Region-based analysis with functional annotation identifies genes associated with cognitive function in South Asians from India

The prevalence of dementia among South Asians across India is approximately 7.4% in those 60 years and older, yet little is known about genetic risk factors for dementia in this population. Most known risk loci for Alzheimer's disease (AD) have been identified from studies conducted in European Ancestry (EA) but are unknown in South Asians. Using whole-genome sequence data from 2680 participants from the Diagnostic Assessment of Dementia for the Longitudinal Aging Study of India (LASI-DAD), we performed a gene-based analysis of 84 genes previously associated with AD in EA. We investigated associations with the Hindi Mental State Examination (HMSE) score and factor scores for general cognitive function and five cognitive domains. For each gene, we examined missense/loss-of-function (LoF) variants and brain-specific promoter/enhancer variants, separately, both with and without incorporating additional annotation weights (e.g., deleteriousness, conservation scores) using the variant-Set Test for Association using Annotation infoRmation (STAAR). In the missense/LoF analysis without annotation weights and controlling for age, sex, state/territory, and genetic ancestry, three genes had an association with at least one measure of cognitive function (FDR q<0.1). APOE was associated with four measures of cognitive function, PICALM was associated with HMSE score, and TSPOAP1 was associated with executive function. The most strongly associated variants in each gene were rs429358 (APOE ε4), rs779406084 (PICALM), and rs9913145 (TSPOAP1). rs779406084 is a rare missense mutation that is more prevalent in LASI-DAD than in EA (minor allele frequency=0.075% vs. 0.0015%); the other two are common variants. No genes in the brain-specific promoter/enhancer analysis met criteria for significance. Results with and without annotation weights were similar. Missense/LoF variants in some genes previously associated with AD in EA are associated with measures of cognitive function in South Asians from India. Analyzing genome sequence data allows identification of potential novel causal variants enriched in South Asians.

Morphometric characteristics and microsatellite markers based diversity and differentiation recognizes the first prospective cattle breed from the Jharkhand state of India

India is bestowed with immense cattle biodiversity with 50 registered breeds. However, the majority (59.3%) is yet not characterized. Identification and characterization are the gateways to the management of prized indigenous resources. Present research described a unique cattle population of Jharkhand state, managed under a traditional low-input, low-output system. It was characterized by morphological traits, performance parameters, and management practices. Animals have the characteristic pre-scapular location of the hump. Genetic variation within this population and its differentiation with the six closely distributed cattle breeds were evaluated using FAO recommended microsatellite markers. Jharkhandi cattle have substantial genetic variation based on gene diversity (>0.6) and the average number of alleles per locus (>8). The population did not suffer from a genetic bottleneck in the recent past. Pairwise Nei's genetic distance, phylogenetic relationship, population differentiation, and the correct assignment of all the animals to self group substantiated its separate genetic identity. Since gene flow (Nm = 2.8-7.32) was identified and admixture was indicated by the Bayesian analysis there is a pressing need for scientific management of this population. Results endow authorities with critical information for registering a new Indian cattle breed (Medini) that contributes to the food security, livelihood, and economic sustainability of rural tribal households.

Estimating the Prevalence of Dementia in India Using a Semi-Supervised Machine Learning Approach

INTRODUCTION

Accurate estimation of dementia prevalence is essential for making effective public and social care policy to support individuals and families suffering from the disease. The purpose of this paper is to estimate the prevalence of dementia in India using a semi-supervised machine learning approach based on a large nationally representative sample.

METHODS

The sample of this study is adults 60 years or older in the wave 1 (2017-2019) of the Longitudinal Aging Study in India (LASI). A subsample in LASI received extensive cognitive assessment and clinical consensus ratings and therefore has diagnoses of dementia. A semi-supervised machine learning model was developed to predict the status of dementia for LASI participants without diagnoses. After obtaining the predictions, sampling weights and age standardization to the World Health Organization (WHO) standard population were applied to generate the estimate for prevalence of dementia in India.

RESULTS

The prevalence of dementia for those aged 60 years and older in India was 8.44% (95% CI: 7.89%-9.01%). The age-standardized prevalence was estimated to be 8.94% (95% CI: 8.36%-9.55%). The prevalence of dementia was greater for those who were older, were females, received no education, and lived in rural areas.

DISCUSSION

The prevalence of dementia in India may be higher than prior estimates derived from local studies. These prevalence estimates provide the information necessary for making long-term planning of public and social care policy. The semi-supervised machine learning approach adopted in this paper may also be useful for other large population aging studies that have a similar data structure.

Micro-morpho-anatomical transitions at various stages of in vitro development of Crinum malabaricum Lekhak and Yadav: A critically endangered medicinal plant

Crinum malabaricum Lekhak & Yadav is a recently discovered and critically endangered aquatic bulbous plant of the family Amaryllidaceae. It gained attention as a wild source of the acetylcholinesterase inhibiting alkaloid 'galanthamine' used to treat Alzheimer and Parkinson diseases. The bulbs of this plant contain the highest amount of galanthamine among Crinum species. In vitro regeneration systems were developed to produce quality uniform plantlets of C. malabaricum. Bright field light microscopy was used to analyse micro-morpho-anatomical developments taking place in the leaves and roots during in vitro, ex vitro and in vivo transitions of plantlets. Leaves and roots of plants raised in vitro possessed a higher degree of microscopic structural anomalies, such as underdeveloped epicuticular wax deposition, immature and non-functional stomata, more aquiferous parenchyma with a reduced lumen. Roots developed in vitro were characterized by extremely large, uneven cortical cells and reduced intercellular spaces. The vascular tissues were under-developed and only primary vascular tissues were observed. As a result of ex vitro acclimation, there was a significant acceleration in the improvement of tissue systems in leaves and roots. Such plantlets can tolerate elevated temperatures and light under in vivo conditions. Thus, the microscopic evaluation of the structural trajectory in different stages of plantlet development provides an understanding of the acclimation process and structural adaptations, which could help enhance survival of in vitro raised plantlets under ex vitro and in vivo conditions.

Surgical Outcome of Cauda Equina Syndrome Secondary to Disc Herniation Presenting Late in Developing Countries

Cauda equina syndrome (CES) is a serious neurologic state in which neurological dysfunction affects the lumbar and sacral nerve roots within the vertebral canal. The nerves of the cauda equine provide the muscles that manage the bladder, bowel and the legs and the dysfunction producing impairment of bladder, bowel or sexual function and perianal or saddle numbness. Identification of CES is not only important to neurosurgeons and spine surgeons, but also to prime care practitioners, emergency room physicians, physiotherapists and allied health care professionals concerned in management of back pain. It is a significant diagnosis from a clinical and medico-legal outlook. Early surgical decompression is endorsed by most authors to best support patient's revival and trim down long term disability. This cross sectional observational study was conducted at Shaheed Suhrawardy Medical College Hospitals, Dhaka, Bangladesh from January 2015 to January 2021 and the aim of this study was to find the predictors and the clinical outcome of cauda equina syndrome after spinal decompression with delayed presentation. Among 680 patients of degenerative disc diseases; 32 cases (4.7%) had CES, those presenting late in course of disease. Time interval between bladder and bowel dysfunction and admission to hospital varied from 2-64 days with mean delay of 15.4 days. The average follow-up was 22.6 months, ranging from 12 to 34 months. There was significant positive correlation (p<0.05) between duration taken for total recovery and delay in surgery and between delayed decompression and a poor outcome. Also there was a clear correlation between the presence of complete perineal anaesthesia and absence of anal wink as both univariate and multivariate predictors of a poor outcome. There was significant association between a slower onset of CES and a favourable outcome. There was no significant correlation found between initial motor function loss, bilateral sciatica and level of the lesions as predictors of a poor outcome.

956 Retained Appendiceal Tip and Abdominal Wall Appendicolith - A Rare Combination of Post Appendicectomy Complications

Appendicitis involving the appendix stump is a recognised post appendicectomy complication but the same involving the appendiceal tip is rare. Similarly, abdominal wall abscess secondary to retained appendicolith is also infrequently encountered. Our case highlights a rare combination of both complications arising separately.

A 29-year-old man presented with 3 days of generalised malaise and progressively worsening right iliac fossa pain some ten months after a laparoscopic appendicectomy. This had been complicated by residual right iliac fossa inflammation that was treated conservatively and serial scans demonstrated gradually resolving inflammation. He also had well controlled ulcerative colitis.

On examination, he was noted to be pyrexial with a tender fluctuant mass in the right flank. An ultrasound scan demonstrated inflammatory changes in the abdominal wall with no intra-abdominal collections. A diagnostic laparoscopy found an inflamed appendix tip, attached to the residual mesoappendix and embedded in the abdominal wall behind the mid-ascending colon. A completion appendicectomy was performed.

The patient recovered well but returned 4 months later with persistent pain and a fluctuant mass over the right iliac fossa. Radiological investigation revealed an abdominal wall collection containing a calcified appendicolith. The collection was refractory to ultrasound guided drainage and an exploration of the abdominal wall allowed extraction of the appendicolith followed by symptomatic relief.

This case emphasizes the importance of complete excision of the appendix and extraction of debris, which can be challenging when the appendix lies in a retro-colic position.

399 A Re-Audit of Secondary Prevention Medications Following Coronary Artery Bypass Grafting: Are We Still Compliant with The Updated Guidelines?

Introduction

In the years following myocardial revascularisation with bypass grafts, patients remain at risk for subsequent ischemia as a result of native coronary artery disease progression or development of graft occlusion. Therefore, secondary measures, primarily medical therapy, play an indispensable role in post-operative care. An audit conducted in 2014 identified reduced compliance to prescription of secondary prevention medications. This audit aims to re- evaluate the level of compliance to updated guidelines.

Method

A retrospective case-note review of 100 patients, who underwent CABG (Coronary Artery Bypass-Grafts), was conducted primarily focusing on prescription of secondary prevention drugs at discharge, indications, and contraindications.

Results

99% patients were discharged on anti-platelet agents. However, 12%, discharged on dual anti-platelet agents, did not have any indications for them. 97 % patients were discharged on beta-blocker. Of the 3 defaulters, one had contraindication to beta blockade. 96% patients were discharged on one or more lipid lowering agents and 74% were discharged on ACEi/ARBs. Of the 26% patients discharged without RAAS (Renin Angiotensin Aldosterone System) inhibitor, 9% had no clear indication for it whereas for 7%, it was contraindicated at discharge.

Conclusions

A generalised improvement in compliance rate is noted for secondary prevention medications prescription according to updated guidelines from the previous audit.

637 Enterolith Ileus Secondary to Small Bowel Diverticulum: A Rare Cause of Small Bowel Obstruction

Small intestinal diverticula are rare and possibly acquired secondary to bowel dyskinesia, abnormal peristalsis, or high intraluminal pressures. Enterolith formation and obstruction are a less encountered complication of these diverticula.

An elderly man, with no history of abdominal surgery, presented with 10 days of colicky right iliac fossa pain and recurrent episodes of bilious vomiting. He initially reported diarrhoea but complained of eventual absolute constipation for last 5 days. Physical examination revealed distended abdomen with right-sided tenderness and no mass or faeces on rectal examination. Abdominal CT revealed a 3.5 cm calculus in the distal ileum causing obstruction initially flagged as gallstone ileus. No gallstones or pneumobilia were identified although some intrahepatic duct dilatation was noted. An emergency laparotomy was conducted, where the radiological findings were reinforced, and the calculus was extracted via enterotomy. There were no abnormal communications between gallbladder and intestinal tract. The small bowel traced from duodenojejunal flexure to terminal ileum did not reveal any further calculi or diverticula. FTIR spectrum analysis of the extracted specimen indicated similarities to enterolith. Retrospective analysis of radiological images revealed a possible duodenal diverticulum. The case highlights the diagnostic conundrum and therapeutic challenges of small bowel diverticular enterolith.

e-TEP repair for midline primary and incisional hernia: technical considerations and initial experience

INTRODUCTION

The Enhanced-View Totally Extra Peritoneal Rives-Stoppa (e-TEP-RS) Technique for the repair of large, complex, ventral abdominal hernias has gained popularity especially in overcoming the disadvantages with Intra Peritoneal Onlay Mesh (IPOM) repairs and to enable siting of a large prosthetic mesh in an anatomical plane distinct from the abdominal cavity and its contents. Evolving variations of the original technique have allowed the definitive repair of such defects in a reproducible manner. We present our initial experience of this approach and detailed steps of our native technical modifications in overcoming the challenges in performing this complex and potentially challenging procedure.

MATERIALS AND METHODS

This is a retrospective review of the clinical data of midline, large, complex, ventral abdominal hernia patients who underwent e-TEP-RS with and without Transversus Abdominis Release (TAR). Patients, with or without Diastasis of Rectus Abdominis Muscle (DRAM) were included. Key outcomes measured were post-operative pain, operative morbidity, readmission, Quality of Life (QoL), hernia recurrence.

RESULTS

A total of 58 midline, ventral abdominal hernia patients who underwent e-TEP-RS with and without Transversus Abdominis Release (TAR), between March 2018 and December 2019 were studied. Mean defect area was 41.0 ± 28 cm² and the mean mesh surface area was 473.5 ± 165 cm². e-TEP-RS was done in 35 cases, e-TEP RS TAR in 15 cases and e-TEP-RS with e-TEP inguinal in 08 cases. There was no intraoperative morbidity. Mean duration of surgery was 156.2 ± 40 min and mean blood loss was 40.5 ± 26 cc. The CCS QoL scores improved from 34.6 (± 2) pre-operatively to 27.2 (± 4) at the end of 6 months. One patient had a supra-umbilical recurrence following bilateral TAR over the superior edge of the mesh. Follow-up ranged from 6 to 22 months, with a mean of 14 months. Major complications (n = 12; 20.7%) were seroma formation and prolonged ileus.

CONCLUSION

The e-TEP-RS technique for large, complex, midline, ventral abdominal hernias can be used with excellent results and acceptable morbidity. This technique is technically challenging and should be mastered in relatively smaller ventral hernias to achieve good results before attempting it in larger, complex ones.

Coronavirus disease 2019: scientific overview of the global pandemic

Coronavirus disease 2019 (COVID-19) is the disease caused by the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Genome sequencing of the virus revealed that it is a new zoonotic virus that might have evolved by jumping from bats to humans with one or more intermediate hosts. The immediate availability of the sequence information in the public domain has accelerated the development of quantitative RT-PCR-based diagnostics. Numerous clinical trials have been prioritized globally for testing new vaccines and treatments against this disease. This review provides a broad insight into different aspects of COVID-19, an introduction to SARS-CoV-2 mitigation strategies and the present status of diagnostics and therapeutics.

Assessing inequities in community health worker’s interaction and its impact in Uttar Pradesh, India

Given the high Neo-natal mortality in the state of Uttar Pradesh, India, an emphasis has been given to community health workers (CHW). CHW provides behavior push to pregnant women for utilizing health services, through the strategies of household contact and messaging. However, the disparity in health outcomes and interaction of CHW is profoundly affected by socio-economic determinants; still, the evidence is limited. This study aims to explore socio-economic inequities in quantity and quality of contacts by the CHW and its differential effect on health service utilization.

Multistage sampling design identified live births in the last 12 months across the 25 highest-risk districts of Uttar Pradesh(n = 3703). Regression models described the relation between household demographics and CHW contact & specific messaging and interactions of demographics and CHW contact & messaging in predicting health service utilization ( &gt; = 4 antenatal care (ANC) visits, Institutional delivery and 100 iron folic acid (IFA) consumption).

No differential likelihood in contact of CHW and specific messaging is found. Further, association of CHW contacts and specific messaging with health outcomes were significantly affected by socio-economic determinants.2 or more contacts along with specific messaging increased the odds of 4+ ANC to a higher degree among illiterate women compared to literate women(AOR:3.39, 95% CI:2.28-5.04 vs AOR:1.44, 95% CI:1.09-1.92). Similarly, the odds of facility delivery increased to a higher degree among lower wealth women compared to higher wealth women (AOR:3.41, 95% CI:2.47-4.71 vs. AOR:1.53, 95% CI: 1.09-2.15).

Specific messaging, along with CHW contacts, have a higher magnitude of effects on the marginalized population. This study provides evidence for adjusting implementation strategies based on socio-economic determinants to achieve equitable health service utilization. However, further research on training of CHW on heterogeneous interaction is recommended

Key messages

There exists differential effects of quantity and quality of contact by community health workers on health service utilization across the different socio-economic strata. Implementation agencies in the LMIC can reduce health inequity by shifting from coverage-oriented target approach towards more prioritized and focused interaction across socio-economic groups.

Racemose Pattern of Intracranial Tuberculoma at the Basal, Suprasellar and Perimesencephalic Cisterns – A Case Report

Central nervous system tuberculosis may present as meningitis, tuberculoma, abscesses, cerebritis or miliary tuberculosis. The most common site of tuberculoma has been reported to be at the grey-white matter junction and the periventricular region. They may even be found in the epidural, subdural and subarachnoid spaces, and the brain stem. Although tuberculosis is very common in developing countries, with the increasing prevalence of immunosuppression owing to human immunodeficiency virus and patients surviving chemotherapy or organ transplantation, the incidence of tubercular infections has been rising in developed countries. The authors report a 15-year-old boy of intracranial tuberculoma at the basal, suprasellar and perimesencephalic cisterns in a patient. Tuberculous involvement was noted in a racemose pattern in the subarachnoid space. The patient’s clinical symptoms resolved with no recurrence of symptoms but only persistence of the radiological abnormality after antitubercular chemotherapy.

0258 Early Semester Sleep Variability Predicts Depression Among College Students

Introduction

Sleep is a critical behavior predicting mental health and depressive symptomatology in young adults.The extant scientific literature generally focuses on self-reported sleep measures over relatively short time frames. Here, we examine whether actigraphy-measured sleep variables early in the academic semester predict depressive symptomatology at the end of the semester among first and second year college students. There is currently debate in the sleep literature about which sleep variables are the most robust predictors of depression among young adults. In this study, we evaluate total sleep time, midpoint sleep time, and sleep variability where variability is defined by the mean-squared successive difference (MSSD) of midpoint sleep as predictors of depression.

Methods

The sample consisted of 160 first and second year college students at a private American university. The students completed a beginning and end of semester assessment of depressive symptomatology using the Center for Epidemiologic Studies Depression Scale (CES-D), and wore a Fitbit throughout the semester to capture sleep features of interest: total sleep time (TST), midpoint sleep, and midpoint MSSD.

Results

When controlling for beginning of semester CES-D, early semester (weeks 3–6) midpoint sleep MSSD significantly (p &lt; 0.05) predicted increased end of semester CES-D. These effects were specific to the sleep variability measure (MSSD). Total sleep time and sleep chronotype (i.e. midpoint sleep) were not significant predictors of end of semester depressive symptomatology.

Conclusion

Early semester sleep window variability among college freshmen, particularly during stressful midterm exams, is a robust risk factor for depression among college students. This work contributes to initial actigraphy studies suggesting that MSSD measures of sleep window variability foster increased mental health risks among young people. This work calls for further investigation to understand possible causal relationships between sleep variability and mental health.

Support

This work was supported by the Life@CMU project funded by the Carnegie Mellon University Provost’s Office.

Comparative analysis of hatcheries contribution to poor development of day-old chicks based on biological and immunological performance

BACKGROUND AND AIM

The quality of day-old chicks is a cornerstone to successful poultry production. Chicks with a poor quality start slowly in the field and may have high feed intake, poor growth rate, and poor feed conversion ratio. The current study aimed to assess chick quality challenges encountered from day-old chicks hatched in most commercial hatcheries in Ghana.

MATERIALS AND METHODS

A total of 300 day-old chicks each were obtained from commercial hatcheries in Ghana and Europe. The chicks were labeled as locally hatched broiler day-old chicks (LBDOC) and foreign hatched broiler day-old chicks (FBDOC), respectively. Chicks were reared and monitored from day old to 21 days post-hatch. Sample of chicks (n=25) from each hatchery was euthanized weekly at 1, 7, 14, and 21 days and blood samples collected for analysis. The parameters measured included physical, hematological, immunological, histological, and bacteriological characteristics. All data were analyzed by SAS Proc GLM at p<0.05.

RESULTS

The live weight of chicks was higher in FBDOC compared to LBDOC on the 1st day. The chick length and shank length of FBDOC were longer than the LBDOC. The 7-day chick mortality was 6% in LBDOC as compared to 1.5% in FBDOC. The LBDOC also had a higher wet and dry residual yolk sac percentages as well as higher residual yolk sac fluid volume than the FBDOC. The rate of yolk sac disappearance of the FBDOC was higher than the LBDOC. More than half of the LBDOC had developed navel strings and leaky navel compared to FBDOC. The LBDOC recorded Escherichia coli, Proteus, Streptococcus spp., and Gram-negative bacteria in the residual yolk sac isolated through the 21 days while FBDOC recorded E. coli, Proteus, and Gram-negative bacteria. The intestinal villi count, lengths, width, and surface area were all not significantly different. The blood monocyte levels appeared higher in FBDOC than LBDOC, which give evidence of higher immunity in FBDOC than LBDOC.

CONCLUSION

The results indicate a challenging situation in maintaining the quality of locally hatched broiler day-old-chicks compared to foreign hatched broiler-day-old-chicks. The study demonstrates that chick quality impact goes beyond the physical characteristics of chick weight and chick length, and the higher performance of FBDOC may be influenced by compliance with international hatchery standards and vaccination protocols.

P5570Contemporary trends and outcomes of percutaneous and surgical mitral valve replacement or repair for mitral insufficiency in cancer patients

Importance

Severe mitral valve insufficiency (MR) is managed using mitral valve replacement or repair. Transcatheter mitral valve repair (TMVR) is an emerging non-invasive treatment option for MR. Cancer patients stand to benefit from non-invasive treatment of MR given the nature of this intervention. Objective:We sought to assess the relative utilization, outcomes, and dispositions associated with TMVR vs. surgical mitral valve procedures (SMVP) in cancer patients.

Methods

The 2012–2015 National Inpatient Sample, a retrospective observational study was queried using ICD-9 codes for adults >18 years with comorbid MR (ICD-9 – 424.0) and cancer without metastatic disease. To maintain a homogenous study population and to limit confounding, those with mitral stenosis, rheumatic disease, infective endocarditis, aortic valve disease, or those undergoing any other vascular or cardiac surgery in the same admission were excluded from the analysis. Multiple in-hospital and disposition outcomes were evaluated. Since the baseline population undergoing SMVP (ICD-9: 35.23, 35.24, 35.12) is quite different from TMVR (ICD-9: 35.97), parallel analyses for outcomes and dispositions were presented but no direct statistical comparisons.

Results

A total of 410,175 out of 2,449,010 patients with mitral insufficiency were found to have non-metastatic cancer (16.7%). A total of 3,600 TMVR procedures were performed during the study period. Over the study period, there has been an increase in the proportion of patients undergoing TMVR among all patients undergoing mitral valve procedures (figure). The increase is higher in cancer patients in the most recent year (14.2% vs. 8.2%, p<0.0001). The four major cancers comprise of 50% of these TMVR patients. TMVR was associated with 1.4% vs. 2.2% in-hospital mortality (p=0.55), 0.7% vs. 0.8% stroke (p=0.87), 9.2% vs. 11.8% major bleeding (p=0.31), 14.1% vs. 16.5% acute kidney injury (p=0.52), 62.0% vs. 64.6% home discharge (p=0.58), and 13.3% vs. 12.0% discharge to nursing home (p=0.58) among cancer vs. non-cancer patients, respectively. On the other hand, SMVP was associated with 3.1% vs. 3.5% in-hospital mortality (p=0.35), 2.6% vs. 3.1% stroke (p=0.16), 35.0% vs. 30.5% major bleeding (p<0.0001), 19.5% vs. 19.6% acute kidney injury (p=0.88), 32.8% vs. 38.6% home discharge (p<0.0001), 37.2% vs. 35.0% home health care use (p<0.0001), and 26.8 vs. 22.8% discharge to nursing home (p=0.05), among cancer vs. non-cancer patients respectively.

TMVR percent in mitral valve procedures

Conclusion

TMVR utilization for MR in cancer has steadily increased in both cancer and non-cancer patients, although it is proportionately higher among cancer patients in recent years. Overall, TMVR was associated with low in-hospital mortality and a similar safety profile in cancer and non-cancer patients, while SMVP appears to have a slightly worse safety profile in cancer patients. Our findings, suggest that TMVR is a reasonable strategy in selective cancer patients with MR.

P2271Contemporary trends and outcomes of percutaneous vs. surgical aortic valve replacement in cancer patients

Importance

Cancer patients with severe AS are often ineligible for surgical aortic valve replacement (SAVR). Transcatheter aortic valve replacement (TAVR) is an emerging non-invasive treatment option for severe AS. Cancer patients likely stand to benefit from TAVR given its non-invasive nature; however, there is a paucity of data regarding the comparative effectiveness of TAVR vs. SAVR in cancer. We sought to assess the relative utilization, outcomes, and dispositions associated with TAVR vs. SAVR in cancer and non-cancer patients.

Methods

The US-based National Inpatient Sample was queried between 2012 and 2015 using ICD-9 codes for adults>18 years with comorbid AS and cancer without metastatic disease. Multiple in-hospital and disposition outcomes were evaluated. Comparison of TAVR vs SAVR required propensity score estimation using demographic, socio-economic, comorbidity, and hospital specific variables. A standardized morbidity ratio (SMR) weight was calculated by assigning TAVR a weight of 1, and those undergoing SAVR weight of PS/(1-PS). SMR-weighted generalized logistic regression was conducted to estimate the average effect of TAVR compared with SAVR. Finally, the Cochran–Mantel–Haenszel (CMH) test for propensity-matched data was utilized to compare the effect modification of cancer on these outcomes.

Results

A total of 979,912 out of 5,611,173 patients with AS were found to have non-metastatic cancer (17.5%). Average Elixhauser's mortality score of patients undergoing TAVR and SAVR was 8.9 vs. 8.1 and 8.5 vs. 7.1 for cancer vs. non-cancer respectively (p<0.0001). Over time, patients undergoing AVR increased in both groups, primarily driven by significantly increased rates of TAVR utilization in the cancer group. Over the study time period, an increase in the proportion of patients undergoing TAVR among all patients undergoing AVR was noted (figure) with 21.8% and 19.6% patient with prostate and breast cancer in 2015. TAVR in cancer patients was associated with lower odds of acute kidney injury [AKI; odds ratio (OR): 0.6, 95% confidence interval (CI): 0.5- 0.8], cardiogenic shock [OR: 0.6 (0.4–0.8)] and major bleeding [OR: 0.4 (0.3–0.5)] with no difference in in-hospital mortality and stroke compared to SAVR. Additionally, TAVR was associated with higher odds of home-discharge [OR: 1.9 (1.7–2.2)], and lower need for nursing facility transfer [OR: 0.7 (0.6–0.8) compared to SAVR among cancer patients. Similar outcomes are noted in the non-cancer cohort upon comparing TAVR to SAVR. However, favorable effect-modification of cancer was noted in regard to AKI (p=0.003), home discharge (p<0.0001), and less nursing facility transfer (p=0.0003), suggesting safety.

Conclusions

Compared to patients without cancer, the utilization of AVR in cancer patients has steadily increased. The benefits of TAVR over SAVR appear to extend to patients, regardless of cancer status. TAVR might be a more suitable procedure for cancer patients with AS.

Real time extended range prediction of heat waves over India

Heat waves over India occur during the months of March-June. This study aims at the real-time monitoring and prediction of heat waves using a multi-model dynamical ensemble prediction system developed at Indian Institute of Tropical Meteorology, India. For this, a criterion has been proposed based on the observed daily gridded maximum temperature (Tmax) datasets, which can be used for real-time prediction as well. A heat wave day is identified when either (1) Tmax (a)≥ its climatological 95^th percentile (calculated from daily values during March-June and for 1981-2010), (b) >36 °C, and (c) its departure from normal is >3.5 °C, Or, (2) when the Tmax >44 °C. Three heat wave prone regions, namely, northwest, southeast and northwest-southeast regions are recognized and heat wave spells of minimum consecutive six days are identified objectively for each region during 1981-2018. It is noticed that the prediction system has reasonable skill in predicting the heat waves over heat wave prone regions of India. Forecast verification of heat wave spells during 2003-2018 reveals that the prediction system has great potential in providing overall indication about the onset, duration and demise of the forthcoming heat wave spell with sufficient lead time albeit with some spatio-temporal error.