SMaRT-PCR: sampling using masks and RT-PCR, a non-invasive diagnostic tool for paediatric pulmonary TB

BACKGROUND

Key challenges in paediatric TB diagnosis are invasive sampling and poor sensitivity of standard methods. This study demonstrates the diagnostic potential of non-invasive sampling of bioaerosols from children using SMaRT-PCR, comprising mask sampling combined with reverse transcriptase-polymerase chain reaction (RT-PCR) for TB.

METHODS

Exhaled bioaerosols were captured on modified N-95 masks in a 10-min talk-cough-breathe process from 51 children (30 with TB confirmed using standard sampling methods and 21 without TB) aged 2-15 years. All mask samples were tested using in-house RT-PCR for 16s and rpoB RNA transcripts. Additional mask samples from children with TB were tested using Xpert® MTB/RIF (n = 3) and Xpert® MTB/RIF Ultra (n = 27).

RESULTS

SMaRT-PCR sensitivity for detecting TB among treatment-naïve children was 96% if 16s or rpoB was present, and 75% if both genes were present, comparable to standard methods (71%) in the same cohort. Specificity was better for both genes, at 95%, than 85% for a single gene detection. Mask sampling with Xpert MTB/RIF or Ultra had a sensitivity of only 13%.

CONCLUSION

This is the first study to provide evidence for testing bioaerosols as a promising alternative for detecting paediatric TB. Sampling is non-invasive and simple, with the potential for point-of-care applications. This pilot study also suggests that RNA transcript-based detection may improve TB diagnostic sensitivity in children; however, further investigation is required to establish its adaptability in clinical settings..

Transient ST-segment Elevation During Atrial Fibrillation Ablation from Septal Stretch by a Multipolar Mapping Catheter

ST-segment elevation (STE) is a very rare complication observed during various cardiac ablation procedures. We report an interesting case of transient STE elevation by inter-atrial septal stretch during introduction of a multipolar mapping catheter during pulmonary vein isolation procedure. We also discuss various mechanisms for this observation.

Evaluating structure-based activity in a high-throughput assay for steroid biosynthesis

Data from a high-throughput human adrenocortical carcinoma assay (HT-H295R) for steroid hormone biosynthesis are available for >2000 chemicals in single concentration and 654 chemicals in multi-concentration (mc). Previously, a metric describing the effect size of a chemical on the biosynthesis of 11 hormones was derived using mc data referred to as the maximum mean Mahalanobis distance (maxmMd). However, mc HT-H295R assay data remain unavailable for many chemicals. This work leverages existing HT-H295R assay data by constructing structure-activity relationships to make predictions for data-poor chemicals, including: (1) identification of individual structural descriptors, known as ToxPrint chemotypes, associated with increased odds of affecting estrogen or androgen synthesis; (2) a random forest (RF) classifier using physicochemical property descriptors to predict HT-H295R maxmMd binary (positive or negative) outcomes; and, (3) a local approach to predict maxmMd binary outcomes using nearest neighbors (NNs) based on two types of chemical fingerprints (chemotype or Morgan). Individual chemotypes demonstrated high specificity (85-98%) for modulators of estrogen and androgen synthesis but with low sensitivity. The best RF model for maxmMd classification included 13 predicted physicochemical descriptors, yielding a balanced accuracy (BA) of 71% with only modest improvement when hundreds of structural features were added. The best two NN models for binary maxmMd prediction demonstrated BAs of 85 and 81% using chemotype and Morgan fingerprints, respectively. Using an external test set of 6302 chemicals (lacking HT-H295R data), 1241 were identified as putative estrogen and androgen modulators. Combined results across the three classification models (global RF model and two local NN models) predict that 1033 of the 6302 chemicals would be more likely to affect HT-H295R bioactivity. Together, these in silico approaches can efficiently prioritize thousands of untested chemicals for screening to further evaluate their effects on steroid biosynthesis.

His-bundle Pacing as a Bailout Therapy for a Patient with Subclavian Stenosis and No Suitable Coronary Sinus Branch: A Double Whammy

We present an interesting case of an 88-year-old man who was referred to our arrhythmia service for an upgrade of his dual-chamber pacemaker to a biventricular pacemaker for right ventricular pacing-induced cardiomyopathy. The patient was found to have stenosis of the left subclavian vein. Here, we describe the approach used to perform venoplasty in this patient. After venoplasty of the left subclavian vein, the patient did not have suitable coronary venous anatomy for deployment of the coronary sinus lead. Subsequently, a His lead was implanted. We achieved significant narrowing of the QRS with good thresholds and other lead parameters. Through this case report, we seek to present our approach of venoplasty in patients with occluded venous access for either an upgrade or a de novo implant.

Differing radiation exposure in scrub technicians and rotating staff in cardiac catheterization laboratory: occupation matters

Funding Acknowledgements

Type of funding sources: None.

Background

Radiation exposure of cardiac catheterization lab personnel is an evolving area of concern, due to long term, repetitive exposure causing deterministic and stochastic effects(1,2). Current radiation protection measures are based on increasing distance, shielding from fluoroscopy source and depend on primary operator behavior(3)

Effective dose(ED) in micro Sieverts( μSv) as a measure of individual absorbed radiation dose provides feedback as to occupational exposure and risks. Dosimeter badges worn over equipment measure ED correlating with radiation exposure of areas unprotected by standard lead apron such as head, neck, lens and upper limbs. (4)

Most studies focus on primary operator exposure (5,6,7), overlooking non physician staff comprising scrub technicians working as assistants to primary operator physicians, and rotating staff involved in peri-procedural care of patients.

Purpose

This study aimed to find out ED acquired by scrub technicians(ED.S) and rotating staff(ED.R) in interventional cardiology and invasive electrophysiology procedures, utilizing external dosimeters worn over lead aprons.

Methods

We prospectively collected radiation data over forty six invasive Cardiology procedures from 15th March 2021 to 1st June 2021 comprising fourteen diagnostic coronary and graft angiograms, seventeen combined diagnostic and interventional cardiology procedures, nine sole percutaneous coronary interventions and six electrophysiology procedures. Nine staff members: two female and seven male members participated as scrub technicians and rotating staff, provided with external dosimeter badges. ED was obtained by logging in dosimeter badges into pre calibrated monitors.

Results

Significantly high mean ED was acquired by rotating staff as compared to scrub technicians, mean ED.R:21.04 μSv( SD: +/-39.64) and mean ED.S: 7.54 μSv( SD:+/- 17.23), this three fold difference in radiation exposure was statistically significant with a p-value of 0.03.

This was consistent across procedure groups, with rotating staff acquiring higher ED compared to their scrub technician colleagues in diagnostic, interventional and electrophysiology cases. Statistically significant differences in radiation exposure of both staff groups were demonstrated in diagnostic and interventional cardiology procedures, with p-values of 0.04 and 0.01 respectively.(See Table)

Conclusion

This small, single center study highlights occupational role as a significant factor in varying radiation exposure amongst non-physician staff . Higher ED was attributed to rotating staff duties involving proximity and mobility around fluoroscopy source and patient, devoid of protective lead shields.

Based on these findings, avoiding fluoroscopy use while staff performs duties involving proximity to patient such is mandatory. Other essential measures should include accessory left sided leads shields, mandatory protective lens and head shields for rotating staff. Abstract Table

The family planning "know-do" gap among married women of reproductive age in urban Pakistan

OBJECTIVE

To examine the prevalence and predictors of family planning (FP) know-do gaps among married women of reproductive age (MWRA) in low socio-economic urban areas of Karachi, Pakistan.

DESIGN

This was a cross-sectional survey of randomly selected 7288 MWRA (16-49 years) to identify predictors of the know-do gap in FP using a logistic regression model.

RESULTS

More than one third (35.5%) of MWRA had FP know-do gap, i.e., despite having a knowledge of contraceptives and desire to limit or delay childbearing, they were not using contraceptives. Women were less likely to use FP if they were getting older (25-35 years: OR 1.45, 95% CI 1.09-1.94; >35 years: OR 3.02, 95% CI 1.90-4.80), from certain ethnicities (Sindhi: OR 1.64, 95% CI 1.11-2.42; Saraiki: OR 1.66, 95% CI 1.01-2.71; other minorities: OR 2.37, 95% CI 1.63-3.44); did not receive FP counselling: OR 1.43, 95% CI 1.13-1.80; and had not made a joint decision on FP: OR 1.44, 95% CI 1.06-1.98). Conversely, women were more likely to use contraceptives if they had >10 years of schooling (OR 0.66, 95% CI 0.46-0.94), with each increasing number of a living child (OR 0.68, 95% CI 0.62-0.75) and each increasing number of contraceptive method known (OR 0.93, 95% CI 0.88-0.98).

CONCLUSION

The predictors associated with the FP know-do gap among MWRA should be considered when planning future strategies to improve the contraceptive prevalence rate in Pakistan.

Marijuana Use and In-Hospital Outcomes After Percutaneous Coronary Intervention in Michigan, United States

OBJECTIVES

The aim of this study was to evaluate the association between reported marijuana use and post-percutaneous coronary intervention (PCI) in-hospital outcomes.

BACKGROUND

Marijuana use is increasing as more states in the United States legalize its use for recreational and medicinal purposes. Little is known about the frequency of use and relative safety of marijuana among patients presenting for PCI.

METHODS

The authors analyzed Blue Cross Blue Shield of Michigan Cardiovascular Consortium PCI registry data between January 1, 2013, and September 30, 2016. One-to-one propensity matching and multivariable logistic regression were used to adjust for differences between patients with or without reported marijuana use, and rates of post-PCI complications were compared.

RESULTS

Among 113,477 patients, 3,970 reported marijuana use. Compared with those without reported marijuana use, patients with reported marijuana use were likely to be younger (53.9 years vs 65.8 years), to use tobacco (73.0% vs 26.8%), to present with ST-segment elevation myocardial infarction (27.3% vs 15.9%), and to have fewer cardiovascular comorbidities. After matching, compared with patients without reported marijuana use, those with reported marijuana use experienced significantly higher risks for bleeding (adjusted odds ratio [aOR]: 1.54; 95% confidence interval [CI]: 1.20-1.97; P < 0.001) and cerebrovascular accident (aOR: 11.01; 95% CI: 1.32-91.67; P = 0.026) and a lower risk for acute kidney injury (aOR: 0.61; 95% CI: 0.42-0.87; P = 0.007). There were no significant differences in risks for transfusion and death.

CONCLUSIONS

A modest fraction of patients undergoing PCI used marijuana. Reported marijuana use was associated with higher risks for cerebrovascular accident and bleeding and a lower risk for acute kidney injury after PCI. Clinicians and patients should be aware of the higher risk for post-PCI complications in these patients.

New TB drugs for the treatment of children and adolescents with rifampicin-resistant TB in Mumbai, India

SETTING: Médecins Sans Frontières (MSF) clinic in Mumbai, India.OBJECTIVE: To determine the final treatment outcomes, culture conversion and adverse events (AEs) during treatment among children and adolescents (0-19 years) with rifampicin-resistant tuberculosis (RR-TB) who received ambulatory injectable-free treatment, including bedaquiline (BDQ) and/or delamanid (DLM) during September 2014-January 2020.DESIGN: This was a retrospective cohort study based on review of routinely collected programme data.RESULTS: Twenty-four patients were included; the median age was 15.5 years (min-max 3-19) and 15 (63%) were females. None were HIV-coinfected. All had fluoroquinolone resistance. Twelve received treatment, including BDQ and DLM, 11 received DLM and one BDQ. The median exposure to BDQ (n = 13) and DLM (n = 23) was 82 (IQR 80-93) and 82 (IQR 77-96) weeks, respectively. Seventeen (94%) patients with positive culture at baseline (n = 18) had negative culture during treatment; median time for culture-conversion was 7 weeks (IQR 5-11). Twenty-three (96%) had successful treatment outcomes: cured (n = 16) or completed treatment (n = 7); one died. Eleven (46%) had 17 episodes of AEs. Two of 12 serious AEs were associated with new drugs (QTcF >500 ms).CONCLUSION: Based on one of the largest global cohorts of children and adolescents to receive new TB drugs, this study has shown that injectable-free regimens containing BDQ and/or DLM on ambulatory basis were effective and well-tolerated among children and adolescents and should be made routinely accessible to these vulnerable groups.

Profile of osteoarticular tuberculosis in children

OBJECTIVE

To determine clinical profile of osteoarticular tuberculosis (TB) in children.

METHODS

Cross-sectional analysis from 2007 to 2013. All patients diagnosed with bone TB, spinal TB or TB abscesses were included.

RESULTS

Out of 1318 children with TB, 39 (2.96%) had osteoarticular TB, of which 16 (42%) had osteomyelitis, 8 (20.5%) had spinal involvement, 7 (17.9%) had TB synovitis, 2 (5.1%) had psoas abscess and 6 (15.4%) had abscesses. The mean age of presentation was 7.1 ± 3.5 years (range 2-14 years). Of the 33 cases in which a culture was done, 25 (64%) showed a positive culture. Drug sensitivity tests were done in 21 patients of which 10 (47.6%) tested were drug resistant, of which 4 (36.4%) were multidrug resistant (MDR), 2 (18.2%) were extensively drug resistant (XDR), 3 were pre-XDR (27.3%) and 1 was polyresistant (9.1%). Nine (23.1%) patients had TB in the past with a treatment duration of 8.3 ± 5.3 months. Contact with a TB patient had occurred in 10 (25.6%) cases. Associated pulmonary TB were seen in 6 (15.39%) and TB meningitis were seen in 1 (2.6%) patients. Surgical intervention was needed in 11 (28.2%) patients of which 5 (45.5%) underwent curettage, drainage was done in 1 (9.1%), arthrotomy in 4 (36.4%) and spinal surgery in 1 (9.1%) patient.

CONCLUSION

Drug resistant osteoarticular TB is an emerging problem in children.

Quantitative prediction of repeat dose toxicity values using GenRA

Computational approaches have recently gained popularity in the field of read-across to automatically fill data-gaps for untested chemicals. Previously, we developed the generalized read-across (GenRA) tool, which utilizes in vitro bioactivity data in conjunction with chemical descriptor information to derive local validity domains to predict hazards observed in in vivo toxicity studies. Here, we modified GenRA to quantitatively predict point of departure (POD) values obtained from US EPA's Toxicity Reference Database (ToxRefDB) version 2.0. To evaluate GenRA predictions, we first aggregated oral Lowest Observed Adverse Effect Levels (LOAEL) for 1,014 chemicals by systemic, developmental, reproductive, and cholinesterase effects. The mean LOAEL values for each chemical were converted to log molar equivalents. Applying GenRA to all chemicals with a minimum Jaccard similarity threshold of 0.05 for Morgan fingerprints and a maximum of 10 nearest neighbors predicted systemic, developmental, reproductive, and cholinesterase inhibition min aggregated LOAEL values with R² values of 0.23, 0.22, 0.14, and 0.43, respectively. However, when evaluating GenRA locally to clusters of structurally-similar chemicals (containing 2 to 362 chemicals), average R² values for systemic, developmental, reproductive, and cholinesterase LOAEL predictions improved to 0.73, 0.66, 0.60 and 0.79, respectively. Our findings highlight the complexity of the chemical-toxicity landscape and the importance of identifying local domains where GenRA can be used most effectively for predicting PODs.

Frequency of Cholesterol Crystals in Culprit Coronary Artery Aspirate During Acute Myocardial Infarction and Their Relation to Inflammation and Myocardial Injury

Cholesterol crystals (CCs) have been associated with plaque rupture through mechanical injury and inflammation. This study evaluated the presence of CCs during acute myocardial infarction (AMI) and associated myocardial injury, inflammation, and arterial blood flow before and after percutaneous coronary intervention. Patients presenting with AMI (n = 286) had aspiration of culprit coronary artery obstruction. Aspirates were evaluated for crystal content, size, composition, and morphology by scanning electron microscopy, crystallography, and infrared spectroscopy. These were correlated with inflammatory biomarkers, cardiac enzymes, % coronary stenosis, and Thrombolysis in Myocardial Infarction (TIMI) blush and flow grades. Crystals were detected in 254 patients (89%) and confirmed to be cholesterol by spectroscopy. Of 286 patients 240 (84%) had CCs compacted into clusters that were large enough to be measured and analyzed. Moderate to extensive CC content was present in 172 cases (60%). Totally occluded arteries had significantly larger CC clusters than partially occluded arteries (p <0.05). Patients with CC cluster area >12,000 µm² had significantly elevated interleukin-1 beta (IL-1β) levels (p <0.01), were less likely to have TIMI blush grade of 3 (p <0.01), and more likely to have TIMI flow grade of 1 (p <0.01). Patients with recurrent AMI had smaller CC cluster area (p <0.04), lower troponin (p <0.02), and IL-1β levels (p <0.04). Women had smaller CC clusters (p <0.04). Macrophages in the aspirates were found to be attached to CCs. Coronary artery aspirates had extensive deposits of CCs during AMI. In conclusion, presence of large CC clusters was associated with increased inflammation (IL-1β), increased arterial narrowing, and diminished reflow following percutaneous coronary intervention.

Robust stabilizing control of nonholonomic systems with uncertainties via adaptive integral sliding mode

This article presents a robust stabilizing control for nonholonomic underwater systems that are affected by uncertainties. The methodology is based on adaptive integral sliding mode control. Firstly, the original underwater system is transformed in a way that the new system has uncertainties in matched form. A change of coordinates is carried out for this purpose, and the nonholonomic system is transformed into chained form system with matched uncertainties. Secondly, the chained form system with uncertainties is transformed into a special structure containing nominal part and some unknown terms through input transformation. The unknown terms are computed adaptively. Afterward, the transformed system is stabilized using integral sliding mode control. The stabilizing controller for the transformed system is constructed which consists of the nominal control plus some compensator control. The compensator controller and the adaptive laws are derived in a way that the derivative of a suitable Lyapunov function becomes strictly negative. Two different cases of perturbation are considered including the bounded uncertainty present in any single control input and the uncertainties present in the overall system model of the underwater vehicle. Finally, simulation results show the validity and correctness of the proposed controllers for both cases of nonholonomic underwater system affected by uncertainties.

Evaluation of the Safety of Everolimus-Eluting Bioresorbable Vascular Scaffold (BVS) Implantation in Patients With Chronic Total Coronary Occlusions: Acute Procedural and Short-Term Clinical Results

AIMS

The bioresorbable vascular scaffold (BVS) (Abbott Vascular) provides temporary scaffolding while eluting everolimus. There are limited data on its use in daily practice, especially in patients with stable angina pectoris referred for elective percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs). The current study aims to investigate the safety and efficacy of BVS implantation in a selected patient cohort with CTO.

METHODS

A total of 70 consecutive patients, who underwent successful recanalization of CTO with BVS between September 13, 2012 and September 20, 2014 in three cardiac centers (Department of Cardiology, Bezmialem Vakif University, Istanbul, Turkey; Department of Interventional Cardiology, San Raffaele Hospital, Milan, Italy; and EMO-GVM Centro Cuore Columbus, Milan, Italy) were included in this CTO registry. Endpoints analyzed included: (1) the composite of all-cause death and non-fatal myocardial infarction (MI); and (2) the composite safety endpoint of major adverse cardiovascular events (MACEs), including death, MI and symptom-driven target lesion revascularization (TLR).

RESULTS

Clinical data were obtained for 70 patients (mean age, 56.9 ± 9.4 years; 90.0% male) with a total number of 76 CTOs. At a median follow-up of 11.0 months (interquartile range, 7-18 months), both MACE and TLR rates were 4.3%. Two patients suffered from ischemia-driven TLR (1 patient at 6 months and 1 patient at 9 months after implantation). No death, MI, or stent thrombosis was observed during the follow-up period.

CONCLUSION

Treatment of CTOs with BVS seems to be safe and effective, with a high technical success rate and acceptable MACE at short-term follow-up.

Eosinophilic meningitis: a case series and review of literature of Angiostrongylus cantonensis and Gnathostoma spinigerum

Eosinophilic meningitis is defined as the presence of >10 eosinophils/μL in cerebrospinal fluid (CSF) or at least 10% eosinophils in the total CSF leukocyte count. Eosinophilic meningitis has been reported in two case series and two case reports in India till date and has not been reported in children below 15 years of age. We present two children with eosinophilic meningitis with peripheral eosinophilia and the proposed etiologic agents based on the clinical setting and their response to antihelminthic agents.

ELECTIVE PERCUTANEOUS CORONARY INTERVENTIONS--A COMPARISION OF EFFICACY OF CLOPIDOGREL AND PRASUGREL

BACKGROUND

Percutaneous coronary interventions are almost always preceded by the loading dose of platelets inhibiter drugs such as clopidogrel or prasugrel and followed by maintenance therapy to decrease the mortality and morbidity due to stent thrombosis. This study was conducted to compare the efficacy of clopidogrel and prasugrel for inhibiting platelet aggregation among patients undergoing elective percutaneous coronary intervention.

METHODS

This randomized controlled trial study was done in Department of Cardiology, Postgraduate Medical Institute Govt. Lady Reading Hospital Peshawar. A total of 148 patients were randomly allocated to either group-A containing 74 patients using clopidogrel or group-B containing 74 patients using prasugrel

RESULTS

Group-A had 55 (74.3%) male and 19 (25.7%) females while group-B had 56(75.7%) males and 18 (24.3%) females (p=0.85). Mean age was 54.9 +/- 11.2 years in group-A and was 57.7 +/- 8.7 years in group-B (p=0.09). Mean body weight was 71.8?6.4 Kg in group-A and 70.8 +/- 6.3 Kg in group-B (p=0.35). Mean Baseline platelet aggregation before drug administration was 10.43 +/- 1.9 ohm in group-A while 10.12 +/- 2.2 ohm in group-B (p=0.36). Mean Follow up platelet aggregation 6 hours after drug administration was 5.88 +/- 2.9 in group-A while it was 3.47 +/- 1.8 ohm in group-B (p=0.001). Mean Difference between basal and follow up platelet aggregation +/-SD was 52.9649 +/- 24.77 in group-A while it was 82.25 +/- 14.34 in group-B (p=0.001). 63(85.15%) of group-A had inhibition of platelets aggregation >10% as compare to 72(97.3%) of group-B had inhibition of platelets aggregation >10% (p=0.009).

CONCLUSION

Prasugrel is more efficacious than clopidogrel in term of inhibition of platelets aggregation.

Adolescent conduct problems and premature mortality: follow-up to age 65 years in a national birth cohort

BACKGROUND

Severe youth antisocial behaviour has been associated with increased risk of premature mortality in high-risk samples for many years, and some evidence now points to similar effects in representative samples. We set out to assess the prospective association between adolescent conduct problems and premature mortality in a population-based sample of men and women followed to the age of 65 years.

METHOD

A total of 4158 members of the Medical Research Council National Survey of Health and Development (the British 1946 birth cohort) were assessed for conduct problems at the ages of 13 and 15 years. Follow-up to the age of 65 years via the UK National Health Service Central Register provided data on date and cause of death.

RESULTS

Dimensional measures of teacher-rated adolescent conduct problems were associated with increased hazards of death from cardiovascular disease by the age of 65 years in men [hazard ratio (HR) 1.17, 95% confidence interval (CI) 1.04-1.32], and of all-cause and cancer mortality by the age of 65 years in women (all-cause HR 1.16, 95% CI 1.07-1.25). Adjustment for childhood cognition and family social class did little to attenuate these risks. Adolescent conduct problems were not associated with increased risks of unnatural/substance-related deaths in men or women in this representative sample.

CONCLUSIONS

Whereas previous studies of high-risk delinquent or offender samples have highlighted increased risks of unnatural and alcohol- or substance abuse-related deaths in early adulthood, we found marked differences in mortality risk from other causes emerging later in the life course among women as well as men.

Using a birth cohort to study ageing: representativeness and response rates in the National Survey of Health and Development

Britain's oldest birth cohort study, the MRC National Survey of Health and Development (NSHD) provides data to explore life time influences on ageing. The latest data collection was undertaken between 2006 and 2011 when study members were aged 60-64 and consisted of postal and pre-assessment questionnaires to eligible study members, followed by invitation to attend one of six clinical research facilities (CRFs) across the UK for clinical assessments, and dietary diaries and activity monitors in the days following the CRF visit. The option of a home visit for clinical assessments was provided if the study member refused or was unable to attend the CRF. We examined response and attrition, here describing rates overall and for postal and clinical assessment modes of data collection, identifying socioeconomic and health-related predictors of response, and assessing the continued representativeness of the sample. In total, 2,661 (84 % of the target sample) responded. Lower educational attainment, lower childhood cognition and lifelong smoking independently predicted lower likelihood of both overall response and CRF cooperation. At 53 years, not owning one's home and not being married predicted lower likelihood of overall response whereas manual social class and obesity predicted lower likelihood of CRF cooperation. Providing for collection of biomedical data in the home and use of assessment instruments and modes to retain study members with lower education attainment, lower cognition and poorer health behaviours should be priorities for helping reduce attrition amongst vulnerable ageing study members.

Kawasaki's disease: An unusual presentation

Atypical presentations of Kawasaki's disease have been described in the form of intestinal pseudo-obstruction, tonsillitis, hemorrhagic serous effusions, thrombocytopenia, and non-fulfillment of all criteria for diagnosis of Kawasaki's disease. However, presentation of Kawasaki's disease with shock and need for ionotropic support have been rarely described. We present a 4-year-old girl with Kawasaki's disease who presented with anasarca, oliguria, shock, and presence of dilated coronary arteries within 5 days of fever and responded to intravenous immunoglobulin (IVIG) and inotropic support.

Reliability of absolute lymphocyte count as a marker to assess the need to initiate antiretroviral therapy in HIV-infected children

BACKGROUND

CD4 counts are a standard laboratory measure of disease progression in HIV-infected children. However, CD4 counting is done by flow cytometry and may not always be possible in every centre treating HIV-infected children in resource-limited countries. Absolute Lymphocyte Count (ALC) can be derived easily by performing a routine white blood cell count. The World Health Organization (WHO) in 2006 had recommended ALC to identify HIV-infected children in need of ART in resource-limited settings, when CD4 cell count is not available.

AIMS

This study aims to assess the reliability of using ALC as a marker for starting antiretroviral therapy (ART) in HIV-infected children in a tertiary hospital setting.

SETTINGS AND DESIGN

Retrospective analysis of 46 HIV-infected children who presented at a pediatric HIV clinic at a tertiary referral centre from 2002-2005.

MATERIALS AND METHODS

Using WHO 2006 guidelines for cutoff values of ALC and 2008 guidelines for CD4% as a comparative standard, a retrospective analysis was done on ART-naοve HIV-infected children who underwent baseline CD4% and ALC, and sensitivity and specificity of ALC was calculated.

STATISTICAL ANALYSIS

Fischer exact two-tailed analysis was used to correlate ALC and CD4 and need for starting ART.

RESULTS

Sensitivity of ALC was 27.6% (72.4% were false negatives), specificity was 70.6%, with positive predictive value of 61.5%. On comparison across all clinical stages of disease, only 13/46 children (28.2%) would have been started on ART according to ALC cutoffs versus 29/46 children (63.04%) using CD4 criteria (P value=0.0015). In children with WHO clinical Stage 1 or 2 of disease, only 1/11 (9.1%) children were identified by ALC as requiring ART as opposed to 6/11 (54.5%) children by CD4% (P=0.0635).

CONCLUSIONS

ALC is an unreliable marker to determine the need for starting ART in HIV-infected children.

Budd-Chiari disease in infancy: three cases

Budd-Chiari syndrome (BCS) is rare in infancy. Three cases are presented. Case 1, an 8-month-old boy, presented with abdominal distension and oliguria. Doppler study of the abdomen showed ascites, hepatomegaly and normal hepatic veins. However, a CT scan demonstrated hepatic vein thrombosis. Case 2, a 5-month-old boy, presented with abdominal distension and diarrhoea. Ultrasound of the abdomen showed hepatic vein thrombosis and hepatomegaly. Case 3, a 7-month-old girl, presented with abdominal distension, diarrhoea and oliguria. Ultrasound of the abdomen showed hepatomegaly and obstructed hepatic veins. None of the cases had fever or jaundice before presentation. Case 1 developed fungal septicaemia and was lost to follow-up. Cases 2 and 3 succumbed to the disease before further intervention.

Preliminary Phytochemical Screening and Antispasmodic Activity of Artemisia macrocephala Jacquem

The current work describes the antispasmodic action of Artemisia macrocephala, which is achieved via blocking of the calcium channels. This explains its traditional use as an antispasmodic.The crude methanolic extract of A. macrocephala was studied for possible relaxant effect(s) on spontaneous rabbits' jejunum preparations. Analytical-grade chemicals were used in the experimental protocols. A. macrocephala gave positive tests for flavonoids, saponins, glycosides, alkaloids, and terpenes. A. macrocephala caused relaxation of spontaneous rabbits' jejunum preparations (n=6) at a dose of 10.0 mg/mL (EC(50) = 6.95 ± 0.20 mg/mL; 95% CI: 6.2 to 7.5). Contractions induced by 80 mM potassium chloride (KCl) were also relaxed by the A. macrocephala at dose of 10.0 mg/mL. Attempting to find an explanation for the possible mode of action, we found that, A. macrocephala at concentration of 1.0 mg/mL produced rightward shift in the calcium chloride curves, with EC(50) value of -1.65 ± 0.02 log [Ca(++)] M vs control with EC(50) value of -2.44 ± 0.043 for calcium chloride curves. At a concentration of 1.0 mg/mL it could produce 52.4% of the control response at log [Ca(++)] M = -1.6. Similarly, verapamil at a concentration of 0.1 μM produced a rightward shift, with EC(50) value of -1.74 ± 0.026 log [Ca(++)] M (95% CI: -1.66 to -1.82; n=6) vs control with EC(50) value of -2.45 ± 0.05 log [Ca(++)] M (95% CI: - 2.23 to -2.91; n=6). The right shift of the EC(50) values is justification for the folkloric use of A. macrocephala as an antispasmodic, suggesting that the possible mode of action is through calcium channel blockade.

Ileal perforation in a child with abdominal tuberculosis

A 6-year-old boy presented with a 1-month history of fever followed by abdominal distension, constipation and bilious vomiting for 2 days. The clinical impression was of intestinal obstruction. At exploratory laparotomy, there was an ileal perforation secondary to tuberculosis. There are many case reports of tubercular ileal perforation in adults but in children it is very rare.

Eptifibatide: The evidence for its role in the management of acute coronary syndromes

Introduction:

Acute coronary syndromes and non-Q-wave myocardial infarction are often initiated by platelet activation. Eptifibatide is a cyclic heptapeptide and is the third inhibitor of glycoprotein (Gp) IIb/IIIa that has found broad acceptance after the specific antibody abciximab and the nonpeptide tirofiban entered the global market. Gp IIb/IIIa inhibitors act by inhibiting the final common pathway of platelet aggregation, and play an important role in the management of acute coronary syndromes.

Aims:

This review assesses the evidence for therapeutic value of eptifibatide as a Gp IIb/IIIa inhibitor in patients with acute coronary syndromes.

Evidence review:

Several large, randomized controlled trials show that eptifibatide as adjunctive therapy to standard care in patients with non-ST segment elevation acute coronary syndrome is associated with a significant reduction in the incidence of death or myocardial infarction. Data are limited regarding the use of eptifibatide in patients with ST segment elevation myocardial infarction. Cost-effectiveness analysis indicates that eptifibatide is associated with a favorable cost-effectiveness ratio relative to standard care. According to US cost-effectiveness analysis about 70% of the acquisition costs of eptifibatide are offset by the reduced medical resource consumption during the first year. Eptifibatide was well tolerated in most of the trials. Bleeding is the most commonly reported adverse event, with most major bleeding episodes occurring at the vascular access site. Major intracranial bleeds, stroke, or profound thrombocytopenia rarely occurred during eptifibatide treatment.

Place in therapy:

Eptifibatide has gained widespread acceptance as an adjunct to standard anticoagulation therapy in patients with acute coronary syndromes, and may be particularly useful in the management of patients with elevated troponin or undergoing percutaneous coronary interventions.

Analysis of limited resuscitations in patients suffering in-hospital cardiac arrest

BACKGROUND

Although clinicians are expected to help patients make decisions about end-of-life care, there is insufficient data to help guide patient preferences. The objective of this study was to determine the frequency of patients who undergo 'limited code' and compare survival to discharge with those who undergo maximum resuscitative efforts ('full code').

METHODS

We performed a retrospective analysis of all adult in-hospital cardiac arrests (IHCA) at a tertiary care teaching hospital from January 1999 to December 2003 to compare survival in patients with limited code to survival in patients with a full code. We collected data on demographic and clinical variables known to influence survival in IHCA. Logistic regression was used to assess the association of code status with subsequent survival through the code and to hospital discharge after adjusting for potential confounding factors.

RESULTS

Of the 309 patients having IHCA, there were 17 (5.5%) patients with limited code status and 292 (94.5%) with full code status. Among full code patients, 171 (58.6%) survived the code compared to five patients (29.4%) who had a limited code (p=0.023). After adjusting for demographic variables and pre-arrest co-morbidities, patients with full code status compared to limited code status had an odds ratio for return of spontaneous circulation of 3.69 (95% CI: 1.13-14.34).

CONCLUSIONS

Patients who opt for limited code have a significantly lower probability of survival compared to patients who choose full code. Patients who choose limited code should be informed of the likely negative outcome as compared to full resuscitation.

Deletion of the mouse α-calcitonin gene-related peptide gene increases the vulnerability of the heart to ischemia-reperfusion injury

Calcitonin gene-related peptide (CGRP), a potent vasodilator released from capsaicin-sensitive C-fiber and Aδ-fiber sensory nerves, has been suggested to play a beneficial role in myocardial ischemia-reperfusion (I/R) injury. Because most previous studies showing a cardioprotective role of CGRP employed pharmacological experiments, the purpose of this study was to utilize a genetic approach by using mice with a targeted deletion of the α-CGRP gene to determine whether this neuropeptide had a modulatory function on the severity of I/R injury. To accomplish this goal, isolated, perfused hearts from α-CGRP knockout (KO) and wild-type (WT) mice were subjected to 30 min of ischemia followed by 5, 15, and 30 min of reperfusion. Cardiac functional parameters, including coronary flow rates, left ventricular developed pressure, maximum rates of pressure development, and left ventricular end-diastolic pressure, were measured before and after I/R injury, as were levels of creatine kinase, to assess myocardial damage, and malonaldehyde, to assess oxidative stress. Following I/R injury, cardiac performance was significantly reduced in the hearts from the α-CGRP KO mice compared with their WT counterparts. The marked reduction in myocardial function in the α-CGRP KO hearts compared with WT hearts after I/R injury was associated with a significant elevation in creatine kinase release into the perfusates and malonaldehyde production in the cardiac tissue. Therefore, these data indicate that, in this in vitro setting, deletion of α-CGRP makes the heart more vulnerable to I/R injury, possibly due, at least in part, to increased oxidative stress.

Maternal and biochemical predictors of antepartum stillbirth among nulliparous women in relation to gestational age of fetal death

OBJECTIVE

To determine whether maternal serum levels of alphafetoprotein (alpha-FP) and human chorionic gonadotrophin (hCG) at 15-21 weeks provided clinically useful prediction of stillbirth in first pregnancies.

DESIGN

Retrospective study of record linkage of a regional serum screening laboratory to national registries of pregnancy outcome and perinatal death.

SETTING

West of Scotland, 1992-2001.

POPULATION

A total of 84,769 eligible primigravid women delivering an infant at or beyond 24 weeks of gestation.

METHODS

The risk of stillbirth between 24 and 43 weeks was assessed using the Cox proportional hazards model. Logistic regression models within gestational windows were then used to estimate predicted probability. Screening performance was assessed as area under the receiver operating characteristic (ROC) curve.

MAIN OUTCOME MEASURE

Antepartum stillbirth unrelated to congenital abnormality.

RESULTS

The odds ratio (95% CI) for stillbirth at 24-28 weeks for women in the top 1% were 11.97 (5.34-26.83) for alpha-FP and 5.80 (2.19-15.40) for hCG. The corresponding odds ratios for stillbirth at or after 37 weeks were 2.44 (0.74-8.10) and 0.79 (0.11-5.86), respectively. Adding biochemical to maternal data increased the area under the ROC curve from 0.66 to 0.75 for stillbirth between 24 and 28 weeks but only increased it from 0.64 to 0.65 for stillbirth at term and post-term. Women in the top 5% of predicted risk had a positive likelihood ratio of 7.8 at 24-28 weeks, 3.7 at 29-32 weeks, 5.1 at 33-36 weeks and 3.4 at 37-43 weeks, and the corresponding positive predictive values were 0.97, 0.33, 0.47 and 0.63%, respectively.

CONCLUSIONS

Maternal serum levels of alpha-FP and hCG were statistically associated with stillbirth risk. However, the predictive ability was generally poor except for losses at extreme preterm gestations, where prevention may be difficult and interventions have the potential to cause significant harm.

Seroprevalence of HIV infection in hospitalized paediatric patients at a tertiary care centre in western India

The prevalence of HIV infection in children in India is not known. In this study, a total of 270 children admitted to paediatric wards in Mumbai were screened for HIV infection by enzyme-linked immunosorbent assay (ELISA). Eight patients (2.96%) had a positive HIV ELISA. Of these two patients (25%) were less than 15 months of old and hence HIV infection in them could not be confirmed. The prevalence of HIV was 2.3%. Three out of 11 patients with tuberculosis (27.3%) and four out of 15 patients with nutritional anaemia (26.7%) had HIV infection (P<0.0001 in each case). Vertical transmission was the cause in all children, suggesting that implementation of Prevention of Parent to Child Transmission of HIV (PPTCT) is required to reduce the rate of paediatric HIV infection.