A comparison of clinical outcomes between Canadian and American patients after nonurgent coronary stenting

BACKGROUND: Practice patterns for percutaneous coronary interventions (PCIs) may differ between Canada and the United States. Few data are available comparing PCI outcomes between the two countries in the era of coronary stenting and adjunctive glycoprotein IIb/IIIa inhibition. METHODS: In the Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy (ESPRIT) trial, 2064 patients were randomly assigned to receive eptifibatide or placebo during nonurgent PCI. The 30-day and one-year rates of death, myocardial infarction (MI) and target vessel revascularization (TVR) were compared between Canadian and American patients enrolled in the ESPRIT trial. RESULTS: There were 1531 American patients and 533 Canadian patients enrolled. Americans were older and heavier, and had a higher incidence of cardiac risk factors than Canadians (P<0.05 for all variables). Canadian patients had a lower incidence of death, MI and TVR at 30 days (6.2% versus 10.4%, P=0.004) and at one year (14.8% versus 21.5%, P=0.0006). After adjusting for known baseline differences, enrollment in Canada remained a significant predictor of reduced ischemic complications at 30 days (OR=0.53, c2=9.0, P=0.003). Similar results were observed at one year. Eptifibatide was superior to placebo in both groups of patients. CONCLUSIONS: This analysis is among the first to show Canadian patients to have fewer adverse events than American patients after nonurgent PCI. This effect was independent of known baseline differences between the patients in each country. The relative treatment effect of eptifibatide in Canadian patients paralleled that observed in the main ESPRIT trial and in American patients.     

Lipid rafts keep NADPH oxidase in the inactive state in human renal proximal tubule cells

Recent studies have indicated the importance of cholesterol-rich membrane lipid rafts (LRs) in oxidative stress-induced signal transduction. Reduced nicotinamide-adenine dinucleotide phosphate (NADPH) oxidases, the major sources of reactive oxygen species, are implicated in cardiovascular diseases, including hypertension. We tested the hypothesis that NADPH oxidase subunits and activity are regulated by LRs in human renal proximal tubule cells. We report that a high proportion of p22(phox) and the small GTPase Rac1 are expressed in LRs in human renal proximal tubule cells. The D(1)-like receptor agonist, fenoldopam (1 micromol/L per 20 minutes) dispersed Nox subunits within LRs and non-LRs and decreased oxidase activity (30.7+/-3.3%). In contrast, cholesterol depletion (2% methyl-beta-cyclodextrin [beta CD]) translocated NADPH oxidase subunits out of LRs and increased oxidase activity (154.0+/-10.5% versus control, 103.1+/-3.4%), which was reversed by cholesterol repletion (118.9+/-9.9%). Moreover, NADPH oxidase activation by beta CD (145.5+/-9.0%; control: 98.6+/-1.6%) was also abrogated by the NADPH oxidase inhibitors apocynin (100.4+/-3.2%) and diphenylene iodonium (9.5+/-3.3%). Furthermore, beta CD-induced reactive oxygen species production was reversed by knocking down either Nox2 (81.0+/-5.1% versus beta CD: 162.0+/-2.0%) or Nox4 (108.0+/-10.8% versus beta CD: 152.0+/-9.8%). We have demonstrated for the first time that disruption of LRs results in NADPH oxidase activation that is abolished by antioxidants and silencing of Nox2 or Nox4. Therefore, in human renal proximal tubule cells, LRs maintain NADPH oxidase in an inactive state.     

Validating the 8 CPCSSN Case Definitions for Chronic Disease Surveillance in a Primary Care Database of Electronic Health Records

PURPOSE

The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is Canada’s first national chronic disease surveillance system based on electronic health record (EHR) data. The purpose of this study was to develop and validate case definitions and case-finding algorithms used to identify 8 common chronic conditions in primary care: chronic obstructive pulmonary disease (COPD), dementia, depression, diabetes, hypertension, osteoarthritis, parkinsonism, and epilepsy.

METHODS

Using a cross-sectional data validation study design, regional and local CPCSSN networks from British Columbia, Alberta (2), Ontario, Nova Scotia, and Newfoundland participated in validating EHR case-finding algorithms. A random sample of EHR charts were reviewed, oversampling for patients older than 60 years and for those with epilepsy or parkinsonism. Charts were reviewed by trained research assistants and residents who were blinded to the algorithmic diagnosis. Sensitivity, specificity, and positive and negative predictive values (PPVs, NPVs) were calculated.

RESULTS

We obtained data from 1,920 charts from 4 different EHR systems (Wolf, Med Access, Nightingale, and PS Suite). For the total sample, sensitivity ranged from 78% (osteoarthritis) to more than 95% (diabetes, epilepsy, and parkinsonism); specificity was greater than 94% for all diseases; PPV ranged from 72% (dementia) to 93% (hypertension); NPV ranged from 86% (hypertension) to greater than 99% (diabetes, dementia, epilepsy, and parkinsonism).

CONCLUSIONS

The CPCSSN diagnostic algorithms showed excellent sensitivity and specificity for hypertension, diabetes, epilepsy, and parkinsonism and acceptable values for the other conditions. CPCSSN data are appropriate for use in public health surveillance, primary care, and health services research, as well as to inform policy for these diseases.     

Growing skull fracture: two rare causes

Introduction

Growing skull fractures are rare complications of head injury in young children. Till date, growing skull fractures due to an underlying arrested hydrocephalus or subdural hygroma have not been reported. We are reporting two such rare cases.

Discussion

A 12-year-old male who was a known case of arrested hydrocephalus sustained a mild head injury and was found to have a linear fracture. One month after the initial injury, a soft swelling was noted in the parietal region. Investigations revealed the dilated ventricular system communicating through a growing skull fracture with a subgaleal CSF collection. The patient underwent a ventriculoperitoneal shunt using a high-pressure shunt system. The patient died suddenly 48 h after the surgery. An 8-month-old female child sustained a mild head injury with a linear fracture in the parieto-occipital region. Two months later, the child presented with seizures and a soft, fluctuant swelling in the parieto-occipital region. Imaging revealed a frontoparietal subdural hygroma with mass effect that was communicating through a growing skull fracture with a subgaleal CSF collection. The patient underwent a subduroperitoneal shunt. The shunt tube was removed 3 months later as it protruded through the abdominal wound. Follow-up imaging studies revealed complete resolution of the subdural hygroma with healing of the growing skull fracture.

Conclusions

Growing skull fractures can occur as complications of mild head injury sustained in the setting of either arrested hydrocephalus or subdural hygroma. Hence, close follow-up of patients with skull fracture and arrested hydrocephalus/subdural hygroma is necessary for early diagnosis of growing skull fractures.     

Mucormycosis in COVID-19 patients

Mucormycosis, commonly known as ‘Black Fungus’ which was then a rare fungal infection, has suddenly come to light post the COVID-19- pandemic, more so during the second wave in India. It thus becomes important not only for the medical fraternity but also the general population to build awareness about the same. The present review will focus on the pathophysiology, etiology, outcomes of some case studies, and current treatment methods of mucormycosis infection. Major focus of the current article is on rhino-orbital-cerebral mucormycosis. All the studies included in the present review article was extracted from the PubMed database.     

Early and late survival in Hodgkin disease among whites and blacks living in the United States

Background. The independent effect of race on response to treatment and prognosis in Hodgkin disease is unclear. Methods. The study included 9482 patients with histologically confirmed Hodgkin disease reported by 1084 different hospitals and institutions in the United States. The independent effect of race on response to treatment and recurrence was estimated using the logistic model. Cox proportional hazard model was applied to determine the independent effect of race and other covariables on risk of death. Results. Complete remission occurred in more white patients (67.3%) than black patients (58.2%). Recurrences were reported more often in black patients than in white patients (40.3% and 30.9% respectively). Controlling for confounding variables, race has a significant independent effect on remission and recurrence (P < 0.05). In the first 5 years after diagnosis of Hodgkin disease, the patient age at diagnosis, clinical stage, and histologic type were significant predictors for the risk of death. At 5–10 years after a diagnosis of Hodgkin disease, age, clinical stage, and race of the patient were found to be significant risk factors (whites versus blacks: RR = 0.56; P < 0.05). Conclusions. Race is a significant predictor for remission, recurrence and survival in Hodgkin disease. Black patients have a more unfavorable prognosis than do white patients.