Outcomes of stroke patients undergoing thrombolysis in Sri Lanka; an observational prospective study from a low-middle income country

Background Stroke related deaths are relatively higher in low- and middle-income countries where only a fraction of eligible patients undergo thrombolysis. There is also limited evidence on post-thrombolysis outcomes of patients from Asian countries in these income bands. Methods This is a single center prospective observational study of a patient cohort with acute ischaemic stroke, undergoing thrombolysis with alteplase (low and standard dose), over a 24-month period in 2019/2020. Modified Rankin scale (mRS) for dependency at 3 months (primary outcome), duration of hospital stay, incidence of symptomatic intracranial haemorrhages and all-cause mortality at 3 months (secondary outcomes) were recorded. Demographic, clinical and treatment related factors associated with these outcomes were explored. Results Eighty-nine patients (males – 61, 69%, mean age: 60 years ±12.18) were recruited. Time from symptom onset to reperfusion was 174 min ± 56.50. Fifty-one patients were independent according to mRS, 11 (12.4%) patients died, and 11 (12.5%) developed symptomatic intracranial haemorrhages by 3 months. Functional independence at 3 months was independently associated with National Institutes of Health Stroke Scale (NIHSS) on admission (p < 0.05). Thrombolysis with low dose alteplase did not lead to better or worse outcomes compared to standard dose. Conclusions On admission NIHSS is predictive of functional independence at 3 months post-thrombolysis. Low dose alteplase may be as efficacious as standard dose alteplase with associated cost savings, but this needs to be confirmed by a prospective clinical trial for the Sri Lankan population.

Nasal High-Flow for Weaning Preterm Newborns with Risk of Chronic Lung Disease from nCPAP

Objective The aim of the study is to compare the duration of oxygen therapy by using two methods of weaning from nasal continuous positive airway pressure (nCPAP) in very preterm babies. Study Design Between April 2014 and December 2016, 90 preterm <32 weeks and birthweight >1,000 g who, after at least 7 days on nCPAP, were clinically stable on <6 cm H2O and FiO2 <30% were randomly assigned to weaning directly from nCPAP or with nasal high flow therapy (nHFT). In the nCPAP group, pressure was gradually reduced until the infant was stable on 4 cm H2O and then discontinued. In the nHFT group, flow rate was reduced until the infant was stable at 3.l pm and then discontinued. Results Eighty-four infants completed the study. There were no differences between the groups for the primary outcome, duration of oxygen therapy (median 33 [14–48] versus 28 [15–37] days; p = 0.17). The incidence of moderate-to-severe bronchopulmonary dysplasia was similar. Weaning time was shorter in the nCPAP group (p = 0.02), but the failure rate was slightly higher although non-significant. In the nHFT group, we observed better perception of patient comfort and a lower incidence of severe nasal injury. Conclusion Weaning by nHFT compared with weaning directly off nCPAP does not prolong duration of oxygen therapy. Rather, it is associated with better perceptions of infant comfort among parents and lower rates of severe nasal injury. Key Points

Evaluation of the Refeeding Syndrome Criteria in Critically Ill Patients in a Chinese Hospital: A Retrospective Study

Background: Refeeding syndrome (RFS) was a group of metabolic disorders associated with refeeding after starvation. However, RFS is underdiagnosed in China due to the highly heterogeneous diagnostic criteria. This study was to evaluate the diagnosis of RFS in our intensive care unit (ICU).Methods: Patients monitoring serum phosphate and accepting nutritional treatment more than 3 days were included in our retrospective study. RFS was defined as the new onset hypophosphatemia (<0.87mmol/l) within 72 h after feeding and serum phosphate concentration decreased more than the extent 30%. According to the lowest serum phosphate level within the first 3 days after feeding, all RFS patients were divided into the three groups: Group 1(between 0.65 and 0.87mmol/L as well as more than 30% decrease from baseline), Group 2 (between 0.32 and 0.65mmol/L as well as at least 0.16mmol/L decrease from baseline ) and Group 3 (lower than 0.32mmol/L). The nutritional and prognostic indices were recorded and analyzed within the three groups.Results: A total of 1678 patients were included, of which 150(8.7%) were regularly monitored for serum phosphate. Among these 150 patients, 27 patients were diagnosed the RFS finally. Except for NRS 2002, there were no significant difference in nutritional index such as BMI, percentage of High-risk RFS, total caloric intake, baseline of potassium, magnesium, phosphate and calcium and time to start feeding among three groups. Also, there were no significant differences in clinical outcome, duration of mechanical ventilation and LOS of ICU and hospital. The NRS2002 scores of the three groups were 0.75±0.957, 3.00±1.541 and 4.50±1.049 respectively, and the higher the decline of serum phosphate, the higher the NRS2002 score was (P=0.001). Conclusions: The refeeding hypophosphatemia incidence was not rare in intensive care unit，even serum phosphate has not been monitored regularly. The higher score of NRS2002 might be correlated with greater decline of serum phosphate. However, changes in serum phosphate may be unrelated to prognosis and not be an optimal indicator of low calorie feeding.Trial registration: ClinicalTrials.gov database, NCT04005300. Registered 1 July 2019, https://clinicaltrials.gov/ct2/show/ NCT04005300

Prevalence Rate of Diabetes and Hypertension in Disaster-Exposed Populations: A Systematic Review and Meta-Analysis

BACKGROUND: Non-communicable diseases (NCD) such as hypertension (HTN) and diabetes mellitus (DM) have been one of the major health problems in the world. The aim of this study was to evaluate the prevalence rate of DM and HTN following natural and man-made disasters that impose significant economic and psychological burdens on human communities.METHODS: In this systematic and meta-analysis review, all crosssectional studies that at least one of their objectives was to measure the prevalence of HTN or DM in individuals affected by natural and man-made disasters were included. Literature review was done in international databases including PubMed, Scopus and Web of Science, from database inception to February 17, 2019. The extracted data included the bibliographic characteristics of the article, the age of the participants, number of participants, gender, sample size, outcome, duration of the follow-up, and prevalence of DM and HTN. Data were analyzed by STATA software (version11) and random effect method and the I2 index were used to investigate heterogeneity between the articles.RESULTS: A total of 16 articles met the inclusion criteria. Based on the quality assessment, 11 papers were categorized as moderate and 5 paper were categorized as high quality. The prevalence of HTN and DM in disaster-exposed populations were 47.35 (CI 95%: 38.53-56.17) and 13.56 (CI 95%: 10.12-17.01), respectively.CONCLUSION: The results of this study show a high prevalence of HTN and DM in survivors of major disasters, which is higher in comparison to the general population.

Congenital vaginal obstruction in young girls: need for standard post-operative dilatation protocol

Background: Congenital vaginal obstruction is a rare disorder in which there is blockage of the vaginal tract during the developmental stage and subsequently leading to accumulation of secretions and or menstrual blood. Surgical relief of obstruction is an effective treatment. Ensuring patency of the tract following surgery in young girls not sexually active can be challenging.Methods: This is a 10-years retrospective analytical study of cases of congenital vaginal obstruction in young girls seen in two centres from February 2007 to January 2017. Data retrieved from the case notes included age at presentation, presenting features, prior intervention, diagnosis, surgery performed, vaginal dilatations, outcome, duration of follow-up. Data was subjected to simple statistical analysis.Results: Eight patients met the inclusion criteria. The age range was 7 to 15years with a median of 12years. The cause of obstruction was transverse vaginal septum in 5 cases, imperforate hymen 2, vaginal hypoplasia 1. Three of the patients had no dilatation post operatively and of these, two came back with recurrent obstruction and hematometra. The third one was a case of imperforate hymen and did not develop stenosis despite not being dilated. There were no mortalities.Conclusions: The occurrence of recurrent obstruction following surgical treatment of congenital vaginal obstruction is high. Post-operative dilatation reduces incidence of recurrence.