Changing pattern of admissions for acute myocardial infarction in India during the COVID-19 pandemic

AIM

Studies on the changes in the presentation and management of acute myocardial infarction (AMI) during the COVID-19 pandemic from low- and middle-income countries are limited. We sought to determine the changes in the number of admissions, management practices, and outcomes of AMI during the pandemic period in India.

METHODS & RESULTS

In this two-timepoint cross-sectional study involving 187 hospitals across India, patients admitted with AMI between 15th March to 15th June in 2020 were compared with those admitted during the corresponding period of 2019. We included 41,832 consecutive adults with AMI. Admissions during the pandemic period (n = 16414) decreased by 35·4% as compared to the corresponding period in 2019 (n = 25418). We observed significant heterogeneity in this decline across India. The weekly average decrease in AMI admissions in 2020 correlated negatively with the number of COVID cases (r = -0·48; r2 = 0·2), but strongly correlated with the stringency of lockdown index (r = 0·95; r2 = 0·90). On a multi-level logistic regression, admissions were lower in 2020 with older age categories, tier 1 cities, and centers with high patient volume. Adjusted utilization rate of coronary angiography, and percutaneous coronary intervention decreased by 11·3%, and 5·9% respectively.

CONCLUSIONS

The magnitude of reduction in AMI admissions across India was not uniform. The nature, time course, and the patient demographics were different compared to reports from other countries, suggesting a significant impact due to the lockdown. These findings have important implications in managing AMI during the pandemic.

Arsenic efflux in Enterobacter cloacae RSN3 isolated from arsenic-rich soil

In the present study, bacterial isolates were screened for arsenic resistance efficiency. Environmental isolates were isolated from arsenic-rich soil samples (i.e., from Rajnandgaon district of Chhattisgarh state, India). Amplification and sequencing of 16S rRNA gene revealed that the isolates were of Bacillus firmus RSN1, Brevibacterium senegalense RSN2, Enterobacter cloacae RSN3, Stenotrophomonas pavanii RSN6, Achromobacter mucicolens RSN7, and Ochrobactrum intermedium RSN10. Arsenite efflux gene (arsB) was successfully amplified in E. cloacae RSN3. Atomic absorption spectroscopy (AAS) analysis showed an absorption of 32.22% arsenic by the RSN3 strain. Furthermore, results of scanning electron microscopy (SEM) for morphological variations revealed an initial increase in the cell size at 1 mM sodium arsenate; however, it was decreased at 10 mM concentration in comparison to control. This change of the cell size in different metal concentrations was due to the uptake and expulsion of the metal from the cell, which also confirmed the arsenite efflux system.

Pattern of acute MI admissions in India during COVID-19 era: A Cardiological Society of India study - Rationale and design

Background

COVID-19 pandemic has affected around 20million patients worldwide and 2.0 million cases from India. The lockdown was employed to delay the pandemic. However, it had an unintentional impact on acute cardiovascular care, especially acute myocardial infarction (AMI). Observational studies have shown a decrease in hospital admissions for AMI in several developed countries during the pandemic period. We aimed to evaluate the impact of COVID-19 on the AMI admissions patterns across India.

Methods

In this multicentric, retrospective, cross-sectional study, we included all AMI cases admitted to participating hospitals during the study period 15th March to 15th June 2020 and compared them using a historical control of all cases of AMI admitted during the corresponding period in the year 2019. Major objective of the study is to analyze the changes inthe number of hospital admissions for AMI in hospitals across India. In addition, we intend to evaluate the impact of COVID-19 on the weekly AMI admission rates, and other performance measures like rates of thrombolysis/primary percutaneous interventions (PCI), window period, door to balloon time, and door to needle time. Other objectives include evaluation of changes in the major complications and mortality rates of AMI and its predictors during COVID-19 pandemic.

Conclusions

This CSI-AMI study will provide scientific evidence about the impact of COVID-19 on AMI care in India. Based on this study, we may be able to suggest appropriate changes to the existing MI guidelines and to educate the public regarding emergency care for AMI during COVID-19 pandemic.

Biventricular Non-Compaction Cardiomyopathy

Left ventricular non-compaction (spongy myocardium) is one of the most misclassified cardiomyopathies. It is characterised by an excessively prominent trabecular meshwork of myocardium and deep intertrabecular myocardium due to an arrest in the compaction process of the myocardial fibres. It could be isolated i.e. without any other structural heart defects or associated with congenital heart defects. The clinical manifestations are variable heart failure, arrhythmia, thromboembolic phenomena depending on extent of non-compaction of cardiac segment.

Consensus evidence-based guidelines for management of hyperglycaemia in patients undergoing coronary artery bypass grafting in patients with diabetes in India

Diabetes is associated with a significant risk of cardiovascular diseases (CVDs). Patients with diabetes are known to suffer from a disproportionately large burden of CVDs, in terms of higher risk, worse prognosis and more adverse outcomes. Acute coronary syndromes, including coronary artery disease, represent a large proportion of this burden and conventionally coronary artery bypass grafting (CABG) has been the mainstay of facilitating reperfusion in patients with diabetes. However, hyperglycaemia is an important factor which affects the outcomes of CABG and shows a grave impact on patients' well-being. Thus, it is important to appropriately manage hyperglycaemia in the peri-and intra-operative periods to assure the best possible outcomes in patients with diabetes. There is scant evidence to show that oral antidiabetic drugs (OADs) or non-insulin based therapies show considerable benefit in patients undergoing CABG. Even with the use of insulin-based therapies, appropriate glycaemic targets, accurately designed algorithm to achieve such targets and specific recommendations to facilitate the appropriate use of such algorithm are important considerations. However, current international guidelines are either country-specific or fail to address context-specific needs in individual countries. In view of the growing incidence of cardiovascular diseases and diabetes in India, as a result of changing lifestyles, it is imperative upon clinicians to formulate India-specific guidelines for effective management of (CVDs). It is the endeavour of the current guideline to present recommendations based on a firm evidentiary foundation coupled with context-specific inputs from experts' consensus opinion. These recommendations represent an effort to address the urgent need for such an exercise both in the academic as well as the clinical realm.

Kinetics of DNA load predict HPV 16 viral clearance

INTRODUCTION

While high HPV 16 viral load measured at a single time point is associated with cervical disease outcomes, few studies have assessed changes in HPV 16 viral load on viral clearance.

OBJECTIVE

To measure the association between changes in HPV 16 viral load and viral clearance in a cohort of Thai women infected with HPV 16.

STUDY DESIGN

Fifty women (n=50) between the ages of 18-35 years enrolled in a prospective cohort study were followed up every three months for two years. Women positive for HPV 16 DNA by multiplex TaqMan assay at two or more study visits were selected for viral load quantitation using a type-specific TaqMan based real-time PCR assay. The strength of the association of change in viral load between two visits and viral clearance at the subsequent visit was assessed using a GEE model for binary outcomes.

RESULTS

At study entry, HPV 16 viral load did not vary by infection outcome. A >2 log decline in viral load across two study visits was found to be strongly associated with viral clearance (AOR: 5.5, 95% CI: 1.4-21.3). HPV 16 viral load measured at a single time point was not associated with viral clearance.

CONCLUSIONS

These results demonstrate that repeated measurement of HPV 16 viral load may be a useful predictor in determining the outcome of early endpoints of viral infection.

Autonomic failure in primary amyloidosis

Amyloidosis is an uncommon plasma cell dyscrasia affecting Multisystem, characterized by deposition of amyloid proteins in extracellular spaces and the tissues. Reported incidence of amyloidosis is 8 cases per million per year. Deposition of amyloid fibrils occurs in peripheral nerves in 20% of the cases in Primary Amyloidosis. Though. polyneuropathy is one of the presenting manifestations in cases of Primary Amyloidosis, pure autonomic failure without involving peripheral nerves is not a documented entity. Here, we present a case of Primary Amyloidosis presenting as Pure Autonomic Failure (Dysautonomia).

White paper on academic emergency medicine in India: INDO-US Joint Working Group (JWG)

Emergency Medicine (EM) is a new discipline for India. As Medical Council of India (MCI) makes progress in recognizing the need to develop EM residency training programs in India it is important that there exist an established training model for future faculty, residents and medical students. This INDO-US white paper makes a serious attempt to recognize the opportunities and challenges in developing academic emergency medicine in India. The contents of this white paper address the overall scenario and are not targeted towards a person, physician, body, hospital or any other associated entity. This paper emphasizes the importance of MCI recognized training in Emergency Medicine for physicians in India.

Pulsed underwater corona discharges as a source of strong oxidants: *OH and H2O2

Because of undesirable side effects of chemical methods pulsed underwater corona discharges are emerging as a potential future advanced oxidation process (AOP) for water disinfection. In pulsed corona discharges a discharge channel is created, which contains a non-thermal plasma with a low degree of ionisation and low electron densities, but with electron energies of up to 10 eV. It has been demonstrated that electrons with this energy can dissociate water and oxygen molecules and produce various reactive radicals (*OH, H*, O*, HO2*), molecular species (H2O2, H2, O2), ultraviolet radiation and shock waves. It is supposed that the combination of all effects leads to a very efficient killing of microorganisms. To understand this in detail and to improve the efficiency of the overall system there is the need to develop suitable diagnostic methods for the quantitative determination of the various oxidants produced during the discharge. In this paper we present preliminary experimental results obtained with different chemical probes for *OH radicals, and H2O2 produced by pulsed corona discharges.

API consensus guidelines for use of antiretroviral therapy in adults (API-ART guidelines). Endorsed by the AIDS Society of India

With rational use of antiretroviral therapy (ART), human immunodeficiency virus (HIV) infection has been transformed into a chronic manageable illness like diabetes and hypertension. These guidelines provide information on state of art, evidence based approach for use of ART in Indian context. When to initiate ART? Antiretroviral therapy is indicated for all symptomatic HIV infected persons regardless of CD4 counts and plasma viral load (PVL) levels. In asymptomatic patients, ART should be offered when the CD4 counts < 200/mm3 and should be considered in patients with CD4 counts between 200-250/mm3. Therapy is not recommended for patients with CD4 count more than 350/ mm3. Involvement of patient in all treatment decisions and assessing readiness is critical before initiating ART. What to start with? A non-nucleoside reverse transcriptase inhibitor (NNRTI) based regimen is recommended for antiretroviral naïve patients. The choice between nevirapine and efavirenz is based on differences in adverse events profiles; cost and availability of convenient fixed dose combinations and need for concomitant use of rifampicin. A backbone of 2-nucleoside reverse transcriptase inhibitors (NRTIs) is combined with the NNRTI. Various combinations and ART strategies not to be used in clinical practice has been enlisted. How to follow up? Recommendations have been made for baseline evaluation and monitoring of patients on ART. These include guidelines on laboratory and clinical evaluation. A plasma viral load at 6 months after initiation of first-line ART is strongly recommended. Yearly estimation of lipid profile has been recommended. How to identify and manage ART failure? The guidelines recognize the issue of identifying ART failure late if only CD4 counts are used for monitoring. In the absence of resistance testing various second-line regimens have been enlisted. A boosted protease inhibitor based regimen is recommended in this situation to be combined with 2-NRTIs. Special situations Recommendations have been made for use of ART in HIV-TB, HIV-HBV, and HIV-HCV co-infected patients. In patients with active TB and a CD4 count < 200/mm3, initiation of ART is recommended as soon as the anti-TB treatment is tolerated. Efavirenz is the only ARV drug, which can be safely used with rifampicin. In pregnancy use of single dose nevirapine for reducing risk of mother to child transmission of HIV is not recommended, because of the risk of development of resistance. For post-exposure prophylaxis taking ART treatment history of the source patient is crucial in designing an effective regimen.

Exercise ECG testing--is it obsolete?

Role of exercise ECG Testing has become controversial with the emergence of so many non-invasive imaging modalities. In spite of that, Exercise ECG Testing still remains the best modality as an initial test for evaluation of chest pain, prognostication and risk stratification of coronary artery disease, rehabilitation following myocardial infarction and various re-vascularization procedures. Further, the test has also been used in other cardiovascular diseases other than coronary artery disease.

Acute pancreatitis and diabetic ketoacidosis in non-diabetic person while on treatment with sodium valproate, chlorpromazine and haloperidol

A nondiabetic young male patient in hypomanic phase of bipolar disorder on maintenance treatment with sodium valproate, developed transient episode of acute pancreatitis and diabetic ketoacidosis after addition of chlorpromazine and halopridol. It subsided completely within six weeks and his blood sugar was normal without any antidiabetic therapy. Simultaneous occurrence of acute pancreatitis and diabetic ketoacidosis is reported as a very rare complication of combination of antipsychotic drugs sodium valproate, chlorpromazine and haloperidol. Blood sugar should be periodically monitored in patients on sodium valproate and antipsychotic medication.

Predicting mortality in stroke

Physicians are faced with the task of predicting the immediate and long term outcome in stroke patients. It is also important to efficiently and optimally utilize resources. We used APACHE III scoring system or predicting in hospital outcome in patients with stroke. We found it to be sensitive (>90%) and resonably specific (73%) in predicting short term, in-hospital mortality, in our study group.

Test of HIV incidence shows continuing HIV transmission in homosexual/bisexual men in England and Wales

It has been suggested that HIV incidence will decrease with the increased use of antiretroviral Therapy (ART) in HIV infected homosexual/bisexual men. HIV incidence was measured using a sensitive/less sensitive assay technique, at a time when combination ART was widespread. The Serological Testing Algorithm for Recent HIV Seroconversion (STARHS)13 technique was applied to syphilis test specimens collected from homosexual/bisexual men attending 15 sexually transmitted infections (STI) clinics which participated in an unlinked anonymous serosurvey of HIV infection during 1998. The HIV incidence rate was adjusted to compensate for patients who had a repeat syphilis test within the same year. Leftover syphilis test sera from 6202 men had been unlinked and anonymised, of which 415 were HIV positive. Sera from 412 (99.3%) patients were available. The STARHS assay showed 62 to have been recently infected with HIV (approximately in the last four months), giving an incidence of 3.33% per annum (95% CI: 2.06%-5.27%). The highest incidence was seen in those aged 35-44 years. About 46% of all HIV-infected homosexual/bisexual men were probably receiving combination ART at this time. If 10% of those on treatment were misclassified as recent infections the incidence would have been 2.58% per annum (95% CI: 1.53%-4.24%). In homosexual/bisexual men having syphilis tests at STI clinics in the UK during 1998 the incidence of HIV infection was between two and three per hundred per year. Treatment with combination ART of almost a half of homosexual/bisexual men who are HIV infected in the population is compatible with appreciable continuing HIV transmission among those at high behavioural risk. Public health surveillance systems for those at high risk for HIV infection should, as soon as possible, incorporate the STARHS methodology for monitoring recent HIV incidence.

The national CD4 surveillance scheme for England and Wales

This paper describes a national surveillance scheme, began in 1995, designed to monitor immunosuppression associated with HIV infection in adults in England and Wales. Currently 60 out of 64 (94%) laboratories performing CD4 cell counts participate in the scheme. The database contains over 42,000 patient records with over 300,000 counts, taken between April 1984 and March 2000. Approximately half of the patient records in the CD4 database match with patient records in the UK database of diagnosed HIV infections; a large proportion of the unmatched patients in the CD4 database may not be HIV-infected. Close to 50% of both men who have sex with men and injecting drug users and two-thirds of those who acquired their infection heterosexually had CD4 cell counts below 350 cells/mm3 at the time of HIV diagnosis. The National CD4 Surveillance Scheme provides important information regarding the epidemiology of HIV infection such as the changes in patterns of early and late diagnosis. It should continue to be used in conjunction with the other HIV surveillance systems to present as complete a picture of the epidemic as possible.

What a test for recent infection might reveal about HIV incidence in England and Wales

BACKGROUND

A laboratory method has been developed that detects recent HIV infection and allows incidence to be estimated by testing single stored antibody-positive specimens. A theoretical exploration of the method's surveillance utility was carried out.

METHODS

Using various data sources, HIV incidence rates were postulated. The confidence intervals (CI) for these postulated incidences were calculated using the expected number of recent infections for each postulated incidence, the actual number tested for HIV, and the known number of HIV-1 positives. A test for trend was used to determine when an important change in incidence could be recognized.

RESULTS

If the incidence was 5% per annum (p.a.) in homosexual/bisexual men attending sexually transmitted diseases (STD) clinics in London, 64 recent infections would be expected in the 392 HIV-seropositive specimens and, if observed, would result in a 95% CI of 3.1-7.9% p.a. for the incidence rate. An incidence of 1% p.a. in pregnant women would be most unlikely as this would require detection of 193 recent infections, 26 more than the total 167 HIV-seropositive specimens found in 1997. In African women attending STD clinics in London, 30% of prevalent infections would be classified as recent if the incidence was 5% p.a. Further, if the incidence in homosexual/bisexual men were to fall by 50% over 3 years, a decrease of this magnitude would be recognized as significant within 2 years.

CONCLUSIONS

The detuned assay will increase the information from HIV serosurveys even where prevalence and incidence are relatively low. Existing surveillance systems should be redesigned to take full advantage of the method.

CD4 cell counts in adults with newly diagnosed HIV infection: results of surveillance in England and Wales, 1990-1998. CD4 Surveillance Scheme Advisory Group

OBJECTIVES

To describe the distribution and changes in CD4 cell counts (both initial and subsequent) in HIV-infected persons over time and determine the factors influencing these counts.

DESIGN

Reports were requested from laboratories measuring CD4 cell counts in England and Wales. Initial counts were analysed and median counts were followed over time.

METHODS

Time trends and the relationship between initial CD4 cell count and age, sex, and HIV risk category were studied using quantile regression methods or chi-square tests.

RESULTS

Between 1990 and 1998, 9553 adults were newly diagnosed with HIV infection and had a CD4 cell count within 6 months of HIV diagnosis. Over 50% of initial CD4 cell counts in each major risk category were below 350 cells/mm3. Older age (P < 0.001), male sex (P < 0.013) and heterosexual risk (P < 0.001) were independently associated with lower initial CD4 cell counts. For heterosexually infected adults, the median initial CD4 cell count was significantly negatively associated with the year of diagnosis (P = 0.03) and the median age increased through the time period examined (P < 0.001), whereas for men who have sex with men (MSM), there was no significant change in these values over time. For each year cohort of newly diagnosed individuals, the median CD4 cell count in subsequent years decreased until 1996 and then increased thereafter, consistent with a treatment effect.

CONCLUSION

Across all major risk groups, a large proportion of HIV-infected adults are being diagnosed late in the course of HIV disease. For the heterosexually infected, the data suggest an ageing cohort effect, whereas for MSM the data are consistent with continuing transmission.

Silent myocardial ischaemia and cardiac autonomic neuropathy in diabetics

Treadmill exercise electrocardiography was performed in 47 patients of diabetes to detect latent coronary artery disease. Eighteen patients (36.3%) were found positive on treadmill test. All forty seven subjects were evaluated for cardiac autonomic neuropathy. The incidence of cardiac autonomic neuropathy in treadmill positive group was 72.2% as compared to 31.0% in treadmill negative group, (p < 0.01). Nine patients from the positive group and 4 patients from the negative group were subjected for coronary angiography, which revealed significant CAD in 8 and 1 subjects in both groups respectively. It is concluded that the incidence of silent myocardial ischaemia in diabetics is very high and cardiac autonomic neuropathy seems to be the most probable reason for absence of pain.

Anatomical note. Venous segmentation in the spleen of the sheep

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Hepatovenous segments in the human liver

The patterns of hepatovenous segments in 95 human livers have been studied after preparing corrosion casts of the hepatic veins in 72 specimens and taking X-rays of 23 livers after injecting barium sulphate into the hepatic veins. Five hepatovenous segments were seen in every specimen: left, middle, right, paracaval and caudate. The sizes of corresponding hepatovenous segments were similar in 77.9% of livers; in the remainder increased or decreased size, at the expense of neighbouring segments, was observed.

Study of venous segments in the spleens of buffalo and dog

By preparing the corrosion cast of the splenic vein and its intrasplenic tree, venous segments have been observed in the spleens of buffalo and dog. The buffalo spleen showed the presence of two venous segments (a dorsal and a ventral) in 85% of cases and three (a dorsal, an intermediate and a ventral) in 15% of cases. The spleen of the dog revealed only two venous segments (a dorsal and a ventral) in all the specimens. The results are compared with descriptions available in the literature.

Arterial segmentation in the spleen of the sheep (Ovis aries)

Forty corrosion casts of the splenic artery and its tree were used to study segmentation in the sheep spleen. Twenty eight spleens (70%) had two arterial segments, a right and a left. One spleen (2.5%) had a visceral and a parietal segment. Eleven spleens (27.5%) showed no arterial segmentation, the artery ramifying irregularly.

Segmentation in the dog spleen. A study by corrosion cast

40 corrosion casts of the dog splenic artery were prepared to observe the vascular segments in the dog spleen. 39 specimens (97.5%) revealed the presence of two segments, a dorsal and a ventral one. However, in 1 specimen (2.5%) no segmentation was seen.

SELECTIVE SOMATIC ELIMINATION OF NICOTIANA GLUTINOSA CHROMOSOMES IN THE F1 HYBRIDS OF N. SUAVEOLENS AND N. GLUTINOSA

The F, hybrids of Nicotiana suaveolen (subgenus Petunioides, 2n = 32) and N. glutinosa (subgenus Tabacum, 2n = 24), were examined during their development, from seedlings to mature plants. It was observed that in the hybrids, there was a progressive change of dominant N. glutinosa morphological characteristics towards those of N. suaveolens, in leaf shape, stem, flower color and branching pattern. A study of mitotic chromosomes in the root-tips and in very young anthers of the mature plants indicated a significantly high average frequency of aberrant mitotic anaphases (bridges and fragments, 12% and 11 % respectively). As a consequence of this phenomenon, variability in the number and size of chromosomes was observed in the PMC's and in mitotic metaphases (29-24 chromosomes). In order to establish whether the N. glufinosa chromosomes were preferentially last, a karyological study of the parents and their F, hybrids was carried out and it was established that the F, hybrids were losing N. glutinosa chromosomes preferentially. A mechanism was suggested for the loss of these chromosomes by means of a chromatid type of breakage-fusion-bridge cycle (b-f-b cycle) and initiation of the b-f-b cycle in the hybrid due to an interaction of the regulatory mechanism of DNA replication in the haploid genomes of the parental species. However, loss of these chromosomes owing to interaction of certain genes from the two parental species cannot be ruled out.