ABSTRACT:Keyhole Craniotomy is the latest advancement in minimal access era. Kilpauk Keyhole craniotomy (KKC) is our innovation to tackle the limitations of the traditional single burr hole endoscopic surgeries. It is applied in various neurotraumatology patients like chronic sub dural hematoma (CSDH) and chronic extra dural hematoma (CEDH). To perform KKC and assess its applications and usefulness in CSDH and other pathology. Hospital based study of a new technique. Patients with CSDH were subjected to endoscopic evacuation with KKC after consent. The KKC is helpful in minimal access neuroendoscopic surgeries. The beveling helps in easy positioning and movement of the endoscope. The Endoscopic-landing zone and Endoscopic-flowing zone of KKC are useful in ergonomic flow of instruments and in reaching the curvatures of the skull. KKC provides better access, easy instruments flow, avoids ergonomic difficulties and complete evacuation of pathology with inner membranectomy, thus providing better patient outcome and prognosis.
Background: Current guidelines rely on millimetric ST-elevation (STEMI) criteria to identify acute coronary occlusion, yet many patients with total occlusion do not meet these thresholds. This systematic review and meta-analysis was aimed to evaluate the diagnostic performance of the ECG criteria based on the Fourth Universal Definition of ST-elevation Myocardial infarction for identifying angiographic acute total coronary occlusion (TIMI 0) and to determine the prevalence of "hidden" Occlusion Myocardial Infarction (OMI) within the NSTEMI population. Methods: Following PRISMA-DTA guidelines, a systematic search was conducted in PubMed, Embase, and Cochrane Library. Eleven studies were included for prevalence analysis of the NSTEMI group, and nine studies were used for diagnostic test accuracy (DTA) in a combined STEMI/NSTEMI cohort. Pooled estimates were calculated using a random-effects model and HSROC analysis. Clinical utility was tested using Decision Curve Analysis. Quality was assessed via QUADAS-2, and publication bias was evaluated using Egger's test. Results: The pooled prevalence of OMI within the NSTEMI population was 39% (11 studies; I² = 99.67%). In the DTA analysis, ST-elevation criteria demonstrated a pooled sensitivity of 0.65 (95% CI: 0.59–0.75) and a specificity of 0.59 (95% CI: 0.22–0.87). Forest plot analysis revealed a "sensitivity ceiling," with the majority of studies falling to the left of the 0.70 threshold. The HSROC AUC was 0.69, while the pooled LR+ (2.09), LR- (0.53), and NPV (0.73) indicated weak discriminative power. Decision Curve Analysis (DCA) showed that the ST Elevation ECG criteria failed to exceed the net benefit of "treat all" or "treat none" strategies across a 0–0.5 threshold range. Risk of bias was low, and Egger's test (P=0.46) showed no significant publication bias. Conclusion: Standard ST-elevation criteria are a clinically inadequate gatekeeper, failing to identify one-third of the 39% of NSTEMI patients with an active total coronary occlusion. The low NPV and lack of net benefit in DCA provide a clear mandate to transition toward a more sensitive OMI/NOMI diagnostic framework to prevent dangerous delays in reperfusion
This case report documents a 20-year-old male who presented with persistent cyanosis and low oxygen saturation levels, initially misdiagnosed and treated for coronavirus disease 2019. Despite negative coronavirus disease 2019 tests and normal cardiac and pulmonary imaging, the patient’s condition did not improve, leading to further investigation. Arterial blood gas analysis revealed elevated methemoglobin levels, and genetic testing identified a homozygous mutation in the cytochrome b5 reductase 3 gene, confirming congenital methemoglobinemia. The patient was treated with vitamin C, a reducing agent that successfully lowered methemoglobin levels and alleviated symptoms. This case underscores the diagnostic challenges of congenital methemoglobinemia, often misdiagnosed due to its rarity and symptom overlap with other conditions. Genetic analysis played a crucial role in identifying the cytochrome b5 reductase 3 mutation, highlighting the importance of considering methemoglobinemia in patients with unexplained cyanosis. Early diagnosis and appropriate treatment are vital for managing this condition and improving patient outcomes.
Introduction:Viral load (VL) testing is the recommended approach for monitoring antiretroviral therapy (ART) effectiveness, while guidelines recommend targeted CD4 testing after ART initiation. This study examined trends in VL and CD4 testing frequencies, as well as the relationship with AIDS diagnosis and mortality among people with HIV in the Asia-Pacific region. Methods:We included adults enrolled in the Treat Asia HIV Observational Database (TAHOD) between 2003-2018 who had been on ART for ≥1 year. VL and CD4 testing rates were analysed using Poisson regression models. Associations between testing frequency and AIDS diagnosis or mortality were evaluated using Fine and Gray competing risk regression. Results:Among 8,446 patients, VL testing rates remained steady at 1 per person-year (PYS) between 2003-2018. Increased VL testing was associated with more frequent CD4 testing (>2 tests in the previous year; IRR=1.57, 95%CI 1.53-1.60), later follow-up years (2008-2012: IRR=1.15, 95%CI 1.12-1.18; 2013-2015: IRR=1.07, 95%CI 1.04-1.10), older age (31-40 years: IRR=1.06, 95%CI 1.03-1.08; 41-50 years: IRR=1.08, 95%CI 1.05-1.11; >50 years: IRR=1.07, 95%CI 1.03-1.11), higher current VL (401-1000 copies/mL: IRR=1.16, 95%CI 1.09-1.24; >1000 copies/mL: IRR=1.07, 95%CI 1.04-1.11), initial ART regimen (NRTI+PI: IRR=1.07, 95%CI 1.04-1.10; other combinations: IRR=1.11, 95%CI 1.05-1.17), and higher country income levels (upper-middle: IRR=2.17, 95%CI 2.11-2.23; high: IRR=3.14, 95%CI 3.03-3.26). CD4 testing rates decreased from 2.04 to 1.06/PYS over the same period. Lower CD4 testing frequency was associated with HIV exposure mode (MSM: IRR=0.94, 95%CI 0.92-0.96; IDU: IRR=0.93, 95%CI 0.90-0.97; other/unknown: IRR=0.90, 95%CI 0.87-0.93), higher current CD4 (201-350 cells/μL: IRR=0.95, 95%CI 0.93-0.97; 351-500 cells/μL: IRR=0.89, 95%CI 0.87-0.91; >500 cells/μL: IRR=0.85, 95%CI 0.83-0.87) and receiving an NRTI+PI first-line combination (IRR=0.96, 95% CI 0.94-0.98). VL and CD4 testing frequencies were not significantly associated with AIDS diagnosis. However, having > 2 CD4 tests in the previous year was associated with higher mortality risk. Conclusion:The trends in the rates for CD4 and VL testing in the region between 2003-2018 were significantly affected by demographic, clinical and socio-economic factors. Recognizing these factors is critical to optimizing differentiated monitoring strategies and improving outcomes for PWH in the region.
Background: Acute Left Main Coronary Artery (LMCA) occlusion is a catastrophic medical emergency often resulting in cardiogenic shock, cardiac arrest, and lethal arrhythmias. Rapid ECG recognition is crucial yet distinguishing ECG features of acute left main occlusion myocardial infarction from other highrisk pathologies remains a significant diagnostic challenge. This meta-analysis evaluates the diagnostic accuracy and clinical utility of 14 ECG criteria in predicting acute LMCA occlusion. Methods: Data from 1993 to 2025 were systematically retrieved in English language from PubMed, Embase, Scopus, Google Scholar, and The Tamil Nadu Dr. M.G.R. Medical University databases. A total of 14 ECG criteria comprising 12,847 myocardial infarction patients including 285 patients with Acute Total LMCA Occlusion (ATOLMA) were analyzed. Performance was assessed via pooled sensitivity, specificity, and summary receiver operating characteristics (SROC). Clinical utility was determined using Decision Curve Analysis (DCA). Results: The criteria of ST-segment depression in inferior leads (II, III, aVF +/- V4–V6) demonstrated a high pooled sensitivity of 0.85, identifying it as a powerful screening tool; however, its specificity was only 0.61, and it remained only marginally above the "treat-all" line in DCA. In the meta-analysis, sensitivity of the ECG criteria declined significantly to 0.42 for mixed occlusions (LAD, LCX and RCA), 0.39 for proximal LAD, and 0.38 for ATOLMA versus ASOLMA; conversely, the meta-analysis demonstrated a consistent and statistically significant (p < 0.0001) increase in QRS width, QTc interval, and leftward axis deviation across all comparison groups in left main patients, reflecting a profound and universal ischemic burden that persists even when ECG criteria failed to provide a clinical net benefit in DCA. Conclusion: Meta-analysis could not demonstrate adequate diagnostic accuracy (sensitivity 0.85) of ECG criteria (sensitivity 0.42) to predict acute left main occlusion myocardial infarction. Although ST-segment depression (STD) in leads II, III, aVF +/- V4–V6 provides a potent screening tool (sensitivity 0.85), ECG criteria were found to exhibit poor overall diagnostic discriminatory capacity (pooled AUC 0.42) and dangerously low sensitivity in distinguishing left main from proximal LAD (0.39) or total from subtotal occlusion (0.38) for the evaluated ECG criteria. All the ECG criteria fell below the Decision Curve Analysis 'treat-all' threshold without demonstrable adequate net clinical benefit. However, the meta-analysis demonstrated that the consistent and statistically significant (p < 0.001) increase in QRS width, QTc interval, and leftward axis deviation across all cohorts remains a universal signature of left main pathology, necessitating the integration of these conduction markers with multi-modal imaging to prevent missed diagnosis of coronary pathology.
