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Patel BM, Reilly JP, Bhalla AK, Smith LS, Khemani RG, Jones TK, Meyer NJ, Harhay MO, Yehya N. Association between Age and Mortality in Pediatric and Adult Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:871-878. [PMID: 38306669 PMCID: PMC10995578 DOI: 10.1164/rccm.202310-1926oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/02/2024] [Indexed: 02/04/2024] Open
Abstract
Rationale: The epidemiology, management, and outcomes of acute respiratory distress syndrome (ARDS) differ between children and adults, with lower mortality rates in children despite comparable severity of hypoxemia. However, the relationship between age and mortality is unclear.Objective: We aimed to define the association between age and mortality in ARDS, hypothesizing that it would be nonlinear.Methods: We performed a retrospective cohort study using data from two pediatric ARDS observational cohorts (n = 1,236), multiple adult ARDS trials (n = 5,547), and an adult observational ARDS cohort (n = 1,079). We aligned all datasets to meet Berlin criteria. We performed unadjusted and adjusted logistic regression using fractional polynomials to assess the potentially nonlinear relationship between age and 90-day mortality, adjusting for sex, PaO2/FiO2, immunosuppressed status, year of study, and observational versus randomized controlled trial, treating each individual study as a fixed effect.Measurements and Main Results: There were 7,862 subjects with median ages of 4 years in the pediatric cohorts, 52 years in the adult trials, and 61 years in the adult observational cohort. Most subjects (43%) had moderate ARDS by Berlin criteria. Ninety-day mortality was 19% in the pediatric cohorts, 33% in the adult trials, and 67% in the adult observational cohort. We found a nonlinear relationship between age and mortality, with mortality risk increasing at an accelerating rate between 11 and 65 years of age, after which mortality risk increased more slowly.Conclusions: There was a nonlinear relationship between age and mortality in pediatric and adult ARDS.
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Affiliation(s)
- Bhavesh M Patel
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John P Reilly
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
| | - Anoopindar K Bhalla
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Lincoln S Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Robinder G Khemani
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Tiffanie K Jones
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
| | - Michael O Harhay
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nadir Yehya
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Loban K, Morgan R, Kute V, Bhalla AK, Sandal S. Are Differences in Living Kidney Donation Rates a Sex or a Gender Disparity? EXP CLIN TRANSPLANT 2024; 22:28-36. [PMID: 38385370 DOI: 10.6002/ect.mesot2023.l21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Sex-disaggregated data reveal significant disparities in living kidney donation, with more female than male living kidney donors in most countries and proportions over 60% in some countries. We summarize the present state of knowledge with respect to the potential drivers of this disparity and argue that it is primarily driven by gender-related factors. First, we present the differences between sex and gender and then proceed to summarize the potential medical reasons that have been proposed to explain why males are less likely to be living kidney donors than females, such as the higher prevalence of kidney failure in males. We then present counterarguments as to why biological sex differences are not enough to explain lower living kidney donation among males, such as a higher prevalence of chronic kidney disease among females, which could affect donation rates. We argue that gender differences likely provide a better explanation as to why there are more women than men living kidney donors and explore the role of economic and social factors, as well as gender roles and expectations, in affecting living kidney donation among both men and women. We conclude with the need for a gender analysis to explain this complex psychosocial phenomenon in living kidney donation.
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Affiliation(s)
- Katya Loban
- From the Research Institute of the McGill University Health Centre and the Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
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Ito Y, Herrera MG, Hotz JC, Kyogoku M, Newth CJL, Bhalla AK, Takeuchi M, Khemani RG. Estimation of inspiratory effort using airway occlusion maneuvers in ventilated children: a secondary analysis of an ongoing randomized trial testing a lung and diaphragm protective ventilation strategy. Crit Care 2023; 27:466. [PMID: 38031116 PMCID: PMC10685539 DOI: 10.1186/s13054-023-04754-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/21/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Monitoring respiratory effort in ventilated patients is important to balance lung and diaphragm protection. Esophageal manometry remains the gold standard for monitoring respiratory effort but is invasive and requires expertise for its measurement and interpretation. Airway pressures during occlusion maneuvers may provide an alternative, although pediatric data are limited. We sought to determine the correlation between change in esophageal pressure during tidal breathing (∆Pes) and airway pressure measured during three airway occlusion maneuvers: (1) expiratory occlusion pressure (Pocc), (2) airway occlusion pressure (P0.1), and (3) respiratory muscle pressure index (PMI) in children. We also sought to explore pediatric threshold values for these pressures to detect excessive or insufficient respiratory effort. METHODS Secondary analysis of physiologic data from children between 1 month and 18 years of age with acute respiratory distress syndrome enrolled in an ongoing randomized clinical trial testing a lung and diaphragm protective ventilation strategy (REDvent, R01HL124666). ∆Pes, Pocc, P0.1, and PMI were measured. Repeated measure correlations were used to investigate correlation coefficients between ∆Pes and the three measures, and linear regression equations were generated to identify potential therapeutic thresholds. RESULTS There were 653 inspiratory and 713 expiratory holds from 97 patients. Pocc had the strongest correlation with ∆Pes (r = 0.68), followed by PMI (r = 0.60) and P0.1 (r = 0.42). ∆Pes could be reliably estimated using the regression equation ∆Pes = 0.66 [Formula: see text] Pocc (R2 = 0.82), with Pocc cut-points having high specificity and moderate sensitivity to detect respective ∆Pes thresholds for high and low respiratory effort. There were minimal differences in the relationship between Pocc and ∆Pes based on age (infant, child, adolescent) or mode of ventilation (SIMV versus Pressure Support), although these differences were more apparent with P0.1 and PMI. CONCLUSIONS Airway occlusion maneuvers may be appropriate alternatives to esophageal pressure measurement to estimate the inspiratory effort in children, and Pocc represents the most promising target. TRIAL REGISTRATION NCT03266016; August 23, 2017.
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Affiliation(s)
- Yukie Ito
- Department of Intensive Care, Osaka Women's and Children's Hospital, Osaka, Japan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
| | - Matías G Herrera
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
- Department of Intensive Care, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Justin C Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
| | - Miyako Kyogoku
- Department of Intensive Care, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Muneyuki Takeuchi
- Department of Intensive Care, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA.
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA.
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Emeriaud G, Pons-Òdena M, Bhalla AK, Shein SL, Killien EY, Alapont VMI, Rowan C, Baudin F, Lin JC, Grégoire G, Napolitano N, Mayordomo-Colunga J, Diaz F, Cruces P, Medina A, Smith L, Khemani RG. Noninvasive Ventilation for Pediatric Acute Respiratory Distress Syndrome: Experience From the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Prospective Cohort Study. Pediatr Crit Care Med 2023; 24:715-726. [PMID: 37255352 PMCID: PMC10524424 DOI: 10.1097/pcc.0000000000003281] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES The worldwide practice and impact of noninvasive ventilation (NIV) in pediatric acute respiratory distress syndrome (PARDS) is unknown. We sought to describe NIV use and associated clinical outcomes in PARDS. DESIGN Planned ancillary study to the 2016/2017 prospective Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study. SETTING One hundred five international PICUs. PATIENTS Patients with newly diagnosed PARDS admitted during 10 study weeks. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Children were categorized by their respiratory support at PARDS diagnosis into NIV or invasive mechanical ventilation (IMV) groups. Of 708 subjects with PARDS, 160 patients (23%) received NIV at PARDS diagnosis (NIV group). NIV failure rate (defined as tracheal intubation or death) was 84 of 160 patients (53%). Higher nonrespiratory pediatric logistic organ dysfunction (PELOD-2) score, Pa o2 /F io2 was less than 100 at PARDS diagnosis, immunosuppression, and male sex were independently associated with NIV failure. NIV failure was 100% among patients with nonrespiratory PELOD-2 score greater than 2, Pa o2 /F io2 less than 100, and immunosuppression all present. Among patients with Pa o2 /F io2 greater than 100, children in the NIV group had shorter total duration of NIV and IMV, than the IMV at initial diagnosis group. We failed to identify associations between NIV use and PICU survival in a multivariable Cox regression analysis (hazard ratio 1.04 [95% CI, 0.61-1.80]) or mortality in a propensity score matched analysis ( p = 0.369). CONCLUSIONS Use of NIV at PARDS diagnosis was associated with shorter exposure to IMV in children with mild to moderate hypoxemia. Even though risk of NIV failure was high in some children, we failed to identify greater hazard of mortality in these patients.
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Affiliation(s)
- Guillaume Emeriaud
- Department of Pediatrics, Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Marti Pons-Òdena
- Inmune and Respiratory dysfunction in the child research group. Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950 Esplugues de Llobregat, Spain
- Pediatric Intensive Care and Intermediate care Department, Sant Joan de Déu University Hospital, Universitat de Barcelona, Esplugues de Llobregat, Spain
| | - Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, USA
| | - Steven L Shein
- Rainbow Babies and Children’s Hospital, Division of Pediatric Critical Care Medicine, Cleveland Ohio USA
| | - Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, USA
| | | | - Courtney Rowan
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Florent Baudin
- Réanimation Pédiatrique, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France
| | - John C Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, USA
| | - Gabrielle Grégoire
- Applied Clinical Research Unit, CHU Sainte-Justine, Montreal, QC, Canada
| | - Natalie Napolitano
- Respiratory Therapy Department, Children’s Hospital of Philadelphia, USA
| | - Juan Mayordomo-Colunga
- Pediatric Intensive Care Unit. Hospital Universitario Central de Asturias, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - Franco Diaz
- Instituto de Ciencias e innovación en medicina (ICIM), Universidad del Desarrollo, Santiago de Chile
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago de Chile
| | - Pablo Cruces
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago de Chile
- Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Alberto Medina
- Pediatric Intensive Care Unit. Hospital Universitario Central de Asturias, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Spain
| | - Lincoln Smith
- Department of Pediatrics, University of Washington, Seattle Children’s Hospital, USA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, USA
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Percy AG, Mai MV, Bhalla AK, Yehya N. Mechanical Power Is Associated With Mortality in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2023; 24:e307-e316. [PMID: 36883840 PMCID: PMC10329976 DOI: 10.1097/pcc.0000000000003214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
OBJECTIVES Mechanical power (MP) transferred from the ventilator to the lungs has been proposed as a summary variable that may impact mortality in children with acute respiratory distress syndrome (ARDS). To date, no study has shown an association between higher MP and mortality in children with ARDS. DESIGN Secondary analysis of a prospective observational study. SETTING Single-center, tertiary, academic PICU. PATIENTS Five hundred forty-six intubated children with ARDS enrolled between January 2013 and December 2019 receiving pressure-controlled ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Higher MP was associated with increased mortality (adjusted hazard ratio [HR] 1.34 per 1 sd increase, 95% CI 1.08-1.65; p = 0.007). When assessing the contribution of individual components of MP, only positive end-expiratory pressure (PEEP) was associated with mortality (HR 1.32; p = 0.007), whereas tidal volume, respiratory rate, and driving pressure (ΔP = [peak inspiratory pressure (PIP)-PEEP]) were not. Finally, we tested whether there remained an association when specific terms were removed from the MP equation by calculating MP from static strain (remove ΔP), MP from dynamic strain (remove PEEP), and mechanical energy (remove respiratory rate). MP from static strain (HR 1.44; p < 0.001), MP from dynamic strain (HR 1.25; p = 0.042), and mechanical energy (HR 1.29; p = 0.009) were all associated with mortality. MP was associated with ventilator-free days only when using MP normalized to predicted body weight, but not when using measured weight. CONCLUSIONS Higher MP was associated with mortality in pediatric ARDS, and PEEP appears to be the component most consistently driving this association. As higher PEEP is used in sicker patients, the association between MP and mortality may reflect a marker of illness severity rather than MP itself being causal for mortality. However, our results support future trials testing different levels of PEEP in children with ARDS as a potential means to improve outcome.
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Affiliation(s)
- Andrew G Percy
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mark V Mai
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Bhalla AK, Chau A, Khemani RG, Newth CJL. The end-tidal alveolar dead space fraction for risk stratification during the first week of invasive mechanical ventilation: an observational cohort study. Crit Care 2023; 27:54. [PMID: 36759925 PMCID: PMC9912669 DOI: 10.1186/s13054-023-04339-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND The end-tidal alveolar dead space fraction (AVDSf = [PaCO2-PETCO2]/PaCO2) is a metric used to estimate alveolar dead space. Higher AVDSf on the first day of mechanical ventilation is associated with mortality and fewer ventilator-free days. It is not clear if AVDSf is associated with length of ventilation in survivors, how AVDSf performs for risk stratification beyond the first day of ventilation, or whether AVDSf adds predictive value to oxygenation (oxygenation index [OI]) or severity of illness (Pediatric Risk of Mortality [PRISM III]) markers. METHODS Retrospective single-center observational cohort study of children and young adults receiving invasive mechanical ventilation. In those with arterial or capillary blood gases, AVDSf was calculated at the time of every blood gas for the first week of mechanical ventilation. RESULTS There were 2335 children and young adults (median age 5.8 years [IQR 1.2, 13.2]) enrolled with 8004 analyzed AVDSf values. Higher AVDSf was associated with mortality and longer length of ventilation in survivors throughout the first week of ventilation after controlling for OI and PRISM III. Higher OI was not associated with increased mortality until ≥ 48 h of ventilation after controlling for AVDSf and PRISM III. When using standardized variables, AVDSf effect estimates were generally higher than OI for mortality, whereas OI effect estimates were generally higher than AVDSf for the length of ventilation in survivors. An AVDSf > 0.3 was associated with a higher mortality than an AVDSf < 0.2 within each pediatric acute respiratory distress syndrome severity category. The maximum AVDSf within 12 h of intensive care unit admission demonstrated good risk stratification for mortality (AUC 0.768 [95% CI 0.732, 0.803]). AVDSf did not improve mortality risk stratification when added to PRISM III but did improve mortality risk stratification when added to the gas exchange components of PRISM III (minimum 12-h PaO2 and maximum 12-h PCO2) (p < 0.00001). CONCLUSIONS AVDSf is associated with mortality and length of ventilation in survivors throughout the first week of invasive mechanical ventilation. Some analyses suggest AVDSf may better stratify mortality risk than OI, whereas OI may better stratify risk for prolonged ventilation in survivors than AVDSf.
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Affiliation(s)
- Anoopindar K. Bhalla
- grid.42505.360000 0001 2156 6853Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, MS#12, Los Angeles, CA 90027 USA
| | - Ariya Chau
- grid.168010.e0000000419368956Division of Cardiology, Department of Pediatrics, Lucile Packard Children’s Hospital at Stanford, Stanford University School of Medicine, Palo Alto, CA USA
| | - Robinder G. Khemani
- grid.42505.360000 0001 2156 6853Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, MS#12, Los Angeles, CA 90027 USA
| | - Christopher J. L. Newth
- grid.42505.360000 0001 2156 6853Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, MS#12, Los Angeles, CA 90027 USA
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Chopra HK, Wander GS, Ponde CK, Nanda NC, Khullar D, Venugopal K, Ray S, Nair T, Rana DS, Kher V, S Sawhney JP, Kasliwa RR, Jabir A, Chakraborty R, Chandra P, Bansal S, Kumar V, Pancholia AK, Kapoor A, Prakash S, Saxena A, Rastogi V, Sharma V, Arora YK, Dasbiswas A, Bhargava M, Jaswal A, Bhargava K, Bhatia M, Omar AK, Khanna NN, Passey R, Bhalla D, Vijayalakshmi IB, Bhalla AK, Moorthy A, Isser HS, Mishra SS, Routray SN, Tandon V, Sinha A, Bansal M, Jain P, Hotchandani R, Jain D, Katyal VK, Gulati S, Tandon R, Jaggi S, Sehgal B, Gupta V, Mehrotra R, Krishnamani NC, Pathak SN, Yadav MS, Chawla R, Pal J, Chatterjee N, Samajdar SS, Shastry NR. The Power and Promise of Angiotensin Receptor Neprilysin Inhibitor (ARNI) in Heart Failure Management: National Consensus Statement. J Assoc Physicians India 2023; 71:11-12. [PMID: 37354473 DOI: 10.5005/japi-11001-0209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/26/2023]
Abstract
;Heart failure (HF) is a huge global public health task due to morbidity, mortality, disturbed quality of life, and major economic burden. It is an area of active research and newer treatment strategies are evolving. Recently angiotensin receptor-neprilysin inhibitor (ARNI), a class of drugs (the first agent in this class, Sacubitril-Valsartan), reduces cardiovascular mortality and morbidity in chronic HF patients with reduced left ventricular ejection fraction (LVEF). Positive therapeutic effects have led to a decrease in cardiovascular mortality and HF hospitalizations (HFH), with a favorable safety profile, and have been documented in several clinical studies with an unquestionable survival benefit with ARNI, Sacubitril-Valsartan. This consensus statement of the Indian group of experts in cardiology, nephrology, and diabetes provides a comprehensive review of the power and promise of ARNI in HF management and an evidence-based appraisal of the use of ARNI as an essential treatment strategy for HF patients in clinical practice. Consensus in this review favors an early utility of Sacubitril-Valsartan in patients with HF with reduced EF (HFrEF), regardless of the previous therapy being given. A lower rate of hospitalizations for HF with Sacubitril-Valsartan in HF patients with preserved EF who are phenotypically heterogeneous suggests possible benefits of ARNI in patients having 40-50% of LVEF, frequent subtle systolic dysfunction, and higher hospitalization risk.
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Affiliation(s)
- H K Chopra
- Senior Consultant Cardiologist, Medanta Moolchand Heart Institute, Delhi
| | - G S Wander
- Professor & Head of Cardiology, Hero DMC Heart Institute, Dayanand Medical College & Hospital (DMCH), Ludhiana, Punjab
| | - C K Ponde
- Consultant Cardiologist and Head of Department, Department of Cardiology, P. D. Hinduja Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Navin C Nanda
- Professor of Medicine and Cardiovascular Disease, Heersink School of Medicine, University of Alabama at Birmingham (UAB), Birmingham, United Kingdom
| | - Dinesh Khullar
- Chairman, Department of Nephrology; Department of Kidney Transplant, Max Super Speciality Hospital, Delhi
| | - K Venugopal
- Professor Emeritus, Department of Cardiology, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala
| | - Saumitra Ray
- Director, Department of Invasive Cardiology, AMRI Hospitals, Kolkata, West Bengal
| | - Tiny Nair
- Head, Department of Cardiology & Interventional Cardiology, PRS Hospital, Trivandrum, Kerala
| | - D S Rana
- Emeritus Consultant Nephrologist, Department of Nephrology, Sir Ganga Ram Hospital
| | - Vijay Kher
- Chairman; Department of Nephrology; Department of Kidney Transplant, Epitome Kidney Urology Institute & Lions Hospital
| | - J P S Sawhney
- Chairman, Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, Delhi
| | - R R Kasliwa
- Adjunct Professor, Department of Cardiology; Chairman, Department of Clinical and Preventive Cardiology, Medanta Moolchand Heart Institute, Gurugram, Haryana
| | - A Jabir
- Senior Consultant Cardiologist, Lisie Hospital, Kochi, Kerala
| | - Rabin Chakraborty
- Senior Vice Chairman and Head of Cardiology, Medica Superspecialty Hospital (MSH), Kolkata, West Bengal
| | - Praveen Chandra
- Chairman, Department of Interventional Cardiology, Medanta Moolchand Heart Institute
| | - Sandeep Bansal
- Professor and HOD, Department of Cardiology, Safdarjung Hospital
| | - Viveka Kumar
- Principal Director and Chief of Cath Lab, Department of Cardiac Sciences, Max Super Speciality Hospital, Delhi
| | - A K Pancholia
- HOD, Department of Medicine and Preventive Cardiology, Arihant Hospital & Research Centre, Indore, Madhya Pradesh
| | - Aditya Kapoor
- Professor and Head of the Department, Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences
| | - Sunil Prakash
- Director and Head, Department of Nephrology; Department of Transplant service BLK, Max Super Speciality Hospital
| | - Anil Saxena
- Executive Director, Department of Cardiac Pacing and Electrophysiology, Fortis Escorts Heart Institute
| | - Vishal Rastogi
- Director of Cardiology, Department of Cardiology, Fortis Escorts Heart Institute
| | - Vinod Sharma
- Vice CEO and Head, Department of Cardiology, National Heart Institute
| | - Y K Arora
- Cardiologist, National Heart Institute, Delhi
| | - Arup Dasbiswas
- Ex-Director, ICVS, Institute of Post Graduate Medical Education and Research (IPGME&R); Chief Cardiologist, Das Biswas Clinic, Kolkata, West Bengal
| | - Mohan Bhargava
- Director, Department of Interventional Cardiology, Max Super Speciality Hospital, Delhi, India
| | - Aparna Jaswal
- Member, Board of Directors, International Board of Heart Rhythm Examiners, Columbia, Washington, United States of America; Director, Department of Cardiac Pacing and Electrophysiology, Fortis Escorts Heart Institute
| | - K Bhargava
- Senior Director, Department of Cardiac Electrophysiology and Pacing, Medanta Moolchand Heart Institute
| | - Mona Bhatia
- Principal, Director, Head, Department of Imaging, Fortis Escorts Heart Institute
| | - A K Omar
- Director, Head, Department of Non-Invasive Cardiology, Fortis Escorts Heart Institute
| | - N N Khanna
- Advisor, Senior Consultant, Department of Cardiology, Indraprastha Apollo Hospitals
| | | | - Dilip Bhalla
- Senior Director, Department of Nephrology and Renal Transplant, Max Super Speciality Hospital, Delhi
| | - I B Vijayalakshmi
- Professor Emeritus, Former HOD, Department of Paediatric Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka
| | - A K Bhalla
- Chairman, Department of Nephrology, Sir Ganga Ram Hospital, Delhi
| | - Asha Moorthy
- Senior Consultant Cardiologist, SIMS Hospital, Chennai, Tamil Nadu
| | - H S Isser
- Department of Cardiology, VMMC & Safdarjung Hospital
| | | | - S N Routray
- Professor, Department of Cardiology, Srirama Chandra Bhanj Medical College & Hospital (S.C.B Medical College), Cuttack, Odisha
| | - Vivek Tandon
- Associate Director, In charge, Non-Invasive Cardiac Laboratory, Max Smart Super Speciality Hospital, Delhi
| | - Ajay Sinha
- Senior Consultant, Cardiologist, Jay Prabha Medanta Super Specialty Hospital, Patna, Bihar
| | - Manish Bansal
- Senior Director, Department Clinical and Preventive Cardiology, Medanta - The Medicity Multi-Speciality Hospital, Gurugram, Haryana
| | - Praveen Jain
- Executive Director, Chief Cardiologist, Lifeline Superspeciality Hospital and Heart Center, Jhansi, Uttar Pradesh
| | - Ramesh Hotchandani
- Consultant, Head, Department of Nephrology, Moolchand Centre for Renal Care and Dialysis, Moolchand Hospital, Delhi
| | - Dharmendra Jain
- Professor, Department of Cardiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
| | - V K Katyal
- HOD, Department of General Medicine, Positron Hospital; Formerly Senior Professor, HOD, Department of Medicine, Pt. B.D.Sharma, Post Graduate Institute of Medical Sciences, Rohtak, Haryana
| | - Sanjiv Gulati
- Principal Director, Department of Nephrology, Fortis Hospital, Delhi
| | - Rohit Tandon
- Senior Consultant Physician, Department of Cardiology, Hero DMC Heart Institute, Dayanand Medical College & Hospital (DMCH), Ludhiana, Punjab
| | - Shalini Jaggi
- Director, Consultant Diabetologist, Lifecare Diabetes Centre
| | - Blessy Sehgal
- Consultant Nephrologist, Department of Nephrology, Sri Balaji Action Medical Institute, Delhi
| | - Vitull Gupta
- Honorary Teaching Faculty, All India Institute of Medical Sciences; Consultant Physician, Kishori Ram Hospital, Bathinda, Punjab
| | - Rahul Mehrotra
- Director and Head, Department of Non-Invasive Cardiology, Max Super Speciality Hospital
| | | | - S N Pathak
- Senior Consultant Interventional Cardiologist, Indraprastha Apollo Hospital
| | - M S Yadav
- Senior Consultant, Department of Interventional Cardiology, Max Super Speciality Hospital
| | - Rajeev Chawla
- Senior Consultant Diabetologist, Director, North Delhi Diabetes Centre, Delhi
| | - Jyotirmoy Pal
- Professor, Department of General Medicine, R.G. Kar Medical College & Hospital
| | - Nandini Chatterjee
- Clinical Pharmacologist, Diabetes & Allergy-Asthma Therapeutics Specialty Clinic
| | - Shambo S Samajdar
- Professor, Department of Medicine, Institute of Post Graduate Medical Education and Research (IPGME&R) - SSKM Hospital
| | - N R Shastry
- Cardiologist, Department of Clinical Cardiology, Medanta-Moolchand Heart Centre, Delhi, India
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8
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Bhalla AK, Khemani RG. Challenges Remain to Assess Post-ICU Morbidity and Identify Attributable Risk in Children With Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2022; 23:571-573. [PMID: 35797575 PMCID: PMC9473307 DOI: 10.1097/pcc.0000000000002980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
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9
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Ito Y, Takeuchi M, Inata Y, Kyogoku M, Hotz JC, Bhalla AK, Newth CJL, Khemani RG. Normalization to Predicted Body Weight May Underestimate Mechanical Energy in Pediatric Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2022; 205:1360-1363. [PMID: 35315733 PMCID: PMC9873119 DOI: 10.1164/rccm.202111-2641le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Yukie Ito
- Osaka Women’s and Children’s HospitalOsaka, Japan
| | - Muneyuki Takeuchi
- Osaka Women’s and Children’s HospitalOsaka, Japan,Corresponding author (e-mail: )
| | - Yu Inata
- Osaka Women’s and Children’s HospitalOsaka, Japan
| | | | | | - Anoopindar K. Bhalla
- Children’s Hospital Los AngelesLos Angeles, California,University of Southern CaliforniaLos Angeles, California
| | - Christopher J. L. Newth
- Children’s Hospital Los AngelesLos Angeles, California,University of Southern CaliforniaLos Angeles, California
| | - Robinder G. Khemani
- Children’s Hospital Los AngelesLos Angeles, California,University of Southern CaliforniaLos Angeles, California
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10
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Gupta A, Bhalla AK, Malik M, Gupta A, Bhargava V, Tiwari V, Gaur L, Gupta P, Jain M, Rana DS. Anti-T-Lymphocyte Immunoglobulin (Grafalon) as an Induction Agent for Renal Transplantation: A Real-World, Retrospective, Single-Center Experience. EXP CLIN TRANSPLANT 2022; 20:480-486. [PMID: 35620891 DOI: 10.6002/ect.2021.0432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Polyclonal antithymocyte globulins are widely used in the induction regimens of solid-organ transplant recipients; however, their doses and outcomes remain to be standardized in Indian patients. We report our clinical experience from the real-world use of Grafalon (an anti-T-lymphocyte globulin; ATG-Fresenius) as an induction agentin renal transplant recipients from India. MATERIALS AND METHODS In this retrospective, single- center, observational study, we analyzed the medical records of 177 consecutive, kidney-only transplant recipients who received induction therapy with Grafalon from September 2016 to March 2018 at our center. Incidences of biopsy-proven acute rejection and graft dysfunction, immunosuppression protocol, Grafalon dosage, 18-month post-transplant graft and patient survival, treatment-related adverse events, and infective complications were reported. RESULTS Mean age of patients was 41.46 years (range, 14-68 years), (85% were males). The average dose of Grafalon was 5.81 ± 1.95 mg/kg (range, 2.41 to 10.07 mg/kg). Graft dysfunction (ie, at least 20% increase in serum creatinine from baseline) was observed in 26 patients (14%): 11 patients (6.2%) had biopsy-proven acute rejections, 11 patients (6.2%) had acute tubular necrosis, and 4 patients (2.2%) had calcineurin inhibitor toxicity. Seven deaths were recorded: 2 each from fungal pneumonia, bacterial pneumonia, and acute coronary syndrome and 1 with urinary tract infection with septicemia. Death-censored graft survival was 100% at 12 months and 98% at 18-month follow-up; overall patient survival was 96%. Infective complications occurred in 40 patients (22.5%), with the most common being urinary tract infection in 32 patients (18%). No malignancies were reported. CONCLUSIONS Use of a potent induction therapy like anti-T-lymphocyte globulin (Grafalon) is often restricted by the risk of side effects and lack of local clinical evidence supporting its role in long-term graft survival. Real-world evidence support the safe and effective use of anti-T-lymphocyte globulin as an induction agent in renal transplant recipients with an individualized dosing approach.
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Affiliation(s)
- Ashwani Gupta
- From the Department of Nephrology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
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11
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Bhalla AK, Klein MJ, Modesto I Alapont V, Emeriaud G, Kneyber MCJ, Medina A, Cruces P, Diaz F, Takeuchi M, Maddux AB, Mourani PM, Camilo C, White BR, Yehya N, Pappachan J, Di Nardo M, Shein S, Newth C, Khemani R. Mechanical power in pediatric acute respiratory distress syndrome: a PARDIE study. Crit Care 2022; 26:2. [PMID: 34980228 PMCID: PMC8722295 DOI: 10.1186/s13054-021-03853-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/01/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Mechanical power is a composite variable for energy transmitted to the respiratory system over time that may better capture risk for ventilator-induced lung injury than individual ventilator management components. We sought to evaluate if mechanical ventilation management with a high mechanical power is associated with fewer ventilator-free days (VFD) in children with pediatric acute respiratory distress syndrome (PARDS). METHODS Retrospective analysis of a prospective observational international cohort study. RESULTS There were 306 children from 55 pediatric intensive care units included. High mechanical power was associated with younger age, higher oxygenation index, a comorbid condition of bronchopulmonary dysplasia, higher tidal volume, higher delta pressure (peak inspiratory pressure-positive end-expiratory pressure), and higher respiratory rate. Higher mechanical power was associated with fewer 28-day VFD after controlling for confounding variables (per 0.1 J·min-1·Kg-1 Subdistribution Hazard Ratio (SHR) 0.93 (0.87, 0.98), p = 0.013). Higher mechanical power was not associated with higher intensive care unit mortality in multivariable analysis in the entire cohort (per 0.1 J·min-1·Kg-1 OR 1.12 [0.94, 1.32], p = 0.20). But was associated with higher mortality when excluding children who died due to neurologic reasons (per 0.1 J·min-1·Kg-1 OR 1.22 [1.01, 1.46], p = 0.036). In subgroup analyses by age, the association between higher mechanical power and fewer 28-day VFD remained only in children < 2-years-old (per 0.1 J·min-1·Kg-1 SHR 0.89 (0.82, 0.96), p = 0.005). Younger children were managed with lower tidal volume, higher delta pressure, higher respiratory rate, lower positive end-expiratory pressure, and higher PCO2 than older children. No individual ventilator management component mediated the effect of mechanical power on 28-day VFD. CONCLUSIONS Higher mechanical power is associated with fewer 28-day VFDs in children with PARDS. This association is strongest in children < 2-years-old in whom there are notable differences in mechanical ventilation management. While further validation is needed, these data highlight that ventilator management is associated with outcome in children with PARDS, and there may be subgroups of children with higher potential benefit from strategies to improve lung-protective ventilation. TAKE HOME MESSAGE Higher mechanical power is associated with fewer 28-day ventilator-free days in children with pediatric acute respiratory distress syndrome. This association is strongest in children <2-years-old in whom there are notable differences in mechanical ventilation management.
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Affiliation(s)
- Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Department of Pediatrics, Université de Montréal, Montreal, Canada
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, University Medical Center Groningen, Beatrix Children's Hospital, University of Groningen, Groningen, The Netherlands
- Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Alberto Medina
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Pablo Cruces
- Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Departamento de Pediatría, Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago, Chile
| | - Franco Diaz
- Instituto de Ciencias e Innovación ed Medicina (ICIM), Universidad del Desarrollo, Santiago, Chile
- Hospital Clínico La Florida, Santiago, Chile
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Aline B Maddux
- Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO, USA
- Children's Hospital Colorado, Aurora, CO, USA
| | - Peter M Mourani
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John Pappachan
- Paediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Steven Shein
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Christopher Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robinder Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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12
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Jeloka TK, Abraham G, Bhalla AK, Balasubramaniam J, Dutta A, Gokulnath, Gupta A, Jha V, Khanna U, Mahajan S, Nayak KS, Prasad KN, Prasad N, Rathi M, Raju S, Rohit A, Sahay M, Sampathkumar K, Sivakumar V, Varughese S. Continuous Ambulatory Peritoneal Dialysis Peritonitis Guidelines - Consensus Statement of Peritoneal Dialysis Society of India - 2020. Indian J Nephrol 2021; 31:425-434. [PMID: 34880551 PMCID: PMC8597799 DOI: 10.4103/ijn.ijn_73_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/08/2019] [Accepted: 06/30/2019] [Indexed: 11/25/2022] Open
Abstract
Continuous ambulatory peritoneal dialysis (CAPD) related peritonitis is a major cause of technique failure, morbidity, and mortality in patients on CAPD. Its prevention and management is key to success of CAPD program. Due to variability in practice, microbiological trends and sensitivity towards antibiotics, there is a need for customized guidelines for management of CAPD related peritonitis (CAPDRP) in India. With this need, Peritoneal Dialysis Society of India (PDSI) organized a structured meeting to discuss various aspects of management of CAPDRP and formulated a consensus agreement which will help in management of patients with CAPDRP.
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Affiliation(s)
- Tarun K Jeloka
- Department of Nephrology, Aditya Birla Memorial Hospital, Pune, Maharashtra, India
| | - Georgi Abraham
- Department of Nephrology, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - A K Bhalla
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - J Balasubramaniam
- Department of Nephrology, Kidney Care Centre, Tirunelveli, Tamil Nadu, India
| | - A Dutta
- Department of Nephrology, Fortis Hospital and Kidney Institute, Kolkata, West Bengal, India
| | - Gokulnath
- Department of Nephrology, Apollo Hospital, Bengaluru, Karnataka, India
| | - Amit Gupta
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute, Lucknow, Uttar Pradesh, India
| | - V Jha
- The George Institute for Global Health, New Delhi, India
| | - Umesh Khanna
- Department of Nephrology, Lancelot Kidney and GI Centre, Mumbai, Maharashtra, India
| | - Sandeep Mahajan
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - K S Nayak
- Department of Nephrology, Virinchi Hospitals, Hyderabad, Telangana, India
| | - K N Prasad
- Department of Microbiology, Sanjay Gandhi Post Graduate Institute, Lucknow, Uttar Pradesh, India
| | - Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute, Lucknow, Uttar Pradesh, India
| | - Manish Rathi
- Department of Nephrology, Post Graduate Institute, Chandigarh, India
| | - Sreebhushan Raju
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Anusha Rohit
- Department of Microbiology, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Manisha Sahay
- Department of Nephrology, Osmania Hospital, Hyderabad, Telangana, India
| | - K Sampathkumar
- Department of Nephrology, Meenakshi Mission Hopsital and Research Centre, Madurai, Tamil Nadu, India
| | - V Sivakumar
- Department of Nephrology, SriVenkateshwara Institute of Medical sciences, Tirupati, Andhra Pradesh, India
| | - Santosh Varughese
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
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13
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Bhalla AK, Klein MJ, Emeriaud G, Lopez-Fernandez YM, Napolitano N, Fernandez A, Al-Subu AM, Gedeit R, Shein SL, Nofziger R, Hsing DD, Briassoulis G, Ilia S, Baudin F, Piñeres-Olave BE, Maria Izquierdo L, Lin JC, Cheifetz IM, Kneyber MCJ, Smith L, Khemani RG, Newth CJL. Adherence to Lung-Protective Ventilation Principles in Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study. Crit Care Med 2021; 49:1779-1789. [PMID: 34259438 PMCID: PMC8448899 DOI: 10.1097/ccm.0000000000005060] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe mechanical ventilation management and factors associated with nonadherence to lung-protective ventilation principles in pediatric acute respiratory distress syndrome. DESIGN A planned ancillary study to a prospective international observational study. Mechanical ventilation management (every 6 hr measurements) during pediatric acute respiratory distress syndrome days 0-3 was described and compared with Pediatric Acute Lung Injury Consensus Conference tidal volume recommendations (< 7 mL/kg in children with impaired respiratory system compliance, < 9 mL/kg in all other children) and the Acute Respiratory Distress Syndrome Network lower positive end-expiratory pressure/higher Fio2 grid recommendations. SETTING Seventy-one international PICUs. PATIENTS Children with pediatric acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Analyses included 422 children. On pediatric acute respiratory distress syndrome day 0, median tidal volume was 7.6 mL/kg (interquartile range, 6.3-8.9 mL/kg) and did not differ by pediatric acute respiratory distress syndrome severity. Plateau pressure was not recorded in 97% of measurements. Using delta pressure (peak inspiratory pressure - positive end-expiratory pressure), median tidal volume increased over quartiles of median delta pressure (p = 0.007). Median delta pressure was greater than or equal to 18 cm H2O for all pediatric acute respiratory distress syndrome severity levels. In severe pediatric acute respiratory distress syndrome, tidal volume was greater than or equal to 7 mL/kg 62% of the time, and positive end-expiratory pressure was lower than recommended by the positive end-expiratory pressure/Fio2 grid 70% of the time. In multivariable analysis, tidal volume nonadherence was more common with severe pediatric acute respiratory distress syndrome, fewer PICU admissions/yr, non-European PICUs, higher delta pressure, corticosteroid use, and pressure control mode. Adherence was associated with underweight stature and cuffed endotracheal tubes. In multivariable analysis, positive end-expiratory pressure/Fio2 grid nonadherence was more common with higher pediatric acute respiratory distress syndrome severity, ventilator decisions made primarily by the attending physician, pre-ICU cardiopulmonary resuscitation, underweight stature, and age less than 2 years. Adherence was associated with respiratory therapist involvement in ventilator management and longer time from pediatric acute respiratory distress syndrome diagnosis. Higher nonadherence to tidal volume and positive end-expiratory pressure recommendations were independently associated with higher mortality and longer duration of ventilation after adjustment for confounding variables. In stratified analyses, these associations were primarily influenced by children with severe pediatric acute respiratory distress syndrome. CONCLUSIONS Nonadherence to lung-protective ventilation principles is common in pediatric acute respiratory distress syndrome and may impact outcome. Modifiable factors exist that may improve adherence.
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Affiliation(s)
- Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, QC, Canada
- Department of Pediatrics, Université de Montréal, Montreal, QC, Canada
| | - Yolanda M Lopez-Fernandez
- Pediatric Intensive Care Unit, Department of Pediatrics, Biocruces-Bizkaia, Bizkaia, Spain
- Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - Natalie Napolitano
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Analia Fernandez
- Pediatric Intensive Care Unit, Hospital General de Agudos "C. Durand", Buenos Aires, Argentina
| | - Awni M Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, American Family Children's Hospital, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Rainer Gedeit
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
- Critical Care Section, Children's Wisconsin, Milwaukee, WI
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Ryan Nofziger
- Department of Pediatrics, Division of Critical Care Medicine, Akron Children's Hospital, Akron, OH
| | - Deyin Doreen Hsing
- Department of Pediatrics, Pediatric Critical Care Medicine, Weill Cornell Medicine, New York City, NY
| | - George Briassoulis
- Pediatric Intensive Care Unit, Medical School, University of Crete, Crete, Greece
| | - Stavroula Ilia
- Pediatric Intensive Care Unit, Medical School, University of Crete, Crete, Greece
| | - Florent Baudin
- Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Réanimation Pédiatrique, Lyon, France
| | | | | | - John C Lin
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Ira M Cheifetz
- Division of Cardiac Critical Care, UH Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Critical Care, Anaesthesiology, Peri-operative and Emergency medicine (CAPE), University of Groningen, Groningen, the Netherlands
| | - Lincoln Smith
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
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14
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Yusuf S, Rana DS, Gupta A, Gupta A, Bhalla AK, Malik M, Bhargava V. Comparison of short-term outcomes with and without induction therapy in low-risk renal transplant recipients. Saudi J Kidney Dis Transpl 2021; 32:1273-1282. [PMID: 35532696 DOI: 10.4103/1319-2442.344746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
With low rates of rejection with current immunosuppression consisting of steroids, mycophenolic acid and tacrolimus, the question arises whether induction offers any additional benefit in low-risk renal transplant recipients. This study evaluated outcomes with and without induction in low-risk renal transplant recipients. A prospective observational study in which 100 low-risk renal transplant recipients were included and divided into two groups - one that received induction (IND) and another that did not (NO IND). They were followed for 1.5 years. Three endpoints were compared - efficacy of induction, patient and graft survival, and adverse effects. Incidence of rejection in early posttransplant period did not differ (4% NO IND vs. 6% IND; P = 0.171). Rejection as cause of late graft dysfunction was seen in 16% in IND vs. 20% NO IND; (P = 0.603). No difference in serum creatinine at end of 1.5 years was seen. Graft survival was also similar. Relapsing and recurrent urinary tract infections (46% IND vs. 16% NO IND; P = 0.09), hospitalization requiring infections (76%IND vs. 64% NO IND; P = 0.119 NS) were more common in IND. Cytomegalovirus infection affected only IND (6% vs. none; P = 0.07). Patient survival at 1.5 years was comparable (94% IND vs. 96% NO IND; P = 0.646). The study showed comparable results between IND and NO IND with however an increased incidence of infections and hospitalizations in the IND group. The use of induction may be avoided in low-risk renal transplant recipients.
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Affiliation(s)
- Sabina Yusuf
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Anurag Gupta
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashwani Gupta
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - A K Bhalla
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Manish Malik
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Vinant Bhargava
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
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15
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Bhoyar A, Bhargava V, Gupta A, Gupta A, Tiwari V, Bhalla AK, Malik M, Rana DS. MO190NORMATIVE DATA FOR GLOMERULAR FILTRATION RATE IN HEALTHY KIDNEY DONOR POPULATION. Nephrol Dial Transplant 2021. [DOI: 10.1093/ndt/gfab092.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background and Aims
Glomerular filtration rate (GFR) is estimated traditionally from 24-hour urinary creatinine clearance. Creatinine is mainly filtered by glomerulus. The collection of 24-hour urinary sample is a difficult task with many patients fail to collect all the urine samples. As measuring GFR is cumbersome, expensive, and not easily available in all centers, various equations are developed for estimating GFR from creatinine like MDRD, CKD EPI creatinine. GFR obtained from serum creatinine shows wide variation as muscle mass and dietary protein intake are important determinants of serum creatinine concentration. Literature shows very few studies with GFR estimation with reference to age in Indian population. Hence, this study is planned to develop age specific nomogram for GFR in healthy kidney donor population as well as to study agreement between GFR obtained by 99m Tc DTPA three sample method and GFR estimated by 24-hour urinary creatinine. The aim of this stidy was to develop age-specific nomogram GFR in healthy kidney donor population and to study the agreement between the GFR measured by Technetium-99m diethylene triamine pentaacetic acid (99m Tc DTPA) and 24-hour urinary creatinine method.
Method
This study was conducted at Sir Ganga Ram hospital, New Delhi. All healthy individuals aged more than 20 years and less than 65 years, undergoing evaluation as prospective kidney donor at our hospital were the part of this study. GFR was measured by 99m Tc DTPA clearance using 3 sample method. GFR measured by DTPA method was used to develop nomogram. Creatinine Clearance was calculated from 24-hour urinary creatinine by formula U x V/P where, U is urinary creatinine level, P is plasma creatinine level and V is total volume of urine. Nomogram was developed with respect to these 3 Age groups; namely, 20 to 40 years, 40 to 50 years and 50 to 65 years
Results
Total 100 kidney donors were included in this study. Enrolled subjects were divided into 3 age groups; 20 to 40 years (n=28), 40 to 50 years (n=46) and 50 to 65 years (n=26). Majority of the donors were females (n=80). The agreement between GFR obtained by 99m Tc DTPA and 24-hour urinary creatinine clearance methods was 92.6 vs. 94 ml/min, 80.4 vs. 76 ml/min and 76.3 vs. 70 ml/min in respective age groups.
Conclusion
In the younger age group (20 to 40 years), there is better agreement in GFR measured by 99m Tc DTPA method and 24-hour urinary creatinine clearance methods.
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Affiliation(s)
- Ashish Bhoyar
- Sir Ganga Ram Hospital, Institute of Nephrology, New Delhi, India
| | - Vinant Bhargava
- Sir Ganga Ram Hospital, Institute of Nephrology, New Delhi, India
| | - Ashwani Gupta
- Sir Ganga Ram Hospital, Institute of Nephrology, New Delhi, India
| | - Anurag Gupta
- Sir Ganga Ram Hospital, Institute of Nephrology, New Delhi, India
| | - Vaibhav Tiwari
- Sir Ganga Ram Hospital, Institute of Nephrology, New Delhi, India
| | - A K Bhalla
- Sir Ganga Ram Hospital, Institute of Nephrology, New Delhi, India
| | - Manish Malik
- Sir Ganga Ram Hospital, Institute of Nephrology, New Delhi, India
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16
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Abstract
BACKGROUND The ventilatory ratio (VR) is a dead-space marker associated with mortality in mechanically ventilated adults with ARDS. The end-tidal alveolar dead space fraction (AVDSf) has been associated with mortality in children. However, AVDSf requires capnography measurements, whereas VR does not. We sought to examine the prognostic value of VR, in comparison to AVDSf, in children and young adults with acute hypoxemic respiratory failure. METHODS We conducted a retrospective study of prospectively collected data from 180 mechanically ventilated children and young adults with acute hypoxemic respiratory failure. VR was calculated as (minute ventilation × [Formula: see text])/(age-adjusted predicted minute ventilation × 37.5). AVDSf was calculated as [Formula: see text]. RESULTS VR and AVDSf had a moderate correlation (rho 0.31, P < .001). VR was similar between survivors at 1.22 (interquartile range [IQR] 1.0-1.52) and nonsurvivors at 1.30 (IQR 0.96-1.95) (P = .2). AVDSf was lower in survivors at 0.12 (IQR 0.03-0.23) than nonsurvivors at 0.24 (IQR 0.13-0.33) (P < .001). In logistic regression and competing risk regression analyses, VR was not associated with mortality or rate of extubation at any given time (competing risk death; all P > .3). An AVDSf in the highest 2 quartiles, in comparison to the lowest quartile (AVDSf < 0.06), was associated with higher mortality after adjustment for oxygenation index and severity of illness (AVDSf ≥ 0.15-0.26: odds ratio 3.58, 95% CI 1.02-12.64, P = .047, and AVDSf ≥ 0.26: odds ratio 3.91 95% CI-1.03-14.83, P = .045). At any given time after intubation, a child with an AVDSf ≥ 0.26 was less likely to be extubated than a child with an AVDSf < 0.06, after adjustment for oxygenation index and severity of illness (AVDSf ≥ 0.26: subdistribution hazard ratio 0.55, 95% CI 0.33-0.94, P = .03). CONCLUSIONS VR should not be used for prognostic purposes in children and young adults. AVDSf added prognostic information to the severity of oxygenation defect and overall severity of illness in children and young adults, consistent with previous research.
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Affiliation(s)
- Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Junzi Dong
- Philips Research North America, Acute Care Solutions Department, Cambridge, Massachusetts
| | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Christopher Jl Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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17
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Gupta P, Dharamdasani S, Gupta A, Bhalla AK, Gupta A, Malik M, Bhargava V, Tiwari V, Rana DS, Sapra RL. Evaluation of factors influencing outcomes in pauci-immune crescentic glomerulonephritis: Single centre experience of 51 cases. Indian J Nephrol 2021; 31:503-506. [PMID: 35068754 PMCID: PMC8722560 DOI: 10.4103/ijn.ijn_108_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/23/2020] [Accepted: 06/22/2020] [Indexed: 11/04/2022] Open
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Bhargava V, Meena P, Satwik A, Srivastava A, Bhalla AK, Gupta A, Malik M, Gupta A, Bedi VS, Rana DS. P1339ARTERIOVENOUS FISTULA AND BASILIC VEIN TRANSPOSITION IN ELDERLY PATIENTS ON HEMODIALYSIS: AN OBSERVATIONAL STUDY. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p1339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and Aims
With the increase in the line expectancy of chronic kidney disease in the older population (>60 years), the numbers requiring haemodialysis is progressively rising. The elderly population may be different from the younger in terms of non-suitable vessels for access creation, non-maturation, and vascular calcifications, and this may alter the outcomes of use of arteriovenous fistula (AVF). This study was conducted to analyse the outcomes of AVF in elderly patients (>60 years).
Method
Retrospective study was conducted in the Department of Nephrology at Sir Ganga Ram Hospital, New Delhi. Patients of more than 60 years of age in whom AVF was created from 1st January 2012 to 31st December 2016 were included in the study. Follow-up data of 3.5 years was analysed. The primary endpoint was to assess primary and secondary patency rates.
Results
A total of 300 patients were included in the study. The mean age was 63.8 years. Radiocephalic AVF (RCAVF) was the most common site of [69.8% (n = 210)], followed by brachiocephalic (BCAVF) in 25.2% (n = 75) and basilic vein transposition (BVT) in 5% (n = 15). At 12 months, overall survival of the AVF was 66.8%. At 42 months, the primary patency rate of RCAVF, BCAVF, and BVT was 50.6%, 52.6%, and 50.4% respectively. The commonest cause of access failure was thrombosis (20.4%) followed by non-maturation (9%). Vascular access abandonment was found least in BCAVF.
Conclusion
AVF remains the preferred vascular access for haemodialysis in the elderly population. Brachiocephalic AVF has higher primary and secondary patency rates. Thrombosis and failure of maturation are major concerns in the elderly AVF.
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Affiliation(s)
- Vinant Bhargava
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
| | - Priti Meena
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
| | - Ambrish Satwik
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
| | - Apurv Srivastava
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
| | - A K Bhalla
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
| | - Ashwani Gupta
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
| | - Manish Malik
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
| | - Anurag Gupta
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
| | - V S Bedi
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
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Tiwari V, Gupta A, Anand Y, Bhargava V, Malik M, Gupta A, Bhalla AK, Rana DS. P1737MICROBIOLOGICAL DIAGNOSIS OF DIARRHEA IN RENAL TRANSPLANT PATIENT BY MULTIPLEX PCR. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p1737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and Aims
Acute gastroenteritis is an unwelcome and harmful yet unavoidable complication in the renal transplant patient. Infections, especially atypical organisms like Norovirus, Cryptosporidium, along with typical microorganisms like E. coli and Giardia, form the significant players in the pathogenesis of diarrhea. Standard methods of staining and culture have reduced sensitivity as well as require considerable time for the reports. Stool Polymerase Chain Reaction (PCR)is a quick, sensitive, and hassle-free method that diagnoses more than 20 organisms within 1 hour. This study aims to determine the infective etiology of acute gastroenteritis in the transplant population as well to compare the yield of stool PCR with conservative methods.
Method
We retrospectively analyzed all renal transplant patients admitted between 2015 to 2018 with complaints of diarrhea (>3 stools/day with loose consistency). The sample was tested for conventional microbiological methods, including a stool routine for microscopy and culture. A stool sample was also sent for Multiplex PCR, which was analyzed by Bio Fire FilmArray GI Panel, which identifies 22 enteropathogens. Endoscopic procedures were also undertaken in suspected cases for CMV colitis and pseudomembranous colitis.
Results
110 diarrheal events (admission for diarrhea) were recorded in 82 patients, with 181 organisms isolated in all samples. 16 events did not reveal any organisms in stool PCR. 85% sample yielded a positive result. The conventional method yielded a positive result in only 32.3% as compared to stool PCR. Co-infections were common, as 71.2% of events were associated with 2 or more organisms. Conventional methods failed to diagnose any co-infections. Norovirus G1/G2(20%) was the most common organism isolated from the stool, followed by Giardia (17%) and Enteropathogenic E. coli (16%). Giardia Lamblia with Norovirus G1/G2 was the most common co-infection in 19% of patients.
Conclusion
Stool PCR significantly improves the diagnostic yield in diagnosing enteric pathogens. Stool PCR is especially sensitive in detecting multiple organisms where conventional microbiological methods were completely unsuccessful. Norovirus is the most common enteropathogen, which is not picked by the conventional method. Giardia with Norovirus was the most common co-infection among post-transplant patients.
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Affiliation(s)
| | | | | | | | | | | | - A K Bhalla
- Sir Ganga Ram Hospital, New Delhi, India
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20
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Gupta A, Kanjilal R, Rana DS, Bhalla AK, Gupta A, Malik M, Bhargava V, Tiwari V. P1778PROFILE OF NON-BACTERIAL INFECTIONS SPECIFIC TO RENAL TRANSPLANT RECIPIENTS. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p1778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and Aims
Infections in renal transplant recipients are a major cause of morbidity and mortality. It is the one of the major cause of patient death with functioning graft. Hence this project was done to study the profile of non-bacterial infections specific to renal transplant recipients and to determine the risk factors associated with such infections.
Method
Renal-transplant recipients admitted to the department of nephrology with suspected infection were included in the study.
Results
: A total of 342 patients were included in the study. The mean age of the patients was 45.2 ± 13.3 years. 17.5% had ABO incompatible renal transplant. 91% (87% received leukocyte depleting and 4% received non-leukocyte depleting agents) had received induction as majority had three or more HLA mismatch (70%) and the most common donor was wife. 12.8% had history of graft rejection. A total of 147 infectious episodes were encountered in 121 patients. The incidence of non-bacterial infections was 35% (121/342). Viral infections (68/147 = 46%) and invasive fungal infections (44/147 = 30%) were the most common. Cytomegalovirus infection was the most common 35%. Other viral infections encountered were BK virus associated nephropathy (2.3%) and reactivation of Hepatitis B or C virus (2.6%). The most common site of invasive fungal infection were lower respiratory tract, urinary tract, CNS cryptococcosis, soft tissue infection or cellulitis and oesophageal candidiasis in 41%, 32%, 9%, 9% and 9% respectively. Aspergillus (61%) and Rhizopus (33%) was the most common organism causing fungal pneumonia. Four patients were diagnosed with Pneumocystis jirovecii pneumonia. Majority (60%) of the infections were detected after one year post-transplant. Risk factors found to have statistically significance were ABO incompatibility, diabetes mellitus (pre or post-transplant) and history of graft rejection. Nine patients (7%) died of non-bacterial infections specific to renal transplant recipients.
Conclusion
Non-bacterial infections are not uncommon in Indian scenario and the timeline of such infections has changed.
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Affiliation(s)
| | | | | | - A K Bhalla
- Sir Ganga Ram Hospital, New Delhi, India
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Tiwari V, Gupta A, Anand Y, Bhargava V, Malik M, Gupta A, Bhalla AK, Rana DS. P1267EFFECT OF SODIUM AND ULTRAFILTRATION MODELING VERSUS LOW TEMPERATURE DIALYSATE IN PREVENTION OF INTRADIALYSIS HYPOTENSION: A SINGLE CENTRE STUDY FROM INDIA. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p1267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background and Aims
Symptomatic intradialytic hypotension is the most frequent complication in patients receiving hemodialysis. It complicates 5 to 30 percent of all dialysis treatments. In our study, we aimed to compare the effect of sodium and ultrafiltration modeling versus low-temperature dialysate on the occurrence of intradialytic hypotensive episodes.
Method
Single center, prospective, randomized trial. Patients with chronic kidney disease (CKD) stage V on maintenance hemodialysis (HD) for at least twice weekly for a minimum of 3 months were observed for the occurrence of ≥1 intradialytic hypotensive episode per month. After full filling the inclusion and exclusion criteria, patients were randomized 1:1 ratio into two groups based on computer-generated randomization numbers allotted to them by the dialysis coordinator.
Group 1: Underwent dialysis with sodium and Ultrafiltration modeling (Linearly decreasing dialysate sodium from 141 mmol/L to 128 mmol/L and linearly decreasing ultrafiltration rate).
Group 2: Underwent dialysis with low-temperature dialysate (36 degrees Celsius).
Primary outcome was number of hypotensive episodes per month. Secondary outcomes were interdialytic weight gain and ultrafiltration volume per session.
Results
A total of 320 patients were observed for 3 months in our centre. Intradialytic hypotension was found in 18.75 % of patients. Diabetic nephropathy (61.66%) was the leading cause of end-stage renal disease in these patients. There was no significant difference between the two groups in mean arterial blood pressure, hemoglobin, cardiac status, and serum albumin before dialysis. Both groups had a similar incidence of intradialytic hypotensive episodes (P >0.05). Interdialytic weight gain and ultrafiltration volume removed per session were also similar in both groups.
Conclusion
Sodium and ultrafiltration modeling and low-temperature dialysate were both equally effective in the prevention of intradialytic hypotensive episodes.
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Affiliation(s)
| | | | | | | | | | | | - A K Bhalla
- Sir Ganga Ram Hospital, New Delhi, India
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Meena P, Bhargava V, Bhalla AK, Gupta A, Malik M, Gupta A, Rana DS. P1181URGENT START OF PERITONEAL DIALYSIS: OUTCOMES AND EXPERIENCE FROM NORTHERN INDIA. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p1181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and Aims
Peritoneal dialysis (PD) widely practiced as the first-line modality for renal replacement therapy in end-stage renal disease (ESRD) patients. Urgent-start PD (use of the PD catheter within 14 days of insertion) is an effective approach to prompt initiation of PD after catheter insertion. However, there is a paucity of data regarding complications of urgent-start PD. We investigated the outcomes of urgent-start PD in our subset (Indian population).
Method
All patients in whom PD was initiated between 01 January 2015 and 31 July 2019 (54 months) were included. Patients were grouped according to the initiation of PD (break-in period) as <8 days (PD1), 8 to 14 days (PD2), and >14 days (PD3).
Results
In 100 patients included in the study, 57.5% were males. Among them, 75%, 10%, and 15% patients were in the PD1, PD2, PD3 break-in groups respectively. The most common cause of ESRD was diabetes mellitus. Functional catheter malfunction was the most frequent complication in PD1. The incidence of mechanical complications during the first six months was similar in all three groups (p = 0.06). No significant differences with respect to the catheter dysfunction requiring surgical intervention (p > 0.05) were observed. In PD1 group, catheter patency rate at the end of the 1-month and 1-year was 98.6% and 95.4% respectively. No significant differences were found in the rate of peritonitis among the three groups. Female sex, low haemoglobin, and low albumin levels were independent risk factors for peritonitis.
Conclusion
Early break-in period of less than seven days is a feasible option for patients requiring urgent dialysis with no increased risk of mechanical or infectious complications. It offers a safe and efficacious option for unplanned ESRD patients.
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Affiliation(s)
- Priti Meena
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
| | - Vinant Bhargava
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
| | - A K Bhalla
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
| | - Ashwani Gupta
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
| | - Manish Malik
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
| | - Anurag Gupta
- Sir Ganga Ram Hospital, Department of Nephrology, New Delhi, India
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Singh RK, Bhalla AK, Gupta A, Bhargava V, Gupta A, Rana DS. P1771NOCARDIOSIS IN RENAL TRANSPLANT RECIPIENTS- TEN YEARS OF SINGLE CENTER EXPERIENCE. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p1771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and Aims
Nocardiosis is a localized or disseminated bacterial infection caused by aerobic Actinomyces that commonly affects immunocompromised hosts. This study aimed to retrospectively review the clinical course and outcome of nocardiosis in renal transplant recipients at our center
Method
Data was obtained from hospital records retrospectively. Sixteen cases of nocardiosis were identified in a series of more than 1800 consecutive renal transplants performed at Sir Ganga Ram Hospital in the last decade from the year 2010 to 2019.
Results
Thirteen out of Sixteen patients(81.25%) had developed nocardiosis within a 1-year post-renal transplant. The diabetic population constituted 31.3%. CMV disease was present in 25% of patients six months prior to the diagnosis of Nocardiosis.56.3% of patients were on Trimethoprim-sulfamethoxazole prophylaxis while they were diagnosed with nocardiosis. Pleuropulmonary nocardiosis was the most common form of infection(68.75%). Primary cutaneous nocardiosis was identified in one patient(6.25%). cerebral nocardiosis and disseminated nocardiosis was diagnosed in two patients each(12.5%).In the last 3 years with the introduction of MALDI-TOF led to the identification of the subspecies of Nocardia which was not possible earlier. In the last 3 years, 6 patients were diagnosed with nocardiosis, in which 4 were infected with Nocardia farcinica, one patient with Nocardia Asiatica and one with Nocardia cyrigeorgica. Nocardia farcinica was resistant to cotrimoxazole, which used to be first-line therapy against Nocardiosis before subspecies identification and sensitivity testing. With the help of proper identification of subspecies by MALDI-TOF and antibiotic susceptibility by E-testing, 5 out of 6 patients could be treated while earlier 6 out of 10 patients could be treated.
Conclusion
Nocardiosis is a rare, difficult-to-diagnose-and-treat infection following kidney transplantation. Trimethoprim-sulfamethoxazole prophylaxis was not effective in the prevention of disease. The Subspecies identification and modification of the plan of management according to antibiotic sensitivity results in improved outcomes.
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Affiliation(s)
| | - A K Bhalla
- Sir Ganga Ram Hospital, New Delhi, India
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Gupta P, Dharamdasani S, Rana DS, Bhalla AK, Gupta A. P0386OUTCOMES OF PAUCI-IMMUNE CRESCENTIC GLOMERULONEPHRITIS BASED ON THE INTERNATIONAL HISTOPATHOLOGICAL CLASSIFICATION AND RECENTLY PROPOSED RENAL RISK SCORE IN ADULTS: A SINGLE CENTER STUDY. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p0386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background and Aims
Pauci-immune crescentic glomerulonephritis is rare form of glomerulonephritis that frequently presents as rapidly progressive renal failure. The histopathological classification proposed by Berden a decade earlier described difference in the outcomes of patients in the focal, crescentic, mixed and sclerotic category with best prognosis for focal and worst for sclerotic group. The newly proposed renal risk score (Brix SR at al.) takes into account both the histopathological parameters (% of normal glomeruli, tubular atrophy and interstitial fibrosis) and clinical parameter (eGFR) which influence outcome in these patients. Present study was undertaken to determine outcomes of pauci-immune crescentic glomerulonephritis based on both of these prognostic systems and also to determine effect of individual risk factors on renal outcome.
Method
64 patients diagnosed as pauci-immune crescentic glomerulonephritis from January 2013 to December 2018 were retrospectively analyzed. There histopathological slides were reviewed for percentage normal glomeruli, extent of interstitial fibrosis and tubular atrophy and biopsies were also grouped according to histopathological classification into focal, crescentic, mixed and sclerotic categories. The clinical parameters including serum creatinine, eGFR at time of biopsy and follow-up, and status of ANCA positivity were obtained from electronic records. Renal biopsies were scored based on renal risk score depending on the % of normal glomeruli (>25%,10-25% and <10%), percentage of tubular atrophy and interstitial fibrosis(≤25%,>25%) and eGFR(>15ml/min,≤15ml/min) into 3 risk categories.
Results
There were 61 adult patients and 3 pediatric patients. Two patient with insufficient glomeruli (<7) on biopsy and 8 patients without follow-up were excluded. A total of 51 adult patients were included of which 28 were male and 23 females. The mean age was 51.2±15.7 years. The mean serum creatinine at the time of biopsy was 7.05±4.57 mg/dl and the mean eGFR was 13.6±12.16 ml/min/1.73m2. There were 33 ANCA positive and 18 ANCA negative(35%) cases. Distribution of patients according to Berden’s histopathological classification was focal(4), crescentic(29), mixed(12) and sclerotic(6). The distribution of patients into risk categories based on renal risk score was low(8),medium(23) and high(20). Univariate Cox regression analysis showed that eGFR at biopsy (p 0.024), % IFTA (p 0.001) and % normal glomeruli in biopsy (p 0.023) are predictors of ESRD. Multivariate Cox regression analysis including age, eGFR, % IFTA and % normal glomeruli in biopsy also confirmed IFTA (p<0.001) and % normal glomeruli in biopsy (p 0.018) as significant predictors of ESRD. When % normal glomeruli was replaced by Berden’s histopathological classed it didn’t reach statistical significance to predict ESRD. Kaplan-Meier survival analysis for histological categories showed best renal survival in focal group and worst in sclerotic group (Log-Rank p=0.046). Kaplan-Meier analysis for the renal risk categories showed best survival in low risk group followed by medium and high risk groups respectively (Log-Rank p=0.002). Kaplan-Meier survival analysis was also done for percentage of normal glomeruli, IFTA and renal function.
Conclusion
In our study of Pauci-immune crescentic glomerulonpehritis ANCA was negative in 35% cases. Percentage of normal glomeruli, IFTA and eGFR at time of biopsy were important histopathological and clinical risk factors influencing renal survival in these patients. Results of our study validate that recently proposed renal risk score is a better predictor of survival (p=0.002) as compared to histological classification proposed by Berden (p=0.046).
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Affiliation(s)
- Pallav Gupta
- Sir Ganga Ram Hospital, Renal Pathology and Histopathology, New Delhi, India
| | | | | | - A K Bhalla
- Sir Ganga Ram Hospital, Nephrology, New Delhi, India
| | - Ashwani Gupta
- Sir Ganga Ram Hospital, Nephrology, New Delhi, India
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25
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Singh R, Gupta A, Bhargava V, Gupta A, Tiwari V, Malik M, Bhalla AK, Rana DS, Jain M. Effect of De novo donor-specific antibodies on graft function in renal allograft recipients. Indian J Transplant 2020. [DOI: 10.4103/ijot.ijot_6_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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26
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Gaur L, Gupta A, Shingada A, Bhalla AK, Gupta A, Malik M, Bhargava V, Rana DS. Norovirus-associated hemolytic uremic syndrome in a renal transplant recipient. Saudi J Kidney Dis Transpl 2019; 29:1519-1522. [PMID: 30588992 DOI: 10.4103/1319-2442.248289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Lovy Gaur
- Department of Nephrology, Sir Gangaram Hospital, New Delhi, India
| | - Anurag Gupta
- Department of Nephrology, Sir Gangaram Hospital, New Delhi, India
| | - Aakash Shingada
- Department of Nephrology, Sir Gangaram Hospital, New Delhi, India
| | - A K Bhalla
- Department of Nephrology, Sir Gangaram Hospital, New Delhi, India
| | - Ashwani Gupta
- Department of Nephrology, Sir Gangaram Hospital, New Delhi, India
| | - Manish Malik
- Department of Nephrology, Sir Gangaram Hospital, New Delhi, India
| | - Vinant Bhargava
- Department of Nephrology, Sir Gangaram Hospital, New Delhi, India
| | - D S Rana
- Department of Nephrology, Sir Gangaram Hospital, New Delhi, India
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27
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Ross PA, Bhalla AK. Reply. J Pediatr 2019; 213:248-249. [PMID: 31307760 DOI: 10.1016/j.jpeds.2019.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 06/18/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Patrick A Ross
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Anoopindar K Bhalla
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
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Khemani RG, Parvathaneni K, Yehya N, Bhalla AK, Thomas NJ, Newth CJL. Positive End-Expiratory Pressure Lower Than the ARDS Network Protocol Is Associated with Higher Pediatric Acute Respiratory Distress Syndrome Mortality. Am J Respir Crit Care Med 2019; 198:77-89. [PMID: 29373802 DOI: 10.1164/rccm.201707-1404oc] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
RATIONALE The ARDS Network (ARDSNet) used a positive end-expiratory pressure (PEEP)/FiO2 model in many studies. In general, pediatric intensivists use less PEEP and higher FiO2 than this model. OBJECTIVES To evaluate whether children managed with PEEP lower than recommended by the ARDSNet PEEP/FiO2 model had higher mortality. METHODS This was a multicenter, retrospective analysis of patients with pediatric acute respiratory distress syndrome (PARDS) managed without a formal PEEP/FiO2 protocol. Four distinct datasets were combined for analysis. We extracted time-matched PEEP/FiO2 values, calculating the difference between PEEP level and the ARDSNet-recommended PEEP level for a given FiO2. We analyzed the median difference over the first 24 hours of PARDS diagnosis against ICU mortality and adjusted for confounding variables, effect modifiers, or factors that may have affected the propensity to use lower PEEP. MEASUREMENTS AND MAIN RESULTS Of the 1,134 patients with PARDS, 26.6% were managed with lower PEEP relative to the amount of FiO2 recommended by the ARDSNet protocol. Patients managed with lower PEEP experienced higher mortality than those who were managed with PEEP levels in line with or higher than recommended by the protocol (P < 0.001). After adjustment for hypoxemia, inotropes, comorbidities, severity of illness, ventilator settings, nitric oxide, and dataset, PEEP lower than recommended by the protocol remained independently associated with higher mortality (odds ratio, 2.05; 95% confidence interval, 1.32-3.17). Findings were similar after propensity-based covariate adjustment (odds ratio, 2.00; 95% confidence interval, 1.24-3.22). CONCLUSIONS Patients with PARDS managed with lower PEEP relative to FiO2 than recommended by the ARDSNet model had higher mortality. Clinical trials targeting PEEP management in PARDS are needed.
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Affiliation(s)
- Robinder G Khemani
- 1 Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,2 Department of Pediatrics, Keck School of Medicine, and
| | - Kaushik Parvathaneni
- 1 Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,3 Department of Biological Sciences, Dana and David Dornsife College of Letters Arts and Sciences, University of Southern California, Los Angeles, California
| | - Nadir Yehya
- 4 Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Anoopindar K Bhalla
- 1 Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,2 Department of Pediatrics, Keck School of Medicine, and
| | - Neal J Thomas
- 5 Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Christopher J L Newth
- 1 Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,2 Department of Pediatrics, Keck School of Medicine, and
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Ross PA, Klein MJ, Nguyen T, Leung D, Khemani RG, Newth CJL, Bhalla AK. Body Habitus and Risk of Mortality in Pediatric Sepsis and Septic Shock: A Retrospective Cohort Study. J Pediatr 2019; 210:178-183.e2. [PMID: 31036411 DOI: 10.1016/j.jpeds.2019.03.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the association between body habitus and mortality in critically ill children with sepsis or septic shock. STUDY DESIGN This was a retrospective cohort study of prospectively collected data of children admitted to US pediatric intensive care units (PICUs) with a primary or secondary diagnosis of sepsis or septic shock. We separated body habitus into underweight, normal weight, overweight, and obese. Outcomes were mortality (primary), treatment with invasive mechanical ventilation (secondary), and time to PICU discharge for survivors (secondary). Multivariable analyses using mixed-effects logistic regression and shared frailty models clustered by unit and adjusted for confounding variables were used to assess the association between body habitus and outcomes. RESULTS There were 7038 children with sepsis or septic shock. Mortality was 10.1% (n = 714) and 52.9% (n = 3720) required invasive mechanical ventilation. Body habitus was not associated with mortality after controlling for hospital level effects and confounding variables. Children who were overweight and obese had greater odds of invasive mechanical ventilation (overweight OR 1.23 [95% CI 1.05-1.45], P = .011 and obese OR 1.57 [95% CI 1.37-1.80], P < .001) compared with children of normal weight. In survivors treated with invasive mechanical ventilation, children who were obese had a longer time to PICU discharge than children of normal weight (obese hazard ratio for discharge 0.84 [95% CI, 0.77-0.92], P < .0001). CONCLUSIONS There was no association between body habitus and mortality in critically ill children with sepsis. Children who were overweight and obese were more likely to receive invasive mechanical ventilation and mechanically ventilated survivors who were obsese had a longer time to PICU discharge.
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Affiliation(s)
- Patrick A Ross
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Margaret J Klein
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Tuan Nguyen
- Department of Pediatrics, Miller Children's and Women's Hospital of Long Beach, Long Beach, CA
| | - Dennis Leung
- Department of Pediatrics, University of North Carolina Healthcare Children's Hospital, Chapel Hill, NC
| | - Robinder G Khemani
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Anoopindar K Bhalla
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Abstract
Mini Abstract: Pregnancy-associated osteoporosis (PAO) is a rare syndrome affecting women during late pregnancy and the early postpartum period. We set out to review the clinical features of ten cases of PAO from a single UK centre. Patients had attended the Royal National Hospital for Rheumatic Diseases, Bath (RNHRD) between January 2000 and June 2016. The principal criterion for inclusion was the occurrence of low trauma fractures either during pregnancy or the immediate post-partum period. Data were obtained from retrospective review of medical notes. Bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry (Hologic ®Discovery system) at the lumbar spine and hip. Data pertaining to the pregnancy, as well as type and duration of treatment received, were reviewed. All ten cases presented with vertebral fractures. In four patients, no risk factors for fracture other than pregnancy or breastfeeding could be identified. Four patients were found to have vitamin D insufficiency at the time of diagnosis, and a further two patients had received treatment with low molecular weight heparin (LMWH). In one case, further investigation led to a diagnosis of osteogenesis imperfecta (OI) confirmed on genetic testing. In terms of treatment, eight out of the ten patients in this series received a bisphosphonate, most commonly risedronate due to its relatively short skeletal retention time. Clinicians should be aware of PAO, a rare but recognised complication of pregnancy. The condition should be especially considered in women presenting with new onset back pain in pregnancy or the postpartum period.
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Affiliation(s)
- S A Hardcastle
- Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK.
| | - F Yahya
- Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - A K Bhalla
- Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK
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31
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Jha V, Bhalla AK, Anil Kumar BT, Chauhan M, Das P, Gandhi B, Hegde U, Jeloka T, Mali M, Jha P, Kher A, Mukkavilli K, Ramachandran R. ABO-incompatible kidney transplantation: Indian working group recommendations. Indian J Transplant 2019. [DOI: 10.4103/ijot.ijot_39_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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32
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Gupta P, Gupta A, Bhalla AK, Malik M, Gupta A, Bhargava V, Rana DS. BK Virus nephropathy in living donor renal allograft recipients: An observational study from a large transplant center in India. Saudi J Kidney Dis Transpl 2018; 29:1366-1370. [PMID: 30588968 DOI: 10.4103/1319-2442.248313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BK virus is a polyoma virus which remains in latent phase in the urinary tract, particularly in the renal tubular epithelial cells. In immunosuppressed patients, it is activated and manifests as tubule-interstitial nephritis causing renal allograft dysfunction. A total of 402 patients who underwent renal allograft biopsy from 2013 to 2016 were included in this study; six patients were diagnosed to have BK virus nephropathy. Histopathology showed ground glass intra-nuclear inclusions accompanied by acute tubular injury, interstitial inflammation, and varying degree of interstitial fibrosis and tubular atrophy. Patients were managed with reduction in the overall immunosuppression. Only one patient progressed to graft failure on follow-up. The overall prevalence of polyoma virus at our center is 1.49%.
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Affiliation(s)
- Pallav Gupta
- Department of Histopathology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashwani Gupta
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - A K Bhalla
- Department of Histopathology, Sir Ganga Ram Hospital, New Delhi, India
| | - Manish Malik
- Department of Histopathology, Sir Ganga Ram Hospital, New Delhi, India
| | - Anurag Gupta
- Department of Histopathology, Sir Ganga Ram Hospital, New Delhi, India
| | - Vinant Bhargava
- Department of Histopathology, Sir Ganga Ram Hospital, New Delhi, India
| | - D S Rana
- Department of Histopathology, Sir Ganga Ram Hospital, New Delhi, India
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33
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Bhalla AK, Khemani RG, Hotz JC, Morzov RP, Newth CJ. Accuracy of Transcutaneous Carbon Dioxide Levels in Comparison to Arterial Carbon Dioxide Levels in Critically Ill Children. Respir Care 2018; 64:201-208. [PMID: 30254042 DOI: 10.4187/respcare.06209] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Widespread use of transcutaneous PCO2 (PtcCO2 ) monitoring is currently limited by concerns many practitioners have regarding accuracy. We compared the accuracy of PtcCO2 with that of PaCO2 measurements in critically ill children, and we investigated whether clinical conditions associated with low cardiac output or increased subcutaneous tissue affect this accuracy. METHODS We performed a single-center prospective study of critically ill children placed on transcutaneous monitoring. RESULTS There were 184 children enrolled with paired PaCO2 and PtcCO2 values. Subjects had a median age of 31.8 mo (interquartile range 3.5-123.3 mo). Most children were mechanically ventilated (n = 161, 87.5%), and many had cardiac disease (n = 76, 41.3%). The median PaCO2 was 44 mm Hg (interquartile range 39-51 mm Hg). The mean bias between PaCO2 and PtcCO2 was 0.6 mm Hg with 95% limits of agreement from -13.6 to 14.7 mm Hg. The PtcCO2 and PaCO2 were within ±5 mm Hg in 126 (68.5%) measurements. In multivariable modeling, cyanotic heart disease (odds ratio 3.5, 95% CI 1.2-10, P = .02) and monitor number 2 (odds ratio 3.8 95% CI 1.3-10.5, P = .01) remained associated with PtcCO2 ≥ 5 mm Hg higher than PaCO2 . Serum lactate, fluid balance, renal failure, obesity, vasoactive-inotrope score, and acyanotic heart disease were not associated with high or low PtcCO2 values. In 130 children with a second paired PtcCO2 and PaCO2 measurement, predicting the second measured PaCO2 by subtracting the initial observed difference between the PtcCO2 and PaCO2 from the subsequent measured PtcCO2 decreased the mean bias between observed and predicted PaCO2 to 0.2 mm Hg and the 95% limits of agreement to -9.4 to 9.7 mm Hg. CONCLUSIONS PtcCO2 provides an acceptable estimate of PaCO2 in many critically ill children, including those with clinical conditions that may be associated with low cardiac output or increased subcutaneous tissue, although it does not perform as well in children with cyanotic heart disease. PtcCO2 may be a useful adjunct monitoring method, but it cannot reliably replace PaCO2 measurement.
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Affiliation(s)
- Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California. .,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Justin C Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Rica P Morzov
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Christopher Jl Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
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Khemani RG, Parvathaneni K, Yehya N, Bhalla AK, Thomas NJ, Newth CJL. Reply to Tremlett and Kanthimathinathan and to Koopman and Kneyber. Am J Respir Crit Care Med 2018; 198:823-824. [DOI: 10.1164/rccm.201806-1039le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Robinder G. Khemani
- Children’s Hospital Los AngelesLos Angeles, California
- University of Southern CaliforniaLos Angeles, California
| | - Kaushik Parvathaneni
- Children’s Hospital Los AngelesLos Angeles, California
- University of Southern CaliforniaLos Angeles, California
| | - Nadir Yehya
- University of PennsylvaniaPhiladelphia, Pennsylvaniaand
| | - Anoopindar K. Bhalla
- Children’s Hospital Los AngelesLos Angeles, California
- University of Southern CaliforniaLos Angeles, California
| | - Neal J. Thomas
- Penn State Hershey Children’s HospitalHershey, Pennsylvania
| | - Christopher J. L. Newth
- Children’s Hospital Los AngelesLos Angeles, California
- University of Southern CaliforniaLos Angeles, California
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35
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Siyaram D, Bhatia P, Dayal D, Bhalla AK, Marathe R. Hypoferremic State in Overweight and Obese Children. Indian Pediatr 2018; 55:72-73. [PMID: 29396942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Children with high body mass index (BMI) are at risk of iron deficiency. In present study, 71 children with overweight or obesity were screened for iron deficiency. Mean BMI, ferritin and plasma soluble transferrin receptor (sTrfR) levels were 26.1 kg/m2, 41.9 µg/L and 0.375 mg/L, respectively. Twenty (28%) children had anemia, and 44 (62%) had an underlying hypoferraemic state.
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Affiliation(s)
- D Siyaram
- Department of Pediatrics, Advanced Pediatrics Centre, PGIMER, Chandigarh, India
| | - P Bhatia
- Department of Pediatrics, Advanced Pediatrics Centre, PGIMER, Chandigarh, India,
| | - D Dayal
- Department of Pediatrics, Advanced Pediatrics Centre, PGIMER, Chandigarh, India
| | - A K Bhalla
- Department of Pediatrics, Advanced Pediatrics Centre, PGIMER, Chandigarh, India
| | - R Marathe
- Department of Pediatrics, Advanced Pediatrics Centre, PGIMER, Chandigarh, India
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36
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Affiliation(s)
- Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine Children's Hospital Los Angeles Keck School of Medicine University of Southern California Los Angeles, California
| | - Robinder Khemani
- Department of Anesthesiology and Critical Care Medicine Children's Hospital Los Angeles Keck School of Medicine University of Southern California Los Angeles, California
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37
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Mohapatra S, Bansal D, Bhalla AK, Verma Attri S, Sachdeva N, Trehan A, Marwaha RK. Is there an increased risk of metabolic syndrome among childhood acute lymphoblastic leukemia survivors? A developing country experience. Pediatr Hematol Oncol 2016; 33:136-49. [PMID: 26984439 DOI: 10.3109/08880018.2016.1152335] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Data on metabolic syndrome (MS) in survivors of childhood acute lymphoblastic leukemia (ALL) from developing countries are lacking. The purpose of this single-center, uncontrolled, observational study was to assess the frequency of MS in our survivors. The survivors of ALL ≤15 years at diagnosis, who had completed therapy ≥2 years earlier, were enrolled. Anthropometric measurements (weight, height, waist circumference), biochemistry (glucose, insulin, triglycerides, high-density lipoprotein [HDL], thyroid function tests, C-reactive protein [CRP], magnesium), measurement of blood pressure, and Tanner staging were performed. MS was defined by International Diabetes Federation (IDF) and the National Cholesterol Education Program Third Adult Treatment Panel guidelines (NCEP ATP III) criteria, modified by Cook et al. (Arch Pediatr Adolesc Med. 2003;157:821-827) and Ford et al. (Diabetes Care. 2005;28:878-881). The median age of 76 survivors was 11.9 years (interquartile range [IQR]: 9.6-13.5). Twenty-four (32%) survivors were obese or overweight. The prevalence of insulin resistance (17%), hypertension (7%), hypertriglyceridemia (20%), and low HDL (37%) was comparable to the prevalence in children/adolescents in historical population-based studies from India. The prevalence of MS ranged from 1.3% to 5.2%, as per different defining criteria. Cranial radiotherapy, age at diagnosis, sex, or socioeconomic status were not risk factors for MS. The prevalence of MS in survivors of childhood ALL, at a median duration of 3 years from completion of chemotherapy, was comparable to the reference population. The prevalence of being obese or overweight was, however, greater than historical controls.
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Affiliation(s)
- Sonali Mohapatra
- a Hematology-Oncology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Deepak Bansal
- a Hematology-Oncology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - A K Bhalla
- b Growth and Anthropology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Savita Verma Attri
- c Biochemistry Unit, Department of Pediatrics, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Naresh Sachdeva
- d Department of Endocrinology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Amita Trehan
- a Hematology-Oncology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - R K Marwaha
- a Hematology-Oncology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
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Armbrecht G, Felsenberg D, Ganswindt M, Lunt M, Kaptoge SK, Abendroth K, Aroso A, Banzer D, Bhalla AK, Dequeker J, Eastell R, Hoszowski K, Lyritis G, Delmas PD, Masaryk P, Miazgowski T, Cannata J, Nuti R, Oei L, Poor G, Redlund-Johnell I, Reid DM, Reisinger W, Schatz H, Todd CJ, Woolf AD, Javaid K, Rivadeneira F, Silman AJ, Cooper C, O'Neill TW, Reeve J. Vertebral Scheuermann's disease in Europe: prevalence, geographic variation and radiological correlates in men and women aged 50 and over. Osteoporos Int 2015; 26:2509-19. [PMID: 26021761 DOI: 10.1007/s00198-015-3170-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/06/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED In 27 centres across Europe, the prevalence of deforming spinal Scheuermann's disease in age-stratified population-based samples of over 10,000 men and women aged 50+ averaged 8% in each sex, but was highly variable between centres. Low DXA BMD was un-associated with Scheuermann's, helping the differential diagnosis from osteoporosis. INTRODUCTION This study aims to assess the prevalence of Scheuermann's disease of the spine across Europe in men and women over 50 years of age, to quantitate its association with bone mineral density (BMD) and to assess its role as a confounder for the radiographic diagnosis of osteoporotic fracture. METHODS In 27 centres participating in the population-based European Vertebral Osteoporosis Study (EVOS), standardised lateral radiographs of the lumbar and of the thoracic spine from T4 to L4 were assessed in all those of adequate quality. The presence of Scheuermann's disease, a confounder for prevalent fracture in later life, was defined by the presence of at least one Schmorl's node or irregular endplate together with kyphosis (sagittal Cobb angle >40° between T4 and T12) or a wedged-shaped vertebral body. Alternatively, the (rare) Edgren-Vaino sign was taken as diagnostic. The 6-point-per-vertebral-body (13 vertebrae) method was used to assess osteoporotic vertebral shape and fracture caseness. DXA BMD of the L2-L4 and femoral neck regions was measured in subsets. We also assessed the presence of Scheuermann's by alternative published algorithms when these used the radiographic signs we assessed. RESULTS Vertebral radiographic images from 4486 men and 5655 women passed all quality checks. Prevalence of Scheuermann's varied considerably between centres, and based on random effect modelling, the overall European prevalence using our method was 8% with no significant difference between sexes. The highest prevalences were seen in Germany, Sweden, the UK and France and low prevalences were seen in Hungary, Poland and Slovakia. Centre-level prevalences in men and women were highly correlated. Scheuermann's was not associated with BMD of the spine or hip. CONCLUSIONS Since most of the variation in population impact of Scheuermann's was unaccounted for by the radiological and anthropometric data, the search for new genetic and environmental determinants of this disease is encouraged.
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Affiliation(s)
- G Armbrecht
- Department of Radiology and Nuclear Medicine, Free University, Berlin, Germany
| | - D Felsenberg
- Department of Radiology and Nuclear Medicine, Free University, Berlin, Germany
| | - M Ganswindt
- Department of Radiology and Nuclear Medicine, Free University, Berlin, Germany
| | - M Lunt
- ARC Epidemiology Unit, University of Manchester Musculoskeletal Biomedical Research Unit & Arthritis Research UK Centre for Epidemiology, Manchester, UK
| | - S K Kaptoge
- Department of Public Health and Primary Care, Strangeways Research Laboratory, Cambridge, UK
| | | | - A Aroso
- Hospital de San Joao, Oporto, Portugal
| | - D Banzer
- Röntgen u Nuklearmed, Krankenhaus Behring, Berlin, Germany
| | - A K Bhalla
- Royal National Hospital for Rheumatic Diseases, Bath, UK
| | | | - R Eastell
- Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | | | - G Lyritis
- Laboratory for Research on the Musculoskeletal System, University of Athens, Athens, Greece
| | - P D Delmas
- Centre de Médécine Specialisée Claude Gauthier, Montceau-les-Mines France & U Inserm 504, Lyon, France
| | - P Masaryk
- Institute of Rheumatic Diseases, Piestany, Slovakia
| | - T Miazgowski
- Department of Hypertension, Pomeranian Medical University, Szczecin, Poland
| | - J Cannata
- Asturias General Hospital, Oviedo, Spain
| | - R Nuti
- Institute of Clinical Medicine, University of Siena, Siena, Italy
| | - L Oei
- Departments of Epidemiology and Internal Medicine, Erasmus University, Rotterdam, Netherlands
| | - G Poor
- National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | | | - D M Reid
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - W Reisinger
- Charité Inst fur Rontgendiagnostik, Berlin, Germany
| | - H Schatz
- Med Klinik & Polyklinik Bochum, Bochum, Germany
| | - C J Todd
- Department of Public Health and Primary Care, Strangeways Research Laboratory, Cambridge, UK
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - K Javaid
- NIHR Musculo-skeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre & Institute of Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | - F Rivadeneira
- Departments of Epidemiology and Internal Medicine, Erasmus University, Rotterdam, Netherlands
| | - A J Silman
- ARC Epidemiology Unit, University of Manchester Musculoskeletal Biomedical Research Unit & Arthritis Research UK Centre for Epidemiology, Manchester, UK
- Arthritis Research UK, Chesterfield, S41 7TD, UK
| | - C Cooper
- NIHR Musculo-skeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre & Institute of Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK
| | - T W O'Neill
- ARC Epidemiology Unit, University of Manchester Musculoskeletal Biomedical Research Unit & Arthritis Research UK Centre for Epidemiology, Manchester, UK
| | - J Reeve
- NIHR Musculo-skeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre & Institute of Musculoskeletal Sciences, Windmill Road, Oxford, OX3 7LD, UK.
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Bhalla AK, Rubin S, Newth CJL, Ross P, Morzov R, Soto-Campos G, Khemani R. Monitoring Dead Space in Mechanically Ventilated Children: Volumetric Capnography Versus Time-Based Capnography. Respir Care 2015. [PMID: 26199451 DOI: 10.4187/respcare.03892] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Volumetric capnography dead-space measurements (physiologic dead-space-to-tidal-volume ratio [VD/VT] and alveolar VD/VT) are considered more accurate than the more readily available time-based capnography dead-space measurement (end-tidal alveolar dead-space fraction [AVDSF]). We sought to investigate the correlation between volumetric capnography and time-based capnography dead-space measurements. METHODS This was a single-center prospective cohort study of 65 mechanically ventilated children with arterial lines. Physiologic VD/VT, alveolar VD/VT, and AVDSF were calculated with each arterial blood gas using capnography data. RESULTS We analyzed 534 arterial blood gases from 65 children (median age 4.9 y, interquartile range 1.7-12.8). The correlation between physiologic VD/VT and AVDSF (r = 0.66, 95% CI 0.59-0.72) was weaker than the correlation between alveolar VD/VT and AVDSF (r = 0.8, 95% CI 0.76-0.85). The correlation between physiologic VD/VT and AVDSF was weaker in children with low PaO2 /FIO2 (< 200 mm Hg), low exhaled VT (< 100 mL), a pulmonary reason for mechanical ventilation, or large airway VD (> 3 mL/kg). All 3 dead-space measurements were highly correlated (r > 0.7) in children without hypoxemia (PaO2 /FIO2 > 300 mm Hg), mechanically ventilated for a neurologic or cardiac reason, or on significant inotropes or vasopressors. CONCLUSIONS In mechanically ventilated children without significant hypoxemia or with cardiac output-related dead-space changes, physiologic VD/VT was highly correlated with AVDSF and alveolar VD/VT. In children with significant hypoxemia, physiologic VD/VT was poorly correlated with AVDSF. Alveolar VD/VT and AVDSF correlated well in most tested circumstances. Therefore, AVDSF may be useful in most children for alveolar dead-space monitoring.
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Affiliation(s)
- Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California. Keck School of Medicine, University of Southern California, Los Angeles, California.
| | - Sarah Rubin
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California. Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California. Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Patrick Ross
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California. Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Rica Morzov
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Gerardo Soto-Campos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Robinder Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California. Keck School of Medicine, University of Southern California, Los Angeles, California
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40
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Gupta P, Rana DS, Bhalla AK, Gupta A, Malik M, Gupta A, Bhargava V. Renal failure due to granulomatous interstitial nephritis in native and allograft renal biopsies: experience from a tertiary care hospital. Ren Fail 2014; 36:1468-70. [PMID: 25155448 DOI: 10.3109/0886022x.2014.950975] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Granulomatous interstitial nephritis is a rare cause of renal failure in both native and allograft renal biopsies. Drugs and sarcoidosis are the commonest causes of granulomatous interstitial nephritis as reported in Western countries. Unlike the west, tuberculosis is the commonest cause of granulomatous interstitial nephritis in Indian subcontinent. The etiological factors, clinical course, glomerular and tubulointerstitial changes associated with granulomatous interstitial nephritis have been analyzed in the present study along with the outcome in patients with granulomatous interstitial nephritis.
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Affiliation(s)
- Pallav Gupta
- Department of Pathology, Sir Ganga Ram Hospital , New Delhi , India and
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Ross PA, Khemani RG, Rubin SS, Bhalla AK, Newth CJL. Elevated positive end-expiratory pressure decreases cardiac index in a rhesus monkey model. Front Pediatr 2014; 2:134. [PMID: 25520944 PMCID: PMC4253666 DOI: 10.3389/fped.2014.00134] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 11/13/2014] [Indexed: 11/13/2022] Open
Abstract
RATIONALE Clinicians are often concerned that higher positive end-expiratory pressure (PEEP) will decrease cardiac index (CI). PEEP affects CI through multiple inter-related mechanisms. The adult Rhesus monkey is an excellent model to study cardiopulmonary interaction due to similar pulmonary and chest wall compliances to human infants. OBJECTIVE Our goal was to examine the impact of increasing PEEP on CI in Rhesus monkeys as a model for critically ill children. METHODS Prospective, experimental animal study. Nine healthy anesthetized, intubated Rhesus monkeys were allowed to breathe spontaneously at a PEEP of 0, 5, 10, and 15 cm H2O while CI was measured with an ultrasonic Doppler (USCOM). MEASUREMENTS AND MAIN RESULTS Cardiac index decreased between PEEP levels of 5 and 15 cm H2O. The mean decrease in CI for the entire cohort of monkeys was 18% (p < 0.01) with a range of -11 to 49%. Stroke volume and oxygen delivery also decreased between PEEP levels of 5 and 15 cm H2O (p < 0.01). CONCLUSION Between PEEP levels of 5 and 15 cm H2O, there was a decrease in CI, stroke volume, and oxygen delivery in intubated Rhesus monkeys. A plausible mechanism is that over-distention of normally compliant lungs at increased PEEP resulted in decreased preload to the right ventricle, outweighing the potentially beneficial decrease in left ventricular afterload or pulmonary vascular resistance. Further investigation is warranted, particularly in children with lung injury, who have historically benefited from increased PEEP levels without over-distention.
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Affiliation(s)
- Patrick A Ross
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine , Los Angeles, CA , USA
| | - Robinder G Khemani
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine , Los Angeles, CA , USA
| | - Sarah S Rubin
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine , Los Angeles, CA , USA
| | - Anoopindar K Bhalla
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine , Los Angeles, CA , USA
| | - Christopher J L Newth
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine , Los Angeles, CA , USA
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Singh MK, Sachdeva N, Singhi S, Attri SV, Jayashree M, Bhalla AK. Vitamin D levels during and after resolution of ketoacidosis in children with new onset Type 1 diabetes. Diabet Med 2013; 30:829-34. [PMID: 23692346 DOI: 10.1111/dme.12200] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2013] [Indexed: 12/13/2022]
Abstract
AIM To study the effect of ketoacidosis on measured 25-hydroxyvitamin D3 in children with new onset Type 1 diabetes. METHODS Measurement of pH and bicarbonate levels was carried out in children with newly diagnosed Type 1 diabetes at presentation with ketoacidosis. 25-hydroxyvitamin D3 estimation was carried out at presentation (timepoint 1) and 1 month later (timepoint 2). There was no significant difference in the mean (±sd) 25-hydroxyvitamin D3 levels [35.39 (±25.79) vs 39.63 (±48.03) nmol/L; P = 0.661) at the two timepoints in the study. RESULTS Correlation analysis revealed a positive correlation between bicarbonate levels and timepoint 1, i.e. the lower the bicarbonate levels, the lower were the timepoint 1 levels and vice versa (correlation coefficient 0.538, P = 0.001). Timepoint 2 levels also showed a positive correlation with serum bicarbonate levels with a correlation coefficient of 0.379 (P = 0.032). None of the variables other than bicarbonate,.(age, gender, BMI, pH or time), was found to have the predictive ability for timepoint1 levels. Similarly for predicting timepoint 2 levels, BMI was found to have independent predictive ability in addition to bicarbonate. CONCLUSIONS Severe ketoacidosis, as judged by bicarbonate but not pH, may transiently lower 25-hydroxyvitamin D3 levels in children with new onset Type 1 diabetes. Persistence of low 25-hydroxyvitamin D3 levels after resolution of ketoacidosis suggests a state of permanent vitamin D deficiency in our patient population.
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Kaur H, Bhalla AK, Kumar P. Longitudinal growth of head circumference in term symmetric and asymmetric small for gestational age infants. Early Hum Dev 2012; 88:473-8. [PMID: 22178000 DOI: 10.1016/j.earlhumdev.2011.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 09/29/2011] [Accepted: 11/03/2011] [Indexed: 11/20/2022]
Abstract
AIMS To study longitudinal growth pattern of head circumference of full-term symmetric and asymmetric small for gestational age (SGA) infants of the two sexes during first year of life. STUDY DESIGN Mixed-longitudinal growth research design. SUBJECTS Head circumference amongst full-term 100 symmetric, 100 asymmetric as well as 100 appropriate for gestational age (AGA) infants was measured at birth, 1, 3, 6, 9 and 12 months of age using standardized technique and instrument. RESULTS The mean head circumference of male symmetric SGA infants measured significantly (p≤0.001) smaller than asymmetric SGA infants while, in female symmetric SGA infants it measured shorter beyond 6 months. As compared to AGA infants, head circumference in symmetric and asymmetric SGA infants measured significantly smaller in size. Growth velocity for head circumference amongst symmetric and asymmetric SGA male infants did not show statistically significant differences. Rate of head circumference growth remained significantly higher amongst female asymmetric SGA infants than the symmetric ones between 3 and 6 months while, a reversal of trend was observed between 9 and 12 months. CONCLUSION The better growth attainments for head circumference of male and female asymmetric SGA infants than their symmetric SGA counterparts during first postnatal year of life may be attributed to the continuation of influence of "head sparing" experienced by asymmetric SGA babies during prenatal life.
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Affiliation(s)
- Harvinder Kaur
- Department of Pediatric Medicine, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Sahni N, Gupta KL, Rana SV, Prasad R, Bhalla AK. Intake of antioxidants and their status in chronic kidney disease patients. J Ren Nutr 2012; 22:389-99. [PMID: 22227184 DOI: 10.1053/j.jrn.2011.09.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 09/03/2011] [Accepted: 09/03/2011] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To evaluate the intake and status of antioxidants in chronic kidney disease (CKD) patients. DESIGN Randomized control trial. SETTING Hospital outpatient department. SUBJECTS One hundred eighty-five subjects (145 predialysis CKD patients and 40 apparently healthy controls) were enrolled for this study. The patients were divided into moderate and severe renal failure groups based on their creatinine and glomerular filtration rates. INTERVENTION All patients completed a food frequency questionnaire, 24-hour dietary recall form, and anthropometric measurements and underwent biochemical and antioxidant lab tests. MAIN OUTCOME MEASURES Dietary intake, anthropometry, biochemical measures of blood and antioxidant enzymes as well as oxidative stress. RESULTS Overall, the diet was significantly lower in antioxidant-rich food intake in all the CKD patients as compared with controls. The oxidative stress measured in blood was found to be in consonance with the intake from diet. CONCLUSION Micronutrients play a major role in the antioxidant status of the patients and must be monitored, as deficiency of these might elevate the oxidative stress of the body, especially in the chronic diseases.
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Affiliation(s)
- N Sahni
- Department of Dietetics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
BACKGROUND To find out whether vitamin D levels are lower in children with newly diagnosed type 1 diabetes (T1D) as compared to non-diabetic subjects. METHODS Plasma levels of vitamin D (25-OHD) were measured by high performance liquid chromatography (HPLC) in 50 children aged between 6 and 12 yr within a week of diagnosis of T1D, and in 50 healthy children. RESULTS The mean levels of vitamin D were significantly lower in patients as compared to their controls [20.02 +/- 10.63 ng/mL (50.05 +/- 26.57 mmol/L) vs. 26.16 +/- 12.28 ng/mL (65.4 +/- 30.7 mmol/L), p-value 0.009]. Twenty-nine (58%) children in the study group were vitamin D deficient (25-OHD level < 20 ng/mL or < 50 mmol/L) as compared to only 16 (32%) in the control group. Overall, 43 (86%) diabetic and 38 (76%) healthy children were either vitamin D deficient or insufficient. CONCLUSION These results suggest that vitamin D levels are low at the onset of T1D, and they strongly support the need for further clinical studies to prospectively evaluate the effect of vitamin D supplementation on T1D rates in this patient population.
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Affiliation(s)
- Vibhor V Borkar
- Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Tobias JH, Hutchinson AP, Hunt LP, McCloskey EV, Stone MD, Martin JC, Thompson PW, Palferman TG, Bhalla AK. Use of clinical risk factors to identify postmenopausal women with vertebral fractures. Osteoporos Int 2007; 18:35-43. [PMID: 16951907 DOI: 10.1007/s00198-006-0209-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Accepted: 07/18/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Previous studies have been unable to identify risk factors for prevalent vertebral fractures (VF), which are suitable for use in selection strategies intended to target high-risk sub-groups for diagnostic assessment. However, these studies generally consisted of large epidemiology surveys based on questionnaires and were only able to evaluate a limited number of risk factors. Here, we investigated whether a stronger relationship exists with prevalent VF when conventional risk factors are combined with additional information obtained from detailed one-to-one assessment. METHODS Women aged 65-75 registered at four geographically distinct GP practices were invited to participate (n=1,518), of whom 540 attended for assessment as follows: a questionnaire asking about risk factors for osteoporosis such as height loss compared to age 25 and history of non-vertebral fracture (NVF), the get-up-and-go test, Margolis back pain score, measurement of wall-tragus and rib-pelvis distances, and BMD as measured by the distal forearm BMD. A lateral thoraco-lumbar spine X-ray was obtained, which was subsequently scored for the presence of significant vertebral deformities. RESULTS Of the 509 subjects who underwent spinal radiographs, 37 (7.3%) were found to have one or more VF. Following logistic regression analysis, the four most predictive clinical risk factors for prevalent VF were: height loss (P=0.006), past NVF (P=0.004), history of back pain (P=0.075) and age (P=0.05). BMD was also significantly associated with prevalent VF (P=0.002), but its inclusion did not affect associations with other variables. Factors elicited from detailed one-to-one assessment were not related to the risk of one or more prevalent VFs. The area under ROC curves derived from these regressions, which suggested that models for prevalent VF had modest predictive accuracy, were as follows: 0.68 (BMD), 0.74 (four clinical risk factors above) and 0.78 (clinical risk factors + BMD). Analyses were repeated in relation to the subgroup of 13 patients with two or more VFs, which revealed that in this instance, the Margolis back pain score and rib-pelvis distance were associated with the presence of multiple VFs (P=0.022 and 0.026, respectively). Moreover, the predictive value as reflected by the ROC curve area was improved: 0.80 (BMD), 0.88 (the four most predictive clinical risk factors consisting of the height loss, past NVF, Margolis back pain score and rib-pelvis distance) and 0.91 (clinical risk factors + BMD). CONCLUSIONS Evaluation of additional risk factors from detailed one-to-one assessment does not improve the predictive value of risk factors for one or more prevalent vertebral deformities in postmenopausal women. However, the use of factors such as the Margolis back pain score and rib-pelvis distance may be helpful in identifying postmenopausal women at high risk of multiple prevalent VFs.
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Affiliation(s)
- J H Tobias
- Department of Clinical Science at South Bristol, University of Bristol, Bristol, BS2 8HW, UK.
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Solanki KK, Creamer P, Bhalla AK. What is your diagnosis? Indian Journal of Rheumatology 2006. [DOI: 10.1016/s0973-3698(10)60207-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Kaptoge S, Benevolenskaya LI, Bhalla AK, Cannata JB, Boonen S, Falch JA, Felsenberg D, Finn JD, Nuti R, Hoszowski K, Lorenc R, Miazgowski T, Jajic I, Lyritis G, Masaryk P, Naves-Diaz M, Poor G, Reid DM, Scheidt-Nave C, Stepan JJ, Todd CJ, Weber K, Woolf AD, Roy DK, Lunt M, Pye SR, O'neill TW, Silman AJ, Reeve J. Low BMD is less predictive than reported falls for future limb fractures in women across Europe: results from the European Prospective Osteoporosis Study. Bone 2005; 36:387-98. [PMID: 15777673 DOI: 10.1016/j.bone.2004.11.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2004] [Revised: 11/10/2004] [Accepted: 11/10/2004] [Indexed: 10/25/2022]
Abstract
We have previously shown that center- and sex-specific fall rates explained one-third of between-center variation in upper limb fractures across Europe. In this current analysis, our aim was to determine how much of the between-center variation in fractures could be attributed to repeated falling, bone mineral density (BMD), and other risk factors in individuals, and to compare the relative contributions of center-specific BMD vs. center-specific fall rates. A clinical history of fracture was assessed prospectively in 2451 men and 2919 women aged 50-80 from 20 centers participating in the European Prospective Osteoporosis Study (EPOS) using standardized questionnaires (mean follow-up = 3 years). Bone mineral density (BMD, femoral neck, trochanter, and/or spine) was measured in 2103 men and 2565 women at these centers. Cox regression was used to model the risk of incident fracture as a function of the person-specific covariates: age, BMD, personal fracture history (PFH), family hip fracture history (FAMHIP), time spent walking/cycling, number of 'all falls' and falls not causing fracture ('fracture-free') during follow-up, alcohol consumption, and body mass index. Center effects were modeled by inclusion of multiplicative gamma-distributed random effects, termed center-shared frailty (CSF), with mean 1 and finite variance theta (theta) acting on the hazard rate. The relative contributions of center-specific fall risk and center-specific BMD on the incidence of limb fractures were evaluated as components of CSF. In women, the risk of any incident nonspine fracture (n = 190) increased with age, PFH, FAMHIP, > or =1 h/day walking/cycling, and number of 'all falls' during follow-up (all P < 0.074). 'Fracture-free' falls (P = 0.726) and femoral neck BMD did not have a significant effect at the individual level, but there was a significant center-shared frailty effect (theta = 0.271, P = 0.001) that was reduced by 4% after adjusting for mean center BMD and reduced by 19% when adjusted for mean center fall rate. Femoral trochanter BMD was a significant determinant of lower limb fractures (n = 53, P = 0.014) and the center-shared frailty effect was significant for upper limb fractures (theta = 0.271, P = 0.011). This upper limb fracture center effect was unchanged after adjusting for mean center BMD but was reduced by 36% after adjusting for center mean fall rates. In men, risk of any nonspine fracture (n = 75) increased with PFH, fall during follow-up (P < 0.026), and with a decrease in trochanteric BMD [RR 1.38 (1.08, 1.79) per 1 SD decrease]. There was no center effect evident (theta = 0.081, P = 0.096). We conclude that BMD alone cannot be validly used to discriminate between the risk of upper limb fractures across populations without taking account of population-specific variations in fall risk and other factors. These variations might reflect shared environmental or possibly genetic factors that contribute quite substantially to the risk of upper limb fractures in women.
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Affiliation(s)
- S Kaptoge
- Strangeways Research Laboratory, University of Cambridge, Wort's Causeway, Cambridge CB1 8RN, UK.
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Birkett V, Ring EFJ, Elvins DM, Taylor G, Bhalla AK. A comparison of bone loss in early and late rheumatoid arthritis using quantitative phalangeal ultrasound. Clin Rheumatol 2004; 22:203-7. [PMID: 14505211 DOI: 10.1007/s10067-003-0699-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2002] [Accepted: 11/12/2002] [Indexed: 11/30/2022]
Abstract
This study compares amplitude-dependent speed of sound (AD-SoS) measured by phalangeal ultrasonography in a group of 60 patients with early rheumatoid arthritis (RA) with those who had had the disease for more than 4 years. The mean duration of the early disease group was 1.4 years, and the mean of the established RA group was 14.6 years. Plasma viscosity (PV), C-reactive protein (CRP) and HAQ scores were obtained. Forty-nine patients with early RA had hand radiographs assessed by the Larsen score method. The DBM Sonic system was assessed on normal volunteers and a coefficient of variation of 0.88% obtained. A significant correlation was found between the left and right hands of the patients groups studied ( r=0.84). The mean Z score of both hands was therefore used in comparing the two clinical groups. Results showed no correlation between CRP, PV and Z scores of AD-SoS. The HAQ scores showed a weak negative correlation, and there was no correlation between the Larsen score and Z score, or the number of swollen joints and Z score. However, the early and established groups with RA were significantly different (#E5/E5#=0.004). Within the early RA group the Z score for AD-SoS was lower in those with disease duration of less than 2 years (-1.71) than in those with disease duration of 2-4 years (-1.01). This suggests that bone loss in the fingers is greater in the first 2 years of disease than in the following 2 years, which might reflect an effect of treatment.
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Affiliation(s)
- V Birkett
- Royal National Hospital for Rheumatic Diseases, Bath, UK
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Cockerill W, Lunt M, Silman AJ, Cooper C, Lips P, Bhalla AK, Cannata JB, Eastell R, Felsenberg D, Gennari C, Johnell O, Kanis JA, Kiss C, Masaryk P, Naves M, Poor G, Raspe H, Reid DM, Reeve J, Stepan J, Todd C, Woolf AD, O'Neill TW. Health-related quality of life and radiographic vertebral fracture. Osteoporos Int 2004; 15:113-9. [PMID: 14618303 DOI: 10.1007/s00198-003-1547-4] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2002] [Accepted: 10/15/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Vertebral fractures are associated with back pain and disability; however, relatively little is known about the impact of radiographic vertebral fractures on quality of life in population samples. The aim of this study was to determine the impact of a recent radiographic vertebral fracture on health-related quality of life (HRQoL). METHODS Men and women aged 50 years and over were recruited from population registers in 12 European centers. Subjects completed an interviewer-administered questionnaire and had lateral spine radiographs performed. Subjects in these centers were followed prospectively and had repeat spinal radiographs performed a mean of 3.8 years later. Prevalent deformities were defined using established morphometric criteria, and incident vertebral fractures by both morphometric criteria and qualitative assessment. For each incident fracture case, three controls matched for age, gender, and center were selected: one with a prevalent deformity (at baseline) and two without prevalent deformities. All subjects were interviewed or completed a postal questionnaire instrument which included Short Form 12 (SF-12), the EQ-5D (former EuroQol), and the quality of life questionnaire of the International Osteoporosis Foundation (QUALEFFO). The median time from the second spinal radiograph until the quality of life survey was 1.9 years. Comparison between cases and their matched controls was undertaken using the signed rank test. RESULTS 73 subjects with incident vertebral fracture (cases), mean age 64.8 years (of whom 23 had a baseline deformity), and 196 controls, mean age 63.9 years (of whom 60 had a baseline deformity), were studied. There were strong correlations between the domain scores for each of the three instruments. There was no statistically significant difference in any of the domain scores between cases and those controls with a prevalent deformity. However, compared with the controls without a prevalent deformity the cases had significantly impaired quality of life as determined using the total QUALEFFO score (38.2 vs 33.7), the physical component score of the SF-12 (39.9 vs 43.7) and the health status score of the EQ-5D (62.3 vs 69.9). When the analysis was repeated after stratification of the cases by baseline deformity status (i.e., cases with and without a prevalent deformity at baseline), cases with a prevalent deformity had impaired quality of life compared with their matched controls, both with and without a prevalent deformity. In contrast there was no significant difference in quality of life among the cases without a prevalent deformity and either control group. CONCLUSIONS In this population-based study a recent vertebral fracture was associated with impairment in quality of life, though this was mainly among those who had sustained a previous vertebral deformity.
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Affiliation(s)
- W Cockerill
- ARC Epidemiology Research Unit, University of Manchester, Stopford Building, M13 9PT, Manchester, UK
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