Trends in outcomes, complications and readmission rates in patients undergoing transcatheter aortic valve implantation: a nationwide analysis from 2012 to 2019

Background

Transcatheter aortic valve implantation (TAVI) has evolved over the years from a procedure requiring surgical vascular access and general anesthesia, to one that can be completed entirely percutaneously with conscious sedation. Advancement in procedural techniques and operator experience has resulted in better outcomes for patients undergoing TAVI.

Purpose

The purpose of our study was to analyze the trends over the years in outcomes, complications and unplanned readmission rate in patients undergoing TAVI.

Methods

The United States Nationwide Readmission Database for the years 2012 to 2019 was queried to identify all adult patients who underwent elective TAVI. The primary outcome of the study was inpatient mortality during TAVI hospitalization. Secondary outcomes included periprocedural complications (like acute kidney injury, bleeding requiring transfusion, need for permanent pacemaker implantation, stroke), length of stay, hospitalization cost, and unplanned 30-day readmission rate. Appropriate International Classification of Diseases (ICD-9 and ICD-10) codes were used to identify comorbidities and complications.

Results

A total of 283,409 patients who underwent TAVI were included in the study. The baseline characteristics of these patients are shown in picture 1. The inpatient mortality during TAVI admission declined steadily and significantly from 5.3% in the year 2012 to 0.0% in the year 2019 (p value for trend <0.001). There was a significant reduction in peri-TAVI occurrence of acute kidney injury (from 18.1% in 2012 to 8.7% in 2019), bleeding requiring transfusion (from 28.0% in 2012 to 4.3% in 2019), and stroke (from 1.8% in 2012 to 0.1% in 2019) (p value for trend <0.001 for all). Periprocedural conduction abnormalities requiring permanent pacemaker implantation increased from 7.4% in 2012 to 12.1% in 2015, before coming down to 8.9% in 2019 (p value for trend <0.001). The mean length of hospital stay and inflation-adjusted costs during admission for TAVI decreased from 9.6 days and $64,695 in the year 2012, to 3.6 days and $49,710 in the year 2019, respectively (p value for both <0.001). The unplanned 30-day all-cause readmission rate after TAVI also reduced steadily and significantly from 18.2% in 2012 to 11.5% in 2019 (p value <0.001).

Conclusion

Over the years, there has been a significant reduction in inpatient mortality, periprocedural complications (such as acute kidney injury, need for blood transfusion, stroke), length of hospital stay, and inflation-adjusted hospital costs in patients undergoing transcatheter aortic valve implantation. Furthermore, there has been a significant decline in the 30-day unplanned readmission rate after transcatheter aortic valve implantation.

Funding Acknowledgement

Type of funding sources: None.

Incidence of in-hospital all-cause mortality, resource utilization and complications in patients with adult congenital heart disease undergoing TAVR-a national inpatient sample study

Background

The prevalence of congenital heart disease (CHD) in adults in the United States is approximately 1.4 million. (1) With the advancement in diagnostic modalities and advanced treatments, including minimally invasive techniques, the life expectancy of individuals with CHD has greatly improved. (2) As these patients enter the 8th decade of their lives, the risk of calcification and aortic stenosis increases like the population without CHD. Current evidence supports transcatheter aortic valve replacement (TAVR) over surgical aortic valve replacement in individuals with moderate to high surgical risk. (3) Adults with acyanotic CHD (ACHD) with a higher risk for surgical complications are candidates for consideration of TAVR. There are sparse data about the cardiovascular outcome in these patients.

Purpose

With this National inpatient sample (NIS) study, the authors have shown the incidence of in-hospital all-cause mortality, resource utilization, and complications in adult patients with ACHD undergoing TAVR.

Methods

NIS 2016–2018 were utilized to conduct the study. Analyses were performed using STATA, version 16.0. Using appropriate ICD-10-PCS codes, authors identified adult patients with ACHD undergoing TAVR. The primary outcome of the study is to identify the impact of ACHD on all-cause in-hospital mortality and complications. Secondary outcomes of interest were resource utilization.

Results

134,170 patients were identified who had TAVR done between 2016–2018. Patients aged ≤18 years were excluded (N=25). Out of 134,170 patients that underwent TAVR, 1,170 (0.87%) were noted to have ACHD. Using the greedy algorithm, 1,115 matched pairs were generated. The ACHD group had a higher burden of co-morbidities including atrial fibrillation (46.2% vs. 38.8%, p=0.016), pulmonary hypertension (27.4% vs. 17.5%, p<0.001), metabolic syndrome (1.3% vs. 0.3%, p=0.005), peripheral vascular disease (29.5% vs. 24.1%, p=0.049), alcohol use disorder (3.0% vs. 1.3%, p=0.018), coagulation disorder (22.7% vs. 12.8%, p<0.001), drug abuse (1.3% vs. 0.4%, p=0.043), liver disease (7.3% vs. 3.1%, p<0.001) and electrolyte disturbances (20.5% vs. 14.9%, p=0.017). We also noted a possible trend towards higher complication odds (cardiac complications such as the need for pericardial drain or cardiac implantable electronic device and cardiac arrest) in patients with ACHD undergoing TAVR without statistical significance based on multivariate analysis. On propensity matching, no difference was found in the incidence of overall cardiac complications between patients with ACHD and patients without ACHD, except STEMI (OR 4.16, 95% CI, 1.08–16.00, p=0.038).

Conclusion(s)

The study points towards the possible safety of pursuing TAVR in ACHD patients provided adequate technical support and operator competency.

Funding Acknowledgement

Type of funding sources: None.

Same-day discharge following transcatheter aortic valve replacement: a propensity-matched analysis from national readmission database

Background

The length of hospital stay following transcatheter aortic valve replacement (TAVR) has decreased in recent years, and next-day discharge strategy is being increasingly adopted in some centers. Whether it is safe to further expedite discharge post-TAVR in selected patients by allowing discharge on the same day as the procedure remains unknown. In addition to potentially decreasing hospitalization costs, it could also limit the inpatient footprint and strain on healthcare resources.

Purpose

The purpose of our study was to compare the 30-day readmission rate in patients receiving TAVR who were discharged the same day (same-day discharge or SDD group) with those who were discharged on a different day (different-day discharge or DDD group). Additionally, we aimed to identify risk factors for readmission after TAVR.

Methods

We used the United States Nationwide Readmission Database to identify all adults who underwent elective TAVR in the years 2015–2019. The primary outcome of this study was all-cause 30-day readmission rate. The secondary outcomes were total hospital costs for the index admission, and risk factors for 30-day readmission. Propensity score matching was conducted to compare the SDD and DDD groups. Independent risk factors of 30-day readmission were identified using multivariate Cox proportional hazards regression analysis of the unmatched cohort.

Results

Of the 196,618 patients who received TAVR (mean age 79.5±8.4 years, 45.0% females), 245 (0.12%) patients were discharged on the same day they received TAVR (SDD group), and the remaining 196,373 were discharged on a different day (DDD group). In the DDD group, the median length of hospital stay was 2 days (interquartile range 1–4 days). A 1:3 propensity score analysis generated a matched cohort including 245 and 889 patients in the SDD and DDD groups, respectively. The 30-day readmission rate was similar between the SDD and DDD groups (11.0% versus 10.8%, hazard ratio [HR] 1.01, 95% confidence interval [CI] 0.59–1.71, p=0.989). Hospitalization costs were significantly lower in the SDD group than the DDD group ($37,811±18,029 versus $49,130±27,007, p<0.001) (see Picture 1). Age, female gender, history of diabetes, chronic kidney disease, chronic pulmonary disease, oxygen use, prior stroke, peripheral vascular disease, anemia, liver disease, and cancer were found to be independent risk factors for 30-day readmission after TAVR (see Picture 2).

Conclusion

In this large nationwide database analysis, patients receiving uncomplicated TAVR who were discharged on the same day as the procedure had a similar all-cause 30-day readmission rate and significantly lower hospital costs compared to those discharged on a different day. These results indicate that same-day discharge after TAVR may be a safe and feasible option in carefully selected patients.

Funding Acknowledgement

Type of funding sources: None.

Meta-analysis comparing the efficacy of dobutamine versus milrinone in acute decompensated heart failure and cardiogenic shock

Objective

This study aims to evaluate the difference between dobutamine and milrinone in patients presenting with acute decompensated heart failure (AHF).

Background

Inotropes are indicated for treating AHF, especially in patients with concomitant hypoperfusion indicative of cardiogenic shock. However, previous studies have not identified the optimal inotrope. We sought to compare outcomes associated with milrinone versus dobutamine in patients with AHF.

Methods

A systematic literature search was performed to identify relevant trials from inception to August 2021. Our primary outcome of interest was mortality. Analysis was sub-categorized according to subpopulation, including AHF, AHF with cardiogenic shock (AHF-shock), AHF with a bridge to transplantation (AHF-BTT), and AHF with destination therapy (AHF-DT). Summary effects were calculated using a fixed-effects model as risk ratio or mean difference with 95% confidence intervals for all the clinical endpoints.

Results

Ten studies, including one randomized controlled trial with 21,106 patients, were included in the analysis (4918 patients were in the Milrinone group, while 15188 were in the Dobutamine group). Milrinone was associated with a lower risk of mortality in patients with AHF [relative risk (RR) 0.87; confidence interval (CI):0.79–0.97; p<0.05, heterogeneity I2=0%] with event rates of 9.4% vs. 9.8% [number needed to treat (NNT) of 250]. Milrinone was also associated with improved mortality with RR 0.76 (0.79–0.95; p<0.05) in patients with AHF-DT. There was a non-significant trend towards improved mortality in AHF-shock patients. However, AHF-BTT patients had a non-significant trend towards improved mortality with dobutamine. There was no difference between the two strategies for the outcomes of acute kidney injury, initiation of renal replacement therapy, mechanical ventilation, arrhythmias, symptomatic hypotension, and length of hospital stay (LOS) in the overall population. Intensive care unit (ICU) LOS was lower in AHF-shock patients in the milrinone group, whereas dobutamine was associated with a lower length of ICU stay in AHF patients.

Conclusion

The cumulative data comparing milrinone with dobutamine indicate an overall marginal benefit of milrinone compared to dobutamine in the totality of patients with AFH with or without cardiogenic shock, and whether or not they are bridged to transplantation or destination assist device. More appropriately powered prospective studies are needed to identify a conclusive benefit of one inotrope over another.

Funding Acknowledgement

Type of funding sources: None.

Trends in the prevalence of infiltrative cardiomyopathy among patients with in-hospital cardiac arrest – insight from the US national inpatient sample database

Background

Sarcoidosis, amyloidosis, hemochromatosis and scleroderma are the most common systemic disorders leading to infiltrative cardiomyopathy (InCM). Each of them has been associated with conduction abnormalities and sudden cardiac death. In patients who undergo in-hospital cardiac arrest, a high index of suspicion is required to rule out InCM as an underlying contributor.

Purpose

We aimed to analyse the temporal trend in the prevalence of InCM among patients with in-hospital cardiac arrest and identify factors associated with increased mortality in this population.

Methods

We analysed data from the National Inpatient Sample (NIS), which is the largest publicly available database of in-hospital patients in the Unites States. Using ICD-10 coding, we identified patients who were hospitalized across 10 years from 2010–2019. Patients with diagnosis codes for both cardiac arrest and a subtype of InCM were included. Demographic characteristics and co-morbidity data were collected. Statistical analysis was performed using STATA.

Results

The total number of patients with a diagnosis of in-hospital cardiac arrest was 19,34,260. Of these, the total number with InCM was 14,803 (0.77%), which comprised our study population. Mean age was 63 years. The overall prevalence of InCM across the years ranged between 0.75 to 0.9%, with a significant temporal increase (p<0.01). Prevalence of females ranged between 51% to 62% and significantly outnumbered males across the time period. (p=0.011). Incidence of in-hospital mortality ranged between 61% to 76% for females and 30 to 38% for males. Race based analysis showed that prevalence of Caucasians ranged from 51% to 62% while that of African Americans (AA) ranged from 57% to 73%. The incidence of mortality was similar in both populations. Sarcoidosis was the most prevalent form of InCM, accounting for nearly two-fifths of all cases while amyloidosis and scleroderma both accounted for nearly 20% each. Haemochromatosis was present in 10% of the population. Overall mortality rate in our study population was 60.6%. The following co-morbidities were more prevalent in patients with InCM than those without: history of heart failure, chronic obstructive pulmonary disease (COPD), chronic kidney disease, anaemia, malignancy, coagulopathy, ventricular tachycardia, acute kidney injury and stroke. The following factors were independent predictors of in-hospital mortality-age (p=0.001), female gender (p=0.016), Hispanic race (p=0.039), history of COPD (p<0.001) and presence of malignancy (p=0.042).

Conclusion

The prevalence of infiltrative cardiomyopathy in patients with in-hospital cardiac arrest is increasing. Females, older patients and Hispanic population are at an increased risk of mortality. Sex and race based disparities in the prevalence of InCM in patients with in-hospital cardiac arrest is an area of further research.

Funding Acknowledgement

Type of funding sources: None.

Impact of age on the utility of CardioMEMs device to guide heart failure therapy: analysis of the National Readmissions Database

Background

Weeks before patients exhibit signs and symptoms of HF, intracardiac and pulmonary artery pressures increase, offering a potential target for early intervention. The CardioMEMs device is an implantable hemodynamic device placed directly into a branch of the pulmonary artery (PA) which allows remote PA pressure monitoring. The aim of our analysis is to compare outcomes of patients admitted with HF receiving implanted CardioMEMs based on their age.

Methods

Data from the National Inpatient Sample (NIS) database from 2014–2019 was used to identify hospitalizations with International Classification of diseases – 9th Revision and International classification of Diseases – 10th Revision procedural codes of patients with heart failure and CardioMEMs implantation. The outcome of interest was readmission rates at 30 days and complications associated with device implantation.

Results

We identified 1841 hospitalizations: 708 (38.5%) for patients <65 years-old (mean age 53.6) and 1,113 (60.1%) for patients >65 years-old (mean age 79.5). Gender was similar between the two age cohorts with females representing 36.6% vs 37.7% of the patients (<65 and >65 years old respectively). The cohort of patients >65 years of age had a higher rate of comorbidities including hypertension (87.9% vs 80.2%; p=0.003), prior CABG (20.3% vs 8.5%; p = <0.001), atrial fibrillation (59.2% vs 38.4%; p = <0.001), PPM (10.9%% vs 2.3%; p = <0.001), and ESRD (56.1% vs 47.3%; p=0.015. The presence of LVAD prior to device implantation was higher in the <65-year-old group at 2.8% vs 1.2% (p=0.065). Diabetes, prior PCI, PVD, pulmonary disease, anemia, cancer, and oxygen dependence were similar among the two cohorts and not statistically significant. Complications including acute kidney injury requiring dialysis, stroke, and transplant post CardioMEMs implantation were similar among the two groups. The patients who survived the index hospitalization, readmission rates were significantly improved in the cardioMEMs arm patients who were <65 years of age (13.8% vs 21.9%) compared to those 65 and above (19.6% vs 20.5%), p for interaction <0.001, Figure 1.

Conclusion

The CardioMEMS device is more effective in a younger patient population to reduce HF admissions.

Funding Acknowledgement

Type of funding sources: None.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Linear lesions in dermatology: a clinicoaetiopathological study

BACKGROUND

Linear lesions are fairly common in our daily practice. However, the appearance of these lesions can vary, thus complicating the diagnosis.

AIMS

To study the various clinical presentations, the demographic profile of patients and the clinicopathological correlations of dermatoses presenting with a linear distribution.

METHODS

We conducted an institution-based, cross-sectional, descriptive study of 281 consecutive patients with linear lesions attending dermatology clinics. MedCalc software (V11.6) was used for statistical analysis.

RESULTS

Patients were divided into eight groups: lesions along the lines of Blaschko (n = 136), lesions along blood vessels (n = 3), lesions along lymphatics (n = 3), Koebner phenomenon (n = 24), autoinoculation (n = 24), external factors (n = 45), infestations (n = 2) and 'other' (n = 44). The mean age at presentation was 24.50 ± 18.82 years and the male/female ratio was 1.32 : 1. The commonest symptom was itching/burning (56.94% of patients), while the commonest site was the arm (44.48%); followed by the leg (30.60%), trunk and abdomen (22.42%), head and neck (19.20%), and genitalia (0.35%). Apart from the common cases, there was a wide gamut of rare conditions (e.g. angiokeratoma circumscriptum naeviforme, porokeratotic eccrine ostial and dermal duct naevus, Blaschko-linear syringocystadenoma papilliferum, progressive cribriform and zosteriform hyperpigmentation, unilateral naevoid acanthosis nigricans, fixed drug eruption, discoid lupus erythematosus).

CONCLUSION

Linear lesions act as diagnostic clues to many dermatological conditions, therefore, the importance of meticulous examination in clinical dermatology cannot be overemphasized.

Impacts of Zn and Cu enrichment under ocean acidification scenario on a phytoplankton community from tropical upwelling system

Increasing dissolution of CO₂ in the surface ocean is rapidly decreasing its pH and changing carbon chemistry which is further affecting marine biota in several ways. Phytoplankton response studies under the combination of elevated CO₂ and trace metals are rare. We have conducted two consecutive onboard incubation experiments (R. V. Sindhu Sadhana; August 2017) in the eastern Arabian Sea (SW coast of India) during an upwelling event. A nutrient enriched diatom bloom was initiated onboard and grown under ambient (≈400 μatm, A-CO₂) and high CO₂ levels (≈1000 μatm; H-CO₂) with different zinc (Zn; 1 nM) and copper (Cu) concentrations (1 nM, 2 nM and 8 nM). Phytoplankton community composition and the dominant genera were different during these two experiments. CO₂ enrichment alone did not show any significant growth stimulating impact on the experimental community except enhanced cell density in the first experiment. Addition of Zn at A-CO₂ level revealed no noticeable responses; whereas, the same treatment under H-CO₂ level significantly reduced cell number. Considerably high protein content under H-CO₂+Zn treatment was possibly counteracting Zn toxicity which also caused slower growth rate. Cu addition did not show any noticeable impact on growth and biomass production except increased protein content as well as decreased carbohydrate: protein ratio. This can be attributed to relatively higher protein synthesis than carbohydrate to alleviate oxidative stress generated by Cu. The centric diatom Chaetoceros and toxin producing pennate diatom Pseudo-nitzschia showed no significant response to either CO₂ or Zn enrichment. Large centric diatom Leptocylindrus and Skeletonema responded positively to Zn addition in both CO₂ levels. The former species showed the most sensitive response at the highest Cu and H-CO₂ treatment; whereas, the pennate diatoms Nitzschia and Pseudo-nitzschia (toxigenic diatom) showed higher resilience under elevated CO₂ and Cu levels. This observation indicated that in future ocean, increasing CO₂ concentrations and trace metal pollution may potentially alter phytoplankton community structure and may facilitate toxigenic diatom bloom in the coastal waters.

A Rare Variety of Takayasu Arteritis

We diagnosed a case of Takayasu arteritis (TA) involving subclavian arteries, the aorta, superior mesenteric artery and renal arteries presenting with stenotic, occlusive, and aneurysmal lesions along with mural thrombus, which responded well to ATD and steroids. We report this case as a rare combination of vascular lesions in a patient with a relatively rare variant of TA.

Bayesian inference in time-varying additive hazards models with applications to disease mapping

Environmental health and disease mapping studies are often concerned with the evaluation of the combined effect of various socio-demographic and behavioral factors, and environmental exposures on time-to-events of interest, such as death of individuals, organisms or plants. In such studies, estimation of the hazard function is often of interest. In addition to known explanatory variables, the hazard function maybe subject to spatial/geographical variations, such that proximally located regions may experience similar hazards than regions that are distantly located. A popular approach for handling this type of spatially-correlated time-to-event data is the Cox's Proportional Hazards (PH) regression model with spatial frailties. However, the PH assumption poses a major practical challenge, as it entails that the effects of the various explanatory variables remain constant over time. This assumption is often unrealistic, for instance, in studies with long follow-ups where the effects of some exposures on the hazard may vary drastically over time. Our goal in this paper is to offer a flexible semiparametric additive hazards model (AH) with spatial frailties. Our proposed model allows both the frailties as well as the regression coefficients to be time-varying, thus relaxing the proportionality assumption. Our estimation framework is Bayesian, powered by carefully tailored posterior sampling strategies via Markov chain Monte Carlo techniques. We apply the model to a dataset on prostate cancer survival from the US state of Louisiana to illustrate its advantages.

A Randomized Controlled Trial Comparing the Efficacy of a Combination of Rifaximin and Lactulose with Lactulose only in the Treatment of Overt Hepatic Encephalopathy

BACKGROUND

Hepatic encephalopathy (HE), or portosystemic encephalopathy, represents a reversible decrease in neurologic function caused by liver disease, and treatment has traditionally been with non-absorbable disaccharides along with antibiotics and supportive measures. The present study was undertaken to evaluate if their combination therapy were superior to the established therapy in management of HE.

METHODS

Ninety six (96) patients of hepatic encephalopathy were randomly assigned to receive either lactulose and rifaximin in standard dosage or lactulose only and their response to therapy was monitored using standard assessment tools. The statistical analysis was done using Kaplan- Meier methods to estimate the percentage of patients maintaining survival over time.

RESULTS

The patients who were on lactulose and placebo revealed to have lower mortality than those on lactulose and rifaximin. Also, improvement in neurological status was of Grade 1 or more was more in patients on lactulose and placebo when compared to those on lactulose and rifaximin. Although survival analysis revealed no statistical difference between two groups, the mean survival in the placebo group was higher.

CONCLUSIONS

The present study reveals that improvement in neurological status of the group treated with lactulose only was that of a higher percentage than that of the group being treated with lactulose and rifaximin, which reiterates the recommendation that lactulose be used as a first line therapy in overt hepatic encephalopathy (OHE). Also the outcome was better in patients who had a lower grade of encephalopathy on admission.

Plasmablastic lymphoma in HIV patients: Experience at a tertiary care hospital in eastern India

BACKGROUND

Plasmablastic lymphoma (PBL), a rare non-Hodgkin's lymphoma (NHL) variant specifically associated with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), expresses well-differentiated plasma cell markers like CD138, bright CD38, and MUM1; but not conventional B-cell markers. It occurs at unusual sites like oral cavity and orbit, and has poor survival rates.

AIMS

This study serves as a review of a clinical experience with six HIV patients with PBL and observes the spectrum of clinical presentations, histopathologies, and 1-year outcomes in PBL patients.

MATERIALS AND METHODS

This review of six PBL patients was conducted at a tertiary care hospital in eastern India using relevant radiological, histopathogical, and immunohistological studies.

RESULTS

Incidence of PBL among HIV patients was 0.58% (6/1,028). Mean CD4 count at presentation was 125.5 ± 71.1 cells/μL. Sites of involvement included pleura, lung parenchyma, suprarenal gland, pelvic cavity, and retroorbital space (one each). Immunohistopathology of biopsied sample in each patient revealed PBL (positive plasma cell markers MUM-1/IRF4, CD38, and CD138/syndecan; and negative of B-cell markers CD3, CD20, and CD30). Three (60%) were positive for Epstein Barr virus (EBV) immunoglobulin G (IgG). Five surviving patients received CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) regimen and attained partial remission (PR) after six cycles. Subsequently, three patients were started on EPOCH (etoposide, cyclophosphamide, doxorubicin, vincristine, prednisone) therapy; two attained near total regression after 6 months (four cycles). Overall, four patients remained alive with good quality of life at the end of 1 year of follow-up.

CONCLUSION

PBL in HIV occurs at unusual sites with varying aggressivity. This study is too small to comment on the long-term outcomes of PBL in HIV; however, coadministration of antiretroviral therapy (ART) with standard chemotherapy may improve survival.

An interesting case of renal amyloidosis

In amyloidosis, there is an extracellular deposition of beta-sheet fibrils. Over 25 proteins have been demonstrated to form amyloid. One of them is Ig amyloid light (AL) chains. We are presenting a 40-year-old female who presented with progressive kyphoscoliosis for last 2 years following a minor trauma and bilateral pedal edema for last 3 months. On further investigation, we found that she had a biclonal variety of MM with amyloidosis of kidney leading to massive proteinuria. Very few case reports are available where patient with biclonal variety of MM develop renal amyloidosis.

Assessment of clinico-immunological profile of newly diagnosed HIV patients presenting to a teaching hospital of eastern India

BACKGROUND & OBJECTIVES

Newly diagnosed HIV patients may be asymptomatic or present with a wide range of symptoms related to opportunistic infections, acute seroconversion illness or other medical illnesses. This study was designed to evaluate the socio-demographic parameters, spectrum of the presenting clinical conditions and concurrent immunological status of newly diagnosed HIV patients and document the WHO clinical stages at the time of HIV diagnosis.

METHODS

This cross-sectional, observational study was undertaken over a 12 month period at a tertiary referral hospital in eastern India. Three hundred sixty consecutive newly diagnosed HIV patients were selected for the study from the HIV clinic and medicine wards of this hospital. Demographic and clinical data and relevant laboratory investigations of the patients were recorded and analyzed.

RESULTS

Mean age of patients was 36.38±10.62 yr, while 63.89 per cent were males. The main mode of transmission of HIV for males and females were unprotected exposure to commercial sex (139, 60.44%) and intercourse with HIV seropositive spouses (89, 68.46%), respectively. Fever (104, 28.89%), weight loss (103, 28.61%) and generalized weakness (80, 22.22%) were the predominant symptoms. Overall mean CD4 count was 176.04±163.49 cells/μl (males 142.19±139.33 cells/μl; females 235.92±185.11 cells/μl). Overall, 224 opportunistic infections were documented in 160 patients, opportunistic diarrhoea (44, 12.22%) and pulmonary tuberculosis (39, 10.83%) being the commonest. There were 83 and 133 patients in WHO clinical stages 3 and 4, respectively; 291 (80.83%) patients were eligible for initiation of first-line antiretrovirals at presentation.

INTERPRETATION & CONCLUSIONS

Advanced immunodeficiency and burden of opportunistic infections characterize newly diagnosed HIV patients in eastern India. The physicians should keep in mind that these patients may have more than one clinical condition at presentation.

Primary sclerosing cholangitis : an atypical presentation

Primary sclerosing cholangitis (PSC) is a chronic inflammatory disease of bile ducts..Patients with PSC usually presents with fatigue, jaundice and pruritus. Ultimately it leads to cirrhosis of liver and portal hypertension. But it rarely presents with decompensated liver disease without any previous symptoms. Here we report a case of PSC which presented with features of decompensated liver disease with K-F rings in the eyes.

Gentamicin in combination with ascorbic acid regulates the severity of Staphylococcus aureus infection-induced septic arthritis in mice

To study the effects of gentamicin in combination with ascorbic acid on septic arthritis, mice were infected with Staphylococcus aureus (S. aureus) and treated with gentamicin, which was given at 5 mg/kg after 24 h of infection, followed by ascorbic acid, given at 20 mg/kg body weight after 2 h of gentamicin treatment. Mice were sacrificed at 3, 9, 15 days post-infection (dpi). Combined treatment of infected mice with gentamicin and ascorbic acid eradicated the bacteria from the blood, spleen and synovial tissue and showed a significant gross reduction in arthritis, reduced serum levels of tumour necrosis factor alpha (TNF-α) and interferon gamma (IFN-γ). S. aureus-infected mice have demonstrated the disturbed antioxidant status measured in terms of cellular antioxidants like reduced glutathione and antioxidant enzymes such as superoxide dismutase (SOD) and catalase. The same were ameliorated when the animals were co-treated with gentamicin along with ascorbic acid.

Etiological study of Fever of unknown origin in patients admitted to medicine ward of a teaching hospital of eastern India

BACKGROUND

In a developing country, infectious disease remains the most important cause of fever, but the noncommunicable diseases, like malignancy, are fast becoming important differential diagnoses. An important clinical problem is the cases labeled as fever of unknown origin (FUO), which often evade diagnosis.

OBJECTIVE

The present study was undertaken to find the cause of FUO in a tertiary care hospital of eastern India.

MATERIALS AND METHODS

This is a prospective study of inpatients, with regard to both clinical signs and investigations.

RESULTS

The main diagnosis in the end was tuberculosis, closely followed by hematological malignancy. A substantial number of cases remained undiagnosed despite all investigations. The provisional diagnosis matched with the final in around two thirds of the cases. While for younger patients leukemia was a significant diagnosis, for older ones, extra-pulmonary tuberculosis was a main concern.

INTERPRETATION

In India, infectious disease still remains the most important cause of fever. Thus the initial investigations should always include tests for that purpose in a case of FUO.

CONCLUSION

Geographic variations and local infection profiles should always be considered when investigating a case of FUO. However, some of the cases always elude diagnosis, although the patients may respond to empirical therapy.

Fall frequency and risk assessment in early Parkinson's disease

BACKGROUND

We sought to define the frequency of falls in early PD and assess potential risk factors for falls in this population.

METHODS

We analyzed the data from two randomized, placebo controlled trials (NET-PD FS1 and FS-TOO) of 413 individuals with early PD over 18 months of follow-up in FS1 and 12 months in FS-TOO. Falls were defined as any report of falls on the UPDRS or the adverse event log. We assessed the frequency of falls overall and by age. The relationship between prespecified fall risk markers and the probability of falling was assessed using logistic and multiple logistic regression. A hurdle Poisson model was used to jointly model the probability of remaining fall-free and the number of falls.

RESULTS

During the follow-up period, 23% of participants fell, and 11% were habitual fallers. In a multiple logistic regression model, age, baseline UPDRS Falling score, and baseline PDQ-39 scores were associated with subsequent fall risk (p < 0.001). Similarly, in a hurdle Poisson regression model, age, baseline UPDRS falling item, and baseline PDQ-39 were all significantly related to the probability of falling, but only UPDRS falling >0 was associated with the number of falls.

CONCLUSION

Falls are frequent and are associated with impaired quality of life, even in early PD. Current standard rating scales do not sufficiently explain future fall risk in the absence of a prior fall history. New assessment methods for falls and postural instability are required to better evaluate this important problem in clinical trials and clinical practice.

Prognostic markers in AIDS-related cryptococcal meningitis

OBJECTIVE

Despite the advent and expanding access to antiretroviral therapy, HIV-associated cryptococcal meningitis (CM) remains a significant cause of mortality and morbidity amongst individuals with this infection in resource-limited settings.

METHODS

We prospectively studied the clinical, biochemical and mycological parameters of 30 HIV patients diagnosed with cryptococcal meningitis at our centre over a period of 6 months with a view to identify prognostic factors predictive of poor outcome.

RESULTS

Our study documented a mortality rate of 36.7%. Age, sex and previous diagnosis of HIV had no bearing on the survival outcome of patients. The study identified several poor prognostic factors including low GCS score, papilledema, elevated CSF opening pressure (>250 mm of H2O) and lack of regular HIV care in those with a prior diagnosis of HIV. CSF pleocytosis was significantly higher in the mortality group.

CONCLUSION

There have been relatively few attempts to focus on poor prognostic markers associated with AIDS related Cryptococcal meningitis in Asian patients. Our study highlights how simple bedside clinical tools like ophthalmoscopy and CSF manometry can help in risk stratification in this group of patients.

Laparoscopic resection for recurrent Crohn's disease: safety, feasibility and short-term outcomes

AIM

The safety, feasibility and short-term outcomes of laparoscopic resection were assessed in patients with recurrent ileocolic Crohn's disease.

METHOD

A consecutive series of patients was identified from a prospectively collated database. Data included patient demographics, previous medical and surgical treatment, operative details and postoperative course. Data from the original index open operation were collected retrospectively by review of the case notes.

RESULTS

Between 2005 and 2009, 27 patients [21 women, mean (range) age 31 years (16-51 years)] underwent laparoscopic resection for recurrent ileocolic Crohn's disease. All had histologically confirmed recurrent disease at the ileocolic anastomosis. Five (18.5%) patients required extended resection for Crohn's colitis, three (11.1%) had fistulating disease and one (3.4%) patient had a psoas abscess. The median (range) operative time was 110 min (70-170 min) with a conversion rate of two (7.4%) of 27 patients. The length of stay was 4 days (2-7 days) with time to return to work or full activity of 3.5 weeks (2-7 weeks).

CONCLUSION

Laparoscopic resection of recurrent ileocolic Crohn's disease is safe, feasible and associated with short-term benefits.

High-precision half-life measurement for the superallowed β+ emitter ²⁶Al(m)

A high-precision half-life measurement for the superallowed β+ emitter 26Al(m) was performed at the TRIUMF-ISAC radioactive ion beam facility yielding T 1/2 6346.54 ± 0.46(stat) ± 0.60 (syst) ms, consistent with, but 2.5 times more precise than, the previous world average. The 26Al(m) half-life and ft value, 3037.53(61) s, are now the most precisely determined for any superallowed β decay. Combined with recent theoretical corrections for isospin-symmetry-breaking and radiative effects, the corrected Ft value for (26)Al(m), 3073.0(12) s, sets a new benchmark for the high-precision superallowed Fermi β-decay studies used to test the conserved vector current hypothesis and determine the V(ud) element of the Cabibbo-Kobayashi-Maskawa quark mixing matrix.

Therapeutic effects of nandrolone and testosterone in adult male HIV patients with AIDS wasting syndrome (AWS): a randomized, double-blind, placebo-controlled trial

PURPOSE

We aimed to compare therapeutic effects of intramuscular (IM) nandrolone decanoate and IM testosterone enanthate in male HIV patients with AIDS wasting syndrome (AWS) with placebo control.

METHODS

In this randomized, double-blind, placebo-controlled, 12-week trial, 104 patients with AWS who satisfied our inclusion criteria were randomly allotted in a 2:2:1 ratio to the 3 intervention groups: nandrolone, testosterone, and placebo. We administered 150 mg nandrolone and 250 mg testosterone (both IM, biweekly). The primary outcome measure was a comparison of absolute change in weight at 12 weeks between the nandrolone decanoate, testosterone, and placebo groups.

RESULTS

Intent-to-treat analysis was done. The nandrolone group recorded maximum mean increase in weight (3.20 kg; post hoc P < .01 compared to placebo). Body mass index (BMI) of subjects in the nandrolone group had a significantly greater increase (mean = 1.28) compared to both testosterone (post hoc P < .05) and placebo (post hoc P < .01). Waist circumference and triceps skinfold thickness of patients on nandrolone showed similar results. Nandrolone also ensured a better quality of life. Patients with low testosterone level (<3 ng/mL) benefited immensely from nandrolone therapy, which increased their weight and BMI significantly compared to placebo (P < .05).

CONCLUSION

Our trial demonstrates the superior therapeutic effects of nandrolone in male AWS patients, including the androgen deficient.

Robust Bayesian Analysis of Heavy-tailed Stochastic Volatility Models using Scale Mixtures of Normal Distributions

A Bayesian analysis of stochastic volatility (SV) models using the class of symmetric scale mixtures of normal (SMN) distributions is considered. In the face of non-normality, this provides an appealing robust alternative to the routine use of the normal distribution. Specific distributions examined include the normal, student-t, slash and the variance gamma distributions. Using a Bayesian paradigm, an efficient Markov chain Monte Carlo (MCMC) algorithm is introduced for parameter estimation. Moreover, the mixing parameters obtained as a by-product of the scale mixture representation can be used to identify outliers. The methods developed are applied to analyze daily stock returns data on S&P500 index. Bayesian model selection criteria as well as out-of- sample forecasting results reveal that the SV models based on heavy-tailed SMN distributions provide significant improvement in model fit as well as prediction to the S&P500 index data over the usual normal model.

Intensive phase non-compliance to anti tubercular treatment in patients with HIV-TB coinfection: a hospital-based cross-sectional study

We aimed to study the prevalence and determinants of non compliance to intensive phase anti tubercular treatment (ATT) in 111 HIV-TB coinfection patients, attending the APEX Referral Center for HIV/AIDS at Medical College, Kolkata with a specially-designed, semi-structured, pre-tested questionnaire. Compliance was defined as taking ≥95% of the total scheduled doses of anti-TB medicines during the intensive phase. Data was collected on socio-demographic parameters, disease information, patient's knowledge and barriers to treatment. The prevalence of non-compliance to ATT in HIV-TB coinfection patients was found to be 40.5% (95% C.I. = 30.5, 50.5). Multivariate logistic regression analysis showed that absence of proper counseling, lack of knowledge about correct route of TB transmission, visiting quacks during ATT and the urge to leave treatment once patient started feeling better were the significant determinants of non-compliance. "No Counseling" increased chances of non- compliance (adjusted O.R.) 47.12 times (95% C.I. = 7.99, 195.27); thereby being the single most influential variable towards the outcome. The present study finds an alarmingly high prevalence of non-compliance to ATT among HIV-TB coinfection patients. The results clearly indicate that adequate counseling about this coinfection and the importance of compliance, along with better patient-friendly orientation of DOTS programme is urgently needed. Collaborative TB-HIV activities are essential to ensure better ATT compliance in coinfection patients.

Non Tuberculous Mycobacteria and toxoplasma co-infection of the central nervous system in a patient with AIDS

New-onset seizures are frequent manifestations in patients infected with Human Immunodeficiency Virus (HIV). We describe the clinical and radiological findings in an 25yr old AIDS patient presenting with new onset seizures as the primary manifestation of cerebral toxoplasmosis and Non Tuberculous Mycobacterial [NTM] co-infection. Cranial computed tomography showed a subtle ventricular dilatation whereas magnetic resonance imaging disclosed prominent temporal horn. Toxoplasma tachyzoites and rapidly growing mycobacteria were recovered from CSF. Seizures were complex partial in nature and refractory to antiepileptic therapy.

Complicated typhoid fever

Acute typhoid fever, caused by the gram negative bacterium Salmonella typhi may have a wide spectrum of clinical presentation. We report a young boy with typhoid fever, who developed myocarditis and splenic abscess, two of the unusual complications in the course of the disease. Judicious use of corticosteroid and antibiotic helped in achieving a favourable outcome.

New features of shape coexistence in ;{152}Sm

Excited states in ;{152}Sm have been investigated with the ;{152}Sm(n,n;{'}gamma) reaction. The lowest four negative-parity band structures have been characterized in detail with respect to their absolute decay properties. Specifically, a new K;{pi} = 0;{-} band has been assigned with its 1;{-} band head at 1681 keV. This newly observed band has a remarkable similarity in its E1 transition rates for decay to the first excited K;{pi} = 0;{+} band at 684 keV to the lowest K;{pi} = 0;{-} band and its decay to the ground-state band. Based on these decay properties, as well as energy considerations, this new band is assigned as a K;{pi} = 0;{-} octupole excitation based on the K;{pi} = 0_{2};{+} state. An emerging pattern of repeating excitations built on the 0_{2};{+} level similar to those built on the ground state may indicate that ;{152}Sm is a complex example of shape coexistence rather than a critical point nucleus.

Utility of abdominal ultrasonography in HIV patients

INTRODUCTION

Various diseases associated with human immunodeficiency virus (HIV) infection are often difficult to diagnose. A poor immune response, atypical presentations and opportunistic pathologies all contribute to this difficulty. We tried to evaluate the utility of routine abdominal ultrasonography (US) in new and follow-up HIV cases, and compared the results among those with a clinical need for US and those where US was performed as a routine screening.

METHODS

150 consecutive seropositive patients were subdivided into four groups depending on the necessity of abdominal US on the initial workup, i.e. Group A (38 patients) or B (112 patients), and whether they were newly-diagnosed HIV patients or follow-up patients, i.e. Group X (62 patients) or Y (88 patients), giving us subgroups, AX (22 patients), AY (16 patients), BX (40 patients) and BY (72 patients).

RESULTS

The prevalence of significant US findings was higher in those with CD4 less than 200 cells/ml (77.8 percent) compared to those with CD4 200-500 cells/ml and CD4 more than 500 cells/ml (65.5 percent and 37 percent, respectively). 24 out of 38 patients with clinical indications and 71 out of 112 patients without any obvious clinical need for US, had positive findings on US, the majority of which had a major therapeutic impact.

CONCLUSION

We conclude that abdominal US is a simple and cost-effective tool in resource-poor countries like India, where HIV care is becoming more and more important.