Increasing the Use of Kidneys From Unconventional and High-Risk Deceased Donors

In this paper, we have reviewed the literature and report on kidney donors that are currently used at relatively low rates. Kidneys from donors with acute kidney injury (AKI) seem to have outcomes equivalent to those from donors without AKI, provided one can rule out significant cortical necrosis. Kidneys from donors with preexisting diabetes or hypertension may have marginally lower aggregate survival but still provide patients with a significant benefit over remaining on the wait list. The Kidney Donor Profile Index derives only an aggregate association with survival with a very modest C statistic; therefore, the data indicated that this index should not be the sole reason to discard a kidney, except perhaps in patients with extremely low estimated posttransplant survival scores. It is important to note that the Scientific Registry of Transplant Recipients models of risk adjustment should allay concerns regarding regulatory issues for observed outcomes falling below expectations. The successful utilization of kidneys from donation after cardiac death over the past decade shows how expanding our thinking can translate into more patients benefiting from transplantation. Given the growing number of patients on the wait list, broadening our approach to kidney acceptance could have an important impact on the population with end-stage renal disease. Many lives could be prolonged by carefully considering use of kidneys that are often discarded.

A Closed Lateral Subtalar Dislocation With Checkrein Deformity of Great Toe due to Entrapment of Flexor Hallucis Longus: A Case Report

Closed lateral subtalar dislocation is a very rare injury. We report a case of closed lateral subtalar dislocation with entrapment of flexor hallucis longus tendon producing a checkrein deformity. The patient was managed immediately with closed reduction under regional anesthesia and fixated with percutaneous Kirschner wires. Early mobilization and weightbearing was started and there were no complications till the last follow-up visit.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case study.

Cardiometabolic Risk in South Asian Inhabitants of California: Hypertriglyceridemic Waist vs Hypertriglyceridemic Body Mass Index

OBJECTIVE

Hypertriglyceridemic waist (HTG-waist), an increased waist circumference (WC) with an elevated triglyceride (TG) concentration, can identify increased cardiometabolic risk in apparently healthy individuals. Since WC and BMI are highly correlated, we examined whether an HTG-BMI would be as effective as an HTG-waist in identifying cardiometabolic risk in apparently healthy South Asians.

DESIGN SETTING AND PARTICIPANTS

In this cross-sectional study, we classified South Asian women (n=1156) and men (n=1842) without diabetes mellitus as having an HTG-waist (TG ≥150 mg/dL and a WC ≥80 cm in women or ≥ 90 cm in men) and an HTG-BMI (TG ≥150 mg/dL and a BMI ≥23 kg/m²).

OUTCOME MEASURES

We measured cardiometabolic risk factors, including blood pressure and fasting lipid profile, glucose, insulin, fibrinogen, and high-sensitivity C-reactive protein.

RESULTS

An HTG-waist was present in 670 individuals, of whom 648 (97%) had an HTG-BMI. The cardiometabolic profile was significantly more adverse in those in whom an HTG-waist was present vs absent; and the same was true when individuals with an HTG-BMI were compared with those without.

CONCLUSIONS

Essentially every individual with an HTG-waist also had an HTG-BMI. An HTG-BMI identified cardiometabolic risk as effectively as an HTG-waist in a population composed entirely of South Asians.

Use of plasma triglyceride/high-density lipoprotein cholesterol ratio to identify increased cardio-metabolic risk in young, healthy South Asians

Background & objectives:

Prevalence of insulin resistance and associated dyslipidaemia [high triglyceride (TG) and low high-density lipoprotein cholesterol (HDL-C) concentrations] are increased in South Asian individuals; likely contributing to their increased risk of type-2 diabetes and cardiovascular disease. The plasma concentration ratio of TG/HDL-C has been proposed as a simple way to identify apparently healthy individuals at high cardio-metabolic risk. This study was carried out to compare the cardio-metabolic risk profiles of high-risk South Asian individuals identified by an elevated TG/HDL-C ratio versus those with a diagnosis of the metabolic syndrome.

Methods:

Body mass index, waist circumference, blood pressure, and fasting plasma glucose, insulin, TG, and HDL-C concentrations were determined in apparently healthy men (n=498) and women (n=526). The cardio-metabolic risk profile of “high risk” individuals identified by TG/HDL-C ratios in men (≥ 3.5) and women (≥2.5) was compared to those identified by a diagnosis of the metabolic syndrome.

Results:

More concentrations of all cardio-metabolic risk factors were significantly higher in “high risk” groups, identified by either the TG/HDL-C ratio or a diagnosis of the metabolic syndrome. TG, HDL-C, and insulin concentrations were not significantly different in “high risk” groups identified by either criterion, whereas plasma glucose and blood pressure were higher in those with the metabolic syndrome.

Interpretation & conclusions:

Apparently healthy South Asian individuals at high cardio-metabolic risk can be identified using either the TG/HDL-C ratio or the metabolic syndrome criteria. The TG/HDL-C ratio may be used as a simple marker to identify such individuals.

Childhood maltreatment and personality disorders in patients with a major depressive disorder: A comparative study between France and Togo

Few studies have examined the association between childhood maltreatment (CM) and personality disorders (PDs) in adulthood in two different cultural contexts, including sub-Saharan Africa. The aims of this study were to compare the frequency of CM between patients in treatment in France and Togo for a major depressive disorder (MDD), to explore the link between CM and PDs, and to examine the mediating effect of personality dimensions in the pathway from CM to PDs in 150 participants (75 in each country). The 28-item Childhood Trauma Questionnaire, the International Personality Item Pool, and the Personality Diagnostic Questionnaire (PDQ-4+) were used to assess CM, personality dimensions, and PDs respectively. Togolese participants reported sexual and physical abuse (PA) and emotional and physical neglect significantly more frequently than French participants. In Togo, severe PA was associated with schizoid, antisocial, narcissistic, obsessive-compulsive, depressive, and negativist PDs whereas in France, PA was only linked to paranoid PD. In Togo, emotional instability partly mediated the relationship between CM and PDs while in France, no personality dimension appeared to mediate this link. Our results support the hypothesis that CM is more common in low-income countries and suggest that the links between CM and PDs are influenced by social environment.

Bacteremic pneumococcal pneumonia: clinical outcomes and preliminary results of inflammatory response

PURPOSE

Further examination of clinical outcomes and inflammatory response of bacteremic pneumococcal community-acquired pneumonia (CAP) is of great interest to enhance the care of patients with pneumococcal CAP.

METHODS

This is a secondary analysis of the Community Acquired Pneumonia Organization (CAPO) to compare the time to clinical stability (TCS), length of hospital stay (LOS), and in-hospital mortality of hospitalized pneumococcal CAP patients with and without bacteremia. To measure the effect of bacteremia in pneumococcal CAP patients on outcomes, we modeled all-cause in-hospital mortality using a Poisson regression model, and TCS and LOS using Cox proportional hazards models. Adjusted multivariate regression models were also used to predict the probability of occurrence of each of the study outcomes. To investigate the inflammatory response, we measured the plasma levels of pro- and anti-inflammatory cytokines [tumor necrosis factor (TNF)-α, interleukin (IL)-1rα, IL-6, IL-8, IL-10], inflammatory biomarkers [C-reactive protein (CRP), pro-calcitonin (PCT), and B-type natriuretic peptide (BNP)], and peripheral blood neutrophil responses in 10 patients, 4 bacteremic and 6 non-bacteremic pneumococcal CAP, upon admission and every other day during the first 6 days of hospitalization. Functional data were presented as median and standard error of the median (SEM); due to small number of samples no statistical comparisons were performed between groups.

RESULTS

From 833 pneumococcal CAP patients, 394 patients (47 %) were bacteremic. Bacteremic pneumococcal CAP were less likely to reach TCS with an adjusted hazard ratio (AHR) of 0.82 (95 % CI 0.69-0.97; p = 0.02) and had higher in-hospital mortality with an AHR of 1.63 (95 % CI 1.06-2.50, p = 0.026). Bacteremic pneumococcal CAP patients had a longer LOS than non-bacteremic pneumococcal CAP (p < 0.003). Higher plasma levels of CRP, PCT, and BNP were found in bacteremic than in non-bacteremic patients. The bacteremic group had consistently higher plasma levels of both pro- and anti-inflammatory cytokines. The blood neutrophil functional responses were similar in both groups of patients.

CONCLUSIONS

Bacteremic pneumococcal CAP patients were significantly associated with higher in-hospital mortality, lower TCS, and longer LOS. HIV-infected patients showed a greater mortality which was not statistically significant. Bacteremic pneumococcal CAP patients had higher levels of biomarkers and systemic cytokines.

Abstract 705: Coronary Artery Calcification and Cardiovascular Risk Factors in South Asians

Compared to other ethnic groups, South Asians are at higher risk for cardiovascular disease and diabetes mellitus. Traditional risk factor assessment, developed mainly in a white European-descent populations, may underestimate the incidence of cardiovascular disease in South Asians. Our study examined the relationship between coronary calcification, a strong predictor of cardiovascular events, and other traditional cardiovascular risk factors in South Asians. We analyzed the association of coronary calcification with both traditional and emerging factors commonly used to predict cardiovascular risk. These factors include the lipid panel (total cholesterol, LDL-C, HDL-C, and triglycerides), fasting blood glucose, high-sensitivity CRP, family history of coronary artery disease and diabetes, and the ACC/AHA-recommended atherosclerotic cardiovascular disease (ASCVD) risk score. We found that fasting blood glucose, glycated hemoglobin, insulin, BMI, and personal history of hypertension, hypercholesterolemia, and diabetes mellitus were all significantly associated with a non-zero calcium score. High-sensitivity CRP, the conventional lipid panel, the ASCVD risk score, and family history of coronary artery disease and diabetes were not. Because the lipid panel was not predictive while the glucose dysmetabolism risk factors were, the evaluation of South Asians should include and focus on pre-diabetic risk factors, such as fasting blood glucose, insulin, and hemoglobin A1c, and measurements of obesity.

Effectiveness of a community screening program for metabolic syndrome and cardiovascular risk factor identification in young South Asians adults

AIMS

Metabolic syndrome has been associated with increased risk of cardiovascular disease. We aimed to determine the effectiveness of a community-based screening program in identifying cardiovascular risk factors in healthy young South Asian population.

MATERIALS AND METHODS

Between 2006 and 2011, 3314 patients of all ages were recruited as a part of a prospective cohort study investigating cardiovascular risk in South Asians. We analyzed 1537 patients between the ages of 18 and 40. Demographic and baseline characteristics including baseline laboratory markers and blood pressures were obtained at initial visit.

RESULTS

The total cohort of 1537 patients was 66.5% male, and the mean age was 35±5 years. Among participants who denied a history of hypercholesterolemia, 62% had elevated LDL-C (>100 mg/dL), and 8% had markedly elevated LDL-C (>160 mg/dL). Overall, diabetes was present in 4%, hypertension was present in 12% and hyperlipidemia was present in 46%. Low HDL-C (50% of men, 52% of women) and elevated triglycerides (44% of men, 18% of women) were the most prevalent components of metabolic syndrome. Metabolic syndrome was present in 14% of men and 8% of women and one-third (30%) of men and one-fifth (19%) of women had at least two component risk factors.

CONCLUSIONS

This is the largest study to date assessing effectiveness of a community based screening program aiming to identify cardiovascular risk in young South Asians. We note significant modifiable risk at a young age. Such community based interventions can be effective at detecting and managing risk factors early in this vulnerable population.

Evaluation of intrabony defects treated with platelet-rich fibrin or autogenous bone graft: A comparative analysis

OBJECTIVE

The primary objective of this study was to compare clinically and radiographically the efficacy of autologous platelet rich fibrin (PRF) and autogenous bone graft (ABG) obtained using bone scrapper in the treatment of intrabony periodontal defects.

MATERIALS AND METHODS

Thirty-eight intrabony defects (IBDs) were treated with either open flap debridement (OFD) with PRF or OFD with ABG. Clinical parameters were recorded at baseline and 6 months postoperatively. The defect-fill and defect resolution at baseline and 6 months were calculated radiographically (intraoral periapical radiographs [IOPA] and orthopantomogram [OPG]).

RESULTS

Significant probing pocket depth (PPD) reduction, clinical attachment level (CAL) gain, defect fill and defect resolution at both PRF and ABG treated sites with OFD was observed. However, inter-group comparison was non-significant (P > 0.05). The bivariate correlation results revealed that any of the two radiographic techniques (IOPA and OPG) can be used for analysis of the regenerative therapy in IBDs.

CONCLUSION

The use of either PRF or ABG were effective in the treatment of three wall IBDs with an uneventful healing of the sites.

Maternal death review in selected countries of South East Asia Region

Understanding the underlying factors that led to maternal deaths through a maternal death review (MDR) throws light on the causes, characteristics and circumstances of the death. We reviewed and report on the implementation of MDR in India, Indonesia, Myanmar, Nepal and Sri Lanka, capturing the experiences of MDR initiatives, follow-up actions and lessons learnet. Overall, while the findings from MDRs have been used to design or change policies and strategies for improvement of services provided, there are still challenges in scaling up these initiatives, particularly in the larger countries.

Does a 'direct' transfer protocol reduce time to coronary angiography for patients with non-ST-elevation acute coronary syndromes? A prospective observational study

OBJECTIVE

National guidelines recommend 'early' coronary angiography within 96 h of presentation for patients with non-ST elevation acute coronary syndromes (NSTE-ACS). Most patients with NSTE-ACS present to their district general hospital (DGH), and await transfer to the regional cardiac centre for angiography. This care model has inherent time delays, and delivery of timely angiography is problematic. The objective of this study was to assess a novel clinical care pathway for the management of NSTE-ACS, known locally as the Heart Attack Centre-Extension or HAC-X, designed to rapidly identify patients with NSTE-ACS while in DGH emergency departments (ED) and facilitate transfer to the regional interventional centre for 'early' coronary angiography.

METHODS

This was an observational study of 702 patients divided into two groups; 391 patients treated before the instigation of the HAC-X pathway (Pre-HAC-X), and 311 patients treated via the novel pathway (Post-HAC-X). Our primary study end point was time from ED admission to coronary angiography. We also assessed the length of hospital stay.

RESULTS

Median time from ED admission to coronary angiography was 7.2 (IQR 5.1-10.2) days pre-HAC-X compared to 1.0 (IQR 0.7-2.0) day post-HAC-X (p<0.001). Median length of hospital stay was 3.0 (IQR 2.0-6.0) days post-HAC-X v 9.0 (IQR 6.0-14.0) days pre-HAC-X (p<0.0005). This equates to a reduction of six hospital bed days per NSTE-ACS admission.

CONCLUSIONS

The introduction of this novel care pathway was associated with significant reductions in time to angiography and in total hospital bed occupancy for patients with NSTE-ACS.

[Should hospitalization be required after the emergency discharge of patients with borderline personality disorder who have attempted suicide (FRENCH CRISIS cohort)?]

BACKGROUND

Borderline personality disorder (BPD) is characterized by a pervasive pattern of instability and impulsivity. There is a high prevalence of BPD patients among those admitted to the emergency department for suicide attempts. However, little empirical research exists to assist clinicians in deciding whether to hospitalize a suicidal patient. Some authors have argued that hospitalization does not prevent suicide and could actually harm these patients, thereby leading to psychosocial regression. Parasuicidal behaviors could be reinforced by the attention given during hospitalization.

OBJECTIVE

Our purpose was to determine whether the hospitalization of suicidal patients who have a high risk of BPD after discharge from the emergency department is associated with a recurrence of suicidal behavior at 6months.

METHOD

We designed a prospective study, acquiring patients from three emergency hospitals. The participants were suicidal subjects admitted for voluntary drug intoxication and were 18years of age or older. The participants completed the Personality Disorder Questionnaire (PDQ-4+) to assess BPD symptomatology. Information on the recurrence of suicidal behavior at 6months was obtained by interview of patients and the review of the charts from the 3 hospitals involved in the study. Other assessments included the BDI-13 (severity of depression), the Hopelessness Scale (hopelessness), the TAS-20 (alexythymia), the AUDIT (alcohol disorder) and the MINI (axis I disorders).

RESULTS

A total of 606 subjects admitted for a suicide attempt participated in this study. A total of 320 (52.8 %) of the subjects completed the PDQ-4+. The sample was divided into three groups: participants at high risk of having at least one BPD (n=197), a group at high risk of having at least one non-BPD PD (n=84) and a group with low risk of having a PD (n=39). Hospitalization following an emergency was not associated with a recurrence of suicide attempts at 6months among patients at high risk of BPD. A logistical regression analysis showed pre-hospitalization antidepressant prescription to be associated with recidivism (OR=2.1, P=.037).

CONCLUSION

Our exploratory study suggests that hospitalization may not increase suicide attempts among patients with BPD when the health organization does not include a specific device such as DBT.

Comparing post-operative resource consumption following transcatheter aortic valve implantation (TAVI) and conventional aortic valve replacement in the UK

OBJECTIVE

To define the in-hospital and 6-month post-discharge resource use, following Transcatheter Aortic Valve Implantation (TAVI) and conventional Aortic Valve Replacement (AVR) surgery within a single UK hospital.

METHODS

A local service evaluation of patients undergoing TAVI or AVR between January 2011 and May 2012 captured data until 6-months post-procedure, collected from hospital records and via a General Practitioner questionnaire. The main end-points were mortality, time in ITU/HDU, hospital length of stay (LoS), discharge destination, re-admission, and post-discharge primary/secondary care resource use. Sub-group analyses were performed for AVR patients aged ≥80 (AVR ≥ 80) and with EuroSCORE of ≥10 (AVR ES ≥ 10) to allow more direct comparison with 'TAVI type' patients.

RESULTS

Results are given as means (standard deviation) for TAVI (n = 51), AVR (n = 188), AVR ≥ 80 (n = 48), and AVR ES ≥ 10 (n = 47), respectively, unless otherwise stated. Age in years was 83.0 (8.1), 71.2 (13.1), 84.1 (2.7), 79.4 (7.1); EuroSCORE was 24.7 (11.9), 8.1 (6.4), 12.0 (6.0), and 16.5 (6.6); post-operative LoS (days) was 11.5 (11.2), 10.9 (10.8), 14.3 (16.7), and 15.2 (17.7). For discharged patients, 0%, 7%, 13%, and 9% had unplanned cardiac-related re-admissions within 30-days of discharge. Time to first readmission was 74.6 (34.0), 35.0 (34.2), 20.8 (9.7), and 22.6 (14.3) days.

LIMITATIONS

This was a single-center retrospective evaluation, not prospectively powered to confirm differences in outcomes.

CONCLUSIONS

Despite TAVI being performed in an older, higher risk population, LoS was similar to AVR. Most strikingly there were no cardiac-related re-admissions within 30-days for TAVI and time to first re-admission was significantly longer. This evaluation suggests that TAVI is clinically appropriate and provides economic advantages in both the hospital and post-discharge setting in this high risk group. Many patients undergoing TAVI are considered unfit for surgery and, hence, TAVI offers a treatment that delivers similar results to traditional AVR without the high risk associated with surgery.