Bone density and microarchitecture in hepatitis C and HIV-coinfected postmenopausal minority women

We found that HIV+/HCV+ women had 7-8% lower areal bone mineral density (aBMD) by dual-energy x-ray absorptiometry (DXA) at the spine, hip, and radius (p < 0.01) and 5-7% lower volumetric BMD (vBMD) by central quantitative computed tomography (cQCT) at the spine and hip (p < 0.05). These data suggest that true deficits in vBMD may contribute to bone fragility and excess fractures reported in HIV+/HCV+ women.

INTRODUCTION

aBMD by DXA is lower in persons coinfected with HIV and HCV (HIV+/HCV+) than with HIV monoinfection (HIV+). However, weight is often also lower with HCV infection, and measurement of aBMD by DXA can be confounded by adiposity; we aimed to determine whether true vBMD is also lower in HIV+/HCV+ coinfection.

METHODS

We measured aBMD of the lumbar spine (LS), total hip (TH), femoral neck (FN), and ultradistal radius (UDR) by DXA and vBMD of the spine and hip by cQCT and of the distal radius and tibia by high-resolution peripheral QCT (HRpQCT) in 37 HIV+/HCV+ and 119 HIV+ postmenopausal women. Groups were compared using Student's t tests with covariate adjustment by multiple regression analysis.

RESULTS

HIV+/HCV+ and HIV+ women were of similar age and race/ethnicity. HIV+/HCV+ women had lower body mass index (BMI) and trunk fat and were more likely to smoke and less likely to have a history of AIDS. In HIV+/HCV+ women, aBMD by DXA was 7-8% lower at the LS, TH, and UDR (p < 0.01). Similarly, vBMD by cQCT was 5-7% lower at the LS and TH (p < 0.05). Between-group differences in LS aBMD and vBMD remained significant after adjustment for BMI, smoking, and AIDS history. Tibial total vBMD by HRpQCT was 10% lower in HIV+/HCV+ women.

CONCLUSION

HIV+/HCV+ postmenopausal women had significantly lower spine aBMD and vBMD. These deficits in vBMD may contribute to bone fragility and excess fractures reported in HIV+/HCV+ women.

Frailty in Postmenopausal African American and Hispanic HIV-Infected Women

Studies suggest frailty occurs earlier in HIV-infected individuals, but data in postmenopausal HIV-infected women are lacking. We assessed the prevalence of frailty and association with anthropometric measures in HIV-infected and uninfected postmenopausal women. Fried's frailty phenotype was measured in HIV-infected and uninfected Hispanic and African American postmenopausal women participating in a study of bone metabolism; fat and lean mass were measured by whole body dual energy x-ray absorptiometry (DXA). Multivariable logistic regression evaluated frailty risk factors. The study was conducted at Columbia University Medical Center between 2002 and 2007. The participants were 61 HIV-infected and 27 uninfected Hispanic and African American postmenopausal women. The study compared prevalence and predictors of frailty in HIV-infected and uninfected postmenopausal women. Prevalence of frailty tended to be higher among HIV-infected than uninfected controls (11.5% vs 0% p=0.07). Surprisingly, among HIV-infected women, total body fat, not lean mass, was associated with frailty in multivariate analysis. Higher prevalence of frailty in African American and Hispanic HIV-infected postmenopausal women (11.5%) was similar to the 11% prevalence reported in minority women who were 10 years older in the general population. Our data suggest that frailty occurs earlier in HIV-infected postmenopausal women, but larger longitudinal studies are necessary to confirm whether musculoskeletal aging is accelerated by HIV infection.

Increased Prevalence of Psychosis in Patients Who Get Admitted with Acute Myocardial Infarction with Worse Outcomes

Objective

To determine trends and impact on outcomes of acute myocardial infarction (AMI) in patients with pre-existing psychosis.

Background

While post-AMI psychosis has been extensively studied, contemporary studies including temporal trends on impact of pre-AMI Psychosis on AMI and post-AMI outcomes are lacking.

Methods

We used Nationwide Inpatient Sample (NIS) from Healthcare Cost and Utilization Project(HCUP) from 2002 to 2012. We identified AMI and psychosis as primary and secondary diagnosis respectively using validated International Classification of Diseases, 9th Revision, and Clinical Modification (ICD9CM) codes, and Cochrane-Armitage trend test and multivariate regression to generate adjusted odds ratios (aOR).

Results

We analyzed total of 7,174,274 AMI hospital admissions from 2002 to 2012 of which 1.77% had psychosis. Proportion of hospitalizations with psychosis increased from 6.94% to 11.85% (P-trend < 0.001). Utilization of percutaneous coronary intervention (PCI) was lower in patients with psychosis (29.98% vs. 40.36%, P < 0.001). Utilization of coronary artery bypass grafting (CABG) was lower in patients with psychosis (8.01% vs. 9.18%, P < 0.001). In-hospital mortality was significantly lower in patients with psychosis (aOR 0.677; 95% CI 0.630–0.727; P < 0.001) but discharge to specialty care higher (aOR 1.870; 95%CI 1.786–1.958; P < 0.001). In addition, median length of hospitalization (3.77 vs. 2.90 days; P < 0.001) was higher in hospitalizations with psychosis.

Conclusions

Our study displayed increasing proportion of patients with psychosis admitted due to AMI in last decade with lower mortality but higher morbidity post-infarction, and significantly less utilization of PCI and CABG. There was also increased length of stay patients with MDD. There is need to explore reasons behind this disparity in outcomes and PCI and CABG utilization to improve post-AMI outcomes in this vulnerable population.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Increased Prevalence of Major Depressive Disorder in Patients who Get Admitted with Atrial Fibrillation with Worse Outcomes

Objective

To determine trends and impact on outcomes of atrial fibrillation (AF) in patients with pre-existing major depressive disorder(MDD).

Background

While post-AF MDD has been extensively studied, contemporary studies including temporal trends on impact of pre-AF MDD on AF and post-AF outcomes are lacking.

Methods

We used Nationwide Inpatient Sample (NIS) from Healthcare Cost and Utilization Project (HCUP) from 2002 to 2012. We identified AF and MDD as primary and secondary diagnosis respectively using validated International Classification of Diseases, 9th Revision, and Clinical Modification (ICD9CM) codes, and used Cochrane-Armitage trend test and multivariate regression to generate adjusted odds ratios (aOR).

Results

We analyzed total of 3,887,827 AF hospital admissions from 2002 to 2012 of which 6.78% had MDD. Proportion of hospitalizations with MDD increased from 4.93% to 14.19% (P-trend < 0.001). Utilization of atrial cardioversion was lower in patients with MDD (34.37% vs. 40.52%, P < 0.001). In-hospital mortality was significantly lower in patients with MDD (aOR0.749; 95% CI 0.664–0.846; P < 0.001) but discharge to specialty care was higher (aOR 1.695; 95%CI 1.650–1.741; P < 0.001). In addition, median length of hospitalization (2.5 vs. 2.13 days; P < 0.001) and median cost of hospitalization (28,246 vs. 22,663; P < 0.001) was higher in hospitalizations with MDD.

Conclusions

Our study displayed an increasing proportion of patients with MDD admitted due to AF in the last decade with lower mortality but higher morbidity post-AF. In addition, there was significantly less utilization of atrial cardioversion in this population along with higher median length and cost of hospitalization. There is a need to explore the reasons behind this disparity in outcomes and atrial cardioversion utilization in order to improve post-AF outcomes in this vulnerable population.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Temporal Trends in Drug Abuse in Adults with Acute Myocardial Infarction Show Worse Outcomes

Objective

To determine temporal trends, invasive treatment utilization and impact on outcomes of pre-infarction drug abuse (DA) on acute myocardial infarction (AMI) in adults.

Background

DA is important risk factor for AMI. However, temporal trends in drug abuse on AMI hospitalization outcomes in adults are lacking.

Methods

We used Nationwide Inpatient Sample (NIS) from Healthcare Cost and Utilization Project (HCUP) from 2002 to 2012. We identified AMI and DA as primary and secondary diagnosis respectively using validated International Classification of Diseases, 9th Revision, and Clinical Modification (ICD9CM) codes, and used the CochraneArmitage trend test and multivariate regression to generate adjusted odds ratios (aOR).

Results

We analyzed total of 7,174,274 AMI hospital admissions from 2002 to 2012 of which 1.67% had DA. Proportion of hospitalizations with DA increased from 5.63% to 12.08% (P trend < 0.001). Utilization of coronary artery bypass grafting (CABG) was lower in patients with DA (7.83% vs. 9.18%, P < 0.001). In-hospital mortality was significantly lower in patients with DA (aOR 0.811; 95% CI 0.693–0.735; P < 0.001) but discharge to specialty care was higher (aOR 1.076; 95% CI 1.025–1.128; P < 0.001). The median cost of hospitalization (40,834 vs. 37,253; P < 0.001) was higher in hospitalizations with DA.

Conclusions

We demonstrate an increasing proportion of adults admitted with AMI have DA over the decade. However, DA has paradoxical association with mortality in adults. DA is associated with lower CABG utilization and higher discharge to specialty care, with a higher mean cost of hospitalization. The reasons for the paradoxical association of DA with mortality and worse morbidity outcomes need to be explored in greater detail.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

An Interface Pressure Sensor for Routine Clinical Use

The art of fitting the environment to the patient is sadly lacking. There are at least 24 000 patients in Great Britain suffering from pressure sores. The art will not improve until relevant parameters of tissue viability are measured routinely wherever patients are cared for. Disorders of temperature and blood pressure were not understood until standard measurements were widely taken. What are the relevant parameters for disorders of tissue viability? The authors single out pressure and movement, and note that pressure recorded with time will also monitor movement. They offer their flanged 28 mm electro-pneumatic pressure sensor as a possible standard instrument for most clinical purposes whether research or routine.

The discussion covers the theoretical objections to interface pressure measurement, analyses the sources of error in their electro-pneumatic technique and compares its accuracy to that of other transducers.

The largest and neglected giant phyllodes tumor of the breast-A case report and literature review

INTRODUCTION

Phyllodes tumours are rare fibro-epithelial lesions. The role of the pathologist in the preoperative diagnosis of phyllodes tumours of the breast is critical to appropriate surgical planning. Wide local excision or mastectomy with adequate margin remains the treatment of choice. Local recurrence occurs in approximately 10- 16.1% of patients (Wei et al., 2014) [1] and distant metastases occurs in 6.3-31% of patients with malignant phyllodes tumours (Wei et al. (2014), Chaney et al., 1998) [1,2] but only in 4% of all phyllodes tumours (Salvador et al., 1989) [3]. Emphasis should be given in early diagnosis and intervention to decrease morbidity and mortality.

Kangaroo care by fathers and mothers: comparison of physiological and stress responses in preterm infants

OBJECTIVE

To compare physiological and biochemical responses in stable preterm neonates and their parents following kangaroo mother care (KMC) and kangaroo father care (KFC).

STUDY DESIGN

We conducted a prospective cross-over design study of stable preterm neonates of <35 weeks gestation in a tertiary Neonatal Unit in Toronto. All neonates received KMC and KFC for 1 h on consecutive days in a random order. Heart rate, temperature, blood pressure, oxygen saturation and salivary cortisol in infants before and after kangaroo care and heart rate, temperature and salivary cortisol in parents before and after kangaroo care were measured. Pairwise comparisons of changes in these measures were analyzed.

RESULT

Twenty-six sets of neonates and their parents were studied for physiological parameters, of which 19 had adequate samples for salivary cortisol assessment. The infants had a mean birth weight of 1096 g (s.d.=217) and a mean postmenstrual age at study of 32 weeks (s.d.=2). There were no significant differences in the changes in mean heart rate (P=0.51), temperature (P=0.37), oxygen saturation (P=0.50), systolic blood pressure (P=0.32), mean blood pressure (0.10) and salivary cortisol (P=0.50) before and after KMC or KFC in the neonates. The changes in mean heart rate (P=0.62), temperature (P=0.28) and salivary cortisol (P=0.59) before and after kangaroo care were similar between mothers and fathers.

CONCLUSION

No significant differences in physiological and stress responses were identified following KMC or KFC in preterm neonates. KFC may be as safe and as effective as KMC.

Primary omental gangrene mimicking appendicular perforation peritonitis-A case report

•

Patient presented as a case of appendicular perofration with pyoperitoneum leading to localized peritonitis which is a common surgical emergency.

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Primary omental torsion is a rare diagnosis and very difficult to diagnose at the emergency room.

•

We report a patient with omental torsion and further gangrene of the omentum leading to pyoperitoneum mimicking appendicuar perforation peritonitis.

•

A review of literature is also included.

Introduction

Primary omental torsion is a rare cause of acute abdomen in adults and presents with variable signs and symptoms. Establishing a preoperative diagnosis may be difficult in the emergency setting. It is rarely diagnosed preoperatively as it mimics common surgical emergencies such as acute appendicitis, appendicular perforation, acute cholecystitis and perforated peptic ulcers and can lead to the clinical deterioration of patient if missed

Presentation of case

A 47 years old male was taken to the operating room with a diagnosis of appendicular perforation peritonitis and during surgery was found to have a primary omental gangrene with pyoperitoneum, for which omentectomy and peritoneal lavage was performed.

Discussion

Torsion of the omentum is a condition in which the organ twists on its long axis to such an extent that its vascularity is compromised. Omental torsion can be primary (idiopathic) or secondary, depending on an underlying cause. Primary omental torsion was first described by Eitel in 1899. However, very few cases have been reported. Our case was a rare case presenting with omental gangrene with pyoperitoneum mimicking appendicular perforation peritonitis.

Conclusion

Primary omental torsion is a rare diagnosis. A high index of clinical suspicion is required for a preoperative diagnosis. In doubtful cases a CT scan may be helpful. Surgical excision of the omentum remains the treatment of choice; however, conservative management may be attempted in an uncomplicated omental torsion.

Stearylated cycloarginine nanosystems for intracellular delivery – simulations, formulation and proof of concept

Novel cationic agent liposomes performed better in silico translating in higher cellular uptake with reduced toxicity.

Panobinostat, a pan-histone deacetylase inhibitor: rationale for and application to treatment of multiple myeloma

Histone deacetylase inhibitors (HDACis) have emerged as novel therapeutic agents for cancer. Currently, four HDACis are approved by the Food and Drug Administration (FDA) to treat various hematologic malignancies. Panobinostat (LBH-589, trade name Farydak®, developed and marketed by Novartis) is a potent pan-HDACi with demonstrated anticancer activities against multiple myeloma, a B-cell malignancy, at a low nanomolar range in preclinical settings, and in 2015 was granted FDA approval for the treatment of relapsed and refractory multiple myeloma. Here, we review the development of HDACis, the unique features of panobinostat, and the rationale for developing panobinostat in a combination setting for the treatment of multiple myeloma. We also review the completed and ongoing clinical trials testing the efficacy of panobinostat in combination therapies and highlight future therapeutically relevant strategies.

Oxygen saturation profile in late-preterm and term infants: a prospective cohort study

OBJECTIVE

To determine oxygen saturation profile over 6 h monitoring period in healthy late-preterm and term neonates during the first 48 h of age, and to assess the impact of gestational age, birth weight and method of delivery on this profile.

STUDY DESIGN

Prospective cohort study of measurement of SpO2 over 6 h in 20 late-preterm (35 to 36 weeks gestation) and 40 term infants within 12 to 48 h of birth was conducted. Infants with cardiorespiratory symptoms or need for cardiorespiratory support at birth were excluded. Percentage time spent at SpO2 >90% and ⩽90% was calculated by gestational age and birth weight.

RESULT

Late-preterm infants and infants born weighing <2.5 kg spent approximately 7% of the time at SpO2 ⩽90%; this time decreased as gestational age and birth weight increased. Time at SpO2 >90% was significantly different between late-preterm and term infants (93% (5%) vs 96% (3%); P =0.002). Time at SpO2 >90% was not significantly different between males and females (95% (5%) vs 95% (4%), both n=30; P =0.72) or between vaginal births and cesarean births (95% (4%), n=32, vs 95% (4%), n=28; P =0.39). Cumulative time with SpO2 <90 was mean (s.d.) of 25 (18) in preterm vs 13 (10) min in term infants.

CONCLUSION

Over a 6-h period healthy late-preterm and term infants spent significant time at SpO2 ⩽90%. Lower gestation and lower birth weight were associated with higher time at SpO2 ⩽90%.

New drugs and novel mechanisms of action in multiple myeloma in 2013: a report from the International Myeloma Working Group (IMWG)

Treatment in medical oncology is gradually shifting from the use of nonspecific chemotherapeutic agents toward an era of novel targeted therapy in which drugs and their combinations target specific aspects of the biology of tumor cells. Multiple myeloma (MM) has become one of the best examples in this regard, reflected in the identification of new pathogenic mechanisms, together with the development of novel drugs that are being explored from the preclinical setting to the early phases of clinical development. We review the biological rationale for the use of the most important new agents for treating MM and summarize their clinical activity in an increasingly busy field. First, we discuss data from already approved and active agents (including second- and third-generation proteasome inhibitors (PIs), immunomodulatory agents and alkylators). Next, we focus on agents with novel mechanisms of action, such as monoclonal antibodies (MoAbs), cell cycle-specific drugs, deacetylase inhibitors, agents acting on the unfolded protein response, signaling transduction pathway inhibitors and kinase inhibitors. Among this plethora of new agents or mechanisms, some are specially promising: anti-CD38 MoAb, such as daratumumab, are the first antibodies with clinical activity as single agents in MM. Moreover, the kinesin spindle protein inhibitor Arry-520 is effective in monotherapy as well as in combination with dexamethasone in heavily pretreated patients. Immunotherapy against MM is also being explored, and probably the most attractive example of this approach is the combination of the anti-CS1 MoAb elotuzumab with lenalidomide and dexamethasone, which has produced exciting results in the relapsed/refractory setting.

The effect of dimensionality of nanostructured carbon on the architecture of organic-inorganic hybrid materials

The natural tendency of carbon nanotubes (CNTs) to agglomerate is an underlying reason that prevents the realization of their full potential. On the other hand, covalent functionalization of CNTs to control dispersion leads to disruption of π-conjugation in CNTs and the non-covalent functionalization leads to a weak CNT-polymer interface. To overcome these challenges, we describe the characteristics of fostering of direct nucleation of polymers on nanostructured carbon (CNTs of diameters (~2-200 nm), carbon nanofibers (~200-300 nm), and graphene), which culminates in interfacial adhesion, resulting from electrostatic and van der Waals interaction in the hybrid nanostructured carbon-polymer architecture. Furthermore, the structure is tunable through a change in undercooling. High density polyethylene and polypropylene were selected as two model polymers and two sets of experiments were carried out. The first set of experiments was carried out using CNTs of diameter ~2-5 nm to explore the effect of undercooling and polymer concentration. The second set of experiments was focused on studying the effect of dimensionality on geometrical confinements. The periodic crystallization of polyethylene on small diameter CNTs is demonstrated to be a consequence of the geometrical confinement effect, rather than epitaxy, such that petal-like disks nucleate on large diameter CNTs, carbon nanofibers, and graphene. The application of the process is illustrated in terms of fabricating a system for cellular uptake and bioimaging.

Dehiscence of the posterior and superior semicircular canal presenting in pregnancy

OBJECTIVE

We present an interesting case of superior and posterior semicircular canal dehiscence in pregnancy.

METHOD

We present a case report and a review of the world literature concerning semicircular canal dehiscence.

CASE REPORT

A 34-year-old woman presented with sound and pressure induced vertigo at 22 weeks gestation. A thinly sliced computed tomography (CT) scan of the petrous temporal bones viewed with coronal reconstructions was performed post-partum. This showed the presence of both left superior canal and posterior canal dehiscence.

CONCLUSION

To our knowledge this is the first reported case of semicircular canal dehiscence in pregnancy. The diagnosis of semicircular canal dehiscence should be suspected in pregnant patients with sound induced vertigo.