Stationary distribution and global stability of stochastic predator-prey model with disease in prey population

In this paper, a new stochastic four-species predator-prey model with disease in the first prey is proposed and studied. First, we present the stochastic model with some biological assumptions and establish the existence of globally positive solutions. Moreover, a condition for species to be permanent and extinction is provided. The above properties can help to save the dangered population in the ecosystem. Through Lyapunov functions, we discuss the asymptotic stability of a positive equilibrium solution for our model. Furthermore, it is also shown that the system has a stationary distribution and indicating the existence of a stable biotic community. Finally, our results of the proposed model have revealed the effect of random fluctuations on the four species ecosystem when adding the alternative food sources for the predator population. To illustrate our theoretical findings, some numerical simulations are presented.

Left main stem stenosis angioplasty with intravascular ultrasound optimisation criteria guidance using a new generation everolimus drug-eluting stent

INTRODUCTION

Intravascular ultrasound (IVUS) is recommended in the use of left main stem (LMS) percutaneous coronary intervention (PCI). Since the LMS diameter is usually larger than other coronary arteries, a new generation everolimus drug-eluting stent (DES), Synergy Megatron DES (Boston Scientific) has better axial and radial strength allowing more post implant overexpansion and consequently better suited for LMS lesions. We performed a study to evaluate the clinical outcomes of PCI using 1) an improved IVUS protocol with optimisation targets and 2) the use of Megatron stents.

MATERIALS AND METHODS

This was a study involving LMS PCI coronary lesions using the Synergy Megatron DES. An IVUS protocol using predefined optimisation targets to evaluate for stent malapposition, longitudinal stent deformation, optimal stent expansion >90% of reference lumen and appropriate distal landing zone was used in all cases. The primary end-point was procedural success, defined by successful stent implantation with <30% residual stenosis. The secondary end-point was in-hospital and 30-day major adverse cardiovascular event (MACE).

RESULTS

Eight patients with significant LMS stenosis were successfully treated with the Megatron stent. The primary end-point was achieved in all patients. There were no cases of stent malapposition or longitudinal stent deformation, one case did not have optimal LMS stent expansion and one case did not have an appropriate distal landing zone. IVUS optimisation criteria were met in 6 (75%) cases. There were no complications of coronary dissection, slow or no reflow, stent thrombosis or vessel perforation. None of the patients suffered in-hospital or 30-day MACE. The average LMS MLD at baseline was 2.1 ± 0.1mm and the post-PCI LMS MLD was 4.0 ± 0.5mm, with a significant acute luminal gain of 1.9 ± 0.7mm (p<0.01). A post-PCI MSA of 17 ± 3.9 mm2 was numerically superior compared to those documented in other LMS PCI trials.

CONCLUSION

This study demonstrates low rates of shortterm major adverse cardiovascular events among patients with LMS PCI using the Megatron stents. It highlights the usefulness of IVUS-guided optimisation in LMS PCI. With the use of intravascular imaging, the new generation stent technology can improve the treatment of large proximal vessels and PCI of LMS lesions.

Intravascular imaging-guided treatment of severe coronary artery calcification with orbital atherectomy: A prospective single-centre registry

INTRODUCTION

Coronary artery calcification can lead to suboptimal results when performing coronary angioplasty with conventional techniques. The presence of severe coronary artery calcium increases the complications of percutaneous coronary intervention as it may impede stent delivery and optimal stent expansion. The purpose of this study was to determine the procedural success and safety of orbital atherectomy (OA) in calcified lesions.

MATERIALS AND METHODS

This was a prospective single-centre study regarding the utility of OA in the treatment of calcified coronaries. Intravascular ultrasound (IVUS) or optical coherence tomography (OCT) was used in all cases to characterise the severity of calcium pre-procedure, guide vessel sizing and assess procedural success. The primary endpoint was procedural success, defined by successful stent implantation following OA treatment. The secondary endpoint was in-hospital and 30-day major adverse cardiovascular event (MACE).

RESULTS

Ten patients with severely calcified lesions were successfully treated with OA. The primary endpoint was achieved in all patients. All of the lesions were severely calcified with concentric calcium. None of the patients suffered in-hospital or 30-day MACE. The average minimal luminal diameter at baseline was 1.7 ± 0.3 mm and the post- PCI luminal diameter was 3.0 ± 0.3 mm, with a significant luminal gain of 1.3 ± 0.3 mm (p < 0.01). Slow flow during procedure occurred in 2 (20%) cases and dissection occurred in 1 (10%) case during procedure. These were successfully treated with stent delivery to achieve TIMI III flow. There were no cases of stent thrombosis or vessel perforation.

CONCLUSION

Our experience demonstrates the feasibility and safety of OA in the management of calcified coronary stenosis. Intravascular imaging is an important adjunct to the use of OA to assess the severity of calcified coronary lesions, success of OA treatment and to aid sizing of the vessel for stent implantation. OA is an effective treatment approach to disrupt coronary calcification, facilitating stent implantation with optimal results. It is a safe procedure with good success rate and low rate of complications.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Treatment of severe coronary artery calcification with intravascular lithotripsy: Initial experience of a prospective single centre registry

INTRODUCTION

Coronary artery calcification can lead to suboptimal results when performing coronary angioplasty with conventional techniques. Shockwave intravascular lithotripsy (IVL) has recently been introduced as a new modality to treat heavily calcified coronary arteries. The purpose of this study was to determine the procedural success and safety of IVL in calcified lesions.

MATERIALS AND METHODS

This was a prospective single-centre study regarding the utility of IVL in treatment of calcified coronary arteries. Intravascular ultrasound (IVUS) was used in all cases to characterise the lesions pre procedure and to assess procedural success post procedure. The primary end point was procedural success, defined by IVL treatment and successful stent implantation. The secondary end point was in-hospital and 30-day major adverse cardiovascular event (MACE).

RESULTS

Five patients with severely calcified lesions were successfully treated with IVL. The primary end point was achieved in all patients. All of the lesions were severely calcified with concentric calcium. Multiple calcium fractures were identified on IVUS after IVL in all cases. None of the patients suffered in-hospital or 30-day MACE. The average diameter stenosis at baseline was 1.8±0.4mm and the post PCI diameter stenosis was 2.9±0.1mm, with significant acute luminal gain of 1.2±0.3mm (p<0.01). There were no complications of coronary dissection, slow or no reflow, stent thrombosis, or vessel perforation.

CONCLUSION

Our initial experience demonstrates the feasibility and safety of IVL in the management of calcified coronary stenosis. The shockwave IVL is an effective treatment approach to disrupt coronary calcification, facilitating stent implantation with optimal results. It is a safe procedure with a good success rate and low rate of complications.

Clinical Profile of Addison's Disease in a Tertiary Care Institute, Southern India - The Changing Landscape

Aims and Objectives

Clinical, biochemical, and radiological profiles of Addison's disease and to assess the various etiological spectrum of primary adrenal insufficiency (PAI) in adults.

Materials and Methods

A retrospective cohort study was carried out in the Department of Endocrinology, Madurai Medical College, Madurai between January 2014 and January 2021 over a 7-year period.

Inclusion Criteria

All the patients with clinical symptoms and or signs of suspected PAI, such as hyperpigmentation, weight loss, persistent nausea or vomiting, fatigue, and hypotension, were recruited. All suspected cases underwent measurement of 8-AM plasma ACTH and cortisol levels. In possible cases and equivocal cortisol levels, patients underwent Co-syntropin/ACTH stimulation test. To know the underlying etiology of PAI, 21-hydroxylase autoantibodies (21OHAb), thyroid function test, Anti TPO, calcium, parathyroid hormone (PTH), LH and FSH, CT of chest and abdomen, and sputum AFB based on the clinical pattern of involvement were performed.

Exclusion Criteria

Patients with onset of PAI at infancy and childhood, secondary adrenal insufficiency or exogenous Cushing's syndrome, and central hypocortisolism, including Sheehan's syndrome, were excluded.

Results

Thirty-six patients were diagnosed with PAI in this study; 19 (53%) were females and 17 were males (47%). The median age of diagnosis was 35 years. Patients were divided into acute presentation and subacute presentation. Twenty-six patients presented with acute presentation and ten were presented with progressive evolved symptoms. Non-tuberculous etiology was the predominant finding noted in our cohort study (87%, 31 out of 36 patients). The other causes of Addison disease included isolated auto-immune PAI, polyglandular autoimmune syndrome type 1 and II, APLA Syndrome, and adrenal metastasis.

Conclusion

Non-tuberculous causes of PAI are the leading etiology in our retrospective study. Autoimmune PAI and Polyglandular autoimmune syndromes are increasingly being recognized as the cause of Addison's disease. PAI individuals require lifelong surveillance for possible development of coexisting autoimmune syndromes and need for glucocorticoid/mineralocorticoid therapy.

Erdheim Chester Disease - Unusual Presentation with Isolated Skeletal Lytic Lesions

Introduction

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis (LCH) of unknown origin that was first described in 1930. Since then, almost 600 cases have been reported worldwide. Even though this disease primarily affects the bone, it has a varied clinical spectrum of presentation ranging from asymptomatic bone lesions to multisystem involvement. Owing to its protean manifestations ECD is often misdiagnosed or diagnosed late.

Case Report

We present a 48-year-old female with a long long-standing history of recurrent bone lesion of the tibia and multiple trivial trauma fractures of long bones. Recently, she also developed a persistent headache and painful swelling of the right shoulder and left hip joint. Radiographs revealed multiple lytic and lytic sclerotic lesions. With the probable diagnosis of LCH, she underwent biopsy which revealed features characteristic of ECD.

Conclusion

This case highlights the fact that histopathological confirmation is the key to distinguish various types of histiocytic neoplasms. Overlapping clinical and radiological features with atypical manifestations can occur in both LCH and ECD and does not rule out either of them.

Intravascular ultrasound guided treatment of severe coronary artery calcification with Shockwave Intravascular Lithotripsy

Coronary artery calcification is a pathological deposition of calcium in the intimal and medial layer of the arterial wall. Shockwave intravascular lithotripsy (IVL) has evolved as a new modality to treat heavily calcified coronary arteries. IVL involves using a percutaneous device to produce acoustic pressure waves resulting in the delivery of sufficient energy to break up superficial and deep calcium deposits. We present a case where highly dense coronary calcium was successfully treated with intravascular ultrasound (IVUS) guided coronary angioplasty and IVL treatment. IVUS demonstrated heavy calcification at the proximal LAD with a 360° calcium arc. Post procedure, IVUS demonstrated multiple fractures of coronary calcium. Stent deployment was done successfully with good stent strut apposition. There was no procedure related complication. The case demonstrates an example where IVL is an important adjunctive tool in the cardiac catheterization laboratory for lesion preparation and optimal percutaneous coronary intervention.

Renal Denervation in the treatment of Resistant Hypertension

Hypertension is a risk factor for coronary artery disease and stroke. Only about half of the patients with hypertension are adequately controlled on medical therapy, and about a quarter may develop severe or resistant hypertension. Resistant hypertension is defined as failure to achieve target blood pressure of <140/90mmHg while on full doses of an appropriate three-drug regimen that includes a diuretic. Increasingly more attention has been paid to the potential of renal denervation (RDN) as treatment for resistant hypertension, guided by a better understanding of renal nerve anatomy. RDN is undergoing transformation as a technology for the treatment of resistant hypertension. Early studies demonstrated efficacy in treating resistant hypertension patients with significant reduction in office blood pressure (BP). However, the randomised sham-controlled trial, Symplicity HTN-3, did not demonstrate any significant difference in BP reduction between the RDN and the sham control arm. Since then, further improvements have been made in developing second generation systems. Subsequent studies showed the importance of more distal and branch renal artery ablation, and multielectrode systems have been utilised. Two randomised shamcontrolled trials, the SPYRAL HTN-OFF MED and SPYRAL HTN-ON MED studies showed the effectiveness of RDN with the second-generation radiofrequency ablation system. These studies showed that RDN significantly reduced office and 24-hour ambulatory BP when compared with sham control treatment. The RADIANCE-HTN SOLO trial also demonstrated efficacy using an ultrasound-based catheter system for RDN treatment of resistant hypertension. These trials have reinvigorated current clinical interest in RDN as treatment for resistant hypertension. There is increasing evidence for RDN as an effective treatment for uncontrolled or resistant hypertension. The RDN procedure has also evolved with time, with an improved practice of delivering a larger number of ablations to distal vessels in addition to main renal arteries. The RDN procedure has a low complication rate and may provide an approach that could potentially reduce the morbidity and mortality risks associated with resistant hypertension in Malaysia.

Complete resolution of constrictive pericarditis after coronary bypass surgery

Classical constrictive pericarditis (CP) is an unusual and rare complication after coronary artery bypass grafting. It can be transient, progressive or fixed form of cardiac constriction. However recently recognized transient variant of constrictive pericarditis can be managed with medical therapy, though other progressive and irreversible forms may require pericardiectomy. We describe a 65-year-old male patient who developed a classical but a very early transient CP, just within two weeks as a result of post cardiac injury syndrome after coronary bypass surgery. The patient had a complete recovery following medical treatment.

Renal sympathetic denervation in the treatment of resistant hypertension

Hypertension is a significant cardiovascular risk factor. Although the mainstay of treatment remains medication, there are a number of patients with resistant hypertension who have elevated blood pressure despite multiple medications. Failure to achieve adequately controlled blood pressures despite medications put these patients at risk of target organ damage and significant morbidity from hypertension. The renal denervation procedure involves the application of radiofrequency energy or ultrasound at the renal arteries to modulate afferent and efferent sympathetic renal activity. This treatment potentially can improve blood pressure control in patients who have resistant hypertension despite medication. This article presents two case reports of successful treatment of resistant hypertension using radiofrequency renal sympathetic denervation (RDN) at a private medical centre using the latest Spyral catheter. We also reviewed the latest RDN trials to give some insights into this procedure.

'H-syndrome': a multisystem genetic disorder with cutaneous clues

We present a case of a 25-year-old man who came to our Endocrine Clinic for evaluation of short stature. He had a history of sensorineural hearing loss, hypertrichosis and hyperpigmentation with the thickening of the skin below the hip, gynecomastia and autoimmune haemolytic anaemia. Investigations showed that he had hypergonadotropic hypogonadism. His phenotype was consistent with that of a rare autosomal recessive genodermatosis of 'H-syndrome'. The diagnosis was confirmed by genetic analysis using next-generation sequencing which showed a homozygous mutation in the SLC29A3 gene (variant: c.1330G>T (p.Glu444Ter)) which was confirmed by Sanger sequencing. This is a rare syndrome with around 100 cases reported in world literature. Though the skin manifestations are pathognomonic of the H-syndrome, it has myriad presentations like short stature, insulin-dependent diabetes mellitus, hypogonadism, hypothyroidism, dyslipidaemia, cardiac anomalies and sensorineural hearing loss. We report this case to highlight the constellation of features of this rare syndrome and bring awareness among the physicians to be vigilant about this syndrome.

Atypical presentation of autoimmune polyglandular syndrome type 1 in the fifth decade

A 45-year-old woman presented to us with a short-term history of nausea, vomiting and giddiness. On arrival at our hospital, examination revealed postural hypotension. Fluid resuscitation with intravenous normal saline was commenced. She also had chronic mucocutaneous candidiasis and nail changes suggestive of ectodermal dystrophy. Detailed history taking revealed that she had never attained menarche. Serum biochemistries showed hyponatraemia, hyperkalaemia, and hypocalcaemia (sodium, 127 mEq/L; potassium, 6 mEq/L; and albumin-corrected calcium, 6 mg/dL). Adrenocorticotropic hormone-stimulated cortisol (16.7 mcg/dL) was suboptimal favouring adrenal insufficiency. She was started on hydrocortisone and fludrocortisone supplementation. Additionally, the parathyroid hormone was inappropriately low (3.8 pg/mL) confirming hypoparathyroidism. Oral calcium and active vitamin D supplementation were added. With the above clinical and biochemical picture, namely, clustering of primary amenorrhoea, adrenal insufficiency and hypoparathyroidism, the diagnosis pointed towards autoimmune polyglandular syndrome. Genetic workup revealed a deletion in exon 8 of the autoimmune regulator gene confirming the diagnosis of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy/autoimmune polyglandular syndrome type 1 .

Clinical, biochemical and genetic characteristics of children with congenital adrenal hyperplasia due to 17α-hydroxylase deficiency

Objectives Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder, that could rarely be due to 17 α-hydroxylase deficiency (17αOHD) and/or 17,20 lyase deficiency. Mutation of CYP17A1 gene causes deficiency of glucocorticoids and androgens but excess of mineralocorticoids. Lack of genital ambiguity in most children causes a delay in diagnosis even until puberty. Classical presentation with hypertension and hypokalemia is often not encountered. We intended to study the clinical, biochemical and genetic characteristics of children diagnosed with CAH due to 17αOHD. Methods Three children who were diagnosed with CAH due to 17αOHD in our institute and on follow up were included in this retrospective study. Clinical, biochemical and genetic characteristics of these children were retrieved and studied from electronic medical records. Results Two children were genetic females and one was genetic male, but all three were raised as females. All had hypertension at diagnosis except one but none had hypokalemia. All of them had mutation in the CYP17A1 gene. The two females responded well to oestrogen and progesterone and had adequate estrogenization clinically. Conclusions Even though CAH due to 17αOHD is quite rare, it should be considered while evaluating young individuals with hypogonadism, hypertension with or without hypokalemia. Lack of genital ambiguity and absence of classical signs at presentation does not rule out this not so uncommon condition and warrants follow up.

Is Paget Disease of Bone more Common in South India? Clinical Characteristics, Therapeutic Outcome and follow-up of 66 Patients from Tamil Nadu

INTRODUCTION

Paget disease of bone (PDB) is a disorder of altered bone remodeling mainly characterized by increased osteoclastic activity. While the exact Indian prevalence remains unknown, a clustering of published cases suggests South Indian predominance.

OBJECTIVE

To study the clinico-biochemical profile and therapeutic response of patients with PDB and briefly review the epidemiology of PDB from an Indian perspective.

MATERIALS AND METHODS

Retrospective data was collected from the charts of patients who have been seen in endocrine out-patient clinics in Tamil Nadu over a 12-year period. Published literature on PDB from India was reviewed.

RESULTS

A total of 66 patients (71% males) predominantly from Tamil Nadu were studied. The mean age at presentation was 67 ± 8 years. Polyostotic involvement was seen in 89% and familial occurrence of PDB in 5 patients. Symptoms at presentation mainly included bone pain (51%) and skeletal deformities (18%). Scalp vein sign (21%) and sensorineural hearing loss (64%) were also noted. Incidental PDB detection by raised serum alkaline phosphatase (SAP) levels was observed in 17% and by abnormal fluorodeoxyglucose-positron emission tomography (FDG-PET) scan in 6% of cases. Mean SAP at presentation was 606 ± 438 IU/L (Normal, 76-140). Major skeletal site involvement includes pelvis (62.1%) and spine (34.8%). Mean (range) follow-up of the cohort was 3.4 yrs (1-12 yrs). In all, 64 subjects received zoledronate and two received alendronate, and mean (SD) SAP at 1-year was 73 ± 42 IU/L. All but two showed remission at the end of 1 year. Two had pathological fractures and two had sarcomas. A review of epidemiology of PDB in Indian literature clearly showed a South Indian predilection for unclear reasons.

CONCLUSION

In our cohort of PDB, male gender, polyostotic involvement, and hearing impairment were noted in more than two-thirds of patients and single-dose intravenous zoledronate was effective in normalizing SAP in almost all patients. PDB is intriguingly more common in South India and this needs more exploration.

Hypothalamic-Pituitary-Adrenal Axis Recovery Following the 1-mg Overnight Dexamethasone Suppression Test in Healthy Volunteers

BACKGROUND

The recovery of hypothalamic-pituitary-adrenal (HPA) axis suppression following pharmacological doses of various steroids has been studied previously. However, no study has been conducted using the more commonly used 1-mg dexamethasone in the overnight dexamethasone suppression test (ODST). Hence, we aimed at evaluating HPA axis recovery after the 1-mg ODST.

OBJECTIVES

This study aimed at investigating the pattern and time of recovery of the HPA axis following the 1-mg ODST in healthy subjects.

METHODS

Ten healthy volunteers aged 18 - 40 years, BMI < 30 kg/m², with neither exposure to steroids nor interfering drugs were included. The 1-mg ODST was performed, and the adrenocorticotropic hormone (ACTH) and cortisol samples were withdrawn at regular intervals. The serum cortisol of < 1.8 µg/dL was considered as HPA axis suppression, whereas the cortisol value equal to or more than baseline was deemed as recovery.

RESULTS

Cortisol and ACTH levels were suppressed in all subjects 9 hours following the 1-mg ODST. Although ACTH showed an early increase after 8 hours, the upsurge was noticed following 24 hours (mean ± SD, 34.42 ± 18 pg/mL). Later, cortisol accompanied ACTH, and both reached their baseline after 72 hours (mean ± SD, ACTH, 37.48 ± 12.44 pg/mL; cortisol, 8.45 ± 3.32 μg/dL). A small dip in ACTH and cortisol (mean ACTH, 23.84 pg/mL; mean cortisol, 2.3 μg/dL) was observed after 24 - 36 hours indicating the return of the diurnal rhythm before complete recovery.

CONCLUSIONS

The complete recovery of the HPA axis occurs only 72 hours following the 1-mg ODST. ACTH begins to recover as early as 8 hours after the maximal suppression and diurnal rhythm of ACTH and cortisol resume 24 to 36 hours later.

P2797Clinical outcomes of an ultra-thin strut sirolimus-eluting stent with biodegradable polymer in all-comers patients undergoing coronary intervention

Background

Thin stent struts may be associated with reduced vessel injury and use of biodegradable polymers may further improve long term outcomes. However, data with earlier stents has been inconsistent; thus further studies with newer devices are needed.

Purpose

To evaluate the efficacy and safety of a new ultra-thin (65um) strut cobalt chromium sirolimus-eluting stent with a hybrid design (closed cell at ends and open cells in middle to reduce edge injury and optimise conformability) in all-comers patients undergoing percutaneous coronary intervention (PCI).

Methods

We enrolled 752 patients from 14 sites undergoing PCI into a prospective, non-randomised, multi-centre, open-label, observational registry. Inclusion of patients with complex anatomy (long stent lengths, bifurcations and chronic total occlusions) was encouraged. Clinical follow-up was scheduled at 1, 9, 12 and 24 months. The primary endpoint was incidence of major adverse cardiac events (MACE) - cardiac death, non-fatal myocardial infarction (MI), or target vessel revascularization (TVR) - at 9 months.

Results

Mean patient age was 64.7±12.2 years, 20.7% had diabetes, 58.8% had dyslipidaemia, 40.4% had multi-vessel disease, 22% had previous PCI, 4.7% had previous coronary-artery bypass graft, and 19.6% had a clinical history of previous MI. Mean lesion length was 25.7±17.3 mm. The primary endpoint of cumulative MACE up to 9 months (from 624 patients reaching 9 months follow-up) occurred in 12 patients (1.92%), including 6 (0.96%) cardiac death, 5 (0.80%) MI and 6 (0.96%) clinically indicated TVR. Definite stent thrombosis was reported in 3 patients (0.48%) and probable stent thrombosis in 2 patients (0.32%).

Conclusions

Use of an ultra-thin strut biodegradable polymer sirolimus-eluting stent in all-comers patients undergoing PCI was associated with good clinical efficacy and safety.

Acknowledgement/Funding

Meril Life

Sertoli-Leydig cell tumour in a patient with non-classic congenital adrenal hyperplasia: an uncommon duo

Polycystic ovary syndrome is the most common cause of hyperandrogenism in young females. Other causes are congenital adrenal hyperplasia (CAH), androgen-producing tumours and drugs. The severity and tempo of virilisation help in distinguishing the tumoural from non-tumoural causes. We report a rare case of non-classic CAH and androgen-producing ovarian tumour in the same patient, causing hyperandrogenism. A 15-year-old female patient presented with secondary amenorrhea, excessive facial hair growth and clitoromegaly for 6 months. Due to severe virilisation, tumoural aetiology was considered. Investigations showed marked elevation of testosterone and mild elevation of 17 hydroxy progesterone (17OHP). Imaging confirmed right ovarian tumour. Adrenocorticotropic hormone stimulated 17OHP, was elevated confirming the diagnosis of underlying non-classic CAH. Surgical removal of the tumour was followed by improvement in hyperandrogenism, but persistent elevation of 17OHP confirmed the underlying presence of non-classic CAH.

The Impact of GE Lunar vs ICMR Database in Diagnosis of Osteoporosis among South Indian Subjects

OBJECTIVE

To study the effect of choosing ICMR reference values on the classification of bone mineral density in Indian patients.

DESIGN

Retrospective analysis of Dual Energy X-ray absorptiometry (DEXA) and clinical data.

PATIENTS

Totally, 316 patients aged more than 65 years attending a tertiary care hospital in South India who underwent DEXA scan were included in the study.

MEASUREMENTS

DEXA scan at femoral neck and lumbar spine.

RESULTS

A total of 316 patients were studied. The mean age was 61.98 ± 7.66 years. There were 46.84% females and 53.16% males. The average BMI was 26.37 ± 4.51. Of these patients, 46 had history of hip fracture (14.55%). The adoption of the ICMR normative data resulted in a significant increase in T scores in both the hip (+0.51, P < 0.05) and the spine (+1.64, P < 0.01). The adoption of ICMR normative values, resulted in reduction of osteoporosis prevalence from 26.58% to 5.06%.

CONCLUSIONS

There is a clinically significant reduction in diagnosis of osteoporosis with the adoption of ICMR reference standard. Clinicians should be recommended to use raw BMD values in gm/cm² in FRAX calculation and avoid the use of T scores, to avoid overestimation of fracture risk. If our results are replicated, the implications are enormous - Osteoporosis is currently being over diagnosed.

Effectiveness of Adjuvant Yoga Therapy in Diabetic Lung: A Randomized Control Trial

Context

Recent studies provide ample evidence of the benefits of yoga in various chronic disorders. Diabetes mellitus is a group of metabolic diseases characterized by chronic hyperglycemia and Sandler coined the term "Diabetic Lung" for the abnormal pulmonary function detected in diabetic patients due underlying pulmonary dysfunction. Yoga therapy may help in achieving better pulmonary function along with enhanced glycaemic control and overall health benefits.

Aim

To study the effect of adjuvant yoga therapy in diabetic lung through spirometry.

Settings and Design

Randomized control trial was made as interdisciplinary collaborative work between departments of Yoga Therapy, Pulmonary Medicine and Endocrinology, of MGMC & RI, Sri Balaji Vidyapeeth Puducherry.

Materials and Methods

72 patients of diabetic lung as confirmed by spirometry (<70% of expected) were randomized into control group (n=36) who received only standard medical treatment and yoga group (n=36) who received yoga training thrice weekly for 4 months along with standard medical management. Yoga therapy protocol included yogic counseling, preparatory practices, Asanas or static postures, Pranayama or breathing techniques and relaxation techniques. Hathenas of the Gitananda Yoga tradition were the main practices used. Spirometry was done at the end of the study period. Data was analyzed by Student's paired and unpaired 't' test as it passed normality.

Results

There was a statistically significant (P < 0.05) reduction in weight, and BMI along with a significant (P < 0.01) improvement in pulmonary function (FEV₁, FVC) in yoga group as compared to control group where parameters worsened over study period.

Conclusion

It is concluded from the present RCT that yoga has a definite role as an adjuvant therapy as it enhances standard medical care and hence is even more significant in routine clinical management of diabetes, improving physical condition and pulmonary function.

FRAX First - Pragmatic Approach in Resource Poor Settings

BACKGROUND

Fracture Risk Assessment Tool (FRAX) is a fracture prediction tool that uses clinical risk factors with or without bone mineral density (BMD). BMD is difficult to obtain in resource-limited setting. Hence, we aimed to compare fracture risk prediction by FRAX without BMD (FRAX) and FRAX with BMD (FRAX/BMD).

OBJECTIVE

We intended to determine if FRAX and FRAX/BMD would produce identical predictions for 10-year probability of hip fracture and major osteoporotic fracture (MOF). We also desired to study the risk factors that could help to identify the similarity of risk prediction.

MATERIALS AND METHODS

A retrospective review of patients who underwent BMD measurement and FRAX assessment was conducted. Men and women >50 years of age with osteopenia and osteoporosis according to the World Health Organization (WHO) definition at one or more sites were included. FRAX prediction scores were calculated with and without BMD using the FRAX India tool.

RESULTS

Of 239 subjects, 207 (86.61%) had identical fracture risk predictions with or without BMD in FRAX estimation. Mean age was lower (P = 0.009), whereas body mass index (BMI), hip BMD, spine BMD, and history of previous fracture were higher (P = 0.005, P < 0.001, P < 0.001, and P = 0.02, respectively) in the identical prediction group.

CONCLUSION

In our study, FRAX provided fracture risk prediction alike FRAX/BMD in most of the cases. FRAX is a good predictor of fractures especially in younger patients with higher BMI. Therefore, we conclude that FRAX is an effective tool to predict osteoporotic fracture risk and would be an inexpensive alternative when access to dual-energy X-ray absorptiometry (DXA) is limited.

The effect of hypothyroidism on serum irisin level in patients with nondiabetic chronic kidney disease: A pilot study with a cross-sectional design

Both chronic kidney disease (CKD) and hypothyroidism are associated with decreased serum irisin level. The presence of hypothyroidism may influence serum irisin level in CKD patients. The objective of this study was to evaluate the effect of hypothyroidism on serum irisin level in patients with nondiabetic CKD. Two hundred nondiabetic CKD patients aged between 18 and 65 years with glomerular filtration rate <60 mL/min/1.73 m² were included in this study. Forty-three (21.5%) patients had hypothyroidism (overt and subclinical both). Forty hypothyroid and forty euthyroid CKD patients matched for age and Body Mass Index underwent body composition, biochemical [fasting plasma glucose (FPG) and C-reactive protein], and hormonal (fasting irisin and insulin) evaluation. Body composition analysis including visceral adipose tissue was done by dual-energy X-ray absorptiometry. Homeostatic model assessment 2 insulin resistance was calculated from FPG and insulin levels. The median serum irisin levels were not significantly different between hypothyroid and euthyroid CKD patients [95 (47.74-261.52) vs. 66 (28.25-224.50) ng/mL, P = 0.30]. There was also no difference in renal function, body composition and other metabolic parameters between the two groups. To conclude, the presence of hypothyroidism does not alter serum irisin level in patients with nondiabetic CKD.

Assessment of insulin injection techniques among diabetes patients in a tertiary care centre

AIMS

The efficacy of insulin therapy in diabetes depends on proper storage and injection technique. The purpose of this study was to assess the practice of insulin administration among diabetes patients in a tertiary care center.

MATERIALS AND METHODS

This observational study was done in Endocrinology department of a tertiary care center during April-June 2015. The consecutive patients using insulin for at least three months by either syringe or pen were recruited. All of them underwent a survey by the questionnaire which focused on key insulin injection parameters.

RESULTS

One hundred and sixty eight (74.67%) patients were storing insulin vials properly. The thigh was the most common site of insulin injection and 209(92.89%) study participants were rotating at the injection sites. Only 48.57% (34/70) subjects were mixing insulin properly before injection. The practice of hand washing and the cleaning of the injection site was practiced by 158(70%) & 171(76.44%) subjects respectively. One hundred and fifty six (69%) patients were injecting with the proper skin fold and 123(55%) subjects were injecting insulin at 90° angle. The majority of patients (91%) were throwing the needle and syringes directly into the garbage and public drainage system.

CONCLUSIONS

There was a significant gap between the insulin administration guidelines and current insulin injection practice. The diabetic education and counseling about proper insulin injection techniques should be provided to all diabetic subjects.

De-Hearsay (Diabetes e-Hearsay)

Hearsay, or reported speech, is an important contributor to diabetes care related behaviour. Modern modes of communication have thrown up a new form of hearsay, termed e-hearsay (electronic hearsay). We describe the concept of diabetes related electronic hearsay or digital hearsay (de-hearsay or dd-hearsay), and suggest pragmatic means of countering negative de-hearsay, so as to benefit diabetes care.

Bifurcation and spatiotemporal patterns of a density-dependent predator–prey model with Crowley–Martin functional response

In this paper, we consider a diffusive density-dependent predator–prey model with Crowley–Martin functional responses subject to Neumann boundary condition. We analyze the stability of the positive equilibrium and the existence of spatially homogeneous and inhomogeneous periodic solutions through the distribution of the eigenvalues. The direction and stability of Hopf bifurcation are determined by the normal form theory and the center manifold theory. Finally, numerical simulations are given to verify our theoretical analysis.