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Kant S, Bhalla A, Alasfar S, Alachkar N. Ten-year outcome of Eculizumab in kidney transplant recipients with atypical hemolytic uremic syndrome- a single center experience. BMC Nephrol 2020; 21:189. [PMID: 32434487 PMCID: PMC7238522 DOI: 10.1186/s12882-020-01847-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/10/2020] [Indexed: 11/29/2022] Open
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) can result in severe kidney dysfunction, secondary to thrombotic microangiopathy. Eculizumab has been used to treat this disorder, and has resulted in favourable outcomes in both, native and transplanted kidneys. There is limited long term follow up data in kidney transplant recipients (KTRs) who received prevention and treatment with Eculizumab. We report our long term follow up data from our center to address safety and efficacy of this therapy in KTRs. Methods We performed a retrospective analysis of KTRs between January 2009 and December 2018. Clinical diagnosis of aHUS established with presence of thrombotic microangiopathy, acute kidney injury, absence of alternate identifiable etiology. We reviewed clinical data, including genetic testing for complement factor mutations, post-transplant course, and response to therapy including therapeutic and prophylactic use of eculizumab. Results Nineteen patients with aHUS received a total of 36 kidney transplants; 10 of them had 2 or more prior kidney transplants. Median age at time of last transplant was 37 years (range 27–59), 72% were female (n = 14), 78% Caucasian (n = 15), with 61% had live donor transplant (n = 12) as the last transplant. Eculizumab prophylaxis was given to 10/19 (56%) at the time of transplantation, with no aHUS recurrence during the follow up. Median duration of follow up was 46 (range 6–237) months. Mean estimated glomerular filtration rate (eGFR) at the time of last follow up was 59.5 ml/min/m2. No infections secondary to encapsulated organisms or other major infectious complications occurred during the follow up. Conclusions Eculizumab prophylaxis is safe and effective in KTRs with aHUS. Long term follow up demonstrates that it may be possible to discontinue prophylaxis carefully in selected patients with no evidence of complement mutations.
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Talwar M, Balaraman V, Bhalla A, Cseprekal O, Yazawa M, Podila PSB, Azhar A, Cossey LN, Eason JD, Molnar MZ. Validation of Prognostic Index for Allograft Outcome in Kidney Transplant Recipients With Transplant Glomerulopathy. Kidney Int Rep 2020; 5:915-920. [PMID: 32518874 PMCID: PMC7271004 DOI: 10.1016/j.ekir.2020.03.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/02/2020] [Accepted: 03/30/2020] [Indexed: 11/23/2022] Open
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Pannu AK, Bhalla A, Gantala J, Sharma N, Kumar S, Dhibar DP. Glucose-insulin-potassium infusion for the treatment of acute aluminum phosphide poisoning: an open-label pilot study. Clin Toxicol (Phila) 2020; 58:1004-1009. [DOI: 10.1080/15563650.2020.1719131] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Bhalla A, Alachkar N, Alasfar S. Complement-Based Therapy in the Management of Antibody-Mediated Rejection. Adv Chronic Kidney Dis 2020; 27:138-148. [PMID: 32553246 DOI: 10.1053/j.ackd.2019.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/11/2019] [Accepted: 12/11/2019] [Indexed: 02/07/2023]
Abstract
Antibody-mediated rejection (AMR) is one of the leading causes of kidney allograft failure and is usually mediated by anti-human leukocyte antigen donor-specific antibodies (DSAs). Activation of classical pathway of the complement system is responsible for downstream effects of DSA and account for significant manifestations of AMR. Currently, the treatment of AMR is based on strategies to remove preformed antibodies or to prevent their production; however, these strategies are often unsuccessful. It is theoretically possible to inhibit complement activity to prevent the effect of DSA on kidney allograft function. Complement inhibitors such as eculizumab, a complement 5 monoclonal antibody, and complement 1 esterase inhibitors (C1 INHs) have been used in prevention and treatment of AMR with variable success. Eculizumab and C1 INH seem to reduce the incidence of early AMR and allow transplantation in highly sensitized kidney transplant recipients, but data on their long-term effect on kidney allograft function are limited. Several case reports described the successful use of eculizumab in the treatment of AMR, but there are no randomized controlled studies that showed efficacy. Treatment of AMR with C1 INH, in addition to standard of care, did not change short-term outcome but long-term studies are underway.
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Golla R, Mukherjee A, Gone RK, Singh H, Pannu AK, Suri V, Bhalla A. Acute intermittent porphyria and anti-tuberculosis therapy. QJM 2020; 113:207-208. [PMID: 31693148 DOI: 10.1093/qjmed/hcz289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Indexed: 11/14/2022] Open
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Singh H, Pannu AK, Dahiya N, Suri V, Bhalla A, Kumari S. 'Crochetage' sign of atrial septal defect. QJM 2020; 113:133-134. [PMID: 31179495 DOI: 10.1093/qjmed/hcz142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Arshad H, Butt S, Bhalla A, Umar R, Khawaja US. COPD, HEART FAILURE A BAD COMBO. COMPARISON OF OUTCOMES IN PATIENTS WITH HEART FAILURE WITH ACUTE EXACERBATION WITH VERSUS WITHOUT CHRONIC OBSTRUCTIVE PULMONARY DISEASE; NATIONWIDE STUDY FROM 2007-2014. Can J Cardiol 2019. [DOI: 10.1016/j.cjca.2019.07.456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Thomas PW, Blackwell JEM, Herrod PJJ, Peacock O, Singh R, Williams JP, Hurst NG, Speake WJ, Bhalla A, Lund JN. Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients. Tech Coloproctol 2019; 23:761-767. [PMID: 31392530 PMCID: PMC6736926 DOI: 10.1007/s10151-019-02056-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/29/2019] [Indexed: 02/08/2023]
Abstract
Background Current evidence suggests that pelvic floor reconstruction following extralevator abdominoperineal excision of rectum (ELAPER) may reduce the risk of perineal herniation of intra-abdominal contents. Options for reconstruction include mesh and myocutaneous flaps, for which long-term follow-up data is lacking. The aim of this study was to evaluate the long-term outcomes of biological mesh (Surgisis®, Biodesign™) reconstruction following ELAPER. Methods A retrospective review of all patients having ELAPER in a single institution between 2008 and 2018 was perfomed. Clinic letters were scrutinised for wound complications and all available cross sectional imaging was reviewed to identify evidence of perineal herniation (defined as presence of intra-abdominal content below a line between the coccyx and the lower margin of the pubic symphysis on sagittal view). Results One hundred patients were identified (median age 66, IQR 59–72 years, 70% male). Median length of follow-up was 4.9 years (IQR 2.3–6.7 years). One, 2- and 5-year mortality rates were 3, 8 and 12%, respectively. Thirty three perineal wounds had not healed by 1 month, but no mesh was infected and no mesh needed to be removed. Only one patient developed a symptomatic perineal hernia requiring repair. On review of imaging a further 7 asymptomatic perineal hernias were detected. At 4 years the cumulative radiologically detected perineal hernia rate was 8%. Conclusions This study demonstrates that pelvic floor reconstruction using biological mesh following ELAPER is both safe and effective as a long-term solution, with low major complication rates. Symptomatic perineal herniation is rare following mesh reconstruction, but may develop sub clinically and be detectable on cross-sectional imaging.
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Mohan K, Kaushal T, Garg S, Pannu AK, Bhalla A, Suri V, Kumari S. Primary hyperparathyroid bone disease. QJM 2019; 112:545. [PMID: 30629246 DOI: 10.1093/qjmed/hcz012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Zheng L, Cockerham G, Hoffman J, Heydlauf M, Peterson D, Bhalla A. A statistical analysis solution to measure the impact of sample processing methods on diagnostic laboratory turnaround time. Clin Chim Acta 2019. [DOI: 10.1016/j.cca.2019.03.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Singh H, Pannu AK, Suri V, Bhalla A, Kumari S. Pericardial effusion and electrical alternans. QJM 2019; 112:135-136. [PMID: 30165695 DOI: 10.1093/qjmed/hcy191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bhalla A. Strategies and Intervention for Cancer Screening at Village Level. J Glob Oncol 2018. [DOI: 10.1200/jgo.18.93500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Cancer is a leading cause of death globally. The World Health Organization estimates that 7.6 million people died of cancer in 2005 and 84 million people will die in the next 10 years if action is not taken. More than 70% of all cancer deaths occur in low- and middle-income countries, where resources available for prevention, diagnosis and treatment of cancer are limited or nonexistent. There are 3 common cancers found in wide range in India (oral, breast and cervical). In India the maximum people die due to oral cancer in men and breast cancer in female. Method: The current cancer screening and intervention approaches for the early prevention and detection of cancer, and to outline strategies for future interventions and research at village level. Results and Conclusion: The cancer screening plan is agreed upon by the stakeholders, it should be given the widest possible distribution within the country In resource constrained countries, a plan is more likely to be implemented if it includes fewer, yet sustainable interventions in line with evidence-based priorities, ranging from prevention to end-of-life care, with measurable process and outcome objectives that can be monitored and evaluated if basic information systems are in place. For example, prevention strategies (such as tobacco control and hepatitis B immunization), and treatment interventions linked to early diagnosis (awareness of early signs and symptoms) of a few cancer types (such as cervical and breast cancers) would be key feasible interventions.
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Gawalkar AA, Tale S, Chhabria BA, Bhalla A. Myocarditis and purpura fulminans in meningococcaemia. QJM 2017; 110:755-756. [PMID: 29024990 DOI: 10.1093/qjmed/hcx144] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Indexed: 11/13/2022] Open
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Chhabria BA, Pannu AK, Bhalla A. Venous thrombo-embolism: thalidomide and leprosy. QJM 2017; 110:383-384. [PMID: 28340061 DOI: 10.1093/qjmed/hcx063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Indexed: 11/13/2022] Open
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Baker BG, Bhalla A, Doleman B, Yarnold E, Simons S, Lund JN, Williams JP. Simulation fails to replicate stress in trainees performing a technical procedure in the clinical environment. MEDICAL TEACHER 2017; 39:53-57. [PMID: 27631579 DOI: 10.1080/0142159x.2016.1230188] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Simulation-based training (SBT) has become an increasingly important method by which doctors learn. Stress has an impact upon learning, performance, technical, and non-technical skills. However, there are currently no studies that compare stress in the clinical and simulated environment. We aimed to compare objective (heart rate variability, HRV) and subjective (state trait anxiety inventory, STAI) measures of stress theatre with a simulated environment. METHODS HRV recordings were obtained from eight anesthetic trainees performing an uncomplicated rapid sequence induction at pre-determined procedural steps using a wireless Polar RS800CX monitor © in an emergency theatre setting. This was repeated in the simulated environment. Participants completed an STAI before and after the procedure. RESULTS Eight trainees completed the study. The theatre environment caused an increase in objective stress vs baseline (p = .004). There was no significant difference between average objective stress levels across all time points (p = .20) between environments. However, there was a significant interaction between the variables of objective stress and environment (p = .045). There was no significant difference in subjective stress (p = .27) between environments. DISCUSSION Simulation was unable to accurately replicate the stress of the technical procedure. This is the first study that compares the stress during SBT with the theatre environment and has implications for the assessment of simulated environments for use in examinations, rating of technical and non-technical skills, and stress management training.
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White PM, Lenthall R, McConachie N, Bhalla A, James M, Dinsmore J, Rodgers H, Rowland-Hill C. Commentary on: Implementing mechanical thrombectomy for acute ischaemic stroke in the UK. Clin Radiol 2016; 72:123-125. [PMID: 27989377 DOI: 10.1016/j.crad.2016.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 11/07/2016] [Accepted: 11/07/2016] [Indexed: 10/20/2022]
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White PM, Bhalla A, Dinsmore J, James M, McConachie N, Roffe C, Young G. Standards for providing safe acute ischaemic stroke thrombectomy services (September 2015). Clin Radiol 2016; 72:175.e1-175.e9. [PMID: 27974152 DOI: 10.1016/j.crad.2016.11.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Doleman B, Blackwell J, Karangizi A, Butt W, Bhalla A, Lund JN, Williams JP. Anaesthetists stress is induced by patient ASA grade and may impair non-technical skills during intubation. Acta Anaesthesiol Scand 2016; 60:910-6. [PMID: 26940201 DOI: 10.1111/aas.12716] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/29/2016] [Accepted: 02/07/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND The aims of this study were to determine if patient ASA grade was associated with increased stress in anaesthetists with a subsequent effect on non-technical skills. METHODS Stress was measured using a validated objective (heart rate variability or heart rate) and subjective tool. We studied eight consultant anaesthetists at baseline (rest) and during 16 episodes of intubation with an ASA 1 or 2 patient vs. an ASA 3 or 4 patient. The primary outcome for the study was objective and subjective stress between both patient groups. Secondary outcomes were non-technical skill ratings and the association between stress measurements. RESULTS ASA 3 or 4 patients were associated with increases in objective stress when compared to baseline (mean 4.6 vs. 6.7; P = 0.004). However, ASA 1 or 2 patients were not associated with increases in stress when compared to baseline (mean 4.6 vs. 4.7; P = 1). There was no significant difference in subjective stress between the groups (P = 0.18). Objective stress negatively affected situational awareness (P = 0.03) and decision-making (P = 0.03); however, these did not decline to a clinically significant threshold. Heart rate variability (r = 0.60; P = 0.002) better correlated with subjective stress when compared to heart rate (r = 0.30; P = 0.15). Agreement between raters for Anaesthetic Non-Technical Skills (ANTS) scores was acceptable (ICC = 0.51; P = 0.003). CONCLUSION This study suggests that higher patient ASA grade can increase stress in anaesthetists, which may impair non-technical skills.
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Miller J, Drew L, Green O, Dukovski D, McEwan B, Villella A, Patel N, Bastos C, Cullen M, Danh H, Wachi S, Giuliano K, Longo K, Bhalla A, Qiu D, Zou C, Ivarsson M, Munoz B, Mehmet H. WS13.5 CFTR amplifiers are mutation-agnostic modulators that increase CFTR protein levels and complement other CF therapeutic modalities. J Cyst Fibros 2016. [DOI: 10.1016/s1569-1993(16)30137-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Biswal M, Kumar A, Sharma N, Bhalla A, Singhi S, Sethi S. Genetic diversity of Orientia tsutsugamushi strains from patients in North India. Int J Infect Dis 2016. [DOI: 10.1016/j.ijid.2016.02.395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Rathour S, Kumar S, Hadda V, Bhalla A, Sharma N, Varma S. PIRO concept: staging of sepsis. J Postgrad Med 2016; 61:235-42. [PMID: 26440393 PMCID: PMC4943374 DOI: 10.4103/0022-3859.166511] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction: Sepsis is common presenting illness to the emergency services and one of the leading causes of hospital mortality. Researchers and clinicians have realized that the systemic inflammatory response syndrome concept for defining sepsis is less useful and lacks specificity. The predisposition, infection (or insult), response and organ dysfunction (PIRO) staging of sepsis similar to malignant diseases (TNM staging) might give better information. Materials and Methods: A prospective observational study was conducted in emergency medical services attached to medicine department of a tertiary care hospital in Northern India. Patients with age 18 years or more with proven sepsis were included in the first 24 hours of the diagnosis. Two hundred patients were recruited. Multivariate logistic regression analysis was done to assess the factors that predicted in-hospital mortality. Results: Two hundred patients with proven sepsis, admitted to the emergency medical services were analysed. Male preponderance was noted (M: F ratio = 1.6:1). Mean age of study cohort was 50.50 ± 16.30 years. Out of 200 patients, 116 (58%) had in-hospital mortality. In multivariate logistic regression analysis, the factors independently associated with in-hospital mortality for predisposition component of PIRO staging were age >70 years, chronic obstructive pulmonary disease, chronic liver disease, cancer and presence of foley's catheter; for infection/insult were pneumonia, urinary tract infection and meningitis/encephalitis; for response variable were tachypnea (respiratory rate >20/minute) and bandemia (band >5%). Organ dysfunction variables associated with hospital mortality were systolic blood pressure <90mm Hg, prolonged activated partial thromboplastin time, raised serum creatinine, partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO2/FiO2) ratio <300, decreased urine output in first two hours of emergency presentation and Glasgow coma scale ≤9. Each of the components of PIRO had good predictive capability for in-hospital mortality but the total score was more accurate than the individual score and increasing PIRO score was associated with higher in-hospital mortality. The area under receiver operating characteristic curve for cumulative PIRO staging system as a predictor of in-hospital mortality was 0.94. Conclusion: This study finds PIRO staging as an important tool to stratify and prognosticate hospitalised patients with sepsis at a tertiary care center. The simplicity of score makes it more practical to be used in busy emergencies as it is based on four easily assessable components.
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Naranje P, Gorsi U, Gupta L, Bhalla A, Khandelwal N. Primary Aortoenteric fistula : An alarming entity warranting early diagnosis. TROPICAL GASTROENTEROLOGY : OFFICIAL JOURNAL OF THE DIGESTIVE DISEASES FOUNDATION 2016; 37:67-70. [PMID: 29668185 DOI: 10.7869/tg.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Das B, Kharbanda P, Bhalla A, Goyal M, Lal V, Prabhakar S, Khandalwal N. Status epilepticus in emergency: our experience in a tertiary care centre in north-western india. J Neurol Sci 2015. [DOI: 10.1016/j.jns.2015.08.498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Bhalla A, Peacock O, Lund JN. Response to: Ileostomy closure in an enhanced recovery setting. Colorectal Dis 2015; 17:929. [PMID: 26095728 DOI: 10.1111/codi.13025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 05/29/2015] [Indexed: 02/08/2023]
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