 3 flow compared to 26.5% of late presenters (p = 0.0001), indicating better coronary artery perfusion in the early intervention group. Conclusion: Early successful PPCI in STEMI patients is associated with superior recovery of left ventricular function and improved coronary reperfusion compared to delayed intervention. Patients who received PPCI within 6 hours of symptom onset demonstrated significantly higher LVEF at follow-up and achieved better TIMI flow grades, highlighting the critical importance of minimizing treatment delays in STEMI management.

COMPARATIVE CHARACTERISTICS OF THE INFORMATIVENESS OF THE LAL TEST AND PROCALCITONIN IN THE DIAGNOSIS OF INFECTIOUS COMPLICATIONS IN ACUTE ALCOHOLIC PANCREATITIS

Acute pancreatitis (AP) is an inflammatory condition of the pancreas, characterized by acute, intense abdominal pain. AP accounts for 20-30% of hospitalizations due to abdominal symptoms. The incidence of AP is increasing globally by 2-5% annually, ranging from 3.4 to 73.4 cases per 100,000 people. A critical concern in AAP is the potential development of infectious complications, which may require surgical intervention and increase mortality rates. Effective management and monitoring of these complications are essential. Research Justification. The diagnosis of AAP in clinical practice commonly relies on serum levels of α-amylase, lipase, C-reactive protein, and leukocyte counts. However, these markers have limitations and do not fully reflect the level of intoxication. The accuracy of C-reactive protein as a marker is not well established and is used mainly as a prognostic indicator. Serum α-amylase levels tend to decrease sharply after the fifth day of illness, regardless of the patient's condition. Lipase levels in diabetic patients can exceed reference values even without pathology, necessitating adjustments for AAP diagnosis. These criteria are most effective during the enzymatic phase of AAP (days 1-5). To predict the course of AAP and assess the adequacy of therapy, as well as to determine the need for surgical intervention, serum procalcitonin levels are commonly used. However, some studies question the diagnostic accuracy of procalcitonin, particularly regarding its correlation with organ failure, infectious complications, and patient mortality. Materials and Methods: This study involved 55 AAP patients, 51 men (92.7%) and 4 women (7.3%), with an average age of 49.49±9.87 years. Patients were categorized based on the severity of their condition: moderate (39 patients, 70.9%) and severe (16 patients, 29.1%). The control group consisted of 10 healthy individuals (9 men, 90.0%; 1 woman, 10.0%; average age 45.22±7.55 years). AAP was classified according to the Atlanta classification of acute pancreatitis. The study included patients with moderate to severe AAP who were hospitalized within 48 hours of symptom onset. All patients received treatment according to clinical guidelines, including intensive fluid therapy with Ringer's lactate. The Limulus Amebocyte Lysate (LAL) test and procalcitonin levels were measured on days 5, 8, 11, and 14 of hospitalization. For suspected infected necrosis, patients underwent contrast-enhanced computed tomography (CT) on day 14, with fine-needle aspiration biopsy or surgical intervention if necessary. Results. On day 5, LAL test values in the moderate and severe AAP groups were within reference ranges, and procalcitonin levels did not exceed 0.5 ng/ml. By day 14, a significant increase in LAL test values was noted in both groups, with a corresponding rise in procalcitonin levels. The ROC analysis for LAL test values on day 14 in the moderate AAP group showed an area under the curve (AUC) of 0.966, with 92.86% sensitivity and 96% specificity. For procalcitonin, the AUC was 0.723, with 71.43% sensitivity and 92% specificity. Conclusion. The LAL test is a sensitive and specific marker for detecting endotoxemia and monitoring the progression of AAP, particularly in predicting the development of infectious complications. The study demonstrates that LAL test values significantly correlate with the severity of AAP and may provide better diagnostic accuracy than procalcitonin, especially in the later stages of the disease.

Efficacy and Safety of Intravenous Tenecteplase Versus Alteplase in Treating Acute Ischemic Stroke With Diabetes and Admission Hyperglycemia.

The aim of this study was to investigate the efficacy and safety of tenecteplase versus alteplase in patients with acute ischemic stroke, considering their diabetes history and admission hyperglycemia status. This was a post hoc analysis of the TRACE-2 (Tenecteplase Reperfusion Therapy in Acute Ischemic Cerebrovascular Events-2) randomized clinical trial that enrolled patients in China between June 2021 and May 2022. Eligible patients with acute ischemic stroke for standard intravenous thrombolysis, but ineligible for endovascular thrombectomy, were randomly assigned (1:1) to tenecteplase or alteplase within 4.5 hours of symptom onset. Admission hyperglycemia was defined as plasma glucose >7.8 mmol/L. The primary efficacy and safety outcome were excellent functional outcome at 90 days (modified Rankin Scale score of 0-1) and symptomatic intracranial hemorrhage within 36 hours, respectively. The Cochran-Mantel-Haenszel χ2 test was used for the outcomes. Of the 1382 patients included, 369 (26.7%) had a history of diabetes, and 482 (34.9%) experienced admission hyperglycemia. The primary efficacy outcome, comparing tenecteplase to alteplase, was achieved in 93 (56.7%) versus 97 (48.3%) among patients with a history of diabetes (P=0.11) and 335 (64.6%) versus 300 (62.2%) among those without diabetes (P=0.45), respectively. The primary efficacy outcome for tenecteplase versus alteplase was comparable among patients with and without admission hyperglycemia (57.5% versus 53.9%, P = 0.44; 65.4% versus 60.4%, P=0.12, respectively). No significant difference in the risk of symptomatic intracranial hemorrhage within 36 hours was observed between tenecteplase and alteplase, regardless of diabetes history or admission hyperglycemia. This study demonstrated that intravenous tenecteplase exhibits similar clinical outcomes compared with alteplase, irrespective of the patient's glucose metabolism status. URL: https://clinicaltrials.gov; Unique identifier: NCT04797013.

Duration of Benefit and Risk of Dual Antiplatelet Therapy up to 72 Hours After Mild Ischemic Stroke and Transient Ischemic Attack.

Clopidogrel-aspirin initiated within 72 hours of symptom onset is effective in patients with mild ischemic stroke or transient ischemic attack (TIA) in the Intensive Statin and Antiplatelet Therapy for Acute High-risk Intracranial or Extracranial Atherosclerosis (INSPIRES) trial. Uncertainties remain about the duration of the treatment effect. This study aimed to assess duration of benefit and risk of clopidogrel-aspirin in these patients. The INSPIRES trial was a 2*2 factorial placebo-controlled randomized trial conducted in 222 hospitals in China. The 2 treatments did not interact and were evaluated separately. In this study, we performed secondary analyses based on antiplatelet treatment. All patients with mild stroke or TIA of presumed atherosclerotic cause within 72 hours of symptom onset enrolled in the trial were included. Patients were randomly assigned to receive clopidogrel-aspirin on days 1-21 followed by clopidogrel on days 22-90 or aspirin alone for 90 days. The primary efficacy outcome was major ischemic event which included the composite of ischemic stroke and nonhemorrhagic death. The primary safety outcome was moderate-to-severe bleeding. We estimated the risk difference between the 2 treatments for each stratified week. All 6,100 patients in the trial were included (3,050 in each group). The mean age was 65 years, and 3,915 patients (64.2%) were men. Compared with aspirin alone, the reduction of major ischemic events by clopidogrel-aspirin mainly occurred in the first week (absolute risk reduction [ARR] 1.42%, 95% CI 0.53%-2.32%) and remained in the second week (ARR 0.49%, 95% CI 0.09%-0.90%) and the third week (ARR 0.29%, 95% CI -0.05% to 0.62%). Numerical higher risk of moderate-to-severe bleedings in the clopidogrel-aspirin group was observed in the first 3 weeks (absolute risk increase 0.05% [95% CI -0.10% to 0.20%], 0.10% [95% CI -0.09% to 0.29%], and 0.18% [95% CI -0.03% to 0.40%] in the first, second, and third weeks, respectively). Among patients with mild ischemic stroke or high-risk TIA of presumed atherosclerotic cause, the net benefit of clopidogrel-aspirin initiated within 72 hours of symptom onset was pronounced in the first week and continued to a lesser degree in the following 2 weeks, outweighing the low, but ongoing hemorrhagic risk. ClinicalTrials.gov Identifier: NCT03635749. This study provides Class II evidence that among patients with mild ischemic stroke or high-risk TIA of presumed atherosclerotic cause, the net benefit of clopidogrel-aspirin initiated within 72 hours of symptom onset was pronounced in the first week and continued to a lesser degree in the following 2 weeks, outweighing the low but ongoing hemorrhagic risk.