Quantitative plaque analysis in coronary artery disease

BACKGROUND: Coronary artery disease is the commonest cause of death worldwide and clinicians have struggled to limit the associated inexorable tide of morbidity and mortality over the past few decades. Most often patients only become aware that they have coronary artery disease when they are admitted to hospital with chest pain. Computed tomography coronary angiography has revolutionised our ability to detect even mild coronary artery disease, improving the prognosis of those with symptoms of stable angina. However, its effectiveness is somewhat limited by physician reliance on the singular factor of the severity of coronary artery stenosis. The ability to characterise and to quantify the extent of coronary artery disease can incrementally improve the prognostic capability of coronary computed tomography angiography in patients with stable angina. However, we have yet to determine whether quantifying plaque is of benefit in the more unstable populations of patients who present to the Emergency Department with acute chest pain. Such patients may or may not have suffered a myocardial infarction. Moreover, in those who have myocardial infarction, this may or may not be due to plaque rupture. Computed tomography and quantitative plaque analysis could provide a novel avenue to assist both in the diagnosis and risk stratification of this patient population. Given this background, there are several questions that we put forward. These include: 1) Can plaque be accurately and reproducibly quantified in patients with a high burden of coronary artery disease? 2) Is there value in quantifying plaque in patients who have had myocardial infarction excluded? 3) In those with myocardial infarction, can quantitative plaque analysis assist in the differentiation between type 1 and type 2 myocardial infarction? 4) Does quantification of plaque burden predict recurrent events and mortality in patients who present with acute chest pain to the Emergency Department? METHODS AND RESULTS: In study one, twenty patients with known multivessel disease underwent repeated computed tomography coronary angiography 2 weeks apart. Coronary artery segments were analysed using semi-automated software by two trained observers to determine intraobserver, interobserver and interscan reproducibility. Overall, 149 coronary arterial segments were analysed. There was excellent intraobserver, interobserver and interscan agreement for all plaque volume measurements. There were no substantial interscan differences for measures of plaque burden. Whilst low-attenuation plaque volume had relatively wider 95% limits of agreement, this reflected the lower absolute volumes of low-attenuation plaque in this cohort of patients with advanced coronary disease. In study two, quantitative plaque analysis was performed on CT coronary angiograms of 242 patients recruited in a single-centre cross-sectional observational study. Patients with acute chest pain who had had myocardial infarction excluded were dichotomised by plasma high-sensitivity cardiac troponin I concentration into low (<5 ng/L, n=81) and intermediate (≥5 ng/L, n=161) risk groups. There was a higher burden of plaque in the intermediate risk group compared to the low risk group. Moreover, low-attenuation plaque burden was associated with intermediate-risk plasma troponin concentrations after adjustment for clinically relevant characteristics suggesting plaque instability may contribute to the underlying cardiovascular risk of these patients. In study three, a post-hoc analysis of two prospective clinical studies of patients with acute chest pain was conducted. Patients were classified as type 1 myocardial infarction, type 2 myocardial infarction or chest pain without infarction. The diagnosis of type 2 myocardial infarction was adjudicated by an expert panel due to the inherent difficulties in making this diagnosis. Quantitative plaque analysis was conducted in 155 patients with type 1 myocardial infarction, 36 patients with type 2 myocardial infarction and 136 patients with chest pain without infarction. We showed that patients with type 1 myocardial infarction had a significantly greater burden of total, non-calcified and low-attenuation plaque compared to those with type 2 myocardial infarction. Low-attenuation plaque was an independent predictor of type 1 myocardial infarction and had better discrimination than non-calcified plaque and even severity of coronary artery stenosis. This suggests that quantitative plaque analysis holds potential to help differentiate between these diagnoses thereby assisting in guiding patient management. In study four, quantitative plaque analysis was conducted on 404 patients who presented to the Emergency Department with suspected acute coronary syndrome. Patients underwent early coronary CT angiography and were followed up for 12 months. We assessed the association between plaque burden and the primary endpoint of 1-year all cause death or non-fatal myocardial infarction and compared this to traditional markers of risk including the GRACE score and the presence of obstructive coronary disease. Following the index admission, 25 patients went on to have an event. Events were associated with larger burdens of all plaque subtypes. Total, non-calcified and low-attenuation plaque were the strongest predictors of future events, and these associations were independent of GRACE score and presence of obstructive coronary disease. Plaque burden therefore was a major predictor of 1-year death or recurrent myocardial infarction in patients who present to hospital with suspected acute coronary syndrome. CONCLUSION: We have demonstrated that quantitative plaque analysis is a reliable tool and gives precise results even in patients with a large burden of coronary atherosclerosis. This technique can be applied to all patients who attend the hospital and are suspected of having acute coronary syndrome. When troponin concentrations do not reach the threshold to diagnose myocardial infarction according to the Universal Definition, quantifying the low-attenuation plaque burden of those with an intermediate concentration of troponin is a powerful risk stratification tool that may assist in the decision to pursue more intensive preventative medical therapy. When myocardial infarction is diagnosed but clinicians are not sure if this is due to plaque rupture or a supply and demand mismatch, the burden of low-attenuation plaque can assist in decision making and help guide downstream medical investigation and management. Finally, in all the above situations, the burden of plaque and low-attenuation plaque in particular can identify those patients at highest risk of recurrent cardiovascular events, further risk stratifying patients in the short to medium term. Taken together, these four studies provide major impetus for future prospective clinical trials that could base treatment decisions on the burden of high-risk low-attenuation plaque

Resistência microbiana a drogas em linhagens de Escherichia coli isoladas de fontes alimentares

A variety of foods and environmental sources harbor bacteria that are resistant to one or more antimicrobial drugs used in medicine and agriculture. Antibiotic resistance in Escherichia coli is of particular concern because it is the most common Gram-negative pathogen in humans. Hence this study was conducted to determine the antibiotic sensitivity pattern of E. coli isolated from different types of food items collected randomly from twelve localities of Hyderabad, India. A total of 150 samples comprising; vegetable salad, raw egg-surface, raw chicken, unpasteurized milk, and raw meat were processed microbiologically to isolate E. coli and to study their antibiotic susceptibility pattern by the Kirby-Bauer method. The highest percentages of drug resistance in isolates of E. coli were detected from raw chicken (23.3%) followed by vegetable salad (20%), raw meat (13.3%), raw egg-surface (10%) and unpasteurized milk (6.7%). The overall incidence of drug resistant E. coli was 14.7%. A total of six (4%) Extended Spectrum β-Lactamase (ESBL) producers were detected, two each from vegetable salads and raw chicken, and one each from raw egg-surface and raw meat. Multidrug resistant strains of E. coli are a matter of concern as resistance genes are easily transferable to other strains. Pathogen cycling through food is very common and might pose a potential health risk to the consumer. Therefore, in order to avoid this, good hygienic practices are necessary in the abattoirs to prevent contamination of cattle and poultry products with intestinal content as well as forbidding the use of untreated sewage in irrigating vegetables.Variedade de alimentos e fontes ambientais contem bactérias resistentes a uma ou mais drogas antimicrobianas usadas em medicina e agricultura. Resistência antibiótica pela Escherichia coli é particularmente preocupante porque ela é o patógeno mais comum Gram negativo em humanos. Portanto este estudo foi conduzido para determinar o aspecto de sensibilidade antibiótica da E. coli isolados de diferentes tipos de alimentos obtidos ao acaso de 12 localidades de Hyderabad, India. Um total de 150 amostras compreendendo saladas, vegetais, superfícies de ovos crus, galinhas cruas, leite não pasteurizado e carne crua foram processados microbiologicamente para isolar E. coli e estudar o quadro de sensibilidade antibiótica pelo método de Kirby-Bauer. A maior percentagem de resistência à droga foi isolada de E. coli obtidos de galinha crua (23,3%) seguido de saladas e vegetais (20%), carne crua (13,3%), superfície do ovo cru (10%) e leite não pasteurizado (6,7%). Incidência total de E. coli resistente foi de 14,7%. Um total de seis (4%) Extended Spectrum β-Lactamase (ESBL) produtores foram detectados, dois cada de salada de vegetais e galinha crua e um cada de superfície de ovo cru e carne crua. Espécies resistentes a múltiplas drogas de E. coli são matéria de preocupação uma vez que os genes de resistência podem facilmente ser transferidos para outras linhagens. O ciclo do patógeno é muito comum nos alimentos e pode ser risco potencial para a saúde do consumidor. Portanto, para evitar isto boas práticas de higiene são necessárias nos abatedouros para prevenir a contaminação de gado e aves com conteúdo intestinal assim como proibir o uso de águas de esgoto não tratadas para irrigar vegetais

Prevalence of prediabetes, diabetes, and Its associated risk factors among males in Saudi Arabia: A population-based survey

Objectives: The study aims at determining the prevalence of prediabetes and diabetes and at ascertaining some concomitant risk factorsamong males in Saudi Arabia.Methods: A population-based cross-sectional study including 381 Saudi adult males from different institutions was recruited. Odds ratios for diabetes risk and risk factors were calculated using log-binomial and multinomial logistic regression, using STATA version 12.Results: The participants included 381 diabetic males with a median age of 45 years, average body mass index of 25 ± 40 kg/m2, whereas waist circumferences ranged from 66 to 180 cm in the male study population. In addition, 27.82% had normal BMI, 32.28% were overweight, and 36.22% were obese. Around 36% had higher waist circumference, that is, \u3e102 cm. Age, BMI, marital status, and educational attainment were statistically significant predictors for prediabetes and diabetes.Conclusion: This study found that the prevalence of diabetes and prediabetes was 9.2% and 27.6%, respectively, for male Al-Kharj study population. The factors that increase the risk of diabetes and prediabetes include older age, obesity and overweight, being married, smoker, and having a civilian job and less education. All these factors were found statistically significant except smoking status and job type. In order to evaluate the causal relationship of these factors, prospective studies are required in future

Prevalence of prediabetes, diabetes and Its predictors among females in alkharj, saudi arabia: A cross-sectional study.

BACKGROUND/OBJECTIVE: The prevalence of prediabetes and diabetes is reaching epidemic proportions across the globe. Therefore, this study aims to determine the prevalence of prediabetes and diabetes, together with its accompanying risk factors, among young females. METHODS: An exploratory cross-sectional survey was conducted with 638 Saudi females in Alkharj, Saudi Arabia. Statistical analysis was carried out using STATA version 14. Odds ratios for the risk of diabetes and associated factors were calculated using log-binomial and multinomial logistic regression. Standardized prevalence and strata-specific prevalence of diabetes and prediabetes for different risk factors were also calculated. FINDINGS: The study revealed that nondiabetics and prediabetics were more prevalent between the ages of 18 and 24 years, while diabetic patients were consistently between 25 to 44 years of age. The average value for HbA1c in females was 5.44. Regression analysis shows that being older, married, obese, a smoker or less educated significantly increases the risk for both prediabetes and diabetes. Mutivariable analysis revealed obesity had a significant association with both prediabetes and diabetes. Prediabetics were 2.35 times more likely to be obese as compared to nondiabetics, with 95% CI (1.38-3.99). Similarly, diabetics were 6.67 times more likely to be obese compared to nondiabetics 95% CI (1.68-26.42). CONCLUSION: Our study shows the prevalence of diabetes and prediabetes among females from Al Kharj was 3.8% and 18.8%, respectively. The diabetic and prediabetic female participants had higher mean BMI and waist circumference, were older in age, were married, and smoked as compared to nondiabetics. In the context of the findings of our study, and keeping in view the the burden of this disease globally and in our population, it has now become extremely important to understand these factors and encourage health-promoting behaviors to construct effective interventions

CLINICAL CARE PATHWAY AND MANAGEMENT OF MAJOR BLEEDING ASSOCIATED WITH NON-VITAMIN K ANTAGONIST ORAL ANTICOAGULANTS: A MODIFIED DELPHI CONSENSUS FROM SAUDI ARABIA AND UAE

Background: The non-vitamin K antagonist oral anticoagulants (NOACs) have become the mainstay anticoagulation therapy for patients requiring oral anticoagulants (OACs) in the Gulf Council Cooperation (GCC) countries. The frequency of NOAC-associated major bleeding is expected to increase in the Emergency Department (ED). Nonetheless, we still lack local guidelines and recommendations for bleeding management in the region. The present Delphi-based consensus aims to establish a standardized and evidence-based clinical care pathway for managing NOAC-associated major bleeding in the Kingdom of Saudi Arabia (KSA) and the United Arab Emirates (UAE). Methods: We adopted a three-step modified Delphi method to develop evidence-based recommendations through two voting rounds and an advisory meeting between the two rounds. A panel of 11 experts from the KSA and UAE participated in the consensus development. Results: Twenty-eight statements reached the consensus level. These statements addressed key aspects of managing major bleeding events associated with NOACs, including the increased use of NOAC in clinical practice, clinical care pathways, and treatment options. Conclusion: The present Delphi consensus provides evidence-based recommendations and protocols for the management of NOAC-associated bleeding in the region. Patients with major NOAC-induced bleeding should be referred to a well-equipped ED with standardized management protocols. A multidisciplinary approach is recommended for establishing the association between NOAC use and major bleeding. Treating physicians should have prompt access to specific reversal agents to optimize patient outcomes. Real-world evidence and national guidelines are needed to aid all stakeholders involved in NOAC-induced bleeding management

Lifestyle habits and type 2 diabetes traits in patients from healthcare centers in Dubai, United Arab Emirates: a cross-sectional study

ObjectivesGiven the increasing prevalence of type 2 diabetes (T2D) in the United Arab Emirates (UAE), in this cross-sectional study we analyzed the dietary habits, physical activity, as well as anthropometric, clinical, and laboratory parameters in patients with T2D and nondiabetic (ND) subjects from the UAE.Subjects and MethodsThis study included 344 UAE nationals, age 18 or older, who completed a questionnaire to assess their dietary habits and physical activity. The mean age of the recruited participants was 50.9 years (+/-14.1) and females presented 63.4% of the sample size. The linear regression analysis was applied to analyze all clinical parameters and dietary habits as outcomes, while a logistic regression analysis was used to determine the association of patient status with physical activity, as an outcome. All models were controlled for age, gender, and BMI.ResultsThere was a difference in dietary habits between the groups (B=-3.7; CI -6.42, -0.92; p=0.009), where patients with T2D had a lower dietary score than ND subjects, indicating a healthier diet. Our results showed that 19% of T2D patients and 32% of nondiabetic individuals were concerned about their weight. Both groups considered dietary changes important, and more than 90% of participants expressed high or moderate confidence in making those changes. Furthermore, the male nondiabetic subjects demonstrated a 4 times higher level of physical activity versus their diabetic counterparts (OR=4.01, CI: 1.01, 15.9, p=0.04), while the difference in physical activity between female subjects with and without T2D was not demonstrated.ConclusionsOur results showed that patients with T2D consumed a healthier diet than nondiabetic subjects, probably resulting in more favorable total cholesterol and LDL-cholesterol profiles. A gender difference in physical activity was also observed in this sample of UAE population. Our findings suggest that although patients with T2D in the UAE may adopt healthier dietary habits, there remains a significant need to address physical activity disparities, particularly among women, to improve overall health outcomes in this population. Addressing these habits through targeted clinical interventions and lifestyle medicine approach can optimize long-term management and prevention strategies for type 2 diabetes in this region

An Analysis of Attitude Towards Online Shopping in Pakistan Using the Technology Acceptance Model

This empirical study aims to examine the factors that Online Shopping Users exhibit which can be used to help the online shopping platforms further work on their online presence in order to make sure that all potential users stay on their platforms and most of all, are content using their platforms. Personality, Web Experiences, Perceived Usefulness, Perceived Ease of Use, Attitude were used to determine how these factors affect Online Shoppers. A survey (Google Forms) was distributed via social media and social messengers which comprised of virtually infinite respondents. The results showed that most of our respondents are not akin to finding the perceived usability or perceived ease of use of online shopping irrespective they have a certain online leadership style, or are impulsive buyers, and are also not deterred even if they are satisfied with a website or are security conscious. But if they end up finding an online system useful and user-friendly, they will definitely intend to come back to the online portal again for future purchases. This research was conducted inside Pakistan comprising respondents distributed in different cities due to the questionnaire being circulated via online mediums. Future researchers can employ the same model to conduct the same research in another country. This study proposes a framework to quantitatively analyzing the link between different aspects of Personality and different aspects of Web Experiences with Perceived Usefulness and Perceived Ease of Use, and furthermore the Attitude of the respondents towards Online Shopping Platforms.</jats:p

Clinical Relevance of Coronary Computed Tomography Angiography Beyond Coronary Artery Stenosis

Background The capabilities of coronary computed tomography angiography (CCTA) have advanced significantly in the past decade. Its capacity to detect stenotic coronary arteries safely and consistently has led to a marked decline in invasive diagnostic angiography. However, CCTA can do much more than identify coronary artery stenoses. Method This review discusses applications of CCTA beyond coronary stenosis assessment, focusing in particular on the visual and quantitative analysis of atherosclerotic plaque. Results Established signs of visually assessed high-risk plaque on CT include positive remodeling, low-attenuation plaque, spotty calcification, and the napkin-ring sign, which correlate with the histological thin-cap fibroatheroma. Recently, quantification of plaque subtypes has further improved the assessment of coronary plaque on CT. Quantitatively assessed low-attenuation plaque, which correlates with the necrotic core of the thin-cap fibroatheroma, has demonstrated superiority over stenosis severity and coronary calcium score in predicting subsequent myocardial infarction. Current research aims to use radiomic and machine learning methods to further improve our understanding of high-risk atherosclerotic plaque subtypes identified on CCTA. Conclusion Despite rapid technological advances in the field of coronary computed tomography angiography, there remains a significant lag in routine clinical practice where use is often limited to lumenography. We summarize some of the most promising techniques that significantly improve the diagnostic and prognostic potential of CCTA. Key Points:  Citation Format </jats:p

Clinical study on management of venous ulcer

Background: Venous ulcer is the most common ulcer affecting the lower limbs, usually associated with varicose veins. They are diagnosed by their location, morphology, skin changes, and association with venous insufficiency. They are complicated with local scarring, ankylosis of ankle joint, and occasionally malignancy. Diagnosis is confirmed by venous duplex imaging. They significantly reduce quality of life due to pain, and reduced mobility leading to loss of income and social isolation. Cost estimates put them at upwards of 2% of national resources. Recurrence is high with conservative treatment. Surgery addressing venous valvular insufficiency plays a major role. Objectives of current study was to assess the role of conservative treatment and surgical management of venous ulcers.Methods: A cross-sectional study of 80 patients in the period 2019 -2020 at a tertiary care center.Results: 84% of the patients were male with maximum patients in the 6th decade. 67% were overweight. Conservative treatment was done in 22% of cases and surgery for 78%. Flush ligation and venous stripping with perforator ligation was the most common surgery done. 89% of the patients achieved healing by the end of 3 months, and 7% by the end of 6 months. Wound healing time in surgical vs conservatively was 8.3 and 10.4 weeks respectively.Conclusions: Correction of underlying venous insufficiency is the main stay of the treatment. Surgery gives best results with long term benefits.</jats:p

Certificates verification on the block chain

All certificates, including those for secondary school graduation, high school diplomas, and college degrees, have been converted to digital form and made accessible to students at higher education institutions. It's essential for learners to keep track of their diplomas. It is a complex and time-consuming process for the institution or organization to verify or authenticate a certificate's validity. This application would aid in the safekeeping of the certificates on the block chain. Digital certificates are created by first digitising the original paper certificates. The certificate's hash code value is generated using the chaotic technique. It is then added to the block chain. The mobile application is used to verify these certifications. We can make digital certificate verification more reliable and safe by implementing block chains