End Stage Renal Disease: Seroprevalence of Hepatitises B and C along with Associated Aetiology and Risk Factors in Children

Blood-borne viral infections in pediatric hemodialysis

Hemodialysis patients are at increased risk for development of blood-borne viral infections. Human immunodeficiency virus (HIV), a once fatal infection, has become treatable, but continues to be associated with increased mortality. Hepatitis B and C viral infections can lead to acute and chronic hepatitis, cirrhosis, or hepatocellular carcinoma. Young children and immunocompromised patients are more likely to develop chronic disease leading to increased morbidity and mortality, as compared to the healthy population. The hemodialysis population is at increased risk of blood-borne viral infections as compared to the general population due to multiple factors. Here we review risk factors of blood-borne viral infections, strategies for prevention, and approach to therapy in the pediatric hemodialysis population.

Using left ventricular assist devices in advanced heart failure patients

Advanced Heart Failure (AHF) is a complex syndrome that affects the physiology of the heart to maintain efficient blood circulation resulting in multiorgan failure and, eventually, death. Left Ventricular Assist Devices (LVADs) have become the cornerstone therapy for AHF patients, both as a bridge to transplantation and as a decisive therapy. Recently the results of the MOMENTUM 3 Trial were published. The trial compared HeartMate 3 LVAD with HeartMate II LVAD in a randomized trial in The Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3 (MOMENTUM 3). Of 366 patients, 190 were assigned to the centrifugal-flow pump group (HeartMate 3) and 176 to the axial-flow (HeartMate II) pump group. In the intention-to-treat population, the primary end point occurred in 151 patients (79.5%) in the centrifugal-flow pump group, as compared with 106 (60.2%) in the axial-flow pump group (P < 0.001 for noninferiority). Reoperation for pump malfunction was less frequent in the centrifugal-flow pump group than in the axial-flow pump group (P < 0.001).The results of the MOMENTUM 3 Trial are a big achievement in the cardiovascular world. Any improvement in LVADs that reduces the risk of stroke, perhaps the most feared complication of these devices, would be meaningful. Besides, given the observed lower rate of pump thrombosis and reoperation for pump malfunction, it already seems likely that the HeartMate 3 will supplant the HeartMate II in clinical practice. In addition, the risks that are associated with reoperation undoubtedly counterbalanced any unintentional bias in performing that intervention.

A closer look at heart failure in patients with concurrent diabetes mellitus using glucose lowering drugs

INTRODUCTION

Type 2 diabetes (T2D) is an independent risk factor for heart failure (HF). With concomitant T2D and HF, recent data suggests an incremental risk of cardiovascular death and hospitalization for HF, as compared to patients with HF without T2D. Areas covered: Management of these two diseases has been a challenge for physicians. The treatment goals for HF patients in T2D are very important. They serve as the endpoint in using a specific treatment for management and treatment of T2D patients hence, decreasing mortality rates. In this review, we examine the effects of oral antidiabetic drugs on HF patients, discussing current evidence-based up-to-date management strategies and guidelines in the general population with HF and T2D. Expert commentary: Future in the management of T2D in HF patients looks bright. Augmenting data on potential cardiovascular side effects of antidiabetic drugs is valuable since millions of people are treated over many years. Newer novel drugs targeting specific signaling pathways are approaching the stages of clinical investigation. They have been a highly attractive concept for the future in the management of these patients. However, while advances in technology elucidated many aspects of these diseases, many mysteries still remain.

Hepatitis C Virus and Interferon-Free Antiviral Therapeutics Revolution: Implications for Pakistan

Hepatitis C virus (HCV) is a major health concern worldwide as a leading cause of liver-related mortalities and morbidities. Pakistan ranks second among countries with endemic HCV infection; ∼11 million cases are reported so far. HCV burden is continuously rising in Pakistan, mainly because of unsafe blood transfusions, surgical procedures, dental procedures, untrained clinicians, reuse of syringes, barbers, and ear/nose piercing tools. Lack of awareness about HCV transmission routes among the general and high-risk population is a major hurdle in disease management. HCV prevalence in the general population and healthy blood donors ranges from 3.13% to 23.83% and from 1.05% to 20.8%, respectively; whereas in the high-risk groups, HCV prevalence is up to 66%. Genotype 3 is most prevalent in Pakistan followed by genotypes 1 and 2 along with an alarming number of untypable viral genotypes in the local community. Mainly interferon-based antiviral regimens are used in Pakistan and are quite effective, because the major prevalent genotype (genotype 3) showed the best sustained virological response (SVR) with it. But a large number of individuals did not show SVR either because of infection with nonresponder genotypes or because of side effects. Due to these reasons, there was a need for interferon-free direct acting antivirals (DAAs). Recently, Sovaldi (Sofosbuvir: NS5B inhibitor) is approved on a heavy discounted rate for Pakistan; it is currently in effective use and showed good SVR. Sovaldi plus ribavirin is used alone or along with interferon to treat different viral genotypes. Sovaldi will be the future treatment regime for Pakistan, because genotype 2 and genotype 3 infected individuals achieve the best SVR with it. For the treatment of other prevalent viral genotypes, approval of some other DAAs such as Ledipasvir on discounted price is required for better disease management.

Topical vasodilator response in skeletonized internal mammary artery: Is there really a difference?

Aim of the Study:

Coronary artery bypass graft surgery is the gold standard for the treatment of multivessel and left main coronary artery disease. However, there is considerable debate that whether left internal mammary artery (IMA) should be taken as pedicled or skeletonized. This study was conducted to assess the difference in blood flow after the application of topical vasodilator in skeletonized and pedicled IMA.

Materials and Methods:

In this study, each patient underwent either skeletonized (n = 25) or pedicled IMA harvesting (n = 25). The type of graft on each individual patient was decided randomly. Intraoperative variables such as conduit length and blood flow were measured by the surgeon himself. The length of the grafted IMA was carefully determined in vivo, with the proximal and distal ends attached, from the first rib to IMA divergence. The IMA flow was measured on two separate occasions, before and after application of topical vasodilator. Known cases of subclavian artery stenosis and previous sternal radiation were excluded from the study.

Results:

The blood flow before the application of topical vasodilator was similar in both the groups (P = 0.227). However, the flow was significantly less in pedicled than skeletonized IMA after application of vasodilator (P < 0.0001). Similarly, the length of skeletonized graft was significantly higher than the length of pedicled graft (P < 0.0001).

Conclusion:

Our study signifies that skeletonization of IMA results in increased graft length and blood flow after the application of topical vasodilator. However, we recommend that long-term clinical trials should be conducted to fully determine long-term patency rates of skeletonized IMA.