Prevalence and Outcomes of Patients With Acute Ischemic Stroke and Concomitant Non-ST-Elevation Myocardial Infarction (Results from the National Inpatient Sample 2016 to 2019)

Acute myocardial infarction (MI) may concomitantly occur with acute ischemic stroke. The incidence and outcomes of acute non-ST-elevation MI (NSTEMI) in acute ischemic stroke are not well studied. We examined hospitalized patients with acute ischemic stroke and a concomitant NSTEMI diagnosis who were included in the National Inpatient Sample 2016 to 2019. Acute ischemic stroke and NSTEMI were defined by using the International Classification of Diseases, Tenth Revision codes. Patients with ST-elevation MI were excluded. The outcomes were expressed as percentages. A multivariable logistic regression analysis was used to examine the association of concomitant acute ischemic stroke and NSTEMI with the primary outcome of mortality and the secondary outcomes. A subgroup analysis of patients with NSTEMI with acute ischemic stroke that underwent percutaneous coronary intervention (PCI) (angiography and angioplasty) was also performed. Of the total hospitalized patients with acute ischemic stroke (n = 1,726,265), 1.60% (n = 27,630) patients (mean age 73.5 years, 52.2% women, 67% White race) had NSTEMI diagnosed during the hospitalization. Of these, 14.1% (n = 3,890) died in the NSTEMI group and 3.4% (n = 57,670) died in the non-NSTEMI group. The most common outcomes in the NSTEMI group were Acute kidney injury 31.8%, Intracranial hemorrhage 6.6%, and sepsis 6.13%. NSTEMI in acute ischemic stroke was associated with mortality (odds ratio [OR] 3.60, 95% confidence interval [CI] 3.29 to 3.93, p ≤0.001), ICH (OR 1.46, 95% CI 1.30 to 1.63, p <0.001), and having any of the secondary outcomes (OR 2.73, 95% CI 2.57 to 2.90, p <0.001). PCI was performed in 9.14% of patients with acute ischemic stroke with NSTEMI. PCI was associated with having any of the secondary outcomes (OR 0.83, 95% CI 0.7 to 1.02, p = 0.8), mortality (OR 0.35, 95% CI 0.23 to 0.54, p <0.001), and ICH (OR 0.42, 95% CI 0.25 to 0.7, p = 0.01). In conclusion, NSTEMI in acute ischemic stroke is associated with increased mortality and other adverse events. PCI in the subgroup of patients with NSTEMI was not associated with increased mortality or intracranial bleeding.

Household COVID-19 secondary attack rate and associated determinants in Pakistan; A retrospective cohort study

Background

COVID-19 household transmissibility remains unclear in Pakistan. To understand the dynamics of Severe Acute Respiratory Syndrome Coronavirus disease epidemiology, this study estimated Secondary Attack Rate (SAR) among household and close contacts of index cases in Pakistan using a statistical transmission model.

Methodology

A retrospective cohort study was conducted using an inclusive contact tracing dataset from the provinces of Punjab and Khyber-Pakhtunkhwa to estimate SAR. We considered the probability of an infected person transmitting the infection to close contacts regardless of residential addresses. This means that close contacts were identified irrespective of their relationship with the index case. We assessed demographic determinants of COVID-19 infectivity and transmissibility. For this purpose based on evolving evidence, and as CDC recommends fully vaccinated people get tested 5–7 days after close contact with a person with suspected or confirmed COVID-19. Therefore we followed the same procedure in the close contacts for secondary infection.

Findings

During the study period from 15th May 2020 to 15th Jan 2021, a total of 339 (33.9%) index cases were studied from 1000 cases initially notified. Among close contact groups (n = 739), households were identified with an assumed mean incubation period of 8.2+4.3 days and a maximum incubation period of 15 days. SAR estimated here is among the household contacts. 117 secondary cases from 739 household contacts, with SAR 11.1% (95% CI 9.0–13.6). All together (240) SAR achieved was 32.48% (95% CI; 29.12–37.87) for symptomatic and confirmed cases. The potential risk factors for SAR identified here included; old age group (>45 years of age), male (gender), household members >5, and residency in urban areas and for index cases high age group. Overall local reproductive number (R) based on the observed household contact frequencies for index/primary cases was 0.9 (95% CI 0.47–1.21) in Khyber Pakhtunkhwa and 1.3 (95% CI 0.73–1.56) in Punjab.

Conclusions

SAR estimated here was high especially in the second phase of the COVID-19 pandemic in Pakistan. The results highlight the need to adopt rigorous preventive measures to cut the chain of viral transmission and prevent another wave of COVID-19.

Clinical, social, and policy factors in COVID-19 cases and deaths: methodological considerations for feature selection and modeling in county-level analyses

BACKGROUND

There is a need to evaluate how the choice of time interval contributes to the lack of consistency of SDoH variables that appear as important to COVID-19 disease burden within an analysis for both case counts and death counts.

METHODS

This study identified SDoH variables associated with U.S county-level COVID-19 cumulative case and death incidence for six different periods: the first 30, 60, 90, 120, 150, and 180 days since each county had COVID-19 one case per 10,000 residents. The set of SDoH variables were in the following domains: resource deprivation, access to care/health resources, population characteristics, traveling behavior, vulnerable populations, and health status. A generalized variance inflation factor (GVIF) analysis was used to identify variables with high multicollinearity. For each dependent variable, a separate model was built for each of the time periods. We used a mixed-effect generalized linear modeling of counts normalized per 100,000 population using negative binomial regression. We performed a Kolmogorov-Smirnov goodness of fit test, an outlier test, and a dispersion test for each model. Sensitivity analysis included altering the county start date to the day each county reached 10 COVID-19 cases per 10,000.

RESULTS

Ninety-seven percent (3059/3140) of the counties were represented in the final analysis. Six features proved important for both the main and sensitivity analysis: adults-with-college-degree, days-sheltering-in-place-at-start, prior-seven-day-median-time-home, percent-black, percent-foreign-born, over-65-years-of-age, black-white-segregation, and days-since-pandemic-start. These variables belonged to the following categories: COVID-19 related, vulnerable populations, and population characteristics. Our diagnostic results show that across our outcomes, the models of the shorter time periods (30 days, 60 days, and 900 days) have a better fit.

CONCLUSION

Our findings demonstrate that the set of SDoH features that are significant for COVID-19 outcomes varies based on the time from the start date of the pandemic and when COVID-19 was present in a county. These results could assist researchers with variable selection and inform decision makers when creating public health policy.

Risk Factors of Fall-Related Emergency Department Visits by Fall Location of Older Adults in the US

Introduction: Prior evidence indicates that predictors of older adult falls vary by indoor-outdoor location of the falls. While a subset of United States’ studies reports this finding using primary data from a single geographic area, other secondary analyses of falls across the country do not distinguish between the two fall locations. Consequently, evidence at the national level on risk factors specific to indoor vs outdoor falls is lacking. Methods: Using the 2017 Nationwide Emergency Department Sample (NEDS) data, we conducted a multivariable analysis of fall-related emergency department (ED) visits disaggregated by indoor vs outdoor fall locations of adults 65 years and older (N = 6,720,937) in the US. Results: Results are compatible with findings from previous primary studies. While women (relative risk [RR] = 1.43, 95% confidence interval [CI], 1.42-1.44) were more likely to report indoor falls, men were more likely to present with an outdoor fall. Visits for indoor falls were highest among those 85 years and older (RR = 2.35, 95% CI, 2.33-2.37) with outdoor fall visits highest among those 84 years and younger. Additionally, the probabilities associated with an indoor fall in the presence of chronic conditions were consistently much higher when compared to an outdoor fall. We also found that residence in metropolitan areas increased the likelihood of an indoor elderly fall compared to higher outdoor fall visits from seniors in non-core rural areas, but both indoor and outdoor fall visits were higher among older adults in higher income ZIP codes. Conclusion: Our findings highlight the contrasting risk profile for elderly ED patients who report indoor vs outdoor falls when compared to the elderly reporting no falls. In conjunction, we highlight implications from three perspectives: a population health standpoint for EDs working with their primary care and community care colleagues; an ED administrative vantage point; and from an individual emergency clinician’s point of view.

Challenges in defining Long COVID: Striking differences across literature, Electronic Health Records, and patient-reported information

Since late 2019, the novel coronavirus SARS-CoV-2 has introduced a wide array of health challenges globally. In addition to a complex acute presentation that can affect multiple organ systems, increasing evidence points to long-term sequelae being common and impactful. The worldwide scientific community is forging ahead to characterize a wide range of outcomes associated with SARS-CoV-2 infection; however the underlying assumptions in these studies have varied so widely that the resulting data are difficult to compareFormal definitions are needed in order to design robust and consistent studies of Long COVID that consistently capture variation in long-term outcomes. Even the condition itself goes by three terms, most widely "Long COVID", but also "COVID-19 syndrome (PACS)" or, "post-acute sequelae of SARS-CoV-2 infection (PASC)". In the present study, we investigate the definitions used in the literature published to date and compare them against data available from electronic health records and patient-reported information collected via surveys. Long COVID holds the potential to produce a second public health crisis on the heels of the pandemic itself. Proactive efforts to identify the characteristics of this heterogeneous condition are imperative for a rigorous scientific effort to investigate and mitigate this threat.

Clinical comorbidities, characteristics, and outcomes of mechanically ventilated patients in the State of Michigan with SARS-CoV-2 pneumonia

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Retrospective multi-center study of patients with confirmed coronavirus (SARS-CoV-2).

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Consecutive patients requiring mechanical ventilation from March 10 to April 15, 2020 enrolled.

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Increased age, hypertension, statin use, increased fluid administration were associated with increased mortality.

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Need for continuous renal replacement therapy (CRRT), and vasopressor use were associated with increased mortality.

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Decreased risk of mortality in patients treated with steroids & vitamin C, & in patients with greater urine output.

Effects of oxytocin administration on salivary sex hormone levels in autistic and neurotypical women

Background

Oxytocin administration, which may be of therapeutic value for individuals with social difficulties, is likely to affect endogenous levels of other socially relevant hormones. However, to date, the effects of oxytocin administration on endogenous hormones have only been examined in neurotypical individuals. The need to consider multi-hormone interactions is particularly warranted in oxytocin trials for autism due to evidence of irregularities in both oxytocin and sex steroid systems.

Methods

In this double-blind cross-over study, saliva samples were collected from 16 autistic and 29 neurotypical women before and after intranasal administration of 24 IU oxytocin or placebo. Oestradiol, testosterone, and oxytocin levels were quantified in saliva samples. Participants also completed the Autism-Spectrum Quotient (AQ) and Empathy Quotient (EQ) questionnaires.

Results

Distinct patterns of change in testosterone and oestradiol levels pre- to-post-administration were observed in autistic relative to neurotypical women (ANCOVA, p < 0.05 main effect of Group), controlling for sample collection time. The mean percent change oestradiol was + 8.8% for the autism group and − 13.0% for the neurotypical group (t = 1.81, p = 0.08), while the mean percent change testosterone was + 1.1% in the autism group and − 12.6% in the neurotypical group (t = 1.26, p = 0.22). In the oxytocin condition, the mean percent change oestradiol was + 12.6% in the autism group and − 6.9% in the neurotypical group (t = 1.78, p = 0.08), while the mean percent change testosterone was + 14.4% in the autism group and − 15.2% in the neurotypical group (t = 3.00, p = 0.006). Robust regression confirmed that group differences in percent change hormone levels were not driven by a small number of influential individuals. Baseline hormone levels did not differ between groups when considered individually. However, baseline testosterone relative to oestradiol (T:E2 ratio) was higher in autistic women (p = 0.023, Cohen’s d = 0.63), and this ratio correlated positively and negatively with AQ and EQ scores, respectively, in the combined sample.

Limitations

Further studies with larger and more diverse autistic sample are warranted to confirm these effects.

Conclusions

This study provides the first evidence that oxytocin influences endogenous testosterone levels in autistic individuals, with autistic women showing increases similar to previous reports of neurotypical men. These findings highlight the need to consider sex steroid hormones as a variable in future oxytocin trials.

Divergent subcortical activity for distinct executive functions: stopping and shifting in obsessive compulsive disorder

BACKGROUND

There is evidence of executive function impairment in obsessive compulsive disorder (OCD) that potentially contributes to symptom development and maintenance. Nevertheless, the precise nature of these executive impairments and their neural basis remains to be defined.

METHOD

We compared stopping and shifting, two key executive functions previously implicated in OCD, in the same task using functional magnetic resonance imaging, in patients with virtually no co-morbidities and age-, verbal IQ- and gender-matched healthy volunteers. The combined task allowed direct comparison of neural activity in stopping and shifting independent of patient sample characteristics and state variables such as arousal, learning, or current symptom expression.

RESULTS

Both OCD patients and controls exhibited right inferior frontal cortex activation during stopping, and left inferior parietal cortex activation during shifting. However, widespread under-activation across frontal-parietal areas was found in OCD patients compared to controls for shifting but not stopping. Conservative, whole-brain analyses also indicated marked divergent abnormal activation in OCD in the caudate and thalamus for these two cognitive functions, with stopping-related over-activation contrasting with shift-related under-activation.

CONCLUSIONS

OCD is associated with selective components of executive function, which engage similar common elements of cortico-striatal regions in different abnormal ways. The results implicate altered neural activation of subcortical origin in executive function abnormalities in OCD that are dependent on the precise cognitive and contextual requirements, informing current theories of symptom expression.

Oxytocin increases eye contact during a real-time, naturalistic social interaction in males with and without autism

Autism spectrum conditions (autism) affect ~1% of the population and are characterized by deficits in social communication. Oxytocin has been widely reported to affect social-communicative function and its neural underpinnings. Here we report the first evidence that intranasal oxytocin administration improves a core problem that individuals with autism have in using eye contact appropriately in real-world social settings. A randomized double-blind, placebo-controlled, within-subjects design is used to examine how intranasal administration of 24 IU of oxytocin affects gaze behavior for 32 adult males with autism and 34 controls in a real-time interaction with a researcher. This interactive paradigm bypasses many of the limitations encountered with conventional static or computer-based stimuli. Eye movements are recorded using eye tracking, providing an objective measurement of looking patterns. The measure is shown to be sensitive to the reduced eye contact commonly reported in autism, with the autism group spending less time looking to the eye region of the face than controls. Oxytocin administration selectively enhanced gaze to the eyes in both the autism and control groups (transformed mean eye-fixation difference per second=0.082; 95% CI:0.025-0.14, P=0.006). Within the autism group, oxytocin has the most effect on fixation duration in individuals with impaired levels of eye contact at baseline (Cohen's d=0.86). These findings demonstrate that the potential benefits of oxytocin in autism extend to a real-time interaction, providing evidence of a therapeutic effect in a key aspect of social communication.

NPR-B natriuretic peptide receptors in human corneal epithelium: mRNA, immunohistochemistochemical, protein, and biochemical pharmacology studies

PURPOSE

To demonstrate the presence of natriuretic peptide receptors (NPRs) in primary human corneal epithelial cells (p-CEPI), SV40-immortalized CEPI cells (CEPI-17-CL4) and in human corneal epithelium, and to define the pharmacology of natriuretic peptide (NP)-induced cGMP accumulation.

METHODS

NPR presence was shown by RT-PCR, western blot analysis, and indirect immunofluoresence. cGMP accumulation was determined using an enzyme immunoassay.

RESULTS

p-CEPI and CEPI-17-CL4 cells expressed mRNAs for NPR-A and NPR-B. Proteins for both NPRs were present in these cells and in human corneal epithelium. C-type NP (CNP), atrial NP (ANP) and brain NP (BNP) stimulated the accumulation of cGMP in a concentration-dependent manner in p-CEPI cells (potency; EC(50s)): CNP (1-53 amino acids) EC(50)=24+/-5 nM; CNP fragment (32-53 amino acids) EC(50)=51+/-8 nM; ANP (1-28 amino acids) EC(50)=>10 microM; BNP (32 amino acids) EC(50)>10 microM (all n=3-4). While the NPs were generally more potent in the CEPI-17-CL4 cells than in p-CEPI cells (n=4-9; p<0.01), the rank order of potency of the peptides was essentially the same in both cell types. Effects of CNP fragment in p-CEPI and CEPI-17-CL4 cells were potently blocked by HS-142-1, an NPR-B receptor subtype-selective antagonist (K(i)=0.25+/-0.05 microM in CEPI-CL4-17; K(i)=0.44+/-0.09 microM in p-CEPIs; n=6-7) but less so by an NPR-A receptor antagonist, isatin (K(i)=5.3-7.8 microM, n=3-7).

CONCLUSIONS

Our studies showed the presence of NPR-A and NPR-B (mRNAs and protein) in p-CEPI and CEPI-17-CL4 cells and in human corneal epithelial tissue. However, detailed pharmacological studies revealed NPR-B to be the predominant functionally active receptor in both cell-types whose activation leads to the generation of cGMP. While the physiologic role(s) of the NP system in corneal function remains to be delineated, our multidisciplinary findings pave the way for such future investigations.

Use of continuous positive airway pressure during spinal anaesthesia in a patient with severe chronic obstructive pulmonary disease

We report the case of a patient with severe chronic obstructive pulmonary disease who underwent local resection of a carcinoma of the rectum under spinal anaesthesia. Although the patient was keen to avoid general anaesthesia and to have the operation under a spinal anaesthetic, pre-operative assessment showed that he could not lie flat. As the surgical procedure required the patient to be in the lithotomy position, ideally with a head-down tilt, it was hoped that continuous positive airway pressure with a facemask during spinal anaesthesia might help him to tolerate the position comfortably. Continuous positive airway pressure at 7.5 cmH(2)O was successfully used to facilitate breathing during surgery under spinal anaesthesia. A combination of regional anaesthesia and continuous positive airway pressure via a facemask is easy to use and may be a useful option in the management of these challenging patients.

Efficacy of alendronate, a bisphosphonate, in the treatment of AVN of the hip. A prospective open-label study

OBJECTIVE

To study the efficacy of alendronate, in the treatment of avascular necrosis (AVN) of the hip.

METHODS

Sixty patients with AVN of the hip (100 hips with AVN) were studied. The follow-up period ranged from 3 months to 5 yr. The most common cause of AVN was steroids. Parameters studied were walking time, standing time, pain and disability on a visual analogue scale (VAS), range of motion of the hip, X-ray and MRI of the hip. All patients were treated with alendronate 10 mg/day (or 70 mg/week) along with 500-1000 mg of daily calcium and vitamin D supplements, and were advised to avoid weight-bearing. NSAIDs and analgesics were permitted as needed and were recorded.

RESULTS

Forty-one patients (71 AVN hips) with AVN have been followed up for a minimum of 1 yr, 24 patients (42 AVN hips) for 2 yr and 21 patients (37 AVN hips) for more than 2 yr (average 37 month). Fourteen patients have been followed up for less than 1 yr (3-9 months). Significant reduction in pain and disability scores (P < 0.001) and significant increase in standing and walking time (P < 0.001) were observed. All hip movements improved at 1 yr (P value 0.000-0.009) with an insignificant decline after that (P > 0.001). Radiologically, the hips either stabilized in the same grade or progressed by one grade. MRI showed a decrease in marrow oedema in most cases at the 1-yr follow-up. Six patients (10 hips) required surgery and there were two (three hips) dropouts. The drug was well tolerated and there was a reduction in NSAID requirement.

CONCLUSION

Alendronate reduces pain, improves function and retards AVN progression. Early surgical intervention can be avoided in most patients.

A longitudinal study of serum creatinine levels in patients of rheumatoid arthritis on long term NSAID therapy

AIM

Primary: To study the effect of long term NSAID therapy on serum creatinine in patients of rheumatoid arthritis. Secondary: To study the effect of discontinuation, reduction in the dose or continuation of NSAID and of rechallenge.

MATERIAL AND METHODS

Case records of RA patients with a minimum two years of follow up were analysed. Age, sex, duration of RA, type, dose and duration of NSAID and DMARD therapy, co-morbid conditions and serial serum creatinine levels were charted.

RESULTS

Ninety nine case records were studied. Incidence of abnormal creatinine level (renal insufficiency) defined as rise in creatinine equal to or above the upper limit of normal was 27.7%. This rise was asymptomatic in all patients. No NSAID was particularly associated with an increased risk in renal insufficiency. The rise of serum creatinine was reversible in most patients irrespective of discontinuation or continuation of NSAID but settled at a higher level. Rechallenge resulted in rise of serum creatinine in 50% patients. Hypertension, DM, IHD and diuretics carried a higher but not statistically significant risk of renal insufficiency.

CONCLUSION

NSAID-induced asymptomatic rise of creatinine in patients of RA on long term NSAIDs is common. It is mostly reversible. Regular monitoring of serum creatinine is essential.

Treatment of AA amyloidosis in rheumatoid arthritis

Four patients of rheumatoid arthritis (RA) with biopsy confirmed AA amyloidosis were treated with chlorambucil. All had established but uncontrolled RA with a persistently raised ESR. Moderate (> 1 gm, < 3.5 gm/d) to nephrotic range (> 3.5 gm/d) proteinuria and a relatively well preserved renal function was noted in three patients. One patient had deranged renal function and required dialysis. On chlorambucil, there was complete recovery, partial improvement and no improvement in one patient each. The fourth patient required haemodialysis, did not tolerate chlorambucil and succumbed to the illness. Therapy with chlorambucil can benefit some patients of RA with AA amyloidosis. Leucopenia is the most important dose limiting side effect.

Efficacy of isoniazid prophylaxis in patients with systemic lupus erythematosus receiving long term steroid treatment

OBJECTIVE

To study the efficacy of isoniazid prophylaxis (INHP) in patients with systemic lupus erythematosus (SLE) receiving long term glucocorticosteroid treatment.

PATIENTS AND METHODS

Treatment with INHP (5 mg/kg/day, max 300 mg/day) together with pyridoxine 10 mg/day for one year was started in all patients with SLE seen between January 1994 and December 1999 and followed up thereafter. Clinical examination and chest radiography were carried out in all patients before the start of INHP treatment. A liver profile was obtained only if liver toxicity was suspected owing to nausea, loss of appetite, and icterus. Only the data of those patients who completed the INHP treatment or who were withdrawn owing to toxicity have been analysed. This was compared with the results of an earlier study of the incidence of tuberculosis (TB) in patients with SLE not receiving INHP.

RESULTS

Ninety seven patients were included, of whom 95 completed one year's treatment with INHP. Treatment was discontinued in two owing to toxicity: hepatitis in one and peripheral neuropathy in one, at eight and 10 months, respectively. One patient developed TB within one month of starting INHP. Seventy patients were followed up further for at least one year (mean 26.4 months, range 12-60 months) after completion of the INHP treatment. During this period one patient developed TB after one month. No deaths due to TB or hepatitis occurred. In comparison with earlier series the incidence of TB decreased from 11% to 2%, a reduction of 82%. The cost of treatment for each case of TB prevented in the first year was 5800 rupees.

CONCLUSION

INHP is safe and effective in SLE.

Adrenal histoplasmosis

A 60 year old diabetic was admitted with the history of low grade fever and weight loss of six weeks duration. After investigations, he was detected to have bilateral adrenal masses which on biopsy proved to be due to histoplasmosis. He was treated with itraconazole and made complete recovery.

Intraoperative colonic irrigation in the management of left sided large bowel emergencies in Jos University Teaching Hospital, Nigeria

OBJECTIVES

To evaluate the safety and benefits of antegrade intraoperative colonic irrigation (lavage) and primary anastomosis, after colonic resection, in the treatment of left sided large bowel emergencies.

DESIGN

A prospective descriptive study.

SETTING

Jos University Teaching Hospital, Jos, Nigeria.

PARTICIPANTS

Thirty seven patients with an average age of 44.86 +/- 16.15 years.

INTERVENTION

Sigmoid colectomy was performed in twenty two sigmoid volvulus, five sigmoid cancer, two faecal fistulae and one sigmoid injury. Left hemicolectomy was offered in four descending colon cancer, one descending colon injury, while anterior resection was carried out in two rectal cancers. Primary anastomosis was performed after intraoperative colonic lavage.

RESULTS

The operative mortality was 2.7%, anastomotic leakage rate 2.7% and superficial wound infection occurred in 10.81%. The average duration of hospital stay was 22.76 +/- 11.26 days. Intraoperative colonic lavage added 35.79 +/- 7.25 minutes to the operating time.

CONCLUSION

The results of this study suggest that intraoperative colonic lavage is an effective method enabling the surgeon to perform a primary anastomosis with reasonable safety after emergency resection of selected distal colonic lesions.

Neuroleptic malignant syndrome occurring in a suspected case of systemic lupus erythematosus

The case of a 40 year old female patient of SLE who developed fatal neuroleptic malignant syndrome following administration of serenase (haloperidol) is reported. Relevant literature has been reviewed.