Impact of COVID-19 pandemic on pediatric cardiac services in India

BACKGROUND

COVID-19 pandemic has disrupted pediatric cardiac services across the globe. Limited data are available on the impact of COVID.19 on pediatric cardiac care in India.

AIMS

The aims are to study the impact of COVID-19 pandemic on the care of children with heart disease in India in terms of number of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries.

SETTINGS AND DESIGN

This is a retrospective, multicentric, observational study.

METHODS

We collected monthly data on the number and characteristics of outpatient visits, hospitalizations, catheter-based interventions, and cardiac surgeries and major hospital statistics, over a period of 5 months (April to August 2020), which coincided with the first wave of COVID-19 pandemic in India and compared it with data from the corresponding months in 2019.

RESULTS

The outpatient visits across the 24 participating pediatric cardiac centers decreased by 74.5% in 2020 (n = 13,878) as compared to the corresponding period in 2019 (n = 54,213). The reduction in the number of hospitalizations, cardiac surgeries, and catheterization procedures was 66.8%, 73.0%, and 74.3%, respectively. The reduction in hospitalization was relatively less pronounced among neonates as compared to infants/children (47.6% vs. 70.1% reduction) and for emergency surgeries as compared to elective indications (27.8% vs. 79.2%). The overall in-hospital mortality was higher in 2020 (8.1%) as compared to 2019 (4.8%), with a higher postoperative mortality (9.1% vs. 4.3%).

CONCLUSIONS

The current COVID-19 pandemic significantly impacted the delivery of pediatric cardiac care across India with two-third reduction in hospitalizations and cardiac surgeries. In an already resource-constrained environment, the impact of such a massive reduction in the number of surgeries could be significant over the coming years. These findings may prove useful in formulating strategy to manage subsequent waves of ongoing COVID-19 pandemic.

Outcome of COVID-19-positive children with heart disease and grown-ups with congenital heart disease: A multicentric study from India

BACKGROUND

Outcome data of children with heart disease who acquired COVID-19 infection are limited.

AIMS

We sought to analyze outcome data and identify risk factors associated with mortality in children with heart disease and grown-ups with congenital heart disease (GUCH) who had a laboratory-confirmed COVID-19 infection.

SETTINGS AND DESIGN

This is a retrospective, multicentric, observational study.

MATERIALS AND METHODS

The study included children with heart disease and GUCH population, who presented with either symptomatic or asymptomatic COVID-19 infection to any of the participating centers. COVID-19-negative patients admitted to these centers constituted the control group.

RESULTS

From 24 pediatric cardiac centers across India, we included 94 patients with a median age of 12.5 (interquartile range 3-96) months and 49 (52.1%) patients were males. Majority (83 patients, 88.3%) were children. One-third of the patients (n = 31, 33.0%) had acyanotic congenital heart disease, and 41.5% (n = 39) were cyanotic, with > 80% of the patients being unoperated. Only 30 (31.9%) patients were symptomatic for COVID-19 infection, while the rest were incidentally detected positive on screening. A total of 13 patients died (case fatality rate: 13.8%). The in-hospital mortality rate among hospitalized patients was significantly higher among COVID-19-positive cases (13 of 48; 27.1%) as compared to COVID-negative admissions (9.2%) during the study period (P < 0.001). On multivariate analysis, the independent predictors of mortality among COVID-19-positive cases were severity of illness at admission (odds ratio [OR]: 535.7, 95% confidence interval [CI]: 6.9-41,605, P = 0.005) and lower socioeconomic class (OR: 29.5, 95% CI: 1.1-814.7, P = 0.046).

CONCLUSIONS

Children with heart disease are at a higher risk of death when they acquire COVID-19 infection. Systematic preventive measures and management strategies are needed for improving the outcomes.

Depth resolved defect characterization of energetic ion irradiated ZnO by positron annihilation techniques and photoluminescence

Depth resolved positron annihilation spectroscopy (PAS) has been employed to characterize the 1.2 MeV Ar and 800 keV O ion beam induced defects in ZnO. The first extraordinary result was the observation of defects in ion beam irradiated ZnO beyond the maximum penetration depth of the respective ions. The positron annihilation results revealed the formation of vacancy clusters consisting of both V_Zn and V_O in ZnO which are saturated at a threshold radiation dose (defined as nuclear energy loss, S_n  ×  fluence). From the photoluminescence (PL) spectra it has been observed that the PL intensity at the band edge degraded with the increase of open volume defects in ZnO. The evolution of the 2.4 eV PL, which is linked with the oxygen vacancies, is more significant due to Ar irradiation than the oxygen irradiation.

Replication of optical microlens array using photoresist coated molds

A cost reduced method of producing injection molding tools is reported and demonstrated for the fabrication of optical microlens arrays. A standard computer-numerical-control (CNC) milling machine was used to make a rough mold in steel. Surface treatment of the steel mold by spray coating with photoresist is used to smooth the mold surface providing good optical quality. The tool and process are demonstrated for the fabrication of an ø50 mm beam homogenizer for a color mixing LED light engine. The acceptance angle of the microlens array is optimized, in order to maximize the optical efficiency from the light engine. Polymer injection molded microlens arrays were produced from both the rough and coated molds and have been characterized for lenslet parameters, surface quality, light scattering, and acceptance angle. The surface roughness (R_a) is improved approximately by a factor of two after the coating process and the light scattering is reduced so that the molded microlens array can be used for the color mixing application. The measured accepted angle of the microlens array is 40° which is in agreement with simulations.

MiR-7-1 potentiated estrogen receptor agonists for functional neuroprotection in VSC4.1 motoneurons

Protection of motoneurons is an important goal in the treatment of spinal cord injury (SCI). We tested whether neuroprotective microRNAs (miRs) like miR-206, miR-17, miR-21, miR-7-1, and miR-106a could enhance efficacy of estrogen receptor (ER) agonists such as 1,3,5-tris (4-hydroxyphenyl)-4-propyl-1H-pyrazole (PPT, ERα agonist), Way200070 (WAY, ERβ agonist), and estrogen (EST, ERα and ERβ agonist) in preventing apoptosis in the calcium ionophore (CI)-insulted ventral spinal cord 4.1 (VSC4.1) motoneurons. We determined that 200 nM CI induced 70% cell death. Treatment with 50 nM PPT, 100 nM WAY, and 150 nM EST induced overexpression of ERα, ERβ, and both receptors, respectively, at mRNA and protein levels. Treatment with ER agonists significantly upregulated miR-206, miR-17, and miR-7-1 in the CI-insulted VSC4.1 motoneurons. Transfection with miR-206, miR-17, or miR-7-1 mimic potentiated WAY or EST to inhibit apoptosis in the CI-insulted VSC4.1 motoneurons. Overexpression of miR-7-1 maximally increased efficacy of WAY and EST for down regulation of pro-apoptotic Bax and upregulation of anti-apoptotic Bcl-2. A search using microRNA database (miRDB) indicated that miR-7-1 could inhibit the expression of L-type Ca(2+) channel protein alpha 1C (CPα1C). miR-7-1 overexpression and WAY or EST treatment down regulated CPα1C but upregulated p-Akt to trigger cell survival signaling. The same therapeutic strategy increased expression of the Ca(2+)/calmodulin-dependent protein kinase II beta (CaMKIIβ) and the phosphorylated cAMP response element binding protein (p-CREB) so as to promote Bcl-2 transcription. Whole cell membrane potential and mitochondrial membrane potential studies indicated that miR-7-1 highly potentiated EST to preserve functionality in the CI-insulted VSC4.1 motoneurons. In conclusion, our data indicated that miR-7-1 most significantly potentiated efficacy of EST for functional neuroprotection and this therapeutic strategy could be used in the future to attenuate apoptosis of motoneurons in SCI.

P2-16-11: Role of Proper Patient Counselling in Combination with Effect of Socioeconomic Deprivation on the Rate of Immediate Breast Reconstruction after Mastectomy

Introduction: current guidelines in the United Kingdom suggest that the possibility of breast reconstruction should be discussed with all patients prior to mastectomy. However, the majority of patients are still treated with mastectomy alone and no reconstruction is carried out. It has also been suggested that women from more deprived areas are less likely to undergo immediate breast reconstruction (IBR). We investigated potential pitfalls in patient counselling and consequent decision making contributing to present IBR rate in combination with the effect of socioeconomic deprivation.

Methods: data from 89 consecutive mastectomy patients was prospectively collected in a single centre in Glasgow between August 2010 and March 2011. Each patient was scored for deprivation based on The Scottish Index of Multiple Deprivation. The patients were then divided into two groups: high and low deprivation levels. Consultations about IR and patients’ acceptance of counselling were analysed. For statistical calculations Fischer's exact test was applied. Results: IBR was offered to 41 (46%) patients, but it was not to 42 (47%) (6 were excluded due to incomplete data). 25 patients accepted IBR, and of those 24 (27%) underwent IBR. 16 of 41 patients refused to undergo IBR due to lack of interest (10), not feeling ready for it (2), preference of delayed procedure (2) and fear of delaying adjuvant therapy (2). Of 42 patients whom IBR was not offered, only 10 were documented in the notes, while there was no reference for discussing reconstruction in 32 (36%) cases. Reasons for not even discussing reconstruction were the following: age (15), co-morbidities (18), locally advanced cancer (2), co-morbidities with age (5), and locally advanced cancer with age (2). As regards to socioeconomic deprivation; 44 (49%) patients were from deprived areas and 39 (44%) from affluent areas. 41 patients were offered IBR and of these 23 (26%) were from affluent areas compared to 18 (20%). Of the 42 patients who were not offered IR, 26 (29%) were from deprived while 16 (18%) from affluent areas (p&lt;0.05). Of the 44 deprived patients, 18 were offered IBR but 26 were not. 15 of 25 patients, who accepted IBR, were from affluent areas. The 16 patients who refused IBR had equal distribution of deprivation.

Conclusions: while none of the reasons for not offering IBR represent absolute contraindication to IBR, decisions about refusal are based mostly on patients’ subjective intuitions. Further, a greater proportion of the patients who were not offered IBR were from more deprived areas, and it seems that patients from affluent areas are more likely to be offered IBR compared to ones from deprived areas. However, confounding factors such as co-morbidities may contribute to the above. We believe, therefore, that detailed counselling about reconstruction of each patient requiring mastectomy is necessary, which is likely to further increase IBR rate.

Pericardial cyst due to tuberculosis in an adolescent

Patient with a mediastinal mass may be diagnosed incidentally or following evaluation for the symptoms due to compressive effects on the adjoining structures. Pericardial cysts account to 6% of mediastinal masses. Echocardiography, computerised tomography and magnetic resonance imaging aid in accurate diagnosis and localization of these cysts. Anaesthesia for patients with these cysts may occasionally turn out to be catastrophic during induction or in postoperative period. Surgery is the preferred choice of treatment in these patients.

Comparison of the prognostic value of selected markers of the systemic inflammatory response in patients with colorectal cancer

There is increasing evidence that the presence of a systemic inflammatory response plays an important role in predicting survival in patients with colorectal cancer. However, it is not clear what components of the systemic inflammatory response best predict survival. The aim of the present study was to compare the prognostic value of an inflammation-based prognostic score (modified Glasgow Prognostic Score (Mgps) 0=C-reactive protein <10 mg l⁻¹, 1=C-reactive protein >10 mg l⁻¹, and 2=C-reactive protein >10 mg l⁻¹ and albumin<35 g l⁻¹) with that of components of the white cell count (neutrophils, lymphocytes, monocytes and platelets using standard thresholds) in patients with colorectal cancer. Two patient groups were studied: 149 patients who underwent potentially curative resection for colorectal cancer and 84 patients who had synchronous unresectable liver metastases. In those patients who underwent potentially curative resection the minimum follow-up was 36 months and 20 patients died of their cancer. On multivariate survival analysis only TNM stage (HR 3.75, 95% CI 1.54–9.17, P=0.004), monocyte count (HR 3.79, 95% CI 1.29–11.12, P=0.015) and mGPS (HR 2.21, 95% CI 1.11–4.41, P=0.024) were independently associated with cancer-specific survival. In patients with synchronous unresectable liver metastases the minimum follow-up was 6 months and 71 patients died of their cancer. On multivariate survival analysis only single liver metastasis >5 cm (HR 1.78, 95% CI 0.99–3.21, P=0.054), extra-hepatic disease (HR 2.09, 95% CI 1.05–4.17, P=0.036), chemotherapy treatment (HR 2.40, 95% CI 1.82–3.17, P<0.001) and mGPS (HR 1.44, 95% CI 1.01–2.04, P=0.043) were independently associated with cancer-specific survival. In summary, markers of the systemic inflammatory response are associated with poor outcome in patients with either primary operable or synchronous unresectable colorectal cancer. An acute-phase protein-based prognostic score, the mGPS, appears to be a superior predictor of survival compared with the cellular components of the systemic inflammatory response.

Anti-GQ1b ganglioside antibodies mediate complement-dependent destruction of the motor nerve terminal

Miller-Fisher syndrome is an autoimmune neuropathy characterized by ataxia, areflexia and ophthalmoplegia, and in the majority of cases the presence of high titres of anti-GQ1b ganglioside antibodies. In an ex vivo model, human and mouse anti-GQ1b antibodies have been shown previously to induce a complement-dependent alpha-latrotoxin-like effect on the murine motor endplate, i.e. they bring about massive quantal release of acetylcholine and eventually block neuromuscular transmission. Using immunofluorescence microscopy with image analysis, we show here that the late stages of this electrophysiological effect temporally coincide with the loss of heavy neurofilament (200 kDa) and type III beta-tubulin immunostaining and structural breakdown of the nerve terminal, as demonstrated by electron microscopy. Ultrastructurally, axon terminals were disorganized, depleted of vesicles, and subdivided by the infiltrating processes of capping Schwann cells. These findings provide clear pathological evidence to support a role for anti-ganglioside antibodies in mediating nerve terminal injury and further advance the view that this site may be of importance as a target in some human neuropathies.

Ab externo 4-point scleral fixation of posterior chamber intraocular lenses

PURPOSE

To evaluate the results of ab externo 4-point scleral fixation of posterior chamber intraocular lenses (PC IOLs) as a primary or secondary procedure.

SETTING

Aravind Eye Hospital, Madurai, India.

METHODS

This retrospective study comprised 25 patients: 17 aphakic and 8 with traumatic subluxated lenses. The subluxated cataracts were removed intracapsularly. All patients had ab externo 4-point flapless scleral fixation of a PC IOL. Preoperative status, intraoperative details, and postoperative outcome were analyzed.

RESULTS

Mean follow-up was 8.02 months (range 6 to 26 months). The preoperative findings included sector iridectomy (n = 6), peripheral anterior synechias (n = 5), corneal scar (n = 2), vitreous hemorrhage (n = 2), traumatic angle recession (n = 1), retinitis pigmentosa (n = 1), primary open-angle glaucoma (n = 1), and macular pigmentary mottling (n = 1). There were no intraoperative problems related to scleral fixation. Postoperative complications and findings included cystoid macular edema (CME) (n = 2), uveitis (n = 1), and a healed macular choroidal tear (n = 1). No patient had suture exposure, IOL tilt/decentration, or infection. Twenty-two patients (88.0%) had a visual acuity of 6/12 or better at final follow-up. The cause of poor visual recovery in 3 patients included pre-existing macular degeneration, healed macular choroidal tear, and CME in 1 patient each.

CONCLUSION

Four-point scleral fixation is a simple technique that in this series of 25 patients was not associated with major intraoperative or postoperative complications and gave satisfactory visual results.

Biodistribution and radioimmunopharmacokinetics of 131I-Ama monoclonal antibody in atherosclerotic rabbits

Monoclonal antibodies have been raised against Ama isolated from human and experimental atherosclerotic plaque. 131I-Ama-MoAb in the whole antibody form was injected into normal NZW rabbits and Watanabe hyperlipidemic rabbits. Biodistribution studies showed that atheromatous aortas had a significantly higher (5-7X) uptake of 131I-Ama-MoAb than that of normal aortas. However, 131I-Ama-MoAb was cleared very slowly from atherosclerotic rabbits. As a result, atheromas could not be identified by imaging because of the low target to non-target ratios.

Selective effect of sufentanil on group III (A delta) and group IV (C) somatosympathetic reflexes

The effect of sufentanil on somatosympathetic reflexes and the subsequent reversal of its effects by naloxone have been observed in dogs anaesthetised with alpha-chloralose, paralysed with suxamethonium and artificially ventilated. When the drug was infused at a rate of 2.5 micrograms kg-1 min-1 the late long latency response evoked by Group IV (C) fibres was totally abolished at a mean dose of 6.40 micrograms kg-1 (+/- 0.99 microgram kg-1) (s.e. mean), while retaining a substantial part of the early short latency response evoked by group III (A delta) fibres; subsequently, during the infusion, this response was also totally abolished at a mean dose of 26.2 micrograms kg-1 (+/- 3.2 mg kg-1). The administration of naloxone (2 mg i.v.) completely reversed the effects of sufentanil within 3-5 min in different preparations. Some of the implications of these results are discussed.

Acute tolerance to fentanyl during anesthesia in dogs

The effect of fentanyl on increases in heart rate and mean arterial pressure elicited by electric stimulation of a branch of the radial nerve was studied in anesthetized, paralyzed, and artificially ventilated dogs. In one group, a bolus of 100 micrograms/kg of fentanyl depressed the evoked changes in heart rate and arterial pressure by 82 and 75%, respectively, by 5 min, and recovery occurred within 90 min. A second group was given increasing bolus doses of fentanyl from 1.5 to 100 micrograms/kg every 20 min for 200 min. The doses and intervals were chosen to give a logarithmic increase in plasma concentration of fentanyl to include a final bolus dose of 100 micrograms/kg and were predicted by a two-compartment pharmacokinetic model derived from data of the first group. In the second group, the bolus dose of 100 micrograms/kg after 5 min had no significant effect on evoked cardiovascular responses. Over the following 2 h, the evoked changes in heart rate and arterial pressure increased above those preceding the 100 micrograms/kg dose. An additional bolus dose of 100 micrograms/kg given 2 h after the first did not depress the evoked reflexes below the control values. It was concluded that tolerance to the effects of fentanyl can occur within 3 h and that for evoked responses to arterial pressure, rebound withdrawal effects can be seen within an additional 90 min.