Procalcitonin for Detecting Culture-Positive Sepsis in Neonates: A Prospective, Multicenter Study

INTRODUCTION

It is unclear if serum procalcitonin (PCT) estimated at sepsis suspicion can help detect culture-positive sepsis in neonates. We evaluated the diagnostic performance of PCT in culture-positive sepsis in neonates.

METHODS

This was a prospective study (February 2016 to September 2020) conducted in four level-3 units in India. We enrolled neonates suspected of sepsis in the first 28 days of life. Neonates with birth weight <750 g, asphyxia, shock, and major malformations were excluded. Blood for PCT assay was drawn along with the blood culture at the time of suspicion of sepsis and before antibiotic initiation. The investigators labeled the neonates as having culture-positive sepsis or "no sepsis" based on the culture reports and clinical course. PCT assay was performed by electrochemiluminescence immunoassay, and the clinicians were masked to the PCT levels while assigning the label of sepsis. Primary outcomes were the sensitivity, specificity, and likelihood ratios to identify culture-positive sepsis.

RESULTS

The mean birth weight (SD) and median gestation (IQR) were 2,113 (727) g and 36 (32-38) weeks, respectively. Of the 1,204 neonates with eligible cultures, 155 (12.9%) had culture-positive sepsis. Most (79.4%) were culture-positive within 72 h of birth. The sensitivity, specificity, and positive and negative likelihood ratios at 2 ng/mL PCT threshold were 52.3% (95% confidence interval: 44.1-60.3), 64.5% (60.7-68.1), 1.47 (1.23-1.76), and 0.74 (0.62-0.88), respectively. Adding PCT to assessing neonates with 12.9% pretest probability of sepsis generated posttest probabilities of 18% and 10% for positive and negative test results, respectively.

CONCLUSION

Serum PCT did not reliably identify culture-positive sepsis in neonates.

Prevalence of arrhythmia in COVID-19 patients with mild/moderate and severe illness: a prospective cohort study

OBJECTIVES

The type of arrhythmias, and their prevalence in mild/moderate and severe COVID-19 patients admitted to the hospital are unknown from a prospective cohort study.

METHODS

We did continuous electrocardiograms along with multiple ECGs in 305 consecutive hospitalized COVID-19 patients.

RESULTS

The incidence of arrhythmias was 6.8% (21/305) in the target population. The incidence of arrhythmias was 9.2% (17/185) in patients with severe COVID-19 illness and 3.3% (4/120) in patients with mild/moderate COVID-19 illness with no significant difference (p = 0.063). All the arrhythmias were new-onset arrhythmias in this study. 95% (20/21) of these arrhythmias were atrial arrhythmia with 71.42% (15/21) being atrial fibrillation and one episode of sustained polymorphic ventricular tachycardia. No episode of high-grade atrioventricular block, sustained monomorphic ventricular arrhythmia, or torsades de pointes arrhythmias were observed in this study. The patients with arrhythmias were admitted to the intensive care unit (80.9% vs. 50.7%; p: 0.007), were on a ventilator (47.6% vs. 21.4%; p: 0.006), and had high in-hospital mortality (57.1% vs. 21.1%; p: 0.0001) than patients without arrhythmias.

CONCLUSION

Atrial arrhythmias were the most frequent arrhythmias in hospital-admitted COVID-19 patients with atrial fibrillation being the most common arrhythmia.

TRIAL REGISTRATION

Clinical Trial Registry India (CTRI) (CTRI/2021/01/030788). (https://www.ctri.nic.in/).

Role of Inflammatory Markers and Clinical Correlate in Children Infected with the Novel SARS-CoV-2: A Prospective Observational Study

Introduction: Inflammatory markers have been used as predictors of adverse outcomes in adults with Coronavirus Disease-2019 (COVID-19) infection. Children mostly have mild infections and raised inflammatory markers have been reported only with severe COVID-19 or Multisystem Inflammatory Disorder (MIS-C). Studies in children showing the role of inflammatory markers in disease prognosis are few, and findings are not conclusive. Aim: To find out correlation, if any, between the inflammatory markers {Interleukin-6 (IL-6), C-reactive Protein (CRP), procalcitonin, Pro-B-type natriuretic Peptide (Pro-BNP), ferritin, D-dimer} with clinical presentation, prognosis, and outcome in children with acute COVID-19. Materials and Methods: The prospective, observational study was conducted at a tertiary care COVID-19 Paediatric Intensive Care Unit {PICU (Vardhaman Medical College and Hospital, New Delhi)}, Northern India, between September 2020 and December 2020. All children aged less than 12 years, with a positive COVID19 report were enrolled and investigated. Data was collected for clinical presentation, severity, treatment and outcome. The following variables were recorded: Complete Blood Count (CBC), Kidney Function Test (KFT) and Liver function Test (LFT), Absolute Lymphocyte Count (ALC), Absolute Neutrophil Count (ANC), Neutrophil-lymphocyte Ratio (NLR), Platelet Count (PLT), C-reactive Protein (CRP), Procalcitonin (PCT), serum ferritin, Lactate Dehydrogenase (LDH), fibrinogen, and Erythrocyte Sedimentation Rate (ESR) and ProBNP. Coagulation parameters like Prothrombin Time (PT), Activated Partial Thromboplastin Time (APTT), International Normalised Ration (INR), D-dimer were taken. Data was analysed using Statistical Package for the Social Sciences (SPSS) software version 21.0. Results: A total of 35 children were admitted during the study period. Seventeen children met the criteria for severe disease. Seven children met the criteria for MIS-C. Children presenting with conjunctivitis (n=3) were more likely to have signs of peripheral inflammation hypotension (n=4), tachycardia (n=6), and raised IL-6 levels (pg/mL) as well as the need for inotropic support. IL-6 values were higher in children (Mean±SD= 182.47±149.83). Median IL-6 value 199.8 (96.17-275.24) was highest in children with CRP <10 mg/dL (p-value<0.01). Children with raised D-dimer (Mean±SD=1881.94±1265.66 mg/dL) had a longer duration of stay (p-value=0.031). Conclusion: The study didn’t find any correlation between inflammatory markers with clinical presentation and the outcome of COVID-19 infection in children.

Study of Clinical, Hematological and Molecular Characteristics of Patients of Thalassemia and Hemoglobinopathies in Tertiary Care Hospital

To study clinical, hematological and molecular characteristics of patients of thalassemia and hemoglobinopathies and to correlate the molecular characteristics with clinical and hematological presentations. Material: This observational cross sectional study included 100 patients of age &gt;12 years of all genders with chronic haemolytic anemia and history of multiple blood transfusion. Blood and radiological investigations were done. Clinical, hematological and molecular characteristics were studied. Observation and Clinical: Pallor was present in all cases and icterus in 32% cases. Total 48% of the patients had hepatomegaly and 98% had splenomegaly. Among genotypes, 15% cases had α-thalassemia, 62% had β thalassemia + δβ thalassemia, 7% had HbS hemoglobinopathy, and 16% had HbE hemoglobinopathy. Hematological: Hemoglobin showed significant association with molecular genotypes of thalassemia with lowest being present in β-thalassemia + δβ thalassemia and HbE.MCV showed significant association with molecular genotypes, with HbE having the lowest MCV of 65.5 fl. LDH levels showed a significant association with molecular genotype with highest being in HbS hemoglobinopathy. Molecular Characteristics: Common mutations in compound α-thalassemia were 3.7, 4.2 and 20.5 deletion. As for β-thalassemia and δβ thalassemia, 47 cases had heterozygous type and 15 cases had homozygous types. In β-thalassemia, the homozygous type showed IVS1- 5(G→C),CD 41/42(→CTT) and IVSII-654(G→T) while heterozygous type showed CD16(→G), CD 41/42(→CTT), IVS1-5(G→C), and IVSII-654(G→T) . In δβ thalassemia, the heterozygous type showed δβ inversion mutation.In HbS hemoglobinopathy, heterozygous type showed Codon 6(A→T) and compound heterozygous type showed IVS1- 5(G→C) and Codon 6(A→T). In HbE hemoglobinopathy,the homozygous type showed CD26(G→A) and compound heterozygous type showed IVS1-5(G→C) and IVSII 654(G→T). Conclusion: The common thalassemia genotypes observed in our study were α-thalassemia (15%), β thalassemia + δβ thalassemia, (62%) HbS hemoglobinopathy (7%), and HbE hemoglobinopathy (16%). The patients presented with pallor, icterus, hepatomegaly, and splenomegaly which were comparable among all molecular genotypes of thalassemia and hemoglobinopathies. α-thalassemia had compound α-thalassemia with common mutations being 3.7, 4.2 and 20.5 deletion. As for β-thalassemia and δβ thalassemia, 47 cases had heterozygous type and 15 cases had homozygous types. In δβ thalassemia, the heterozygous type showed δβ inversion mutation in 5 cases. MCH, Retic count, ferritin stores, and peripheral blood smear were similar in all molecular genotypes. Hemoglobin, MCV and LDH showed a significant association with molecular genotypes. Microcytic hypochromic anaemia was commonest among all.The findings of the present study show that the genotypes of thalassemia are characterized by diversity as well as significant genetic heterogeneities.

Iron Deficiency Anaemia among Exclusively Breastfed Term Infants of 4-6 Months Age and its Contributing Factors: A Cross-sectional Study

Introduction: The risk of Iron Deficiency (ID) is a major concern associated with exclusively breastfed infants of age 4-6 months. According to World Health Organisation (WHO) iron should be universally supplemented from six months onwards instead of four months as recommended by American Academy of Paediatrics (AAP). Aim: To determine ID and Iron Deficiency Anaemia (IDA) among infants of age 4-6 months and relation of same to various socioeconomic and maternal parameters. Materials and Methods: This was a hospital-based, prospective, cross-sectional study conducted in the Department of Paediatrics of a tertiary care hospital in India. It included a sample population of 200 exclusively breastfed term infants, of age 4-6 months. Iron status was determined by studying the haemoglobin and serum ferritin levels and their associations to demographic, socio-economic and maternal parameters. Qualitative variables were analysed using the Chi-square test/Fisher's-exact test. Univariate and multivariate logistic regression was used to find out significant risk factors of ID and IDA. Results: Age wise distribution of infants was 91 (45.5%), 62 (31%), and 47 (23.5%) at 4, 5, and 6 months. Male-to-female ratio was 1.7:1. Mean±SD value of haemoglobin and serum ferritin was 10.82±0.60 g/dL and 44.60±25.02 μg/L, respectively. Prevalence of ID was 11 (12.09%), 16 (25.81%), and 16 (34.04%) at ages 4, 5, and 6 months, respectively. On multivariate regression analysis, age of mother <20 years (p-value 0.043), and increasing parity (p-value 0.001) were associated with low iron status. Conclusion: Almost one-third healthy, term exclusively breastfed infants become iron deficient by the age of six months. The study supports the need for iron supplementation from the age of four months universally instead of six months in exclusively breastfed term infants.

Visual estimate of coronary artery calcium predicts prevalent coronary artery disease in patients with respiratory disease

Background

Coronary artery calcification (CAC) measured using ECG-triggered coronary computed tomography correlates strongly with overt cardiovascular disease risk. Evidence is emerging to suggest CAC measured on non-gated thoracic CT scans may also correlate with cardiovascular disease. Herein, we sought to ascertain the utility of Weston scoring (visual score for CAC) in predicting prevalent coronary artery disease (CAD) and incident cardiovascular disease (CVD) for patients undergoing lung cancer screening or follow-up for interstitial lung disease with a non-triggered high-resolution CT (HRCT) thorax.

Methods

The Computerised Radiology Information Service (CRIS) database was manually searched to determine all HRCT scans performed in a single UK trust from 01/05/2016 to 01/05/2017 for the aforementioned indications. Radiology reports and images of selected studies were reviewed. For patients with evidence of CAC, we calculated the calcium score using the Agatston and Weston methods. Clinical events were determined from the electronic medical record without knowledge of patients' CAC findings. At baseline, significant CAC was defined as Agatston &gt;400 and Weston &gt;7.

Results

2152 scans were analysed. Data at follow up was available for 100% of patients, with a median duration of follow up of 3.6 years. A history of CAD was reported by 8% (172) of subjects at baseline, who were subsequently excluded from analysis. Significant CAC was found in 450 (22.5%) and 650 (32.5%) by Weston and Agatston scores respectively, with a significant correlation between the two scores (r-0.71, p&lt;0.01). During follow up 7.4% (160) of patients developed incident CVD. Patients with low Weston scores of ≤7 and Agatston scores of ≤400 had a lower incidence of CVD compared to those with Weston &gt;7 and Agatston &gt;400 (31 [19.3%] vs 129 [80.6%]; P=0.003 for Weston scores; 37 [23.1%] vs 123 [76.9%] for Agatston scores; P&lt;0.001).

Conclusion

In this retrospective study of patients with respiratory disease attending for HRCT scanning, the Weston visual score for CAC performs well in predicting prevalent CAD and future CVD events. With previous data demonstrating excellent inter- and intra- observer agreement, our study demonstrates Weston scoring is a valid tool in reporting non-gated CT scans, removing the need for dedicated software analysis as required with the Agatston score, and has a high overall positive and negative predictive value for future CVD. Further multi-centre prospective studies of this strategy, should be conducted to clarify the utility of Weston CAC scoring in non-gated CTs as a prediction tool which may be used to modify cardiac risk and reduce the risk of incident cardiovascular events.

Funding Acknowledgement

Type of funding sources: None.

An evaluation of patient outcomes following transcatheter pulmonary valve implantation: a meta-analysis

Background

Transcatheter pulmonary valve implantation has emerged as an effective alternative to surgery in patients with congenital Right Ventricular Outflow Tract Dysfunction (RVOT). There is demonstrable evidence that Percutaneous Pulmonary Valve Implantation (PPVI) effectively restores conduit graft viability with a consequent improvement in right ventricular pressures.

Aim

The objective of this study was to perform a meta-analysis of all previously published studies examining the outcome of PPVI and the associated early and late peri-procedural factors in patients with RVOT dysfunction. Data from procedures performed within our own centre have also been included.

Methodology

We performed a meta-analysis of all observational studies investigating early and late outcomes following PPVI. Risk ratios and risk differences were pooled in a random-effects model. The I2 statistic was used to quantify heterogeneity between studies. We searched EMBASE, MEDLINE, CINAHL, PsychInfo and Cochrane databases from their inception until 2021. Studies were included if they reported any comparative data regarding study endpoints. Primary endpoint was mean RVOT gradient. Secondary end points include pulmonary regurgitation fraction, left and right ventricular end-diastolic and systolic volume indexes, and left ventricular ejection fraction. Complication rates were considered a safety endpoint.

Results

A total of 23 studies with 1501 participants enrolled were included in the final meta-analysis. The RVOT gradient decreased significantly [weighted mean difference (WMD) = −20.32 mmHg; 95% confidence interval (CI): −22.15, −19.11; p&lt;0.001]. Mean right ventricular (RV) systolic pressures fell significantly [(WMD)= −18.4 mmHg; 95% CI: −16.4, −20.2; p&lt;0.001) and RV diastolic pressures decreased significantly [(WMD) = −6.3 mmHg, 95% CI: −4.3, −8.9; p&lt;0.001). Pulmonary regurgitation fraction (PRF) also decreased notably (WMD = −24.38%, 95% CI: −28.27, −17.32; p&lt;0.001).The incidence of infective endocarditis was 1.8% (95% CI: 0.7–3.8).

Conclusion

PPVI is an effective and safe strategy in relieving right ventricular remodelling and improving haemodynamic and clinical outcomes in patients with RVOT dysfunction. Multi-centre collaborations are essential to further determine the long-term effects of PPVI on cardiac function, exercise tolerance and quality of life in RVOT dysfunction.

Funding Acknowledgement

Type of funding sources: None.

The clinical implications of incidental coronary artery calcification in routine, non-triggered high-resolution thoracic computed tomography: a retrospective study

Background

Coronary artery calcium (CAC) is a marker of atherosclerosis and an independent risk factor for cardiac-related mortality. The measurement of this score has traditionally been based on using ECG triggered computed tomography (CT). However, CAC, identified on non-contrast high resolution chest computed tomography (HRCT), should be considered diagnostic for coronary artery disease (CAD). We aimed to evaluate the incidental prevalence and burden of CAC on non-gated HRCT thorax used for patients undergoing lung cancer screening or follow-up for interstitial lung disease. We also assessed how often Radiologists reported CAC as an incidental finding on these scans.

Methods

Computerised Radiology Information Service (CRIS) was manually searched to determine all HRCT scans performed in our Trust from 01/05/2018 to 01/05/2019. The reports issued by Radiologists and images of selected studies were reviewed.

Results

2185 HRCT scans were performed over this period. Patients were divided into three groups of age &lt;50 (Group 1); 50-&lt;60 (Group 2) and 60 (Group 3). 100 scans were randomly selected from each group using a random number generator to give a total of 300 patients. The mean ages of patients in Group 1, 2 and 3 were 48.3±2.3, 54.8±2.4 and 65±3.2 respectively. There was, approximately, the same number of males as females in each group. CAC was noted in 15% of scans in Group 1, 82% of scans in Group 2 and 94% scans in Group 3. CAC was only noted in 1/15 (6.7%) of scan reports in Group 1, 41/82 (50%) in Group 2 and 37/94 (39.4%) in Group 3. Among the 79 patients with radiologist-reported incidental CAC, statin and aspirin prescriptions increased by approximately 7 percentage points each. A diagnosis of CAD was eventually made in 9 (11.4%) patients through functional imaging or coronary angiogram. Two authors independently calculated the Agatston scores of HRCT scans whose reports did not comment on the degree of calcification. We excluded 15/112 (13.4%) scans as they were uninterpretable due to motion artefacts. Of the remaining 97 scans analysed 58/97 (59.8%) had severe CAC with an Agatston score of &gt;400 with the remaining showing moderate calcification (101–400). Cohen κ agreement between the two authors rating was 0.90 (95% confidence interval [CI] 0.87–0.96). Group 2 and 3 had significantly more patients with severe CAC then group 1 (p&lt;0.001). Left anterior descending artery was most commonly affected.

Conclusion

This study shows that CAC is under reported on non-gated HRCT scans which represents a missed opportunity to implement strategies for primary and secondary prevention. Given that respiratory disease is an independent risk factor for developing cardiac disease, it is incumbent upon the interpreting clinician to report all findings and ensure that critical findings are highlighted. The images of calcified coronary arteries may also potentially have a role in convincing people to make correct lifestyle choices.

Funding Acknowledgement

Type of funding source: None

The utility of coronary artery calcium in non-gated high resolution CT thorax scans in predicting cardiac events as compared to the Framingham risk score: a retrospective study

Background

There is existing evidence to suggest a correlation between coronary artery calcification (CAC) measured using ECG-triggered chest computed tomography and cardiovascular disease. Further evidence has emerged to suggest a correlation between CAC measured using non-gated CT scans and cardiovascular disease. Herein, we sought to ascertain the utility of incidental findings of CAC on non-triggered high resolution CT (HRCT) thorax used for patients undergoing lung cancer screening or follow-up for interstitial lung disease and Framingham risk score (FRS) in predicting cardiovascular events.

Methods

The Computerised Radiology Information Service (CRIS) database was manually searched to determine all HRCT scans performed in a single trust from 05/2015 to 05/2016. The reports issued by Radiologists and images of selected studies were reviewed. For patients with CAC, we calculated the calcium score for patients using the Agatston method. Clinical events were determined from the electronic medical record without knowledge of patients' CAC findings. For these patients, the Framingham Risk Score (FRS) was also calculated. The primary end point of the study was composite of all-cause mortality and cardiac events (non-fatal myocardial infarction, coronary revascularization, new atrial fibrillation or heart failure episode requiring hospitalization).

Results

We selected 300 scans from a total of approximately 2000 scans performed over this time. Data at follow up was available for 100% of the patients, with a median duration of follow up of 1.6 years. Moderate to severe CAC was found in 35% of people. Multivariable analysis showed good concordance between CAC and FRS in predicting composite clinical end point. The Odds Ratio for cardiac events in patients with moderate to severe CAC was 5.3 (p&lt;0.01) and for composite clinical end point was 3.4 (p&lt;0.01). This is similar to the OR predicted by the FRS: 4.8; p&lt;0.01 and 3.1; p&lt;0.01 respectively. Only 6.2% of patients with moderate to severe CAC were currently statin treated.

Conclusion

In this retrospective study of patients with respiratory disease attending for HRCT scanning, co-incidentally detected CAC predicts cardiac events, with good concordance with the FRS. The incidental finding of CAC on non-gated CT scanning should be reported with Agatston score calculation allowing consideration of intervention to mitigate cardiovascular risk and optimize. Further multi-centre prospective studies of this strategy, with a larger patient cohort should be conducted to clarify the utility of CAC as a prediction tool to modify cardiac risk.

Funding Acknowledgement

Type of funding source: None

Safety and effectiveness of intravenous iron sucrose versus standard oral iron therapy in pregnant women with moderate-to-severe anaemia in India: a multicentre, open-label, phase 3, randomised, controlled trial

BACKGROUND

Intravenous iron sucrose is a promising therapy for increasing haemoglobin concentration; however, its effect on clinical outcomes in pregnancy is not yet established. We aimed to assess the safety and clinical effectiveness of intravenous iron sucrose (intervention) versus standard oral iron (control) therapy in the treatment of women with moderate-to-severe iron deficiency anaemia in pregnancy.

METHODS

We did a multicentre, open-label, phase 3, randomised, controlled trial at four government medical colleges in India. Pregnant women, aged 18 years or older, at 20-28 weeks of gestation with a haemoglobin concentration of 5-8 g/dL, or at 29-32 weeks of gestation with a haemoglobin concentration of 5-9 g/dL, were randomly assigned (1:1) to receive intravenous iron sucrose (dose was calculated using a formula based on bodyweight and haemoglobin deficit) or standard oral iron therapy (100 mg elemental iron twice daily). Logistic regression was used to compare the primary maternal composite outcome consisting of potentially life-threatening conditions during peripartum and postpartum periods (postpartum haemorrhage, the need for blood transfusion during and after delivery, puerperal sepsis, shock, prolonged hospital stay [>3 days following vaginal delivery and >7 days after lower segment caesarean section], and intensive care unit admission or referral to higher centres) adjusted for site and severity of anaemia. The primary outcome was analysed in a modified intention-to-treat population, which excluded participants who refused to participate after randomisation, those who were lost to follow-up, and those whose outcome data were missing. Safety was assessed in both modified intention-to-treat and as-treated populations. The data safety monitoring board recommended stopping the trial after the first interim analysis because of futility (conditional power 1·14% under the null effects, 3·0% under the continued effects, and 44·83% under hypothesised effects). This trial is registered with the Clinical Trial Registry of India, CTRI/2012/05/002626.

FINDINGS

Between Jan 31, 2014, and July 31, 2017, 2018 women were enrolled, and 999 were randomly assigned to the intravenous iron sucrose group and 1019 to the standard therapy group. The primary maternal composite outcome was reported in 89 (9%) of 958 patients in the intravenous iron sucrose group and in 95 (10%) of 976 patients in the standard therapy group (adjusted odds ratio 0·95, 95% CI 0·70-1·29). 16 (2%) of 958 women in the intravenous iron sucrose group and 13 (1%) of 976 women in the standard therapy group had serious maternal adverse events. Serious fetal and neonatal adverse events were reported by 39 (4%) of 961 women in the intravenous iron sucrose group and 45 (5%) of 982 women in the standard therapy group. At 6 weeks post-randomisation, minor side-effects were reported by 117 (16%) of 737 women in the intravenous iron sucrose group versus 155 (21%) of 721 women in the standard therapy group. None of the serious adverse events was found to be related to the trial procedures or the interventions as per the causality assessment made by the trial investigators, ethics committees, and regulatory body.

INTERPRETATION

The study was stopped due to futility. There is insufficient evidence to show the effectiveness of intravenous iron sucrose in reducing clinical outcomes compared with standard oral iron therapy in pregnant women with moderate-to-severe anaemia.

FUNDING

WHO, India.

Foot ulceration and its association with mortality in diabetes mellitus: a meta-analysis

BACKGROUND

Diabetic foot ulcers portend an almost twofold increase in all-cause mortality compared with diabetes on its own.

AIM

To investigate the association between diabetic foot ulcers and risk of death.

METHODS

We performed a meta-analysis of all observational studies investigating the association between diabetic foot ulcers and all-cause mortality. Risk ratios and risk differences were pooled in a random-effects model. The I² statistic was used to quantify heterogeneity between studies.

RESULTS

Altogether, we identified 11 studies that reported 84 131 deaths from any cause in 446 916 participants with diabetes during a total of 643 499 person-years of follow-up. The crude event rate for all-cause mortality in individuals with diabetes who did not develop foot ulceration was 22% lower at 181.5 deaths (per 1000 person-years) than in those who developed foot ulcers (230.8 per 1000 person-years). Diabetic foot ulceration was associated with an increased risk of all-cause mortality (pooled relative risk 2.45, 95% CI 1.85-2.85). We did not observe any tangible differences in risk of all-cause mortality from diagnosis in studies reporting a mean duration of follow-up of ≤3 years (relative risk 2.43, 95% CI 2.27-2.61) or >3 years (relative risk 2.26, 95% CI 2.13-2.40) years. Funnel plot inspection revealed no significant publication bias among studies included in this meta-analysis.

CONCLUSIONS

Our study shows an excess rate of all-cause mortality in people with diabetic foot ulceration when compared to those without foot ulceration. It is imperative that early interventions to prevent foot ulceration and modify cardiovascular disease risk factors are put in place to reduce excess mortality.

Nationwide study of appendicitis in children

Background

Paediatric surgical care is increasingly being centralized away from low‐volume centres, and prehospital delay is considered a risk factor for more complicated appendicitis. The aim of this study was to determine the incidence of paediatric appendicitis in Sweden, and to assess whether distance to the hospital was a risk factor for complicated disease.

Methods

A nationwide cohort study of all paediatric appendicitis cases in Sweden, 2001–2014, was undertaken, including incidence of disease in different population strata, with trends over time. The risk of complicated disease was determined by regression methods, with travel time as the primary exposure and individual‐level socioeconomic determinants as independent variables.

Results

Some 38 939 children with appendicitis were identified. Of these, 16·8 per cent had complicated disease, and the estimated risk of paediatric appendicitis by age 18 years was 2·5 per cent. Travel time to the treating hospital was not associated with complicated disease (adjusted odds ratio (OR) 1·00 (95 per cent c.i. 0·96 to 1·05) per 30‐min increase; P = 0·934). Level of education (P = 0·177) and family income (P = 0·120) were not independently associated with increased risk of complicated disease. Parental unemployment (adjusted OR 1·17, 95 per cent c.i. 1·05 to 1·32; P = 0·006) and having parents born outside Sweden (1 parent born in Sweden: adjusted OR 1·12, 1·01 to 1·25; both parents born outside Sweden: adjusted OR 1·32, 1·18 to 1·47; P < 0·001) were associated with an increased risk of complicated appendicitis.

Conclusion

Every sixth child diagnosed with appendicitis in Sweden has a more complicated course of disease. Geographical distance to the surgical facility was not a risk factor for complicated appendicitis.

Synthesis of 3 H, 13 C2 , 2 H414 C-SCH 430765 and 35 S-SCH 500946, potent and selective inhibitors of the NPY5 receptor

SCH 430765 and SCH 500496 are potent and selective antagonists of the NPY₅ receptor. NPY₅ receptor antagonists have the potential for the treatment of obesity. [³⁵ S]SCH 500946 was prepared for a competition binding assay which led to the identification of SCH 430765. Three distinct isotopically labelled forms of SCH 430765 were synthesized. [³ H]SCH 430765 was prepared for a preliminary absorption, distribution, metabolism and excretion data evaluation of the compound and [¹⁴ C]SCH 430765 for more definitive absorption, distribution, metabolism and excretion data work. In addition, [¹³ C₂ ,² H₄ ]SCH 430765 was prepared as an internal standard for a LC-MS bioanalytical method. The paper discusses the synthesis of 3 isotopically labelled forms of SCH 430765 and [³⁵ S]SCH 500946.

Expression of Apoptosis Related and Proliferative Proteins in Malignant Lympho-Proliferative Disorders

BACKGROUND & OBJECTIVE

The current study aimed to perform an immunohistochemical analysis of patterns of apoptotic and cell proliferative related protein expression in different histological grades and immune phenotypes of malignant lymphomas and other lymphoproliferative disorders.

METHODS

This observational study was carried on 60lymph node biopsies of lymphoproliferative disorders. The biopsies were analyzed histologically and immunohistochemically.

RESULTS

A total of 60 lymph node biopsies were included in the study, of which 81.6% were of malignant lympho-proliferative lesions. The majority of the biopsies were B-cell (66%) and were grouped in the intermediate grade. Bax and BCL-2 protein expression was presented by percentage of immune positive neoplastic cells per 10fields and graded on a scale of 1 to4. A Bcl-2, Bax Protein Ratio (BBPR) was determined for each case by dividing the estimated Bcl-2 protein (percentage of Bcl-2 positive cells x Bcl-2 staining intensity) by the estimated Bax protein (percentage of Bax positive cells x Bax immunostaining intensity). The mean BBPR was found to be significantly higher in indolent lymphomas (2.64 ± 1.3) as compared to aggressive lymphomas (0.47 ± 0.9) (P<0.01). The expression of P53 and PCNA in 35 biopsies of Non Hodgkin Lymphomas (NHL) was found to increase from low to high grade tumors.

CONCLUSIONS

A significant correlation was found between BBPR and predicted biological behavior of indolent and aggressive lymphomas. This indicates the important role of Bcl-2 and Bax in biological behavior of lymphomas. Furthermore, P53 and PCNA expression were found to increase from low to high-grade tumors suggesting their prognostic value in NHL.

Synthesis of 3 H, 2 H4 , and 14 C-MK 3814 (preladenant)

MK 3814 is a potent and selective antagonist of the A_2a receptor. A_2a receptor antagonists have the potential for the treatment of Parkinson disease. Three distinct isotopically labelled forms of MK 3814 were synthesized. [³ H]MK 3814 was prepared for a preliminary absorption, distribution, metabolism, and excretion data (ADME) evaluation of the compound and [¹⁴ C]MK 3814 for more definitive ADME work, including an absorption, metabolism, and excretion study in man. In addition, [² H₄ ]MK 3814 was prepared as an internal standard for a liquid chromatography mass spectrometry bioanalytical method. This paper discusses the synthesis of 3 isotopically labelled forms of MK 3814.

Synthesis of (3) H, (2) H4 and (14) C-SCH 417690 (Vicriviroc)

Vicriviroc or SCH 417690 is a potent and selective antagonist of the CCR5 receptor. CCR5 receptor antagonists have the potential for the treatment of HIV infections. Four distinct isotopically labelled forms of SCH 417690 were synthesized. Low specific activity [(3) H]SCH 417690 was prepared for a preliminary absorption, distribution, metabolism and excretion evaluation of the compound and [(14) C]SCH 417690 for more definitive absorption, distribution, metabolism and excretion work, including an absorption, metabolism and excretion study in man. In addition, high specific activity [(3) H]SCH 417690 was prepared for CCR5 receptor binding work and [(2) H4 ]SCH 417690 was prepared as an internal standard for a liquid chromatography-mass spectrometry bioanalytical method. The paper discusses the synthesis of four isotopically labelled forms of SCH 417690.

Platelet functions and coagulation changes in Indian children with nephrotic syndrome

INTRODUCTION

Only little is known on the effect of the platelet function in the paediatric nephrotic syndrome. The earlier studies which had been done on hypercoagulability have mainly featured the secondary forms of the nephrotic syndrome and the data on the minimal change type of disease is limited. We therefore, made an effort to study the platelet functions and the coagulation profile in children with the nephrotic syndrome,to find the relationship between the steroid response and the coagulation profile, and to look for the correlation between thromboembolism and the hypercoagulable states.

METHODOLOGY

Twenty nine children with the steroid responsive nephrotic syndromewere studied to see the platelet aggregation and the coagulation parameters and their response to the steroid therapy. Doppler studies were done for the renal vein and the inferior vena cava (IVC) thrombus.

RESULTS

It was seen that an increased aggregability of the platelets occurred with Adenosine diphosphate (ADP) and collagen (out of the four agonists, ADP, Collagen, Ristocetin and Arachidonic acid) which were used as agonists for the assay. We also observed that the Partial thromboplastin time (PTT) had become prolonged and a significant decline in the high values of the procoagulant proteins (Protein C and Protein S) was seen after the steroid therapy and when the children went into remission. These findings were suggestive of a reversibility of the changes in the steroid responsive nephrotic syndrome with the steroid therapy. One child was found to have thrombosis of the inferior vena cava (IVC) on Doppler studies, which resolved with treatment subsequently.

CONCLUSIONS

An increased platelet aggregability contributes to the hypercoagulable states, that may increase the incidence of thrombosis in such patients. Although the incidence of such complications is very low, in a given child with the hypercoagulable states, Doppler may be used to look for any evidence of a latent thrombus and, an early intervention could be instituted. A change in the coagulation parameters points to the reversibility of the changes which are produced in a diseased state.

Imaging diagnosis of neonatal anemia: report of two unusual etiologies

Anemia in neonatal period is rare, with the common causes being Rh and ABO blood group incompatibility, hemorrhagic disease of newborn, congenital hemolytic anemia, hemoglobinopathies, and TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes virus) infections. Congenital leukemia and infantile osteopetrosis (OP) are among the rare causes of neonatal anemia. A review of the literature shows approximately 200 reported cases of congenital leukemia. Articles describing the imaging features of congenital leukemia are still rarer. Infantile OP, another rare disorder with a reported incidence of 1 in 250,000 has characteristic imaging features, which are diagnostic of the disease. We report a case each, of two rare diseases: Congenital leukemia and infantile osteopetrosis. Additionally, our report highlights the radiological and imaging features of congenital leukemia and infantile OP and their crucial role in arriving at an early diagnosis.

High order interactions of xenobiotic metabolizing genes and P53 codon 72 polymorphisms in acute leukemia

Polymorphisms in xenobiotic metabolizing genes are associated with altered metabolism of carcinogens in acute leukemia (AL). This study applied two data mining approaches to explore potential interactions among P53 and xenobiotic metabolizing genes in 230 AL patients [131 acute myeloid leukemia (AML) and 99 acute lymphoblastic leukemia (ALL)] and 199 controls. Individually, none of the genotypes showed significant associations with AML risk. However, in ALL the CYP1A12A TC genotype was associated with increased risk (OR = 2.02; 95% CI = 1.14-3.58; P = 0.01), whereas the GSTM1 null genotype imparted reduced risk (OR = 0.55; 95% CI = 0.31-0.96; P = 0.03). In classification and regression tree analysis, combinations of GSTM1 present, CYP1A12C AA or GG, EPHX1 exon3 TC, and EPHX1 exon4 AA or GG genotype strongly enhanced the risk of AML (OR = 5.89; 95% CI = 1.40-26.62; P = 0.01). In ALL, combinations of CYP1A12A TT, P53 GG or CC and GSTP1 AG genotypes conferred the highest risk (OR = 4.19; 95% CI = 1.45-12.25; P = 0.004). In multifactor dimensionality reduction analysis, a four locus model (GSTP1, P53, EPHX1 exon3, and CYP1A12A) was the best predictor model for ALL risk. The association between this model and ALL risk remained true even at low prior probabilities of 0.01% (false positive report probability = 0.05). Interaction entropy interpretations of the best model of ALL revealed that two-way interactions were mostly synergistic. These results suggest that high order gene-gene interactions play an important role in AL risk.

Disseminated intravascular coagulation with intracranial haematoma in neonatal congenital syphilis

Disseminated intravascular coagulation (DIC) although a well known complication in neonatal sepsis is extremely rare in congenital syphilis and there are scanty reports of this entity in the literature. Intracranial bleeding following DIC in neonatal congenital syphilis is even rarer, and has been reported only once earlier. We are reporting the second case of neonatal DIC with intracranial haematoma due to congenital syphilis in a newborn. Our patient also had clinical and biochemical evidence of hepatitis which predisposes to DIC. Extensive investigations and emergent use of imaging modalities including ultrasound and CT scan led to early diagnosis and treatment in our patient, who could therefore be salvaged from an otherwise life threatening disease.

Association of glutathione S-transferase, EPHX, and p53 codon 72 gene polymorphisms with adult acute myeloid leukemia

Polymorphisms in genes encoding detoxification enzymes have been suggested as susceptibility factors for many solid tumors. However, their association with hematological malignancies is controversial. A case-control study was done to determine the association between glutathione S-transferase M1 (GSTM1), GSTT1, GSTP1, EPHX1, and p53 codon 72 polymorphisms as risk factors in 120 adult acute myeloid leukemia (AML) cases and 202 healthy controls by polymerase chain reaction-restriction fragment length polymorphism techniques. Data were analyzed using χ(2) and conditional logistic regression model. None of the polymorphisms studied alone was associated with increased risk for AML. However, the frequency of GSTT1 null genotype was higher among controls (28.7%) than AML cases (21.6%), which showed a protective effect of the null genotype (odds ratio = 0.58, 95% confidence interval: 0.33-1.05, p = 0.07). In a combined analysis, both EPHX1 (His113His) and GSTP1 (Ile/Val) genes imparted a fourfold risk for adult AML but did not reach statistical significance (odds ratio = 4.22, 95% confidence interval: 0.992-17.99, p = 0.05). These findings suggest that the etiology of adult AML cannot be explained by polymorphism at a single locus, perhaps because of complexity involved in the metabolism of diverse xenobiotic compounds, and therefore, multiple gene-gene interactions should be investigated to predict the risk of AML.

Coagulation profile in diabetes and its association with diabetic microvascular complications

OBJECTIVES

To investigate the haemostatic parameters and to assesss their relationship with microvascular complications in type 2 diabetes mellitus.

MATERIALS AND METHODS

Coagulation and fibrinolysis parameters were measured in 60 type 2 diabetic patients (M:F 1:1) with (n=40) and without (n=20) diabetic microvascular complications and in 30 nondiabetic healthy subjects (M:F 1:1).

RESULTS

The mean age of diabetic patients and healthy controls was 56.9 +/- 8.78 and 53.2 +/- 7.58 respectively (p = 0.05). The plasma levels of PAI-1 (22.6 +/- 6.85 vs 44.8 +/- 20.8, p = 0.00), serum fibrinogen (227.5 +/- 22.8 vs. 252.75 +/- 40.23, p = 0.002) and vWF activity (99.4 +/- 28.18 vs. 144.78 +/- 36.21, p = 0.00) were found to be increased in diabetics compared to healthy controls. Plasma PAI-1 levels (37.15 +/- 15.18 vs 48.65 +/- 22.29, p = 0.0) and vWF activity (123.19 +/- 29.63 vs. 155.57 +/- 34.61, p = 0.007) were significantly increased in diabetic patients with microvascular complications than those without microvascular complications.Amongst the diabetic patients, protein S activity (63.05 +/- 16.85 vs. 51.59 +/- 10.7, p = 0.002) was significantly lower in patients with microvascular complications than in patients without these complications. Diabetic retinopathy was associated with decreased protein S levels (63.05 +/- 16.85 vs. 48.48 +/- 8.72, p = 0.005) and vWF activity (123.19 +/- 29.63 vs. 151.85 +/- 29.74, p = 0.009). Diabetic nephropathy was associated with increased PAI-1 levels (39.55 +/- 13.20 vs. 51.69 +/- 26.53, p = 0.02) and vWF activity (134.99 +/- 32.54 vs. 157.57 +/- 37.37, p = 0.007). Diabetic neuropathy did not show any significant relationship with any of the haemostatic variables.

CONCLUSION

Hypercoagulable state as indicated by decreased fibrinolysis and increased coagulability is responsible as one of the factors for the development of microvascular complications of diabetes mellitus.

Relation of cell viability and apoptosis with clinical remission following induction chemotherapy in ALL and AML

Evaluation of in vitro spontaneous apoptosis of acute leukemic blast cells after incubating for different time period and its correlation with clinical outcome is well documented in the literature. However, there is insufficient information available on the flowcytometric determination of cell viability immediately after separating blast cells and its correlation with the clinical response. In this study, we attempted to evaluate the relationship between viability of freshly isolated leukemic cells and the clinical response. Cell viability was evaluated in freshly isolated leukemic cells from 84 patients with acute leukemia (AL) using 7-Amino-Actinomycin D and was correlated with the clinical response following induction chemotherapy. Patients with ALL who achieved complete remission (CR) had significantly lower mean live cell (70.9%) compared to those patients who did not achieve CR (93.3%) (p=0.02). Furthermore, ALL responders had also significantly higher mean early apoptotic cell (19.4%) as compared to non responders (5%) (p=0.04). No significant difference was found in the mean live / early apoptotic cell count of responders and non responders of AML patients. The probability of obtaining CR in ALL patients was 3.7 and 2.7 times higher in those who had mean live cell count less than 70% and apoptotic cell count more than 10%, respectively. A lower cell viability and higher apoptosis in freshly isolated leukemic cells at the time of diagnosis may indicate a favorable response in patients with ALL but may not provide any sufficient information in predicting the response in AML patients to induction chemotherapy.

Combined transmesocolic and left paraduodenal hernia: barium, CT and MRI features

Internal hernia is difficult to diagnose clinically because the symptoms are often non-specific. Although this entity is an uncommon cause of small-bowel obstruction, prompt diagnosis is essential for a favorable outcome. We report the barium, CT and MRI features of a rare case of non-obstructing combined transmesocolic and left paraduodenal hernia.

Elevated levels of interferon-gamma, interleukin-10, and interleukin-6 during active disease in Indian kala azar

We have evaluated levels of 6 cytokines in sera of 35 patients of kala azar (KA), 29 post kala azar dermal leishmaniasis (PKDL), and 18 healthy controls using cytometric bead array technology. Results indicated significantly high levels of interferon gamma (IFN-gamma), interleukin (IL)-10, and IL-6 during active KA, while tumor necrosis factor alpha (TNF-alpha), IL-2, and IL-4 were minimal. Serum level of cytokines in PKDL was comparable to the controls while TNF-alpha was significantly elevated compared to KA or control. At post-treatment stage, KA patients showed a significant decrement in the levels of IFN-gamma, IL-10, and IL-6; however, IL-6 remained significantly elevated above control levels. Further, comparison of cytokine levels in children and adults revealed elevated level of IL-10 in pediatric cases. SAG unresponsive cases showed significantly elevated levels of IFN-gamma in comparison with the responsive cases. The results depict that type1 response is not depressed during active KA and suggest the possibility that unresponsiveness to type1 stimuli may prevail.

Disseminated histoplasmosis with reactive haemophagocytosis presenting as PUO in an immunocompetent host

Disseminated histoplasmosis (DH) with reactive haemophagocytosis has been described in literature mainly in immunocompromised hosts. Only sporadic case reports exist in immunocompetent hosts. Here, we present a rare case of DH with reactive haemophagocytosis in an immunocompetent host presenting as PUO.