Urology

The health-care crisis in India – Can urology remain untouched? Arabind Panda Indian Journal of Urology 2019 35(3):177-178

Round up Apul Goel Indian Journal of Urology 2019 35(3):179-182

What's inside Rajeev Kumar Indian Journal of Urology 2019 35(3):183-184

The Urological Society of India Guidelines for the Evaluation and Management of Nonneurogenic Urinary Incontinence in Adults (Executive Summary) Sanjay Sinha, Mayank Mohan Agarwal, Pawan Vasudeva, Nikhil Khattar, Vijay Kumar Sarma Madduri, Shirish Yande, Kalyan Sarkar, Anita Patel, Ajit Vaze, Shailesh Raina, Amita Jain, Manu Gupta, Nagendranath Mishra Indian Journal of Urology 2019 35(3):185-188

The resurgence of estrogens in the treatment of castration-resistant prostate cancer H Krishna Moorthy, GG Laxman Prabhu, P Venugopal Indian Journal of Urology 2019 35(3):189-196 Use of exogenous estrogens in manipulating the androgenestrogen equilibrium was one of the earliest therapeutic strategies developed to treat prostate cancer which followed close on heels the discovery of hormone dependence of this tumor. Despite its well-documented benefit, estrogen therapy fell out of favor with the advent of other forms of androgen deprivation therapy (ADT) as the former registered a higher incidence of cardiovascular complications and poorer overall survival. Clearer understanding of the mechanism of action of estrogen coupled with the adoption of alternative routes of administration has triggered a renewed interest in estrogen therapy. Since then, many studies have not only proved the therapeutic benefit of estrogens but also explored the ways and means of minimizing the dreaded side effects deterring its use. Further, the fact that estrogen therapy offered a clear advantage of reduced cost of treatment over other treatments has led many countries to readopt it in the treatment of advanced prostatic cancer. We reviewed the published data on the use of estrogens in CRPC, which may affect its revival as an efficacious treatment option having minimal side effects, with modified dosage and route of administration. Estrogen therapy would be a less expensive option having equivalent or even better therapeutic effect than ADT in advanced carcinoma of prostate.

Development of an innovative intrarenal pressure regulation system for mini-PCNL: A preliminary study Ashish V Rawandale-Patil, Arvind P Ganpule, Lokesh G Patni Indian Journal of Urology 2019 35(3):197-201 Introduction: Miniaturized percutaneous nephrolithotomy (mini-PCNL) requires saline irrigation at high-pressures to maintain visual clarity. However, this may raise the intrarenal pelvic pressures (IRPs) beyond a safe range and may result in a higher complication rate. The aim of this study was to make and validate an automated pressure saline irrigation system to regulate IRPs during mini-PCNL. Materials and Methods: A ureteric catheter was connected to an urodynamic machine and the minimum, maximum, and average IRPs reached during a standard 15 Fr mini-PCNL were measured in ten cases. Next, an intrarenal pressure regulation system (IPRS) was conceptualized, designed, patented, and constructed. IPRS was then tested on a mannequin model using the routine instruments. Lastly, the IPRS was evaluated on – five cases of 15 Fr mini-PCNL. The mean maximum IRP as recorded in the baseline data was set as the maximum permissible pressure on IPRS. The efficacy of IPRS was assessed by measuring the IRP, recorded in parallel, on both the IPRS and the urodynamic machine at various stages of the procedure. Results: The mean maximum IRP reached during baseline evaluation was 25 cm of water which was set as the maximum permissible limit of the IPRS. Evaluation of the IRPS on mannequin models and validation clinical cases showed that IPRS measured the IRP accurately and prevented the pressure surge above the set limits Overall, higher IRPs were recorded during stone pulverization as compared to the other surgical steps. Conclusions: The current IPRS is the first of its kind open platform, portable, automated pressure saline irrigation system. It precisely monitors and controls the IRP and has the potential to reduce the irrigation pressure-related complications.

Comparison of percentage free PSA, MRI and GaPSMA PET scan for diagnosing cancer prostate in men with PSA between 4 and 20 ng/ml Niraj Kumar, Siddharth Yadav, Sandeep Kumar, Kumar Saurav, Vishnu Prasad, Pawan Vasudeva Indian Journal of Urology 2019 35(3):202-207 Introduction: We compared the diagnostic accuracy of percentage free prostate-specific antigen (PSA), multiparametric magnetic resonance imaging (mpMRI), and gallium-68 prostate-specific membrane antigen positron emission tomography (Ga-PSMA PET) to detect cancer prostate in men with PSA between 4 and 20 ng/ml in prebiopsy settings. Materials and Methods: This prospective study evaluated men with PSA values between 4 and 20 ng/ml, and all patients underwent percentage free PSA estimation, mpMRI, and Ga-PSMA PET scan, followed by cognitive fusion/registration biopsy along with systematic 12-core biopsy to detect cancer prostate. The diagnostic accuracy of percentage free PSA, mpMRI, and Ga-PSMA PET scan was compared with results of cognitive fusion/registration biopsy. Results: A total of 15 patients were included, of which 11 had an identifiable lesion on imaging and 9 had malignancy on the final histopathology report. The sensitivity, specificity, positive predictive value, negative predictive value (NPV), and diagnostic accuracy of mpMRI were 62.5%, 71.4%, 71.4%, 62.5%, and 66.6%, respectively, and that of Ga-PSMA PET scan were 88.8%, 66.6%, 80%, 80%, and 80%, respectively. The sensitivity of detection of clinically significant cancers for Ga-PSMA was higher (100%) compared to MRI (33.3%). However, Ga-PSMA also detected a greater number of insignificant lesions as compared to MRI. Conclusion: Ga-PSMA PET scan has high NPV and accuracy in predicting presence of cancer and can also be used to direct specific biopsy cores during systematic biopsy.

MRI - ultrasound fusion guided biopsy of the prostate: lesion volume as a predictor of cancer in patients with repeat biopsies Scott Alan Blaine, Haidar M Abdul-Muhsin, Nicholas J Jakob, Paul E Andrews, Robert G Ferrigni, Stephen S Cha, Ashkahn Golshani, Alvin C Silva, Akira Kawashima, Mitchell R Humphreys Indian Journal of Urology 2019 35(3):208-212 Introduction: The objective was to analyze the diagnostic value of multiparametric magnetic resonance imaging (MRI) prostate lesion volume (PLV) and its correlation with the subsequent MRI–ultrasound (MRI-US) fusion biopsy results. Materials and Methods: Between March 2014 and July 2016, 150 men underwent MRI-US fusion biopsies at our institution. All suspicious prostate lesions were graded according to the Prostate Imaging Reporting and Data System (PIRADS) and their volumes were measured. These lesions were subsequently biopsied. All data were prospectively collected and retrospectively analyzed. The PLV of all suspicious lesions was correlated with the presence of cancer on the final MRI-US fusion biopsy. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Results: There were 206 suspicious lesions identified in 150 men. The overall cancer detection rate was 102/206 (49.5%). The mean PLV for benign lesions was 0.63 ± 0.94 cm3 versus 1.44 ± 1.76 cm3 for cancerous lesions (P < 0.01). There was a statistically significant difference between the PLV of PIRADS 5 lesions when compared to PIRADS 4, 3, and 2 lesions (P < 0.0001, < 0.0001, and 0.006, respectively). The area under the curve for volume in predicting prostate cancer (PCa) was 0.66. The optimal volume for predicting PCa was 0.26 cm3 with a sensitivity, specificity, PPV, and NPV of 80.7%, 42.7%, 41.2%, and 74.6%, respectively. Conclusion: PLV may serve as a useful measure to triage patients prior to MRI-US fusion biopsy and help better understand the limits of this technology for individual patients.

Clinicopathological features and outcomes of adrenocortical carcinoma: A single institution experience Lekha Madhavan Nair, KM Jagathnath Krishna, Aswin Kumar, Susan Mathews, John Joseph, Francis Vadakkumparambil James Indian Journal of Urology 2019 35(3):213-217 Introduction: Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with aggressive behavior. Most of our knowledge about this rare tumor is based on retrospective case series. This study aimed at analyzing the clinicopathological features and outcomes of patients treated at a tertiary cancer center in India. Patients and Methods: We retrospectively reviewed the data of patients with ACC registered from January 2006 to December 2015. Results: Thirty-seven patients were included in the study, 20 males and 17 females. Median age was 49 (18–78) years. Hormonal overproduction was noticed in 27% of patients. Median tumor size was 10 cm (2–22). Seventeen patients had metastatic disease and 20 patients were localised at diagnosis. Median follow-up was 22 months and median overall survival (OS) was 23.46 months. OS at 2 years and 5 years was 46.1% and 21%, respectively. The median disease-free survival (DFS) was 20 months. DFS at 2 years and 5 years was 45% and 24%, respectively. Age, sex, tumor size, hormonal overproduction, tumor laterality, and stage of the disease did not influence survival. However, advanced stage was associated with higher risk for recurrence. (P = 0.03). Conclusion: ACC is a rare endocrine malignancy with very poor survival rates. Rate of recurrence is high even after complete surgery. Systemic treatment options are limited. Newer agents are needed to improve outcome.

Native ureteroureterostomy in renal allograft recipient surgery: A single-center 5-year experience Vipin Tyagi, Saurabh Jain, Mahendra Singh, Mrinal Pahwa, Sudhir Chadha, Shahnawaz Rasool Indian Journal of Urology 2019 35(3):218-221 Introduction: In renal transplant, surgeons use a myriad of ureteral anastomotic techniques. Although ureteroneocystostomy (UNC) using Lich-Gregoir extravesical anastomosis is used most commonly, ureteroureterostomy with native ureter has its own importance in certain situations. Materials and Methods: We retrospectively reviewed records of patients who underwent renal transplantation at our center from March 2011 to February 2016. Records of patients who underwent ureteroureterostomy with the native ureter were reviewed for the indications and complications of the procedure. Results: Of 1050 renal transplants during the study period, 32 patients underwent native ureteroureterostomy. Among these 32 patients, 20 patients were planned preoperatively for native ureteroureterostomy (elective), and intraoperative decision was made in 12 patients (emergency). On follow-up, only one patient had ureteral obstruction due to kink just distal to ureteroureterostomy and was managed by double-J stenting. Other patients had an expected postoperative course. Conclusion: In our experience, ureteroureterostomy with native ureter is technically and functionally good option for ureteric reimplantation in kidney transplant patients. It can be used selectively for elective and emergency situations where UNC is not possible. Hence, the kidney transplant surgeon should be well versed with both techniques.

Supportive and Palliative Care

Standardized measurement of breathlessness during exercise Purpose of review Exertional breathlessness is common and pervasive across various chronic disease populations. To accurately assess response to intervention and optimize clinical (symptom) management, detailed assessment of exertional breathlessness is imperative. This review provides an update on current approaches to assess exertional breathlessness and presents the need for individualized assessment of breathlessness standardized for the level of exertion. Recent findings Breathlessness assessment tools commonly invite people to recall their breathlessness while at rest with reference to activities of daily living. To directly quantify breathlessness, however, requires assessment of the dimensions of breathlessness (e.g., sensory intensity, quality, and unpleasantness) in response to a standardized exercise stimulus. Different exercise stimuli (e.g., self-paced, incremental, and constant work rate exercise tests) have been used to elicit a breathlessness response. Self-paced (e.g., 6-min walk test) and incremental exercise tests assess exercise tolerance or endurance, and are not recommended for assessment of exertional breathlessness. Constant work rate tests, however, including recently validated 3-min constant-rate stair stepping and walking tests, standardize the exercise stimulus to enable the breathlessness response to be directly quantified and monitored over time. Summary To adequately guide symptom management and assess intervention efficacy, clinicians and researchers should assess breathlessness with multidimensional assessment tools in response to a standardized and individualized exercise stimulus. Correspondence to Dennis Jensen, Currie Memorial Gymnasium, 475 Pine Avenue West, Montreal, Quebec, H2W 1S4, Canada. Tel: +1 514 398 4184; e-mail: dennis.jensen@mcgill.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Why treatment efficacy on breathlessness in laboratory but not daily life trials? The importance of standardized exertion Purpose of review Treatments for chronic breathlessness, including opioids and oxygen, have shown efficacy in the controlled laboratory setting, whereas effects have been inconsistent or absent in trials in daily life. This review discusses the lack of standardized exertion as a potential cause of false negative findings for breathlessness in daily life. Recent findings The level of breathlessness can be modified by patients by changing their level of physical activity. Effects of opioids and oxygen have been shown at standardized level of exertion (iso-time) but not at the end of symptom-limited (peak) exertion. Trials in daily life reporting no effects on breathlessness did not standardize the exertion or employed insensitive methods, such as the 6-min walk test that should not be used for measuring breathlessness. Novel tests – the 3-min walk and stepping tests have been validated in chronic obstructive pulmonary disease and are responsive for measuring change in breathlessness. Summary Breathlessness should be measured at standardized exertion, otherwise treatment effects may be biased or overlooked. Tests for valid measurement of breathlessness in clinical practice and daily life are available and emerging. Correspondence to Magnus Ekström, MD, PhD, Associate Professor, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, Lund, Karlskrona SE-371 85, Sweden. Tel: +46(0)455731000; e-mail:pmekstrom@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Why treatment efficacy on breathlessness in laboratory but... : Current ... of false negative findings for breathlessness in daily life. Recent findings The level of breathlessness can ...

Recent research on the social network concept and cancer
Purpose of review This review covers articles in 2018 and early 2019 that employed the concept of networks and social interactions in research on how patients with cancer cope, receive and respond to medical treatment and allied support. The use of social aspects, and more formally the method of social network analysis for research on cancer is quite new. Although we paid special attention to articles that used formal social network analysis, we noted that those articles cover just over a quarter of the material we reviewed. Most articles that incorporated social aspects of cancer did not intend to formalize them by measuring specific relationships but treated the network concept as a way to characterize social support, social influence, or social responsibilities. Recent findings We identified 74 recent articles that mentioned the network concept for research about cancer, excluding gene interaction networks. Of those 74 articles, 21 measured specific relationships between individuals or organizations and/or attributes of those individuals or organizations connected to participants or to others. Primary foci of the network analysis and nonnetwork analysis studies were breast cancer and social support for patients, and they usually at least considered sex and age of the cancer patients/survivors. Social media received some attention, and there were some studies considering quality of life and mental health. Among network analysis studies, size of network and number of people providing emotional/informational/instrumental support occurred in more than a couple studies but not the majority. There was little similarity among studies – whether using network analysis or not – suggesting that theory building and methodological development are in early stages. Summary Implications of the review include opportunities for more systematic research using the network concept to understand people's experience of cancer as well as research on cancer. Researchers can make considerable contributions at this stage in the field's development, and practitioners can help develop interventions that make fuller use of the insights of social network analysis. Correspondence to Eric C. Jones, UTHSCH, 1851 Wiggins Way, HSN 487, El Paso, TX 79968, USA. Tel: +1 915 747 8503; fax: +1 915 747 8512; e-mail: Eric.C.Jones@uth.tmc.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Recent research on the social network concept and cancer : Current Opini... f social network analysis for research on cancer is quite new. Although we paid special attention to articles th...

Multimorbidity in older adults living with and beyond cancer
Purpose of review The current review draws attention to the need for longer term management of multiple conditions in older adults with cancer. Recent findings Older people living with and beyond cancer are more likely than younger people to have higher prevalence of multimorbidity leading to an overall increase in illness and treatment burdens, limiting health-related quality of life (QoL), and capacity to self-manage. Older age presents a higher risk of cancer treatment side-effects and development or progression of other conditions, leading to worsening health, long-lasting functional problems, and social isolation. Although many prioritize functional independence and continuance of valued activities over survival, older people living with multimorbidity are more likely to experience poor physical functioning during and beyond cancer treatment. Summary Cancer treatment decisions and survivorship plans should be developed in the context of other conditions and in line with the individual's priorities for continued QoL. More research is needed to guide service development and clinical practice in this important area. Correspondence to Dr Teresa Corbett, School of Health Sciences, University of Southampton, Building 67 Room 3031, Highfield, Southampton SO17 1BJ, UK. Tel: +44 2380598292; e-mail:t.k.corbett@soton.ac.uk Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Multimorbidity in older adults living with and beyond cancer : Current O... o an overall increase in illness and treatment burdens, limiting health-related quality of life (QoL), and capac...

Caring for the informal cancer caregiver
Purpose of review Informal cancer caregivers play a vital role in the physical, functional, and emotional well being of cancer patients. However, the majority of informal caregivers are not prepared for their caregiving role. We reviewed and synthesized the recent literature (last 18 months) and focused on research in the following understudied areas: technology-driven interventions for informal caregivers; informal caregivers of older adults with cancer; interrelationship between informal caregiver and dyadic outcomes; and research priorities and guidelines to improve informal caregiver support. Recent findings Studies focused on technology-driven informal caregiver interventions, with evidence of good feasibility and acceptability with benefits for burden and quality of life (QOL). Studies also focused on QOL for caregivers of older adults with cancer. Finally, research priorities and clinical guidelines were established through Delphi survey studies. Summary Despite the substantial evidence on informal cancer caregiving, more research is needed to further characterize caregivers at high risk for burden, explicate interrelationships between caregiver/patient outcomes, and test innovative and scalable interventions. Studies are also needed to understand the specific needs of informal caregivers in cancer surgery, an understudied treatment population. Correspondence to Virginia Sun, PhD, RN, Associate Professor, Division of Nursing Research and Education, Department of Population Sciences, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA. Tel: +1 626/218 3122; e-mail: vsun@coh.orgCopyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Complexity when living with cancer
No abstract available

Ketamine and lidocaine infusions decrease opioid consumption during vaso-occlusive crisis in adolescents with sickle cell disease
Purpose of review Recurrent exposure to opioids can lead to development of opioid tolerance and opioid-induced hyperalgesia through activation of N-methyl-D-aspartate receptors. N-methyl-D-aspartate receptor antagonists ketamine and lidocaine can modulate development of opioid tolerance and OIH. This study evaluated the utility of ketamine and/or lidocaine in decreasing opioid consumption during acute pain episodes in adolescents with sickle cell disease. There has been an increased effort to promote opioid-sparing pain relieving methods given the ongoing opioid epidemic. Recent findings There have been six studies published over the past decade that highlight the ability of ketamine to reduce opioid consumption in the management of sickle cell disease-related pain, primarily in adult patients. There has been one study (2015) that demonstrated a similar benefit with lidocaine, however this was also in adult patients. Summary We retrospectively evaluated treatment with ketamine and/or lidocaine infusions in adolescents hospitalized for vaso-occlusive crisis (VOC). Patients served as self-controls using a comparison with a previous control admission for VOC. The use of ketamine and/or lidocaine as adjuncts to opioids resulted in lower daily opioid consumption in three of four patients. Our study suggests that ketamine and/or lidocaine infusions may be useful adjuncts in reducing opioid exposure during VOC pain. Correspondence to Doralina L. Anghelescu, MD, Department of Pediatric Medicine, Division of Anesthesiology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail Stop 130, Memphis, TN 38105, USA. Tel: +1 901 595 4032; fax: +1 901 595 4061; e-mail: doralina.anghelescu@stjude.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Interdisciplinary management of chronic breathlessness
Purpose of review Breathlessness is a common yet complex symptom of advanced disease. Effective management will most likely draw upon the skills of multiple disciplines and professions. This review considers recent advances in the management of chronic breathlessness with regards to interdisciplinary working. Recent findings There are growing data on interventions for chronic breathlessness that incorporate psychosocial mechanisms of action, for example, active mind–body treatments; and holistic breathlessness services that exemplify interprofessional working with professionals sharing skills and practice for user benefit. Patients value the personalized, empathetic and understanding tenor of care provided by breathlessness services, above the profession that delivers any intervention. Workforce training, decision support tools and self-management interventions may provide methods to scale-up these services and improve reach, though testing around the clinical effects of these approaches is required. Summary Chronic breathlessness provides an ideal context within which to realize the benefits of interdisciplinary working. Holistic breathlessness services can commit to a comprehensive approach to initial assessment, as they can subsequently deliver a wide range of interventions suited to needs as they are identified. Correspondence to Dr Matthew Maddocks, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, Bessemer road, London SE5 9PJ, UK. Tel: +44 202 7848 5252; e-mail: matthew.maddocks@kcl.ac.uk Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Multidimensional measurement of breathlessness: recent advances
Purpose of review Breathlessness is a multidimensional sensation for which a range of instruments exists for children, youth and adults, capable or unable to self-report distress with breathing. This review presents developments and applications of multidimensional assessments of breathlessness. Recent findings Excluding unidimensional measures and instruments assessing the impact of breathlessness, at least eight psychometrically robust instruments exist, which comprehensively assess one or more specific domains of the sensation of breathlessness (intensity, sensory quality, affective distress). These instruments have evolved from modest beginnings (describing breathlessness in various patient cohorts) to a growing use as primary or secondary outcomes in observational, clinical, and experimental trials exploring breathlessness mechanisms and intervention effects. For adults and children unable to consciously communicate breathing discomfort, instruments include combinations of physiological and behavioural markers of distress. Nonverbal (graphic scales) have potential use beyond paediatric applications. Summary Traditionally, breathlessness has been considered as a 'black box' with unidimensional measures reflecting box size (intensity, unpleasantness). Multidimensional instruments reveal the composition of the black box of breathlessness allowing detailed descriptions of an individual's breathlessness experience, quantification of sensory qualities, affective distress, and emotional responses with the potential to capture change over time and treatment effects in each dimension. Correspondence to Dr Marie T. Williams, Alliance for Research in Exercise, Nutrition and Activity (ARENA), School of Health Sciences, University of South Australia, North Terrace, Adelaide, SA 5000, South Australia, Australia. Tel: +61 8 8302 1153; fax: +61 8 830 22853; e-mail: Marie.williams@unisa.edu.au Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Supplemental oxygen for the management of dyspnea in interstitial lung disease
Purpose of review This article presents a summary of the evidence relating to supplemental oxygen use for the management of dyspnea in patients with interstitial lung disease (ILD). Recent findings In contrast to the majority of the available literature, recent findings suggest that supplemental oxygen can significantly reduce exertional dyspnea in ILD. ILD patients' need for supplemental oxygen often surpasses the levels that the most commonly used oxygen delivery systems provide. More effective delivery of supplemental oxygen has the potential for greater relief of dyspnea. There is also evidence suggesting that indications for supplemental oxygen may differ in ILD compared with other chronic lung diseases. Summary Large clinical trials are needed to determine if the reductions in dyspnea with supplemental oxygen observed in the laboratory setting can translate into meaningful benefits in everyday life for patients with ILD. More effective and practical oxygen delivery systems are needed. Future guidelines should consider including recommendations addressing the potential role of supplemental oxygen for mildly hypoxemic patients with ILD as well as recommendations specific to supplemental oxygen use for exercise training in ILD. Correspondence to Michele R. Schaeffer, PhD, Centre for Heart Lung Innovation, Providence Healthcare Research Institute, The University of British Columbia, St. Paul's Hospital, 166-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. Tel: +1 604 806 8835; e-mail: michele.schaeffer@hli.ubc.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Allergy

Ocular allergy: update on clinical trials Purpose of review The purpose of this article is to provide an update on the advances made through recent clinical trials regarding the treatment of the signs and symptoms of allergic conjunctivitis and its associated conditions. Recent findings Recent studies have demonstrated significant advancement in the various forms of immunotherapy treatments. Nutritional interventions such as probiotics have surfaced as a viable complementary treatment option. Novel delivery methods such as contact lenses have been further studied along with a new tacrolimus formulation to improve ocular levels of the drug. Summary Currently, the primary advances in treatment for allergic conjunctivitis has shifted from new ophthalmic agents to immunotherapy and improvement of drug delivery. This includes the classic subcutaneous and sublingual and the novel epicutaneous and intralymphatic immunotherapy delivery systems as well as an edible rice vaccine. New targets for treatment have spurred research into new antagonist drugs such as (OC000459), a prostaglandin D2 antagonist. The Marinosolv formulation using tacrolimus shows promise and may be considered for other ophthalmic agents in the future. Other nonpharmacological treatments such as stenting and mechanical barrier gel have demonstrated their usefulness in treating ocular symptoms. Correspondence to Leonard Bielory, MD, University Ophthalmology and Allergy Associates, 400 Mountain Avenue, Springfield, NJ 07081, USA. Tel: +1 973 912 9817; e-mail: drbielory@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Asthma and anaphylaxis Purpose of review Both asthma and anaphylaxis are recognized noncommunicable hypersensitivity conditions, which should be correctly diagnosed and treated/controlled in order to decrease avoidable deaths. Nevertheless, their association is not completely clear. We here propose to review the current and new evidence-based data of asthma and anaphylaxis in the view of the new knowledge in the field that can support the quality practice and empower allergists and health professionals in treating symptoms and preventing death. Recent findings Hypersensitivity life-threatening conditions, such as anaphylaxis and asthma can coexist, mimic or worse each other. Asthma itself is not a strong predictor of more severe anaphylaxis. However, poor asthma control associated with more severe anaphylaxis reactions in all ages. In children, asthma is associated with the severity and recurrences of anaphylactic reactions. Summary Although recent data point for the association between asthma and anaphylaxis, we still do not have harmonized evidence to confirm if we are dealing with two independent comorbidities one worsening each other. However, as far as this review is covering two relevant public health problems in the field of allergy, it is mandatory put in place decisions supporting recommendations to better manage the affected patients and reduce the risk. General strategies should include regular notification of this association, optimization of the classification and coding for anaphylaxis and asthma (new ICD 11 anaphylaxis codes) in order to harmonize epidemiological stratified data, early diagnosis of asthma in childhood, regular investigation of asthma in cases of anaphylaxis and optimization of the asthma control and lung function for all patients with indication to provocation tests, desensitization or allergen immunotherapy regardless to the trigger. Implementation of these strategies will involve national and international support for ongoing efforts in relationship with networks of centres of excellence to provide personalized management for the most at-risk patients and prevent death. Correspondence to Luciana Kase Tanno, MD, PhD, Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, 371, av. du Doyen Gaston Giraud - 34295, Montpellier Cedex 5, France. Tel: +33 467336107; fax: +33 467633645; e-mail: luciana.tanno@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Impact of climate change on insect–human interactions Purpose of review To update the influence of the global climate change on Hymenoptera venom allergy. Recent findings Climate change facilitates biological invasions of hymenopteran species and plays a role in the impact of introduced species relevant for human health. It contributes to a rise in the incidence of sting injuries and allergy reactions across the world. Summary Global climate change has contributed to the expansion and the redistribution of allergenic insect species, increasing the number of allergy cases caused by stinging insects worldwide. Imported insects are trending species in systemic reactions for multiple stings or hymenopteran venom allergy. They represent a threat for humans and a challenge for the allergists. Correspondence to Arantza Vega, MD, PhD, Allergy Service, Hospital Universitario de Guadalajara, CL Donante de sangre s/n, 19002 Guadalajara, Spain. Tel: +34 949209200 (Ext 927) e-mail: avega@sescam.jccm.es Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Mastocytosis presenting as insect anaphylaxis: gender differences and natural history Purpose of the review Currently, there is strong evidence about an association between hymenoptera venom anaphylaxis (HVA) and mastocytosis. This review is focused on the most relevant clinical and biological features of systemic mastocytosis associated with HVA. Recent findings HVA is a relatively common complication that modifies the natural course of patients with mastocytosis, particularly men with indolent systemic mastocytosis without skin lesions (ISMs−) in whom HVA can be the presenting symptom in up to around one-half of the cases. Patients with ISMs− associated with HVA are typically males with cardiovascular symptoms in the absence of itching, urticaria, and angioedema during anaphylaxis. Noteworthy, ISMs− is characterized by a low bone marrow mast cell load and a low risk for disease progression. Early and more recent studies support that specific venom immunotherapy (VIT) is a well-tolerated and effective treatment in patients with mastocytosis. Summary VIT should be given life-long to all patients with mastocytosis and proven immunoglobulin E (IgE)-mediated HVA. In patients with negative venom skin test and undetectable IgE antibodies, additional studies such as component-based allergy testing might contribute to confirm an IgE-mediated mechanism of anaphylaxis in some cases, thus providing the indication of VIT. Correspondence to Iván Alvarez-Twose, MD, PhD, Instituto de Estudios de Mastocitosis de Castilla La Mancha (CLMast), Hospital Virgen del Valle, Complejo Hospitalario de Toledo, Ctra. Cobisa S/N, Toledo 45071, Spain. Tel.: +34925269336;. e-mail:ivana@sescam.jccm.es Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Current market trends in anterior ocular inflammatory disease landscape Purpose of review In the US anterior ocular inflammatory disease (AOID) composed of the spectrum of ocular allergies, different forms of infectious conjunctivitis, and dry eye diseases, affects over 40% of the population. This review evaluates the current economic costs for AOID associated pharmacotherapies. Recent findings In recent years, with improved understanding in pathophysiology of the AOID, providing novel targets for pharmacotherapy, have led to considerable improvements in outcomes for patients. Despite these advances, there continues to be a need for interventions that inhibit key inflammatory mediators or pathways in the ophthalmic space. In 2018, AOID drugs market represents ∼40% of the costs for the total ophthalmic drugs: dry eye (43%), antiinfectives (15%), antiallergics (13%), and antiinflammatory agents (29%). With increasing treatment costs, the need for improved, cost-effective modalities persists along with treatment algorithms to derive optimal benefits for patients. Summary There has been a dramatic increase in the economic burden of AOID with the annual expenditure for the prescription drugs approaching close to $11 billion in 2018. With increasing prevalence of ocular disease, further investment is required to provide more effective treatment options and deliver improved public health and economic outcomes. Correspondence to Leonard Bielory, MD, 400 Mountain Avenue, Springfield, New Jersey 07081. E-mail: drlbielory@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Office-based ocular procedures for the allergist Purpose The aim of this study is to suggest principles for ocular procedures to be performed by allergists in their offices in helping their diagnosis of ocular diseases and suggest better interactions between allergists and ophthalmologists. Recent findings Diagnosis of ocular allergy is based on clinical history and signs and symptoms, with the support of in-vivo and in-vitro tests for the identification of the specific allergen. Unfortunately, ocular manifestations are frequently misdiagnosed and not properly managed. Summary A multidisciplinary allergist–ophthalmologist approach may improve early differential diagnosis and the prognosis of patients with allergic disease and conjunctivitis through shared management and earlier etiological treatment. Correspondence to Andrea Leonardi, MD, Department of Neuroscience, Ophthalmology Unit, University of Padua, via Giustiniani 2, 35128 Padua, Italy. Fax: +39 049 875 5168; e-mail: andrea.leonardi@unipd.it Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The roles of omega-3 fatty acids and resolvins in allergic conjunctivitis Purpose of review Lipids are one of the most important constituents in our body. Advances of lipidomics are elucidating the new roles of various lipid molecules in allergic diseases. For example, some reports showed anti-inflammatory effects of omega-3 fatty acids (FAs), such as docosahexaenoic acid, eicosapentaenoic acid, and their metabolites, on allergic diseases. Here, we introduce the role of lipid mediators in allergic conjunctivitis mouse model. Recent findings Lipidomics using liquid chromatography–tandem mass spectrometry can profile numerous lipid molecules from small tissue samples such as conjunctival specimens. Lipidomics analysis showed that various inflammatory lipid mediators are produced in the conjunctival tissue of allergic conjunctivitis mouse model. Dietary omega-3 FAs reduced these inflammatory lipid mediators in the conjunctiva and alleviated allergic conjunctivitis symptoms in mouse models. In addition, the roles of specialized proresolving lipid mediators (SPMs) have been reported for allergic inflammation. Summary Lipid mediators have important roles for the pathophysiology of the allergic diseases including allergic conjunctivitis. Omega-3 FAs and SPMs are expected as new treatment tools for allergic conjunctivitis. Correspondence to Akira Matsuda, Laboratory of Ocular Atopic Diseases, Department of Ophthalmology, Juntendo University Graduate School of Medicine, Hongo 2-1-1, Bunkyo-ku, Tokyo 113-8421, Japan. Tel: +81 3 5802 1031; fax: +81 3 5802 5889; e-mail: akimatsu@juntendo.ac.jp Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Role of the ocular surface microbiome in allergic disease Purpose of review The purpose of this review is to provide an update regarding new and emerging data on the role of the ocular surface microbiome in allergic disease. Recent findings Recent findings support the role of the microbiome in the pathophysiology of allergic disease of the ocular surface. Summary Understanding the role of the ocular surface microbiome in allergic disease may provide a new target for the development of therapeutic interventions. Correspondence to Kara M. Cavuoto, MD, 900 NW 17th Street, Miami, FL 33136, USA. Tel.: +1 305 326 6324;. fax: +1 305 547 3675; e-mail: kcavuoto@med.miami.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Biologics and anaphylaxis Purpose of review The use of biologicals as therapeutic agents in oncology and other inflammatory diseases has dramatically increased during the last years. Due to their biological nature and inherent immunological activity, they are able to induce important adverse events, such as cytokine release reactions (rapid release of proinflammatory cytokines), serum sickness disease, and immediate or delayed hypersensitivity reactions, including anaphylaxis. The aim of the current article is to review the state of the art of anaphylaxis because of biological agents. Recent findings Different phenotypes, and potential underlying endotypes, have been described in anaphylactic reactions to biologicals. There seems to be a spectrum from type 1 reactions (IgE or non-IgE-mediated) to cytokine release reactions, with some reactions falling in between both. Management should be directed according to such phenotypes. Summary There is ongoing research to further define immediate adverse reactions to biologicals and to find relevant biomarkers to aid in their diagnosis. Such information will serve in defining their immediate and long term management. Correspondence to Victoria Cardona, MD, PhD, Allergy Section, Department of Internal medicine, Hospital Universitari Vall d'Hebron, Ps. Vall d'Hebron 119-129, 08035 Barcelona, Spain. Tel: +34 93 274 6169; e-mail: vcardona@vhebron.net Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Topical tacrolimus for allergic eye diseases Purpose of review The spectrum of allergic eye diseases includes a variety of conditions, each characterized by complex immunopathologies. Antiallergic drugs, such as antihistamines and mast cell stabilizers, are often insufficient without concomitant topical corticosteroid treatment. The chronic course of the more severe allergic eye diseases, such as vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC), limits the treatment with topical corticosteroids to short courses. In addition, topical corticosteroid treatment puts patients at high risk of developing severe ocular complications, particularly during childhood when VKC most frequently occurs. The immunopathology of chronic diseases, such as VKC and AKC, involves predominantly T lymphocytes, and as such, immunomodulators that inhibit T-cell activation seem to be the appropriate treatment for these chronic diseases. In the past years, there is an increased incidence of managing chronic allergic eye diseases with the immunomodulator tacrolimus. The current review presents an update of the recent clinical experience with topical tacrolimus for the management of chronic allergic eye diseases. Recent findings Topical tacrolimus significantly improves the symptoms and signs of the various forms of chronic allergic eye disease. Recent studies also demonstrate the efficacy of low concentrations of topical tacrolimus for VKC. Early medical treatment with topical tacrolimus can also prevent the development of serious ocular complications of VKC, such as shield ulcers or limbal stem cell deficiency. Summary Topical tacrolimus has significantly changed the management approaches in severe and chronic allergic eye diseases and has minimized the need for topical corticosteroids. Correspondence to Abraham Solomon, MD, Cornea & Refractive Surgery Service, Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel. Tel: +972 507874664; e-mail: dr.avi.solomon@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

ALEXANDROS SFAKIANAKIS ANAPAFSEOS 5 AGIOS NIKOLAOS CRETE 72100 GREECE +306932607174 +302841026182

Cardiology

Echocardiographic findings in Nigerian patients with stroke Jamila Ado Ya'u, Kamilu Musa Karaye, BN Okeahialam Nigerian Journal of Cardiology 2018 15(2):71-76 Stroke is the third leading cause of death in several industrial countries and cardio-embolism accounts for 15–30% of ischaemic strokes. Studies investigating associations between echocardiographic parameters and stroke mechanisms are limited. This study therefore aimed at assessing echocardiographic parameters and left ventricular (LV) functions in stroke patients in comparison with apparent healthy controls. This was a case-control study conducted at Aminu Kano Teaching Hospital Kano, Nigeria. 100 stroke subjects were consecutively recruited and compared with 100 age and sex matched controls. Echocardiographic parameters studied include LV and Left atrial (LA) dimensions, LV hypertrophy (LVH), LV systolic and diastolic dysfunctions, regional wall motion abnormalities (RWMA), intracardiac thrombus, and valvular diseases using transthoracic echocardiography. The mean age of cases and controls was 56.4 ± 15.8years and 54.5 ± 15.4 years (P = 0.39), and M:F ratio was 1.1:1 among both cases and controls (P = 0.887). LVH was the most prevalent echocardiographic finding; found in 62% and 21% (P<0.01) of the cases and controls, respectively. Concentric LVH was found in 42% of the cases and 13% of controls, eccentric LVH in 23% of cases and 9% of the controls, while concentric remodeling was found in 5% of cases and 2% of controls (P < 0.001, 0.002 and 0.272 respectively). LV systolic dysfunction was found in 10% of the cases and 3% of the controls (P = 0.044), LV diastolic dysfunction in 48% of the cases and 18% of the controls (P < 0.001), while combined systolic and diastolic dysfunction was found in 12% of cases and 4% of the controls respectively (P = 0.038). Regional wall motion abnormality, Increased LA size, Aortic valve sclerosis and rheumatic valvular heart disease were commoner amongst cases than controls. Echocardiographic abnormalities were common among stroke patients and their presence could influence clinical decisions and outcomes. This study therefore supports echocardiographic evaluation of stroke patients.

Microalbuminuria among participants with high-normal blood pressure attending a tertiary health institution in Nigeria Saidu Hadiza, Karaye K Musa, Okeahialam Basil Nigerian Journal of Cardiology 2018 15(2):77-82 Background: Participants with high-normal blood pressure (BP) (systolic BP [SBP] 130–139 mmHg and/or diastolic BP [DBP] 85–89 mmHg) have higher cardiovascular disease (CVD) risk factors compared with optimal BP (SBP <120 mmHg and/or DBP <80 mmHg). In the present study, the prevalence of microalbuminuria, factors associated with it, and other CVD risk factors were assessed among participants with high-normal BP in comparison to controls. Methods and Results: Out of 200 participants screened, 92 with high-normal BP (Group 1) and 97 with optimal BP (Group 2) who had no history of hypertension or diabetes mellitus were consecutively recruited after satisfying the inclusion criteria. Microalbuminuria was determined using Micral test strips using first-morning urine sample. The mean age of participants in Group 1 was 33.39 ± 5.17 years, while that for Group 2 was 27.01 ± 7.4 years (P ≤ 0.001). The prevalence of microalbuminuria was higher among participants in Group 1 than in participants in Group 2 (12.9% vs. 4.1%, P = 0.037). Participants in Group 1 were older, had higher mean SBP, DBP, body mass index (BMI), fasting plasma glucose, total cholesterol, low-density lipoprotein cholesterol, and triglycerides than those in Group 2. Pearson's correlation coefficient showed a significant association between BMI and microalbuminuria among all the study participants (r = 0.625, P ≤ 0.007), and the BMI explains 37.7% of the variability of urinary albumin excretion among participants (R2 = 0.377, P = 0.007). Conclusion: Participants with high-normal BP had a higher prevalence of microalbuminuria and risk factors for CVD than those with optimal BP. The results suggest that participants' BMI is linked to urinary albumin excretion, and if proven in larger studies, the findings might be useful in the early prevention of CVD among individuals with high-normal BP.

Audit of 24 h ambulatory electrocardiography (Holter) of 281 Nigerian patients in Benin city metropolis Veronica Adaku Josephs, W Sadoh, J Ikhidero Nigerian Journal of Cardiology 2018 15(2):83-88 Background: Recent advances in cardiovascular management have been the result of the implementation of technological advances in the form of facilities in patient care. Continuous ambulatory electrocardiography (ECG) is used for the diagnosis of symptomatic and asymptomatic arrhythmias of the cardiac patient which are not immediately apparent to the clinician, but otherwise amenable to treatment. Objective: The aim of this study is to examine the relevance of 24-h ambulatory ECG in the management of arrhythmias in the Nigerian patient. The study was carried out from Winsephs' family clinic, a private cardiology clinic in Benin City. Methods: A retrospective study of 281 adult patients referred for 24 h ambulatory ECG (Holter) between January 2006 and June 2015. Results: The indications for Holter-ECG were as follows: unexplained recurrent palpitations (174) (61.9%); effort intolerance (67) (23.8%); probable ischemic heart disease (53) (18.9%); chest pain (53) (18.9%); and an assessment of arrhythmia in congestive cardiac failure (48) (17.1%). Others were syncopal attacks (23) (8.9%) and extreme weakness (15) (5.3%). The most common rhythm abnormalities and the number of individuals affected were as follows: premature atrial contractions (PAC) (188) (66.1%), sinus tachycardia (ST) (165) (58.7%), ventricular extrasystoles (148) (52.7%), paroxysmal supraventricular tachycardia (127) (45.2%), ventricular tachycardia (55) (19.6%), bradycardia (57) (20.3%), and pause (51) (18.2%). Other significant rhythm abnormalities were atrial fibrillation (17) (6.1%) and atrial flutter (10) (3.6%). Myocardial ischemia indicated by ST depressive episodes was observed in (32) (11.4%) patients, and the majority of those affected were >55 years of age. There were five normal reports. Conclusion: Holter-ECG is becoming an indispensable tool in diagnosis, management, and follow up of the cardiac patient.

Clinical utility of transthoracic echocardiography in assessing frequency and pattern of atrial masses among patients with cardiac diseases Tolulope Taiwo Shogade, Ime Okon Essien, Idongesit Odudu Umoh, Clement Tom Utin, Joseph John Andy Nigerian Journal of Cardiology 2018 15(2):89-93 Background: Echocardiography plays a fundamental role in the evaluation of patients with atrial masses. The ability to distinguish tissue characteristics such as location, attachment, shape, size, and mobility noninvasively, quickly, cheaply, and without the use of ionizing radiation makes echocardiography the ideal diagnostic modality. With careful attention to mass location and morphology and appropriate application of clinical information, echocardiography can usually distinguish between the three principal atrial masses as follows: tumor, thrombus, and vegetation. Although transesophageal echocardiography has better sensitivity and specificity for detecting atrial masses, transthoracic echocardiography (TTE) can also detect atrial masses with specificity and sensitivity of about 58% and 98%, respectively. Objectives: The study is aimed at assessing the frequency and patterns of atrial masses in an urban teaching hospital using TTE. Materials and Methods: A retrospective review of our echocardiogram reports from July 2009 to June 2014 was done to identify the frequency of atrial masses, gender distribution, sizes, clinical presentations, and locations. Results: A total of 1027 echo examinations were done over this period, comprising 503 males (48.98%) and 524 females (51.02%). Nonvegetative atrial masses were found in six of these patients representing 0.58% of the study population. Myxoma was the most common mass noted, 3 out of 4 were found in female, and all were found in the left atrium. The two atrial thrombi were detected in the right atrium and both were found in males. Conclusion: Atrial masses are not rare and TTE is still valuable in the diagnosis and initial characterization of atrial masses.

Availability and utilization of electrocardiogram as cardiac diagnostic tool in private hospitals in Port Harcourt Chizindu Akubudike Alikor, Chibuike Eze Nwafor Nigerian Journal of Cardiology 2018 15(2):94-97 Background: Electrocardiography is a low cost, easy to perform method of investigation of the cardiovascular system with diagnostic and prognostic value, and great clinical usefulness. There is an increasing prevalence of cardiovascular disease in Africa and other developing nations of the world. The private hospitals serve as the first port of call to a large number of cardiac patients. Hence, they need to determine the availability and utilization of electrocardiogram (ECG) in the private hospitals. Methodology: This is a cross-sectional, descriptive study involving medical practitioners who offer medical services in the private hospitals in Port Harcourt. A structured self-administered questionnaire was used in this study with a total of 120 analyzable data generated. Results: In this study, 72.5% of the respondents were male with females constituting 27.5%. Most of the respondents were general practitioners and mostly < 10 years of medical practice. This study found that approximately two-third of the respondents had ECG facility in their practice with good utilization (83.2%). However, most of the respondents (60%) have no formal training in the interpretation of ECG with only 6.2% having competence in ECG interpretation, and only 15.6% would seek specialist opinion/interpretation. This study further found that 98.3% of the respondents expressed willingness for formal training to improve their ECG interpretation skills. Conclusion: There are good availability and utilization of ECG facilities among private practitioners in Port Harcourt. The knowledge and competence for interpretation of ECG are poor. There is, therefore, a need for formal training in ECG interpretation for general and private medical practitioners in Port Harcourt, Nigeria.

Consanguineous marriage makes congenital heart diseases more complex Ramachandra Barik, Prafulla Kumar Swain, Mimansa Barik Nigerian Journal of Cardiology 2018 15(2):98-101 Introduction: Inbreeding increases homozygotes for autosomal recessive disorders resulting in high prevalence of congenital heart disease (CHD). This cross-section looks whether consanguineous marriage (CM) makes CHDs more complex. Subjects and Methods: This was an observational study which looked at the cross-section of a cohort of consecutive 113 patients having different CHD who visited Nizam Institute of Medical Sciences, Andhra Pradesh, during the year 2016 for surgery or intervention. The definitive diagnosis of CHD was supported by clinical profile, chest X-ray, echo, ultrasound abdomen, and cardiac catheterization which is appropriate. The study population was divided into CM group and distance marriage (DM) group. The categorical variables were analyzed using descriptive statistics. Results: Out of 113 patients with CHD, 61 (54%) were females. A majority 104 (94%) were Hindu. About 74% of patients were from below poverty line category. Approximately 27% and 73% patients were born out of consanguineous and DM, respectively. Most of the patients were from a rural background, and 63.7% had an education level of ≤10th class. Approximately, a total of 50 (44.2%) patients had complex CHDs (CCHDs). CCHD had significant association with CM (odds ratio: 2.60 95% confidence interval: 1.11–6.09, and P = 0.02). Conclusion: As there was a significant association of CCHD with inbreed marriage, this observation discourages CM.

Relationship between some electrocardiographic parameters of ventricular repolarization and Vitamin D status in apparently healthy individuals Erdogan Sokmen, Cahit Uçar, Mustafa Çelik, Serkan Sivri, Yalçin Boduroglu, Sinan Cemgil Özbek, Alp Yildirim Nigerian Journal of Cardiology 2018 15(2):102-107 Background: Vitamin D (VitD) is a vitamin affective on the cardiovascular system. VitD deficiency has been related to increased cardiac and all-cause mortality even in healthy controls. Evidence showed that such relatively novel electrocardiographic (ECG) parameters of ventricular repolarization (EPVR) as Tp-e interval, Tp-e/QT, and Tp-e/QTc ratios might be related to increase cardiac arrhythmias and even sudden cardiac death. Little data are available about the effect of VitD deficiency on EPVR. The purpose of this study was to evaluate the EPVR in apparently healthy controls with VitD deficiency. Methods: A total of 72 consecutive VitD deficient and 51 consecutive VitD nondeficient healthy controls who presented to our hospital's outpatient clinics were included in the study as two different groups. The relevant data were obtained through physical examination, electrocardiography, and echocardiography. Tp-e interval, Tp-e/QT, and Tp-e/QTc ratios were calculated from surface ECG and compared between the two groups using the Mann–Whitney U-test. Results: Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were all observed to be greater in VitD deficient group compared with the VitD nondeficient group, with robust statistical significance (68.1 ms [61.7–75.4] vs. 58 ms [54–66.2]; 0.197 [0.179–0.210] vs. 0.164 [0.147–0.187]; and 0.172 (0.156–0.191) versus 0.150 (0.137–0.164); respectively; P ≤ 0.001]). Conclusion: Our study reveals that Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio increase in VitD deficiency in apparently healthy controls, which may be related to SCD. Further studies are needed to support our results.

First successful atrial myxoma excision in Nigeria: A 21-year follow-up Dabeluchi Chiedozie Ngwu, Vincent Adindu Okwulehie, Martins Anthony C Aghaji Nigerian Journal of Cardiology 2018 15(2):108-110 A young man presented to our institution in New York Heart Association (NYHA) Class III, following a referral from a peripheral hospital where he had been on asthma treatment for over 8 years until he developed digital clubbing, and further clinical evaluation suggested cardiac disease. The preoperative diagnosis of left atrial myxoma was confirmed with transthoracic echocardiography. He had successful excision of the tumor, made a quick recovery, and has remained in NYHA Class I, with no cardiac events.

A rare case of bidirectional ventricular tachycardia due to aconite poisoning Biswajit Majumder, Praveen Shukla, KN Sudeep, Pritam K Chatterjee, Subhro Chakraborty Nigerian Journal of Cardiology 2018 15(2):111-113 A 45-year-old female patient presented with sweating and palpitation with wide spectrum of electrocardiography changes from polymorphic ventricular ectopics to bidirectional ventricular tachycardia (VT). She had a concealed history of aconite intake in large doses as part of homeopathic use. There are very few causes of bidirectional tachycardia such as digitalis toxicity, catecholaminergic polymorphic VT, and rarely aconite poisoning. Here, we report a rare case of aconite poisoning presenting with bidirectional VT.

Secondary prophylaxis to control rheumatic heart disease in developing countries: Put rheumatic heart disease into a cage if cannot be eradicated Ramachandra Barik Nigerian Journal of Cardiology 2018 15(2):114-117

Alexandros Sfakianakis
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