A study of multidrug resistant tuberculosis among symptomatic household contacts of MDR-TB patients

BackgroundDiagnosis and management of multidrug-resistant tuberculosis (MDR-TB) remains a global challenge and is associated with high morbidity and mortality. Burden of TB among symptomatic household contacts of MDR-TB is not extensively studied and screening of symptomatic contacts may provide a better opportunity for optimum management and effective TB control.MethodsThis prospective observational study was conducted in the department of Tuberculosis & Chest diseases, S.N. Medical College, Agra from February 2016 to January 2018. The study recruited 271 symptomatic household contacts of 87 index MDR-TB cases. Symptomatic contacts were screened for active disease and latent TB infection. Risk factors for the spread of disease were also looked for.ResultsOut of 271 symptomatic household contacts, 97 (35.79%) had active TB. Among 97 diseased, 62 (22.87%) had MDR-TB and 35 (12.91%) had drug-susceptible TB. 124 contacts (45%) had latent TB infection. Risk factors associated with occurrence of TB included age less than 18 years (OR = 7160, p = 0.1908, RR = 0.8082, p = 0.1887), male sex (OR = 2.3108, p = 0.0021, RR = 1.7444, p = 0.0034), Sibling as index case (OR = 0.6404, p = 0.0804, RR = 0.7520, p = 0.0806), lack of BCG vaccination (OR = 1.7763, p = 0.0271, RR = 1.4338, p = 0.0247) malnutrition (OR = 1.8980, p = 0.0138, RR = 1.5166, p = 0.0159) and lower socioeconomic status (OR = 3.2399, p < 0.0001, RR = 2.1524, p < 0.0001).ConclusionThe high case detection rate by screening symptomatic household contacts shows MDR-TB is highly transmissible and household contacts are at a higher risk of developing active disease. It provides an opportunity for early diagnosis, adequate treatment, and interrupt the chain of transmission. Identifying risk factors help prevent the progression of latent TB infection to active disease.     

Impact of antiphospholipid syndrome on disease characteristics and outcome in patients with systemic lupus erythematosus

Aim of the workTo assess the impact of antiphospholipid syndrome (APS) on systemic lupus erythematosus (SLE) clinical characteristics and disease outcome.Patients and methods216 SLE patients were classified according to the presence of APS into: SLE group (n = 109) and SLE-APS (n = 107). Evaluation of clinical, laboratory tests, immunological tests, SLE disease activity index 2000 (SLEDAI-2 K) and SLE damage index (SDI) were done.ResultsThe 216 patients mean age was 32.1 ± 8.4 years and the F:M was 8.4:1. There was a significantly higher frequency of abortion, neurological and cardiac manifestations (p < 0.001, p = 0.008, p = 0.016 respectively) in SLE-APS group. The SDI was significantly higher in SLE-APS patients (p < 0.001) with special attention to the presence of cerebrovascular accident (CVA) (p = 0.01), pulmonary hypertension (p = 0.04), cardiomyopathy (p = 0.034) and venous thrombosis (p < 0.0001). The frequency of thrombosis and active SLEDAI-2 K visits were significantly related to higher damage in SLE-APS (p < 0.001 and p < 0.001 respectively). Damage in SLE group was associated with hypocomplementemia (p = 0.015) and thrombosis (p = 0.049). Factors associated with damage in all SLE patients were male gender (p = 0.024), serositis (p = 0.02), neurological involvement (p < 0.001), thrombotic events (p < 0.001), cumulative doses of oral (p = 0.02) and pulse (p = 0.004) steroids and frequency of cyclophosphamide (CYC) use (p = 0.003). Predictors of damage included male gender, APS, neurological manifestations, use of steroids and CYC (p = 0.045, OR = 8.5; p < 0.0001, OR = 4.3; p = 0.001, OR = 6.3; p = 0.047, OR = 1.03; p = 0.005, OR = 2.96, respectively).ConclusionAPS adversely affect SLE disease course with prominent impact on end organ damage especially cerebral, cardiopulmonary and vascular events denoting the need for strict control of disease activity and early diagnosis.     

Plasma homocysteine is associated with nonproliferative retinopathy in patients with type 2 diabetes without renal disease

Background and aimsThis study aimed to assess the role of plasma homocysteine (Hcy) in the development of nonproliferative diabetic retinopathy (NPDR) in patients with type 2 diabetes (T2DM) without chronic kidney disease.MethodsThis was a cross-sectional study that included 94 T2DM. Hcy, serum 25-hydroxy (25-OH) vitamin D, vitamin B12, and folate were determined by the CMIA method. NPDR was determined according to the EURODIAB retinal photography methodology and optical coherence tomography (OCT) of the macula.ResultsCompared to patients without NPDR, patients with NPDR had longer diabetes duration (p < 0.001), higher Hcy (p < 0.001), lower vitamin B12 (p = 0.028) and lower estimated glomerular filtration rate (eGFR) (p = 0.004). NPDR was positively associated with diabetes duration (p < 0.001), HbA₁c (p = 0.049) and Hcy (p < 0.001), and negatively with vitamin B12 (p = 0.027) and eGFR (p = 0.005). Logistic regression analyses showed that diabetes duration (OR = 1.13, p < 0.001), Hcy (OR = 1.06, p = 0.047), and eGFR (OR = 0.96, p = 0.004) were the main predictors of NPDR in T2DM. Stepwise regression analyses showed that the best model for predicting Hcy (R2 = 0.104) included vitamins B12 and D.ConclusionsHigher Hcy is associated with NPDR and may play a role as a risk factor for its development in T2DM. Vitamins B12 and D seem to modify this association.     

The impact of intra- and postoperative fluid balance in pancreatic surgery - A retrospective cohort study

Background/objectivesThe aim of this study was to evaluate the impact of perioperative fluid administration in pancreatic surgery.MethodsPatients who underwent pancreatic resections were identified from our institution's prospectively maintained database. Fluid balances were recorded intraoperatively and at 24hr postoperatively. Patients were stratified into tertiles of fluid administration (low, medium, high). Adjusted multivariable analysis was performed and outcome measures were postoperative complications.ResultsA total of 211 patients were included from 2012 to 2017. Complication rates were POPF(B/C) 19.4%, DGE(B/C) 14.7%, PPH(C) 10.0% and CDC ≥ IIIb 26.1%. In multivariable analysis, high perioperative fluid balance was an independent risk factor associated with POPF (OR = 10.5, 95%CI 2.7–40.7, p = .001), CDC (OR = 2.5, 95%CI 1.2–5.3, p < .002), DGE (OR = 2.3, 95%CI 1.0–5.2, p = .017), PPH (OR = 6.7 95%CI 2.2–20.0, p = .038) and reoperation (OR = 3.1, 95%CI 1.6–6.2, p = .006). In multivariable analysis with intraoperative and postoperative fluid balances as separate predictors, intraoperative (OR = 2,5, 95%CI 1.2–5.5, p = .04) and postoperative fluid balance (OR = 2.5, 95%CI 1.2–5.5, p = .02) were predictors of POPF. Postoperative fluid balance was the only predictor for mortality (OR = 4.5, 95%CI 1.0–18.9, p = .041) and predictor for CDC (OR = 2.0, 95%CI 1.0–4.0, p = .043) and OHS days (OR = 6.9, 95%CI 0.03–13.7, p = .038).ConclusionsHigh postoperative fluid balance in particular is associated with postoperative morbidity. Maintaining a fluid-restrictive strategy postoperatively should be recommended for patients undergoing pancreatic surgery.     

Systemic anti-oxidant capacity is inversely correlated with systolic blood pressure and pulse pressure in children with obesity

Background and aimsOxidative stress leading to endothelial dysfunction is a candidate driver of obesity-related hypertension. We aimed to assess whether the total anti-oxidant capacity (TAC) was associated with blood pressure in children/adolescents with obesity.Methods and resultsOne hundred and fifty-two children/adolescents with obesity (79 boys; age 11.9+/−2.5 years) underwent blood drawing for the assessment of TAC, lipids and HOMA-IR. Blood pressure was measured and classified according to the latest American Academy of Pediatrics Guidelines. Serum TAC was measured by a commercial kit (Sigma–Aldrich). The average TAC was 1.11+/−0.4 mMol/Trolox equivalents. Systolic blood pressure was predicted by TAC (B = −5.8, p = 0.003), z-BMI (B = 2.39, p = 0.008), height [cm] (B = 0.38, p < 0.001) and diastolic blood pressure (B = 0.56, p < 0.001). Diastolic blood pressure was predicted by age [years] (B = 0.58, p = 0.001), log-HOMA-IR (B = 3.0, p = 0.002), and systolic blood pressure (B = 0.26, p < 0.001), but not by TAC. The pulse pressure was predicted only by TAC (B = − 6.6, p = 0.002), and height [cm] (B = 0.42, p < 0.001). Overall “elevated blood pressure + hypertension” or hypertension alone were not associated with TAC. However, systolic “elevated blood pressure + hypertension” was associated with TAC (OR = 0.4 [0.1–0.9], p = 0.037), and z-BMI (OR = 2.1 [1.3–3.6], p = 0.004).ConclusionThe systemic anti-oxidant capacity is inversely associated with systolic blood pressure and pulse pressure in children and adolescents with obesity.     

Preoperative biliary drainage of severely obstructive jaundiced patients decreases overall postoperative complications after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis

ObjectivesThe influence of preoperative biliary drainage (PBD) for obstructive jaundiced patients before pancreaticoduodenectomy is debated in the past decades. The aim of this study is to assess the impact of preoperative biliary drainage on intraoperative and postoperative outcomes in patients with severely obstructive jaundice.MethodsData were collected retrospectively from severely obstructive jaundiced patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy from January 2012 to December 2017. The univariate and multivariate analyses were performed to assess independent risk factors for overall postoperative complications. A propensity score-matched (PSM) analysis was performed to adjust baseline characteristics between PBD and direct surgery (DS) groups. After PSM, intraoperative data and postoperative complications were compared between the two groups.ResultsA total of 200 patients were included. The rate of overall postoperative complication occurred in 119 (59.5%) patients, with prealbumin <150 mg/L (OR = 3.03; 95%CI = [1.63–5.62]; p < 0.001), ASA (American Society of Anesthesiology score) classification II-III (OR = 2.27; 95%CI = [1.21–4.27]; p = 0.011), and direct surgery (OR = 3.88; 95%CI = [1.67–8.99]; p = 0.002) identified as independent risk factors in multivariate analysis. After PSM, there was similar operative time and intraoperative transfusion between PBD and DS group. However, DS group had a higher incidence of overall postoperative complication (p = 0.005), grades B and C of post-pancreatectomy hemorrhage (PPH) (p = 0.032), and grades B and C of postoperative pancreatic fistula (POPF) (p = 0.045) compared to PBD group.ConclusionsIn this retrospective study, in order to reduce overall postoperative complications, PBD should be performed routinely for those patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy.     

Delayed gastric emptying following distal pancreatectomy: incidence and predisposing factors

BackgroundDelayed gastric emptying (DGE) following elective distal pancreatectomy (DP) is poorly known. This study aimed to report incidence of DGE following DP, to identify its predisposing factors, and to assess its impact on hospital stay.MethodsPatients who had elective DP without additional organ or vascular resection (2012–2017) in two academic hospitals were included. Factors predisposing to DGE, defined according to the International Study Group of Pancreatic Surgery, were identified by multivariate analysis. A systematic review was performed to evaluate DGE incidence following elective DP.Results311 elective DPs were performed. Three perioperative mortalities (1.0%) were unrelated to DGE. DGE occurred in 31 (10.0%) patients (grade A = 21, grade B = 7, grade C = 3) with a median hospital stay of 16 (13–22) days versus 10 (7–14) without DGE (p < 0.001). In multivariate analysis, predisposing factors of DGE were age>75 years (OR = 4.32 [1.53–12.19]; p = 0.006), open approach (OR = 2.97 [1.1–8]; p = 0.031) and POPF grade B–C (OR = 2.54 [1.05–6.1]; p = 0.038). The systematic review identified 7 series including 876 patients with an overall 8.1% DGE incidence.ConclusionDGE complicates around 10% of elective DP. Laparoscopic approach and prevention of POPF should be encouraged to reduce DGE incidence.     

Histologic detection of Helicobacter pylori by the immunohistochemical method using anti-Helicobacter pylori polyclonal antibody: A cross-sectional study of patients with gastric pathologies at the Muhimbili National Hospital in Dar-es-salaam,Tanzania

Background and study aimImmunohistochemistry is one of the superior methods and is regarded as the gold standard for the detection of Helicobacter pylori. We aimed to detect the presence of Helicobacter pylori in gastric biopsies among patients at the Muhimbili National Hospital from January 2012 to December 2016. Also, we determined the predictors of Helicobacter pylori infection.Patients and methodsRetrospectively, we retrieved the tissue blocks of gastric biopsies at the Central Pathology Laboratory of the patients with different gastric pathologies at the Muhimbili National Hospital from January 2012 to December 2016. Helicobacter pylori were detected using anti-Helicobacter pylori polyclonal antibodies. Binary logistic regression analysis was done to determine the predictors of Helicobacter pylori infection. A two-tailed p < 0.05 was considered significant.ResultsThe prevalence of detection of Helicobacter pylori was 37.1% (63/170) using immunohistochemistry compared to 32.4% (55/170) using histology. Peptic ulcer disease, the absence of gastric cancer, and chronic gastritis were the predictors of Helicobacter pylori infection in our study (AOR = 0.2, 95% CI = 0.06–0.70, p = 0.011, AOR = 3.23, 95% CI = 1.02–10.29, p = 0.047, AOR = 0.32, 95% CI = 0.12–0.87, p = 0.025, respectively).ConclusionIn this study, Helicobacter pylori infection was associated with the presence of peptic ulcer disease, chronic gastritis, and the absence of gastric cancer. The rate of detection of Helicobacter pylori infection was higher in tissue blocks of elderly patients than in those of young patients. Also, gastric cancer was more prevalent in old female patients.     

Serum level of galectin-9 in systemic lupus erythematosus patients with lupus nephritis: Relation to clinical characteristics and disease activity

Aim of the workTo assess galectin-9 (Gal-9) level in the serum of systemic lupus erythematosus (SLE) patients with and without renal involvement and clarify its relation with disease activity.Patients and methods50 SLE patients; 25 with lupus nephritis (LN) and 25 without as well as 25 controls were studied. Systemic Lupus International Collaborating Clinics (SLICC) renal activity score and SLE disease activity index 2000 (SLEDAI-2 K) were determined. Serum Gal-9 was measured in all participants.ResultsGal-9 level was significantly elevated in SLE patients with (16.7; 11.6–33.7 ng/ml) and without (15.9; 11.8–25 ng/ml) compared to controls (3.9; 2.8–5.4 ng/ml) (p < 0.001) but was comparable between the patients groups (p = 0.83). In LN patients, serum Gal-9 and SLICC renal activity score significantly correlated (r = 0.48, p = 0.016). Serum Gal-9 significantly correlated with SLEDAI-2 K in patients with (r = 0.71, p < 0.001) and without (r = 0.95, p < 0.001) LN, with anti-double stranded deoxyribonucleic acid (anti-ds-DNA) titers (with r = 0.57, p < 0.001 and without r = 0.79, p < 0.001) and inversely with C3 (with r = -0.44, p = 0.027 and without r = -0.63, p < 0.001) and C4 (with r = -0.47, p = 0.018 and without r = -0.43, p = 0.03). Gal-9 had an area under the curve (AUC) of 0.96 to distinguish SLE cases from control. However, AUC between LN group and non-nephritic SLE was 0.48. On regression, SLEDAI-2 K was the only significant factor associated with serum Gal-9 (p < 0.001).ConclusionIn SLE patients, significantly raised Gal-9 levels and relation with disease activity were detected indicating its clinical relevance as biomarker of disease activity and its potential value in the disease diagnosis. Its value in discriminating LN from non-nephritic SLE is limited.     

Failure to rescue in patients with distal pancreatectomy: a nationwide analysis of 10,632 patients

BackgroundFTR appears as a major cause of postoperative mortality (POM). Hospital volume has an impact on FTR in pancreatic surgery but no study has investigated this relationship more specifically in DP.MethodsWe analysed patients with DP between 2009 and 2018 through a nationwide database. FTR definition was mortality among patients who experiment major complications. The cutoff between high and low volume centers was 20 pancreatectomies per year.ResultsSome 10,632 patients underwent DP, 5048 (47.5%) were operated in 602 (95.4%) low volume centers and 5584 (52.5%) in 29 (4.6%) high volume centers. Overall FTR occurred in 11.2% of patients and was significantly reduced in high volume centers compared to low volume centers (10.2% vs 12.5%, p = 0.047). In multivariate analysis, surgery in a high volume center was a protective factor for POM (OR = 0.570, CI95% [0.505–0.643], p < 0.001) and also for FTR (OR = 0.550, CI95% [0.486–0.630], p < 0.001).ConclusionHospital volume has a positive impact on FTR in DP. Patients with higher risk of FTR are men, with high modified Charlson comorbidity index, malignant conditions and open procedures.     

Depression in Behçet’s disease patients: Relationship with disease pattern,activity and quality of life

Aim of the workTo determine the frequency of depression in Behçet’s disease (BD) patients and to clarify its burden on patients’ clinical manifestations, disease activity status and quality of life (QoL).Patients and methods35 BD patients with 35 matched control were included in this study. Disease activity was assessed by Behçet Syndrome Activity Score (BSAS). All participants were requested to complete the Hamilton depression rating scale (HDRS), Multidimensional assessment of fatigue (MAF) questionnaire and the short form-36 (SF-36) QoL Scale.ResultsThe mean age of the patients was 40.3 ± 13.5 years (17–72 years) and they were 27 males and 8 females. The frequency of depression in BD patients was 74.3% with increased male frequency (p = 0.007) and major organ involvement (p = 0.04) among depressed patients. Significant differences (p < 0.001, p = 0.04, p = 0.001 respectively) between depressed and non depressed BD patients with respect to BSAS, MAF and SF-36. Highly significant positive correlations between HDRS and number of major organ, BSAS, MAF, (p < 0.001) and significant correlation with number of non major organs (r = 0.3, p = 0.04). Significant negative associations were observed between HDRS and SF-36 (r = ?0.6, p < 0.001). On regression number of major organ involvement (p < 0.001), BSAS (p = 0.01), MAF (p = 0.002), and SF-36 QoL (p < 0.001) significantly correlated with HDRS.ConclusionDepression is a significant comorbidity in patients with BD and is closely related to fatigue, number of major organ involvement and overall disease activity with a negative impact on QoL. Therefore, early interference and depression management in routine clinical practice is important to reduce patients’ symptoms, and improve QoL.     

Natural course of chronic pancreatitis and predictors of its progression

BackgroundThe natural course of chronic pancreatitis(CP) and its complications has been inadequately explored. We aimed to describe the natural history and factors affecting the progression of alcoholic(ACP), idiopathic juvenile(IJCP) and idiopathic senile(ISCP) variants of CP.MethodsThis study was a retrospective analysis from a prospectively maintained database of patients with CP following up at a tertiary care centre from 1998 to 2019. Cumulative rates of pain resolution, diabetes, steatorrhea, pseudocysts and pancreatic cancer were computed using Kaplan-Meier analysis, and the factors affecting their incidence were identified on multivariable-adjusted Cox-proportional-hazards model.ResultsA total of 1415 patients were included, with 540(38.1%) ACP, 668(47.2%) IJCP and 207(14.6%) ISCP with a median follow-up of 3.5 years(Inter-quartile range: 1.5–7.5 years). Diabetes occurred at 11.5, 28 and 5.8 years(p < 0.001) while steatorrhea occurred at 16, 24 and 18 years(p = 0.004) after onset for ACP, IJCP and ISCP respectively. Local complications including pseudocysts occurred predominantly in ACP(p < 0.001). Ten-year risk of pancreatic cancer was 0.9%, 0.2% and 5.2% in ACP, IJCP and ISCP, respectively(p < 0.001). Pain resolution occurred more frequently in patients with older age of onset[Multivariate Hazard Ratio(HR):1.7(95%CI:1.4–2.0; p < 0.001)], non-smokers[HR:0.51(95%CI:0.34–0.78); p = 0.002] and in non-calcific CP[HR:0.81(0.66–1.0); p = 0.047]. Occurrence of steatorrhea[HR:1.3(1.03–1.7); p = 0.028] and diabetes[HR:2.7(2.2–3.4); p < 0.001] depended primarily on age at onset. Occurrence of pancreatic cancer depended on age at onset[HR:12.1(4.7–31.2); p < 0.001], smoking-history[HR:6.5(2.2–19.0); p < 0.001] and non-alcoholic etiology[HR:0.14(0.05–0.4); p < 0.001].ConclusionACP, IJCP and ISCP represent distinct entities with different natural course. Age at onset of CP plays a major prognostic role in all manifestations, with alcohol predominantly causing local inflammatory complications.     

Predictors of hospital transfer and associated risks of mortality in acute pancreatitis

BackgroundThere is limited research in prognosticators of hospital transfer in acute pancreatitis (AP). Hence, we sought to determine the predictors of hospital transfer from small/medium-sized hospitals and outcomes following transfer to large acute-care hospitals.MethodsUsing the 2010–2013 Nationwide Inpatient Sample (NIS), patients ≥18 years of age with a primary diagnosis of AP were identified. Hospital size was classified using standard NIS Definitions. Multivariable analyses were performed for predictors of “transfer-out” from small/medium-sized hospitals and mortality in large acute-care hospitals.ResultsAmong 381,818 patients admitted with AP to small/medium-sized hospitals, 13,947 (4%) were transferred out to another acute-care hospital. Multivariable analysis revealed that older patients (OR = 1.04; 95%CI 1.03–1.06), men (OR = 1.15; 95%CI 1.06–1.24), lower income quartiles (OR = 1.54; 95%CI 1.35–1.76), admission to a non-teaching hospital (OR = 3.38; 95%CI 3.00–3.80), gallstone pancreatitis (OR = 3.32; 95%CI 2.90–3.79), pancreatic surgery (OR = 3.14; 95%CI 1.76–5.58), and severe AP (OR = 3.07; 95%CI 2.78–3.38) were predictors of “transfer-out”. ERCP (OR = 0.53; 95%CI 0.43–0.66) and cholecystectomy (OR = 0.14; 95%CI 0.12–0.18) were associated with decreased odds of “transfer-out”.Among 507,619 patients admitted with AP to large hospitals, 31,058 (6.1%) were “transferred-in” from other hospitals. The mortality rate for patients “transferred-in” was higher than those directly admitted (2.54% vs. 0.91%, p < 0.001). Multivariable analysis revealed that being “transferred-in” from other hospitals was an independent predictor of mortality (OR = 1.47; 95% CI 1.22–1.77).ConclusionsPatients with AP transferred into large acute-care hospitals had a higher mortality than those directly admitted likely secondary to more severe disease. Early implementation of published clinical guidelines, triage, and prompt transfer of high-risk patients may potentially offset these negative outcomes.     

Improved risk assessment of coronary artery disease by substituting paraoxonase 1 activity for HDL-C: Novel cardiometabolic biomarkers based on HDL functionality

Background and aimsDeveloping laboratory assays to evaluate HDL functions and improve cardiovascular disease (CVD) risk assessment has recently emerged as a challenge. The present study was conducted to help predict the risk of coronary artery disease (CAD) by investigating new cardiometabolic risk factors based on substituting paraoxonase 1 (PON1) as a critical enzyme in the functionality of HDL for that of HDL-C.Methods and resultsThe present study recruited 274 subjects undergoing diagnostic coronary angiography, 92 without significant CAD (non-CAD), and 182 with a severe CAD. The diagnostic accuracy of the new biomarkers in non-CAD versus multi-vessel disease was obtained in descending order of AUC as 0.72 (P < 0.001) for log (TG/PON1), 0.70 (P < 0.001) for nonHDL-C/PON1, and 0.67 (P < 0.001) for LDL-C/PON1. After performing a multivariate adjustment for age, gender, BMI, statin therapy, and diabetes mellitus, the increased odds of CAD remained significant for the new cardiometabolic ratios as independent variables [adjusted OR = 1.47 (1.15–1.88), p = 0.002 for LDL-C/PON1; adjusted OR = 2.15 (1.41–3.5), p = 0.009 for nonHDL-C/PON1; adjusted OR = 5.03 (2.14–13.02), p = 0.004 for log (TG/PON1)]. CAD was diagnosed with an optimal discriminating cutoff of 1.84 for LDL-C/PON1, 2.8 for nonHDL-C/PON1, and 0.48 for log (TG/PON1).ConclusionsTo improve CAD's risk assessment, the PON1 activity was proposed as an alternative to HDL-C in the commonly used atherogenic lipid ratios. Substituting the PON1 activity for the HDL-C concentration can provide an index of the HDL activity. The present study sought to exploit the lipoprotein-related risk factors of CAD from a more effective perspective.     

Predictive Utility of Left Heart Catheterization Indices for Left Ventricular Thrombus Formation After Anterior ST-Elevation Myocardial Infarction

BackgroundLeft ventricular thrombus (LVT) has a 5% incidence after anterior ST-elevation myocardial infarction (STEMI). Multiple risk factors predispose to LVT formation, including left ventricular systolic dysfunction and infarct size, however measurable predictors during index left heart catheterization (LHC) have not been determined.MethodsWe performed a retrospective analysis of patients presenting between January 2010 and September 2017 with anterior STEMI who had in-hospital transthoracic echocardiography (TTE). LHC variables that were assessed included coronary anatomy, location of culprit stenosis, presence of diffuse stenosis, number of severely diseased vessels, apical akinesis on left ventriculogram (LVG), left ventricular end diastolic pressure, and success of percutaneous coronary intervention (PCI).ResultsOf 598 consecutive anterior STEMI patients, records and inpatient TTE results were available in 425 patients. The incidence of LVT was 6.8% (n = 29). After multivariate adjustment, severe triple vessel coronary disease (OR = 8.27, CI = 2.97–23.00, p ≤0.001), apical akinesis on LVG (OR = 6.74, CI = 1.48–30.73, p = 0.014), wrap-around left anterior descending (LAD) anatomy (OR = 5.10, CI = 1.97–13.23, p = 0.001), and failure of recanalization after PCI (OR = 3.94, CI = 1.06–14.66, p = 0.04) were predictors for LVT formation. The combined negative predictive value (NPV) for the absence of these four indices was 99.2%.ConclusionSevere triple vessel disease, apical akinesis on LVG during index admission, wrap-around LAD, and failure of recanalization after PCI are associated with increased risk of LVT formation after anterior STEMI. The high NPV for the absence of these indices could serve as a risk stratification tool for LVT risk to guide early TTE utilization.     

Glucose dysregulation and its association with COVID-19 mortality and hospital length of stay

Background and aimsWe investigate the impact of blood glucose on mortality and hospital length of stay (HLOS) among COVID-19 patients.MethodsRetrospective study of 456 patients with confirmed COVID-19 and glycemic dysregulation in the New York City area.ResultsWe found that impaired glucose adjusted for other organs systems involved (OR:1.87; 95% CI:1.36–2.57, p < 0.001), increased glucose nadir (OR:34.28; 95% CI:3.97–296.05, p < 0.01) and abnormal blood glucose levels at discharge (OR:5.07; 95% CI:2.31–11.14, p < 0.001) were each significantly associated with increased odds for mortality. New or higher from baseline insulin requirement during hospitalization (OR:0.34; 95% CI:0.15–0.78; p < 0.05) was significantly associated with decreased odds for mortality. Increased glucose peak (B = 0.001, SE=<0.001, p < 0.001), new or higher from baseline insulin requirement during hospitalization (B = 0.11, SE = 0.03, p < 0.001), and increased days to dysglycemia (B = 0.15, SE = 0.04, p < 0.001) were each significantly associated with increased HLOS. Increased glucose nadir (B = ?0.67, SE = 0.07, p < 0.001), insulin intravenous drip (B = ?0.10, SE = 0.05, p < 0.05), and increased proportion days endocrine system involved (B = ?0.25, SE = 0.06, p < 0.001) were each significantly associated with decreased HLOS.ConclusionGlucose dysregulation adversely affects mortality and HLOS in COVID-19. These data can help clinicians to guide patient treatment and management in COVID-19 patients.     

Novel predictors and adverse long-term outcomes of No-reflow phenomenon in patients with acute ST elevation myocardial infarction undergoing primary percutaneous coronary intervention

ObjectivesThe no-reflow phenomenon occurs in 25% of patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), and may be associated with adverse outcomes. The aim of our study was to detect novel predictors of no-reflow phenomenon and the resulting adverse long term outcomes.MethodsWe enrolled 400 STEMI patients undergoing primary PCI; 228 patients had TIMI flow 3 after PCI (57%) and the remaining 172 patients had TIMI flow <3 (43%). Fibrinogen to albumin ratio (FAR), high sensitive C-reactive protein to albumin ratio (CAR), and atherogenic index of plasma (AIP) were calculated. Long term mortality and morbidity during 6 months follow up were recorded. These data were compared among both groups.ResultsIn multivariate regression analysis, old age (OR = 1.115, 95% CI: 1.032–1.205, P = 0.006), higher troponin level >5.6 ng/mL (OR = 1.040, 95% CI: 1.001–1.080, P = 0.04), diabetes mellitus (OR = 4.401, 95% CI: 1.081–17.923, P = 0.04) and heavy thrombus burden (OR = 16.915, 95% CI: 5.055–56.602, P < 0.001) could be considered as predictors for the development of no-reflow. Interestingly, CAR >0.21, FAR >11.56, and AIP >0.52 could be considered as novel powerful independent predictors (OR = 3.357, 95% CI: 2.288–4.927, P < 0.001, OR = 4.187, 95% CI: 2.761–6.349, P < 0.001, OR = 16.794, 95% CI: 1.018–277.01, P = 0.04, respectively). Higher long term mortality (P < 0.001) and heart failure (P < 0.001) was also strongly related to incidence of no-reflow.ConclusionNo-reflow could be attributed to novel predictors as CAR, FAR, and AIP. This phenomenon was associated with long term adverse events as higher mortality and pump failure.     

Interleukin-37 gene polymorphism and susceptibility to pulmonary tuberculosis among Iraqi patients

BackgroundControl of tuberculosis (TB) depends on a balance between host's immune factors and bacterial evasion strategies. Interleukin-37 (IL-37) is among the immunomodulatory factors that have been proposed to influence susceptibility to tuberculosis.MethodsA case–control study was conducted on 105 patients with pulmonary TB (37 active, 41 multi-drug resistant and 27 relapse) and 79 healthy controls to determine serum levels and single nucleotide polymorphisms (SNPs) of IL-37. The IL-37 level was assessed with an enzyme-linked immunosorbent kit, while DNA-sequencing was used to detect SNPs in the promoter region of IL37 gene.Results: Median level of IL-37 was markedly increased in serum of TB patients compared to controls (325.0 vs. 169.1 pg/mL; p < 0.001). This increase was universally determined in subgroups of patients distributed according to gender, age groups, and clinical type of disease, while no significant differences were found between the subgroups in patients or controls. Analysis of receiver operating characteristic curve confirmed these findings and IL-37 occupied a very good area under the curve, which was 0.816 (95% CI = 0.744–0.888; p < 0.001). At a cut-off value of 185.6 pg/mL, the sensitivity and specificity of IL-37 were 81.0 and 82.3%, respectively. Of the nine detected SNPs (rs2466449 G/A, rs2466450 A/G, rs2723168 G/A, rs3811042 G/A, rs3811045 T/C, rs3811046 G/T, rs3811047 A/G, rs3811048 G/A and rs200782323 G/A), only rs3811048 showed a significant association with TB; the G allele showed a significantly decreased frequency in TB patients compared to controls (25.2 vs. 44.9%; OR = 0.41; p < 0.001). It was possible to assign five haplotypes, and three showed significant differences between patients and controls. Frequency of haplotype A-A-G-A-C-T-G-A-G (0.331 vs. 0.213; OR = 2.10; p = 0.015) was significantly increased in TB patients compared to controls. On the contrary, frequencies of haplotypes A-A-G-A-C-T-G-G-G (0.029 vs. 0.116; OR = 0.24; p = 0.01) and A-A-G-G-T-G-A-G-G (0.140 vs. 0.275; OR = 0.45; p = 0.015) were significantly decreased in patients.ConclusionsIL-37 was up-regulated in the serum of TB patients irrespective of their gender, age or clinical type of disease. SNPs in the promoter region of IL37 gene were proposed to be associated with susceptibility to TB.     

Predictors of outcomes in children with Central Nervous System tuberculosis

BackgroundCentral Nervous system tuberculosis (CNS–Tb) is the most lethal form of extra-pulmonary tuberculosis in children. The lack of markers of outcome provides little information on the efficacy of the current treatment protocols for CNS–Tb and thus results in a higher mortality rate than other extrapulmonary manifestations of tuberculosis. This study aims to identify significant factors that will reliably predict the outcomes at discharge in children admitted with CNS–Tb.Methods and materialThis is a prospective observational study in children with neurotuberculosis admitted at a tertiary care hospital. Clinical presentations at the time of admission were studied. Outcomes at the end of in-patient care (completely cured, survival with some/severe disability or death) were correlated with clinical, laboratory, microbiological, and radiological parameters. Univariate and multivariate analyses were applied to study the parameters and a p-value ≤ 0.05 with a confidence interval (CI) of 95% was considered as statistically significant.FindingsThe study included 100 children between 4 months and 12 years of age with a mean of 5.84 (±3.5) years. At discharge, 55% of children recovered completely, 20% had some or severe disability and 25% died. On multivariate analysis, high CSF protein (p = 0.050) and drug resistance (p = 0.034) were highly associated with fatality. Meningeal enhancements with basal exudates (p = 0.021) and CSF lymphocyte count >90% were highly associated with survival with disability. Stage I disease at presentation (p < 0.0001) was the only variable associated with complete recovery.InterpretationReliable prognostic markers for CNS–Tb can aid in predicting the efficacy of the current treatment and the anticipated outcome in the children with this disease.FundingThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.