Fetal circular shunt in Ebstein's anomaly and non-steroidal anti-inflammatory treatment

A circular shunt is a poor prognostic factor associated with Ebstein's anomaly. Targeting the constriction of the ductus arteriosus (DA) in order to limit or resolve the circular shunt, has been shown to improve fetal outcomes. Prenatal non-steroidal anti-inflammatory drugs (NSAIDs) have been known to constrict the DA. Recently, prenatal NSAIDs have been used for that purpose in the treatment of circular shunt. Limited research shows that it may be an effective treatment leading to improved fetal outcomes. In this article, we did an extensive review of literature to describe this therapy's effectiveness and outcomes. 82% of fetuses were able to achieve ductal constriction with prenatal NSAID therapy. For fetuses who achieved ductal constriction, fetal demise was less likely (6%) when compared to those who were unable to achieve the same (50%). Of all the fetuses with hydrops, 50% had resoluation of hydrops with prenatal NSAID treatment.

Correlation of the Geriatric Assessment with Overall Survival in Older Patients with Cancer

AIMS

Global guidelines recommend that all older patients with cancer receiving chemotherapy should undergo a geriatric assessment. However, utilisation of the geriatric assessment is often constrained by its time-intensive nature, which limits its adoption in settings with limited resources and high demand. There is a lack of evidence correlating the results of the geriatric assessment with survival from the Indian subcontinent. Therefore, the aims of the present study were to assess the impact of the geriatric assessment on survival in older Indian patients with cancer and to identify the factors associated with survival in these older patients.

MATERIALS AND METHODS

This was an observational study, conducted in the geriatric oncology clinic of the Tata Memorial Hospital (Mumbai, India). Patients aged 60 years and older with cancer who underwent a geriatric assessment were enrolled. We assessed the non-oncological geriatric domains of function and falls, nutrition, comorbidities, cognition, psychology, social support and medications. Patients exhibiting impairment in two or more domains were classified as frail.

RESULTS

Between June 2018 and January 2022, we enrolled 897 patients. The median age was 69 (interquartile range 65-73) years. The common malignancies were lung (40.5%), oesophagus (31.9%) and genitourinary (12.1%); 54.6% had metastatic disease. Based on the results of the geriatric assessment, 767 (85.4%) patients were frail. The estimated median overall survival in fit patients was 24.3 (95% confidence interval 18.2-not reached) months, compared with 11.2 (10.1-12.8) months in frail patients (hazard ratio 0.54; 95% confidence interval 0.41-0.72, P < 0.001). This difference in overall survival remained significant after adjusting for age, sex, primary tumour and metastatic status (hazard ratio 0.56; 95% confidence interval 0.41-0.74, P < 0.001). In the patients with a performance status of 0 or 1 (n = 454), 365 (80.4%) were frail; the median overall survival in the performance status 0-1 group was 33.0 months (95% confidence interval 24.31-not reached) in the fit group versus 14.4 months (95% confidence interval 12.25-18.73) in the frail patients (hazard ratio 0.50; 95% confidence interval 0.34-0.74, P = 0.001). In the multivariate analysis, the geriatric assessment domains that were predictive of survival were function (hazard ratio 0.68; 95% confidence interval 0.52-0.88; P = 0.003), nutrition (hazard ratio 0.64; 95% confidence interval 0.48-0.85, P = 0.002) and cognition (hazard ratio 0.67; 95% confidence interval 0.49-0.91, P = 0.011).

DISCUSSION

The geriatric assessment is a powerful prognostic tool for survival among older Indian patients with cancer. The geriatric assessment is prognostic even in the cohort of patients thought to be the fittest, i.e. performance status 0 and 1. Our study re-emphasises the critical importance of the geriatric assessment in all older patients planned for cancer-directed therapy.

Clinical Profile of Nonproteinuric Kidney Disease in Type 2 Diabetic Patients in India

Background

Diabetic kidney disease (DKD) is the commonest cause of end-stage renal disease (ESRD) across the world. Development of microalbuminuria is the earliest marker of DKD and predicts progressive decline in estimated glomerular filtration rate (eGFR). However, recent evidence has suggested that a significant proportion of type 2 diabetic patients have chronic kidney disease (CKD) without proteinuria.

Methods

In this single-center, prospective observational study, 400 consecutive type 2 diabetic patients with either overt proteinuria (>500 mg/day) and/or renal dysfunction eGFR <60 ml/min/1.73 m2) were recruited. Baseline demographic and clinical data were recorded. eGFR and proteinuria were recorded at 6 months and 1 year. Patients with proteinuric (proteinuria >0.5 g/day) and nonproteinuric phenotypes were compared for progression of renal dysfunction in terms of doubling of serum creatinine and need for dialysis.

Results

In our study cohort, 106 (26.5%) were nonproteinuric. Both the groups were similar in terms of gender, duration of diabetes, comorbidities, body mass index (BMI), blood pressure control, and glycemic control. The nonproteinuric group was older (56.5 ± 2.1 vs. 54.7 ± 11.6 years, P = 0.012), had lesser prevalence of diabetic retinopathy (49 [46.2%] vs. 218 [74.1%], P < 0.001), higher hemoglobin levels (11.3 ± 1.7 vs. 10.5 ± 2.0 g/dl, P < 0.001), and higher cholesterol levels (169.3 ± 43.3 vs 157.1 ± 58.1 mg/dl, P = 0.025). The nonproteinuric phenotype had higher eGFR at baseline, 6 months, and 1 year. However, doubling of serum creatinine (10 [9.4%] vs. 48 [16.3%]) and progression to ESRD (5 [4.7%] vs. 19 [6.5%], P = 0.159) were not different between the two phenotypes.

Conclusion

Nonproteinuric DKD is common. Patients with nonproteinuric DKD tend to be older with a slower decline in eGFR.

Evaluation of plasma and urine neutrophil gelatinase-associated lipocalin (NGAL) as an early diagnostic marker of acute kidney injury (AKI) in critically ill trauma patients

Background and Aims

Acute kidney injury (AKI) is a frequent complication of severe trauma associated with high mortality. The aim of this study was to evaluate the diagnostic ability of plasma and urine neutrophil gelatinase-associated lipocalin (NGAL) as an early marker of AKI assessed by RIFLE criteria as reference in trauma patients in intensive care unit (ICU).

Material and Methods

This was a prospective observational study. Four hundred and eighteen patients admitted in the trauma ICU with age ≥18 years without known renal diseases were followed-up (serum creatinine, urine output, and estimated glomerular filtration rate) for 5 consecutive days. As per RIFLE criteria, 70 patients were broadly classified as AKI and rest of the patients (n = 348) as non-AKI. Plasma and urine samples of AKI (n = 70) and non-AKI (n = 70) patients were further assessed for 3 consecutive days following admission.

Results

Mean plasma NGAL (pNGAL) was significantly elevated in AKI patients as compared with non-AKI patients; on admission: 204.08 versus 93.74 ng/mL (P = 0.01); at 24 h: 216.73 versus 94.63 ng/mL (P = 0.01); and 48 h: 212.77 versus 86.32 ng/mL (P = 0.01). Mean urine NGAL (uNGAL) at 48 h was also significantly elevated: 15.45 ng/mL in AKI patients as compared with 13.48 ng/mL in non-AKI patients (P = 0.01). Plasma and urine NGAL levels were significantly associated with increased mortality.

Conclusion

pNGAL had good predictive value on admission (area under the receiver operative characteristic [AUROC] 0.84), at 24 h (AUROC 0.88) and 48 h (AUROC 0.87), while uNGAL had moderate performance at 24 h (AUROC 0.61) and 48 h (AUROC 0.71). pNGAL can be used as an early and potent diagnostic and predictive marker of AKI and mortality in critically ill trauma patients.

Utility and patient acceptance of telemedicine in nephrology

PURPOSE

There is an increasing burden of kidney diseases worldwide and access to specialist care is limited. Telemedicine, has been relatively less used in developing countries like India. The current study aims to assess the feasibility and acceptance of telenephrology services at our institute, a public hospital.

METHODS

A total of 150 patients were selected by stratified random sampling from the list of attendees who had undergone both in-person outpatient consultation and telenephrology consultation. Patient's attitude towards, and knowledge and acceptance of telenephrology services were evaluated.

RESULTS

The average age of the study cohort was 42.52 ± 15.1 years. More than one-third (39.3%) of our patients belonged to the lower middle socioeconomic class. The median distance traveled to reach our outpatient clinic was 113.5 km (3-2249 km). Patients reported lost workdays in 54.7% cases. The majority (95%) of patients managed to consult through teleservices successfully. Ninety percent of the patients gave a satisfaction score of 4 (out of 5) or above for their tele-consultation experience. The most important perceived benefit of teleconsultation was the reduced risk of infection (40.6%) followed by economic benefits (32%). The major disadvantage (36%) was the absence of physical examination. A combination of physical and telenephrology services was the option preferred by 84% of the patients.

CONCLUSION

In developing countries like India, with the majority of the population residing outside major cities and with limited medical access, telenephrology has a huge potential to provide quality nephrology care to the remotest parts of the country.

Vacuum rhexis - A novel capsulorhexis technique for white cataracts

Capsulorhexis in white intumescent cataract is often associated with extension leading to radial tears or biradial extension "Argentinian flag sign" and associated complications. We describe a novel technique of managing this situation. Vacuum rhexis is performed with a 24 G bent cannula attached to a 10-ml syringe. The flap is lifted and then caught using 24 G cannula. The suction is manually controlled by the surgeon, and the rhexis is completed using circumferential movement. The chamber stability is well maintained as there is no leakage, and the bent tip gives excellent fulcrum for movement. The advantage of this technique is that a single port is used for maintaining the chamber stability and it needs no special surgical instruments. Vacuum rhexis is a novel surgical technique used for performing successful continuous curvilinear capsulorhexis (CCC) of adequate size in white and intumescent cataracts, with a consistent and predictable outcome.

Antibiogram of microorganisms isolated from fresh and frozen semen of crossbred frieswal bulls

BACKGROUND

The bacterial contaminants in the semen are a major concern for most of the semen production laboratories because they adversely affect the semen quality. During sperm cryopreservation, the inclusion of antimicrobials in extenders may help to minimize bacterial growth. However, due to bacterial resistance to commonly used antimicrobials, they cannot fully assure microbiological safety to the frozen semen.

OBJECTIVE

To estimate the microbial load and antibiogram of microorganisms isolated from the fresh and frozen bull semen.

MATERIALS AND METHODS

The bacterial load was estimated in fresh and frozen semen samples of crossbred Frieswal bulls by the pour plate method. Microorganisms were identified as Gram positive and Gram negative by Gram staining. The representative bacterial colonies were streaked onto different specific media which were further confirmed by biochemical tests. Bacterial isolates were subjected to in vitro antibiotic sensitivity test.

RESULTS

The average microbial load of fresh and frozen semen samples was found to be 8397.4 ± 524.3 cfu per mL and 680.9 ± 105.4 cfuper mL, respectively. Microorganisms belonging to Staphylococcus aureus, Staphylococcus epidermidis, Proteus, Klebsiella, Bacillus cereus, Bacillus subtilis, Actinomyces, E. coli, Rhodococcus, Neisseria and Micrococcus were identified in the semen samples. The antibiotic sensitivity testing of the bacterial isolates revealed that benzyl penicillin was found to be the least effective against the isolated organisms while gentamicin and spectinomycin were found to be most effective among the antibiotics used. Lincomycin, tylosin and streptomycin showed moderate efficacy against the bacterial isolates.

CONCLUSION

Gentamicin, tylosin, lincomycin, and spectinomycin (GTLS) antibiotic combination is more effective against bacterial isolates and may be added to semen extender to better control bacterial load and semen quality. doi.org/10.54680/fr22610110512.

Effects of unconjugated gold, silver and titanium dioxide nanoparticles on bovine spermatozoa at various stages of cryopreservation

BACKGROUND

The increasing use of nanoparticles (NP) for gender-selected spermatozoa, sperm-enriched semen and novel extenders raises the concern of undesirable effects on fertility and sperm function.

OBJECTIVE

To investigate the effects of gold (Au-), silver (Ag-), and titanium dioxide (TiO₂-) NPs on the motility and sperm functions in bovine spermatozoa at various stages of cryopreservation.

MATERIALS AND METHODS

Frieswal (Sahiwal × Holstein Friesian) bull semen ejaculates (N = 24) were challenged with unconjugated and ligand-free Au-, Ag-, and TiO₂-NPs.

RESULTS

At post-dilution (fresh) stage, there was no significant difference observed in progressive motility and viability amongst the control and any nanoparticle-treated groups, though plasma membrane integrity was significantly reduced in nanoparticle-treated groups (p < 0.05). The acrosome intactness was also significantly reduced in the groups of Ag-NP and TiO₂ -NP (p < 0.05), while there was no effect observed in the Au-NP group. At post-equilibration stage, a significant reduction in motility, viability, and plasma membrane integrity was observed in all three nanoparticle-treated groups (p < 0.05). There was no difference in intact acrosome between the control and Au-NPs groups; which was significantly higher than the Ag-NP and TiO₂ -NP groups (p < 0.05). At post-thaw stage, all NP groups resulted in a significant reduction of motility, viability, acrosome intactness and plasma membrane integrity (p < 0.05). Besides, TiO₂-NPs appear to be significant more toxic (p < 0.05) among three NP groups, and Au-NPs appear to be lesser toxic.

CONCLUSION

Bovine spermatozoa are adversely affected by Au-, Ag- and TiO₂ -NPs that may impair sperm motility and other functions. doi.org/10.54680/fr22310110512.

Dialysis Initiation in Patients With Chronic Coronary Disease and Advanced Chronic Kidney Disease in ISCHEMIA-CKD

Background In participants with concomitant chronic coronary disease and advanced chronic kidney disease (CKD), the effect of treatment strategies on the timing of dialysis initiation is not well characterized. Methods and Results In ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease), 777 participants with advanced CKD and moderate or severe ischemia were randomized to either an initial invasive or conservative management strategy. Herein, we compare the proportion of randomized participants with non-dialysis-requiring CKD at baseline (n=362) who initiated dialysis and compare the time to dialysis initiation between invasive versus conservative management arms. Using multivariable Cox regression analysis, we also sought to identify the effect of invasive versus conservative chronic coronary disease management strategies on dialysis initiation. At a median follow-up of 23 months (25th-75th interquartile range, 14-32 months), dialysis was initiated in 18.9% of participants (36/190) in the invasive strategy and 16.9% of participants (29/172) in the conservative strategy (P=0.22). The median time to dialysis initiation was 6.0 months (interquartile range, 3.0-16.0 months) in the invasive group and 18.2 months (interquartile range, 12.2-25.0 months) in the conservative group (P=0.004), with no difference in procedural acute kidney injury rates between the groups (7.8% versus 5.4%; P=0.26). Baseline clinical factors associated with earlier dialysis initiation were lower baseline estimated glomerular filtration rate (hazard ratio [HR] associated with 5-unit decrease, 2.08 [95% CI, 1.72-2.56]; P<0.001), diabetes (HR, 2.30 [95% CI, 1.28-4.13]; P=0.005), hypertension (HR, 7.97 [95% CI, 1.09-58.21]; P=0.041), and Hispanic ethnicity (HR, 2.34 [95% CI, 1.22-4.47]; P=0.010). Conclusions In participants with non-dialysis-requiring CKD in ISCHEMIA-CKD, randomization to an invasive chronic coronary disease management strategy (relative to a conservative chronic coronary disease management strategy) is associated with an accelerated time to initiation of maintenance dialysis for kidney failure. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01985360.

The International IgA nephropathy network (IIgANN) prediction tool underestimates disease progression in Indian patients

Introduction

International IgA nephropathy (IgAN) network (IIgANN) prediction tool was developed to predict risk of progression in IgAN. We attempted to externally validate this tool in an Indian cohort because the original study did not include Indian patients.

Methods

Adult patients with primary IgAN were stratified to low, intermediate, higher, and highest risk groups, as per the original model. Primary outcome was reduction in estimated glomerular filtration rate (eGFR) by >50% or kidney failure. Both models were evaluated using discrimination: concordance statistics (C-statistics), time-dependent receiver operating characteristic (ROC) curves, R²d, Kaplan–Meier survival curves between risk groups and calibration plots. Reclassification with net reclassification improvement and integrated discrimination improvement (IDI) was used to compare the 2 models with and without race.

Results

A total of 316 patients with median follow-up of 2.8 years had 87 primary outcome events. Both models with and without race showed reasonable discrimination (C-statistics 0.845 for both models, R²d 49.9% and 44.7%, respectively, and well-separated survival curves) but underestimated risk of progression across all risk groups. The calibration slopes were 1.234 (95% CI: 0.973–1.494) and 1.211 (95% CI: 0.954–1.468), respectively. Both models demonstrated poor calibration for predicting risk at 2.8 and 5 years. There was limited improvement in risk reclassification risk at 5 and 2.8 years when comparing model with and without race.

Conclusion

IIgANN prediction tool showed reasonable discrimination of risk in Indian patients but underestimated the trajectory of disease progression across all risk groups.

Timing of intraoperative crystalloid infusion may decrease total volume of infusate without affecting early graft function in live related renal transplant surgery: A randomized, surgeon-blinded clinical study

INTRODUCTION

Early graft function is crucial for successful kidney transplantation. Intravascular volume maintenance is paramount in ensuring reperfusion of transplanted kidney. This study was planned to compare whether the timing of fluid infusion can help to decrease amount of fluid given without altering early graft function during renal transplantation.

MATERIALS AND METHODS

The present study included forty recipients, randomized into standard (Group-S) or targeted fluid therapy (Group-T). Group S received fluid according to conventional fasting deficit while Group T received at 1 ml/kg/h from the start of surgery till start of vascular anastomosis after which fluid infusion rate in both group was increased to maintain a central venous pressure of 13-15 mm of Hg till reperfusion. Primary outcome measured was serum creatinine level on first postoperative day while secondary outcomes were IV fluid given, perioperative hemodynamics, onset of diuresis, graft turgidity, urine output, and renal function during first 6 postoperative days.

RESULTS

The study showed Group T postoperatively had early fall in serum creatinine (day 3) than S (day 6) although this difference was not statistically significant. Group T had received significantly less fluid per kg of dry weight (T-42.7 ± 9.7 ml/kg, S-61.1 ± 11.1 ml/kg, P < 0.001), had early diuresis, better graft turgidity and urine output than Group S.

CONCLUSION

Targeted hydration significantly decreases the total amount of fluid infused during the intraoperative period without altering early graft function. Targeted hydration during vascular anastomosis produced stable hemodynamics and early diuresis without any side-effects pertaining to hypo or hyper-volemia.Clinical trial identifier number-CTRI/2016/07/007111.

Does laparoscopic omentectomy reduce CAPD catheter malfunction: A three-arm pilot randomized trial

Introduction:

Catheter malfunction secondary to omental wrapping is a frequent complication of continuous ambulatory peritoneal dialysis (CAPD). Of the various methods of peritoneal dialysis catheter insertion (PDCI), open surgical insertion under local anesthesia is most widely practiced. Laparoscopic omentectomy is often undertaken as a salvage procedure in case of malfunctioning catheters. However, there is no randomized controlled trial (RCT) to evaluate the role of prophylactic laparoscopic omentectomy on catheter function. This pilot RCT was undertaken to evaluate the impact of laparoscopic omentectomy on the incidence of catheter malfunction.

Materials and Methods:

Consecutive patients were randomized into three groups: laparoscopic PDCI with omentectomy (Group A), laparoscopic PDCI without omentectomy (Group B) and open surgical PDCI (Group C). The primary outcome was the incidence of catheter malfunction at 6 weeks and 3 months.

Results:

Forty-one patients completed follow-up, with 16, 11, and 14 patients in Groups A, B, and C, respectively. Incidence of catheter malfunction was 6.2%, 27.3%, and 14.3% in Groups A, B, and C, respectively, at 6 weeks and 6.2%, 36.4%, and 21.4% at 3 months, respectively. In patients with previously failed catheter insertion (n = 23), malfunction at 3 months was 8.3% (1/12) in patients who had omentectomy, compared with 45.5% (5/11) in those who did not (P = 0.069). Operating time was significantly higher (P < 0.001) in Group A.

Conclusions:

Laparoscopic omentectomy may be associated with a lower incidence of catheter malfunction, especially in patients with previously failed peritoneal dialysis catheter. Data from this pilot RCT can be used to design a large trial with an adequate number of patients.

Continuous Ambulatory Peritoneal Dialysis Peritonitis Guidelines - Consensus Statement of Peritoneal Dialysis Society of India - 2020

Continuous ambulatory peritoneal dialysis (CAPD) related peritonitis is a major cause of technique failure, morbidity, and mortality in patients on CAPD. Its prevention and management is key to success of CAPD program. Due to variability in practice, microbiological trends and sensitivity towards antibiotics, there is a need for customized guidelines for management of CAPD related peritonitis (CAPDRP) in India. With this need, Peritoneal Dialysis Society of India (PDSI) organized a structured meeting to discuss various aspects of management of CAPDRP and formulated a consensus agreement which will help in management of patients with CAPDRP.

Isolation and genetic characterization of canine adenovirus type 2 from a domestic dog showing neurological symptoms

Canine adenoviruses (CAVs) are of two types: canine adenovirus type 1 (CAV-1), which causes infectious canine hepatitis, and canine adenovirus type 2 (CAV-2), which is mainly associated with the respiratory type of disease in dogs. Due to the widespread use of modified live vaccines to control canine adenoviral infections and subsequently reduced disease incidence, CAVs are often neglected by clinicians. Although a number of studies are available about CAV-1 prevalence in India, only meagre information is available about CAV-2. This study reports the CAV-2 infection in a vaccinated dog with neurological and respiratory symptoms which was found negative for other canine pathogens like canine distemper virus and canine parvovirus. The virus was successfully isolated from rectal swab in MDCK cells and characterized by immunofluorescence assay and virus neutralization test. On phylogenetic analysis of partial E3 region, the Indian CAV-2 grouped in a separate clade different from established subgroups. An insertion of "G" nucleotide was reported at nucleotide (nt.) position 1077 in the E3 gene of Indian CAV-2 isolates which led to a frameshift in the coding region of E3 gene thereby imparting additional eleven amino acids to its C-terminal end in comparison to isolates from other parts of the world. This may have an implication on the functional role of E3 protein inside the cell. This study reinforces the unique signature insertion in the E3 gene of Indian CAV-2 and is the second study in the world to report the association of CAV-2 with neurological disease in dogs.

Outcomes of Participants With Diabetes in the ISCHEMIA Trials

BACKGROUND

Among patients with diabetes and chronic coronary disease, it is unclear if invasive management improves outcomes when added to medical therapy.

METHODS

The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trials (ie, ISCHEMIA and ISCHEMIA-Chronic Kidney Disease) randomized chronic coronary disease patients to an invasive (medical therapy + angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). Cohorts were combined after no trial-specific effects were observed. Diabetes was defined by history, hemoglobin A1c ≥6.5%, or use of glucose-lowering medication. The primary outcome was all-cause death or myocardial infarction (MI). Heterogeneity of effect of invasive management on death or MI was evaluated using a Bayesian approach to protect against random high or low estimates of treatment effect for patients with versus without diabetes and for diabetes subgroups of clinical (female sex and insulin use) and anatomic features (coronary artery disease severity or left ventricular function).

RESULTS

Of 5900 participants with complete baseline data, the median age was 64 years (interquartile range, 57-70), 24% were female, and the median estimated glomerular filtration was 80 mL·min^-1·1.73^-2 (interquartile range, 64-95). Among the 2553 (43%) of participants with diabetes, the median percent hemoglobin A1c was 7% (interquartile range, 7-8), and 30% were insulin-treated. Participants with diabetes had a 49% increased hazard of death or MI (hazard ratio, 1.49 [95% CI, 1.31-1.70]; P<0.001). At median 3.1-year follow-up the adjusted event-free survival was 0.54 (95% bootstrapped CI, 0.48-0.60) and 0.66 (95% bootstrapped CI, 0.61-0.71) for patients with diabetes versus without diabetes, respectively, with a 12% (95% bootstrapped CI, 4%-20%) absolute decrease in event-free survival among participants with diabetes. Female and male patients with insulin-treated diabetes had an adjusted event-free survival of 0.52 (95% bootstrapped CI, 0.42-0.56) and 0.49 (95% bootstrapped CI, 0.42-0.56), respectively. There was no difference in death or MI between strategies for patients with diabetes versus without diabetes, or for clinical (female sex or insulin use) or anatomic features (coronary artery disease severity or left ventricular function) of patients with diabetes.

CONCLUSIONS

Despite higher risk for death or MI, chronic coronary disease patients with diabetes did not derive incremental benefit from routine invasive management compared with initial medical therapy alone. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

Transcatheter aortic valve implantation outcomes compared between bicuspid aortic and tricuspid aortic valve stenosis: an updated systematic review and meta-analysis

Background

TAVI has emerged as an attractive treatment modality based on promising recent trial data. Patients with BAV, a commonly encountered clinical condition have largely been excluded from a majority of trials.

Purpose

Elderly patients with BAV and severe AS are increasingly encountered in clinical practice. This meta-analysis compares clinical outcomes between bicuspid and tricuspid AV patients to address the current knowledge-gap and identify optimal management strategies of these patients.

Methods

A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify the available observational studies comparing outcomes of TAVI in BAV and TAV patients. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints.

Results

16 Observational studies met inclusion criteria, comprising 10,053 patients with BAV and 173,307 patients with TAV that underwent TAVI. No significant differences in 30-day and long-term mortality rates were observed. Patients with BAV had an increased risk of stroke (OR 1.23; 95% CI [1.06–1.44], p=0.007), re-intervention (OR 1.90; 95% CI [1.15–3.15], p=0.01), paravalvular leak (OR 1.42; 95% CI [1.25–1.61], p&lt;0.ehab724.22251), conversion to open surgery (OR 1.93; 95% CI [1.21–3.07], p=0.006), and new pacemaker implantation (1.57; 95% CI (1.06 - 2.33, p=0.02). Adverse event rates are lower with the use of newer generation of valves. No significant difference in major vascular complications, major bleeding, or incidence of AKI was noted.

Conclusions

Complication rates for BAV TAVI are higher, but mortality is similar to TAV TAVI indicating TAVI is an appropriate alternative for intermediate-high risk patients with BAV. A better understanding of valve anatomy, physician expertise, the use of newer-generation valves can help reduce these complications.

Funding Acknowledgement

Type of funding sources: None.

Outcomes of permanent pacemaker insertion after TAVR: a systematic review and meta-analysis

Background/Introduction

Conduction abnormalities are frequently encountered after transcatheter aortic valve replacement (TAVR) performed for severe aortic stenosis, leading to post-procedure permanent pacemaker (PPM) insertion. Although the predictors of- and factors leading to post-TAVR PPM have been studied extensively, its short-term and long-term outcomes have not been established.

Purpose

PPM placement can lead to significant changes in outcomes in post-TAVR patients, which remain unclear. With this analysis, we aim to evaluate the differences between outcomes of patients requiring PPM and those not requiring PPM post-TAVR.

Methods

A comprehensive literature search was performed in PubMed, EMBASE, and Cochrane to identify relevant trials. Outcomes were compared between the two groups of patients- those requiring post-TAVR PPM and those not requiring post-TAVR PPM. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio (OD) with 95% confidence intervals (CI) for all the clinical endpoints.

Results

34 studies, including observational and prospective studies, met our inclusion criteria, with a total of 76,402 patients undergoing TAVR and 10,381 requiring post-TAVR PPM. There were no significant differences between 30-days (OR 1.04; 95% CI 0.96–1.13) and 1-year (OR 1.09; 95% CI 0.72–1.03) all-cause mortality rates, and 30-days (OR 0.86; 95% CI 0.72–1.03) and 1-year (OR 0.85; 95% CI 0.70–1.04) cardiovascular deaths among the two groups. Incidence of heart failure was higher in the post-TAVR PPM group at 30 days (OR 1.26; 95% CI 1.05–1.51) but not at 1 year (OR 1.21; 95% CI 0.93–1.57). No significant difference was noted between the two groups in 30-days or 1-year stroke, 30-days or 1-year myocardial infarction, 30-days or 1-year atrial fibrillation, 30-days or 1-year major bleeding, or 30-days and 1-year readmission rate. Other outcomes, including post-procedure aortic regurgitation, major vascular complications, minor bleeding, valve migration, and device success, also did not have any statistically significant difference in the two patient groups (Figure 1). Of all the patients who received post-TAVR PPM, an average of 46.4% and 58.5% patients had &gt;40% ventricular pacing, and 48.9% and 41.4% had &lt;40% ventricular pacing at 1-month, and 1-year follow up respectively.

Conclusions

Although there were no differences in the outcomes between the two groups at 30-days and 1-year follow-ups (except the higher incidence of heart failure at 30 days in the post-TAVR PPM group), long-term follow-up studies would be needed to identify any possible adverse events after one year. Also, a significant number of patients requiring post-TAVR PPM had &lt;40% ventricular pacing at 1-month and even at 1-year intervals, which might suggest adopting an alternate approach of closely monitoring any conduction disturbances and avoiding early PPM implantation in post-TAVR patients, if possible.

Funding Acknowledgement

Type of funding sources: None. Forest plot of differences in outcomes

Natural infection of Delta mutant of SARS-CoV-2 in Asiatic lions of India

The current pandemic caused by a novel coronavirus (SARS‐CoV‐2) has underlined the importance of emerging diseases of zoonotic importance. Along with human beings, several species of wild and pet animals have been demonstrated to be infected by SARS‐CoV‐2, both naturally and experimentally. In addition, with constant emergence of new variants, the species susceptibility might further change which warrants intensified screening efforts. India is a vast and second most populated country, with a habitat of a very diverse range of animal species. In this study we place on record of SARS‐CoV‐2 infections in three captive Asiatic lions. Detailed genomic characterization revealed involvement of Delta mutant (Pango lineage B.1.617.2) of SARS‐CoV‐2 at two different locations. Interestingly, no other feline species enclosed in the zoo/park were found infected. The epidemiological and molecular analysis will contribute to the understanding of the emerging mutants of SARS‐CoV‐2 in wild and domestic animals.

Erratum: Azimuthal Anisotropy at the Relativistic Heavy Ion Collider: The First and Fourth Harmonics [Phys. Rev. Lett. 92, 062301 (2004)]

This corrects the article DOI: 10.1103/PhysRevLett.92.062301.

Metabolic acidosis in the initial 6 months after renal transplantation: A prospective study

BACKGROUND

There is limited information about the incidence of metabolic acidosis (MA) after renal transplantation. This single centre prospective study aimed to delineate the incidence and risk factors of MA in the first 6 months after renal transplantation (RTX).

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

Patients who underwent RTX between November 2018 and July 2020 were monitored with weekly measurement of serum bicarbonate level for 6 months and those who were diagnosed with MA were evaluated further to characterize the type of MA.

RESULTS

One hundred and twenty-five patients were included in the study, 89 (71.2%) of whom developed MA. Seventy-two patients developed MA in the first month, 11 during the 2-3 months and 6 between 4 and 6 months after transplantation. Of the 89 patients, 55(61.8%) had type 1 renal tubular acidosis (T1RTA), 27 (30.3%) had type 2 RTA (T2RTA) and 7 (7.9%) type 4 RTA (T4RTA). Two patient who had T1RTA, subsequently developed high anion gap MA following severe graft rejection. On stepwise multivariate regression analysis, serum creatinine at time of diagnosis of MA [OR (95% CI): 12.02 (1.79 to 80.59), p = .01] and high tacrolimus C0 levels [OR (95% CI): 2.43 (1.0 to 5.90), p = .049], were independent risk factors for MA.

CONCLUSION

There is a high incidence of MA in the initial 6 months post-transplant with serum creatinine and high tacrolimus C0 levels being independent risk factors.

Simplifying assessment of dimensions of oral lesions using a syringe and 'impression planimetry' with printer paper

Two novel methods of measuring the dimensions of oral lesions are described, which would be of help in deciding relative efficacies of different therapeutic agents when used in clinical trials after larger studies quantitatively assessed for inter/intraobserver variability.

Impact of clinical parameters and vascular haemodynamics on arterio-venous fistula maturation in patients with end stage renal disease: A prospective study on Indian patients

BACKGROUND

About 18%-65% of Arterio-Venous fistula (AVF) made to facilitate haemodialysis in end stage renal disease patient fail to mature. This study was designed to evaluate the impact of clinical parameters and vascular haemodynamics on maturation of AVF on Indian patients.

MATERIAL AND METHODS

This was a prospective observational study. Eligible patients' clinical profiles and vascular haemodynamics by Doppler ultrasonography were noted. All patients underwent radio-cephalic AVF on the non-dominant arm under local anaesthesia. Clinical definition was used to assess success rate of AVFs which is defined as successful six settings of satisfactory dialysis. Data were analysed using Stata/12.0 software. Independent t-test, chi-square test, logistic regression analysis and multivariate analysis were used. The p-value of <0.05 was considered significant.

RESULTS

A total of 205 patients were enrolled and analysed. Among clinical factors, age, sex, serum creatinine, hypertension had no significant association with failure (p = 0.5, 0.08, 0.76 and 0.74). Patient's BMI and presence of diabetes had significant impact on outcome (p < 0.001 and 0.02 respectively). Among vascular haemodynamics, radial vein diameter of >2.5 mm and radial artery flow rate >40 ml/min had no significant association with failure (p = 0.12 and 0.28). Diameter of radial artery (>2 mm) and intra-operatively immediate thrill were independent predictor of success (p = 0.002 and <0.001).

CONCLUSION

In the present study rate of fistula, maturation was 73.2% without any post-operative radiological intervention. Radial artery diameter >2 mm and presence of immediate thrill post-operatively were significantly associated with successful cannulation.

Renal cystic diseases during the perinatal and neonatal period

Renal cystic diseases are a clinically and genetically diverse group of renal diseases that can manifest in utero, infancy, or throughout childhood and adulthood. These diseases may be unilateral or bilateral with a single cyst or multiple cysts, or with increased echogenicity of the renal cortex without macroscopic cysts. Certain cystic renal diseases are life-threatening, with many developing chronic kidney and hepatic disease if not recognized early enough. Therefore, due to the prevalence and life-altering complications of this specific group of diseases in vulnerable populations, it is crucial for clinicians and healthcare providers to have an overall understanding of cystic diseases and how to pre-emptively detect and manage these conditions. In this review, we discuss in detail the epidemiology, genetics and pathophysiology, diagnosis, presentation, and management of numerous genetic and sporadic renal cystic diseases, such as polycystic kidney disease, multicystic dysplastic kidney, and calyceal diverticula, with an emphasis on prenatal care and pregnancy counseling.

Peritoneal Dialysis Patients During COVID 19 Pandemic

COVID pandemic poses challenges to peritoneal dialysis patients, caretaker, and service provider to the PD patients as well. The chronic peritoneal dialysis (PD) patients are trained to do the PD procedure at home, therefore can avoid in-center hospital visit unlike patients on hemodialysis. Thus, PD patients can avoid undue exposure to the novel coronavirus. The PD can be offered in COVID induced AKI patients, even in remote places where hemodialysis cannot be offered. The paper is aimed to provide guidelines about the safe use of PD and treatment of complications during the COVID pandemic.

Effect of Local Mupirocin Application on Exit-Site Infection and Peritonitis in an Indian Peritoneal Dialysis Population

Background

Staphylococcus aureus-associated peritonitis and catheter exit-site infections (ESIs) are important causes of hospitalization and catheter loss in patients undergoing chronic peritoneal dialysis. Intranasal and topical use of mupirocin has been found to be an effective strategy in decreasing S. aureus-related infectious complications in persons who are carriers of S. aureus; however, there is no consensus regarding the prophylactic use of mupirocin irrespective of carrier status. We aimed to determine the potential effectiveness of application of mupirocin cream at the catheter exit site in preventing ESI and peritonitis irrespective of carrier status in a tropical country such as India.

Methods

This prospective historically controlled study was done in a total of 40 patients. From August 2003, all patients, incident and prevalent, were instructed to apply 2% mupirocin cream daily to the exit site instead of the older practice of povidone-iodine and gauze dressing. Patients were not screened to determine whether they were S. aureus carriers. The infection-related data for 1 year, until July 2004, were compared with the historical control, which was infection-related data for the year preceding the year of mupirocin application.

Results

Mean age of the study population was 62 years, with 61.8% being male and 64.3% being diabetic. Local application of mupirocin led to a significant reduction in the incidence density per patient-month of both ESI and peritonitis compared to controls (0.15 vs 0.37 and 0.37 vs 0.67, p = 0.01 for both). This amounted to a relative reduction of 60.5% and 55% respectively. ESI and peritonitis due to S. aureus were also significantly lower in the study group compared to controls (incidence density per patient-month 0.05 vs 0.13 and zero vs 0.17 respectively, p < 0.01 for both). There occurred no catheter removal due to infection-related complications during the study period compared to two during the control period. None of the patients reported a mupirocin-related adverse effect.

Conclusions

Daily application of mupirocin at the exit site is a well-tolerated and effective strategy in reducing the incidence of ESI and peritonitis in a tropical country such as India. It can thus significantly reduce morbidity, catheter loss, and transfer to hemodialysis in peritoneal dialysis patients.

Factors Affecting the use of Peritoneal Dialysis among the Esrd Population in India: A Single-Center Study

Objectives

Factors such as limited health-care budget allotment and poor accessibility of the majority of the population to hemodialysis (HD) facilities should favor the use of peritoneal dialysis (PD) in India. However, only 6% of end-stage renal disease patients undergoing dialysis in India are on PD. We undertook this prospective study to evaluate various factors that could contribute to this low rate of use of PD at a tertiary-care state-run hospital in Northern India.

Methods

All the patients who entered our HD or PD program from August 2001 to December 2003 were interviewed using a preset questionnaire. The questionnaire recorded their basic disease and comorbidity, social and demographic characteristics, awareness of the various modalities of renal replacement therapy (RRT), and the reasons for choosing their present modality of therapy. Treating nephrologists were also interviewed with respect to the factors that, in their opinion, were responsible for the limited use of PD at our institute.

Results

In total, 342 patients on HD, 66 patients on PD, and 24 nephrologists were interviewed. The rate of PD use was 16.2%. Mean age of patients on HD and PD was 34.6 ± 11.8 years and 62.9 ± 10.3 years respectively ( p < 0.0001). The incidence of diabetes mellitus and coronary artery disease in the HD and PD populations was 2.5% and 62.5%, and 9.1% and 46.7% respectively ( p < 0.0001 for both). Only 30.4% of patients on HD were aware of PD as a modality of RRT and 83.6% of them found PD to be expensive, 65.4% had low enthusiasm toward a domiciliary therapy such as PD, and 61.5% were not recommended PD by their nephrologist. Only 5 (7.6%) patients were initiated on PD directly, the remaining 61 patients were shifted from HD after a mean duration on HD of 185.3 ± 15.4 days: 67.1% were shifted due to poor tolerance of HD, 29.4% were advised to shift to PD because of comorbidity and vascular access problems, and only 3.3% took up PD because of the independent lifestyle it offered. None of the interviewed nephrologists routinely discussed PD in predialysis counseling. They found financial constraints (100%), lack of patient enthusiasm (100%), doubtful patient compliance (83.2%), and lack of an organized PD program (79.2%) to be the main factors limiting more widespread use of PD at our institute.

Conclusions

Peritoneal dialysis is an underused modality of RRT at our institute. The patients who are taken up for PD at our institute are elderly and have a higher incidence of other comorbid conditions, such as diabetes mellitus and coronary artery disease. Also, most patients who switch to PD do so due to their unsuitability for HD rather than by their own choice. The factors contributing to this low rate of use of PD are ignorance of PD, increased cost of therapy, low enthusiasm toward domiciliary therapy, and lack of adequate infrastructure for PD at our institute. Effective predialysis counseling, reduction in the cost of the therapy, and development of an adequate infrastructure can increase the rate of use of PD.

Infection is the chief cause of mortality and non-death censored graft loss in the first year after renal transplantation in a resource limited population: A single centre study

AIM

Few studies have assessed the impact of infections after renal transplantation (RTX) in low and middle income countries. This single centre study aimed to delineate the profile and impact of infections requiring hospitalization (IRH) occurring in the first year after RTX in India.

METHOD

Patients who underwent RTX between July 2012 and June 2015 were followed up for 12 months after transplantation.

RESULTS

60.2% of the 387 patients studied had at least one IRH and total 492 infections were diagnosed. The most common were urinary tract (30.3%), gastrointestinal (17.1%) and pulmonary (11.2%) infections. Viral aetiology (33.3%) was most frequent, followed by bacterial (23.6%), parasitic (5.1%), tuberculosis (4.5%), and fungal infections (3.9%). 86.4% deaths were due to infections. One year patient and graft survival were inferior among recipients with IRH compared to those with no IRH: 91.8% vs. 98.1% (log rank = 0.010) and 90.1% vs. 97.4% (log rank = 0.006) respectively. Average monthly income per family member <5000 Rupees (75 USD), NODAT, and acute rejection were independent risk factors for IRH.

CONCLUSION

The profile of IRH is unique involving opportunistic, community-acquired and endemic infections seen in this country. It is the predominant cause of mortality and graft loss in the first year after RTX. Poor economic status is an important determinant of IRH in our population.

Study of Rheology and Plug Assist Thermoforming of Linear and Branched PP Homopolymer and Impact Copolymer

Polypropylene (PP) is one of the fastest growing thermoplastic polymers in the world, second only to polyethylene. This is primarily due to its excellent balance of physical and chemical properties at a lower cost. PP however possesses low melt strength on account of its linear structure and hence is not easily amenable to processing techniques that involve free surface stretching deformations like thermoforming, blow molding and extrusion film casting. One way to enhance the melt strength of PP is to incorporate long chain branches in its molecular architecture. The present study focuses on the impact of rheology of linear and branched PP on their thermoforming characteristics. Two grades each of linear and long chain branched (LCB) PP homopolymer and impact copolymer (ICP) were used. It was observed that the LCB-PP homopolymer and LCB-ICP showed higher flow activation energy, reduced value of loss tangent and nearly equal frequency dependence of storage and loss moduli in shear rheology. Also, a strong strain hardening behavior was displayed in extensional rheology by the LCB grades. Plug assist thermoforming experiments were carried out to assess the effect of long chain branching on surface strain and thickness distribution for axisymmetric cups of two draw ratios. Biaxial surface strain maps of the formed cups were quantified using Grid Strain Analysis (GSA). Thermoformed cups made from LCB-PP homopolymer and LCB-impact copolymer showed lower surface strain and overall higher thickness as compared to cups made from their linear counterparts, which is in accordance with what might be expected from their rheology.

What do we actually see in intracellular SERS? Investigating nanosensor-induced variation

Plasmonic nanoparticles (NPs), predominantly gold (AuNPs), are easily internalised into cells and commonly employed as nanosensors for reporter-based and reporter-free intracellular SERS applications. While AuNPs are generally considered non-toxic to cells, many biological and toxicity studies report that exposure to NPs induces cell stress through the generation of reactive oxygen species (ROS) and the upregulated transcription of pro-inflammatory genes, which can result in severe genotoxicity and apoptosis. Despite this, the extent to which normal cellular metabolism is affected by AuNP internalisation remains a relative unknown along with the contribution of the uptake itself to the SERS spectra obtained from within so called 'healthy' cells, as indicated by traditional viability tests. This work aims to interrogate the perturbation created by treatment with AuNPs under different conditions and the corresponding effect on the SERS spectra obtained. We characterise the changes induced by varying AuNP concentrations and medium serum compositions using biochemical assays and correlate them to the corresponding intracellular reporter-free SERS spectra. The different serum conditions lead to different extents of nanoparticle internalisation. We observe that changes in SERS spectra are correlated to an increasing amount of internalisation, confirmed qualitatively and quantitatively by confocal imaging and ICP-MS analysis, respectively. We analyse spectra and characterise changes that can be attributed to nanoparticle induced changes. Thus, our study highlights a need for understanding condition-dependent NP-cell interactions and standardisation of nanoparticle treatments in order to establish the validity of intracellular SERS experiments for use in all arising applications.

Spectrum of biopsy-proven renal disease in northern India: A single-centre study

AIM

Pattern of kidney diseases varies across geographies due to multiple factors. There is a paucity of information from South Asia due to the absence of nationwide/regional biopsy registries. This study aimed to delineate the spectrum of renal parenchymal diseases in our region.

METHODS

Records of kidney biopsies done in our nephrology department between 2006 and 2016 were analysed. Clinico-pathological correlation was done from the available records.

RESULTS

Of the 3275 biopsy evaluated, 61.9% were males, and mean age was 33.2 ± 14.2 years. 6.2% patients were elderly (age ≥ 60 years). Nephrotic syndrome (60.3%) was the commonest indication for biopsy. On histology, 73.0% patients had primary glomerulonephritis (GN), 15.5% secondary GN, 5.3% tubulo-interstitial and 3.7% vascular disease. Focal segmental glomerulosclerosis (FSGS) was the commonest primary GN accounting for 18.2% of all GNs, followed by minimal change disease (16.8%), membranous nephropathy (MN) (16.0%) and IgA nephropathy (10.4%). Lupus nephritis (10.6%) and amyloidosis (3.7%) were the commonest secondary GN. The commonest cause of nephrotic syndrome was minimal change disease (22.9%), acute nephritic syndrome was lupus nephritis (30.6%), rapidly progressive renal failure was pauci-immune crescentic GN (24.5%). IgA nephropathy was the commonest etiology of asymptomatic urinary abnormalities (26.3%) and gross haematuria (50%). About 60.9% patients of undetermined chronic kidney disease had glomerular diseases, and 13.6% had chronic tubulointerstitial nephritis. Lupus nephritis and acute cortical necrosis were significantly more common in females compared with males.

CONCLUSION

This is one of the largest cohorts of kidney biopsies from India, and it delineates the unique features and differences in the pattern of kidney disease in our population.

Novel Heterozygous Mutations of Congenital Thrombotic Thrombocytopenic Purpura: A Rare Case Report

Hereditary thrombotic thrombocytopenic purpura (TTP) is a genetic condition caused by mutations in ADAMTS13 gene, leading to very low levels of ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type I domain 13) activity. It is a rare condition associated with multiple reported mutations. Here, we describe a case of hereditary TTP with a compound novel heterozygous mutation along with secondary focal segmental glomerulosclerosis. The patient responded clinically to plasma infusions with resolution of thrombocytopenia, stabilization of renal function, and control of blood pressures. Genetic analysis of the entire family helped in the characterization of the inheritance of this mutation. Our case illustrates the need for focused genetic analysis in a subset of patients presenting with features of TTP to decide the therapeutic plan and manage accordingly.

To Study the Impact of Donor Nephrectomy on Blood Pressure as Measured by Ambulatory Blood Pressure Monitoring and Renal Function

Prospective living kidney donors need meticulous evaluation prior to kidney donation. Ambulatory blood pressure monitoring (ABPM) is considered the reference standard for diagnosing hypertension. With no prior study available in India in this context, we undertook this study to evaluate the utility of ABPM in kidney donors and effect of donor nephrectomy on renal function. This was a prospective observational study involving healthy prospective kidney donors between 18 and 70 years with normal office blood pressure measurements (OBPM). Detailed clinical and biochemical parameters were recorded. OBPM and 24-hour ABPM was done preoperatively and 3 months following donor nephrectomy. There were 51 donors with a mean age of 46.1 ± 11.3 years, of which 40 (78.4%) were females. Preoperatively, three (5.8%) donors were hypertensive on ABPM but normal on OBPM (P = 0.08). Three months post nephrectomy, hypertension was present in seven (13.7%) donors by ABPM, while only two (3.9%) donors were diagnosed as hypertensive by OBPM (P = 0.02). Median pre-nephrectomy proteinuria was 70 mg (10 mg-180 mg) with a mean estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease (MDRD) formula of 86.86 ± 19.1 ml/min. Six donors developed >300 mg/day proteinuria, and 17 (33.3%) had a 24-hour urinary protein excretion greater than 150 mg/day. Mean serum creatinine (0.79 ± 0.11 vs 1.03 ± 0.16 mg/dl) significantly increased post donation, more so in donors >55 years of age (1.14 ± 0.25 mg/dl). Our study shows that in transplant donors, ABPM is better for diagnosing hypertension, which otherwise remains masked in 10% of the donors on routine OBPM. Significance of post-nephrectomy hypertension and increasing proteinuria needs further evaluation.