Factor Xa Inhibitors and Low Molecular Weight Heparins in Perioperative Surgical Thromboprophylaxis: A Network Meta-Analysis.

BACKGROUND: venous thromboembolism (VTE) prophylaxis is crucial for reducing the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). This network metaanalysis was carried out to determine the most effective intervention among selective Xa inhibitors and low molecular weight heparins (LMWHs) for perioperative surgical thromboprophylaxis in major abdominal, pelvic, lumbar spine, and lower limb surgeries. METHODS: A systematic literature search was conducted for randomized controlled trials (RCTs) comparing selective factor Xa inhibitors, LMWHs, and placebo as thromboprophylaxis agents in major abdominal, pelvic, lumbar spine, and lower limb surgeries. A Bayesian network metaanalysis was performed to compare all interventions for the risk of developing DVT, VTE, major VTE, total bleeding, and major bleeding. The surface under the cumulative ranking curves was used to rank all interventions. RESULTS: Of 1788 retrieved references, 42 RCTs comparing 11 anticoagulants were included. As compared to enoxaparin, the risk of DVT was significantly reduced in patients treated with fondaparinux [RR: 0.53 (95% CrI: 0.31, 0.93)] and rivaroxaban [RR: 0.42 (95% CrI: 0.27, 0.64)]; VTE in patients treated with bemiparin [RR: 0.09 (95% CrI: 0, 0.7)], edoxaban [RR: 0.43 (95% CrI: 0.18, 0.96)], fondaparinux [RR: 0.55 (95% CrI: 0.34, 0.91)] and rivaroxaban [RR: 0.56 (95% CrI: 0.34, 0.85)]; major VTE in patients treated with rivaroxaban [RR: 0.26 (95% CrI: 0.11, 0.6)]. According to the surface under the cumulative ranking curves (SUCRA) value, fondaparinux and bemiparin increase the risk of serious bleeding more than other factor Xa inhibitors and LMWHs. CONCLUSION: Rivaroxaban, fondaparinux, edoxaban, and bemiparin are superior perioperative thromboprophylaxis agents than enoxaparin in major surgeries. Fondaparinux and bemiparin have shown the highest risk of major bleeding compared to other factor Xa inhibitors and LMWHs.

Fibromyxomatous Tumour of Nose: A Combined Approach to this Enigmatic Mass.

Fibromyxomatous spindle cell neoplasms are an unusual form of dysplasia. It is extremely rare in the nose and paranasal sinuses. We present a 60 year lady with swelling over the dorsum of nose and nasal block for 4 years. She underwent combined approach excision of mass. Histopathology revealed fibromyxomatous spindle cell tumour.

Patient Perceptions and Knowledge Surrounding Pregnancy After Heart Transplantation: A Multicenter Study.

BACKGROUND: More women of childbearing age are surviving after heart transplantation (HT), many of whom have a desire to become pregnant. Limited data exist evaluating patients' perspectives, receipt of counseling, and knowledge surrounding contraception, pregnancy, breastfeeding, and medication safety after HT. METHODS: We conducted a voluntary, confidential, web-based cross-sectional survey of women who were childbearing age (defined as 18-45 years) at the time of HT. Transplants occurred between January 2005 and January 2020. Surveys were conducted across 6 high-volume HT centers in the United States. RESULTS: There were 64 responses from women who were of childbearing age at the time of HT. Twenty-five women (39.1%) were pregnant before HT, and 6 (9.4%) women reported at least 1 pregnancy post-transplant. Fifty-three percent (n=34) reported they did not receive enough information on post-HT pregnancy before listing for HT, and 26% (n=16) did not discuss their ability to become pregnant with their care team before proceeding with HT. Following HT, 44% (n=28) still felt that they had not received enough information regarding pregnancy. The majority of women (n=49, 77%) had discussed contraception to prevent unplanned pregnancy with their transplant team. Twenty percent (n=13) reported that pregnancy was never safe after transplantation based on the information they had received from their transplant providers. CONCLUSIONS: Many women feel they are not receiving adequate counseling with regard to posttransplant reproductive health. This survey highlights an opportunity to improve both provider education and patient communication to better support women with HT desiring posttransplant pregnancy.

Appropriate and inappropriate ICD shocks in patients with LVADs: Prevalence, associated factors, and etiologies.

BACKGROUND: Implantable cardioverter-defibrillator (ICD) shocks are a common complication after left ventricular assist device (LVAD) implantation; however, data on their frequency and causes are limited. OBJECTIVE: The purpose of this study was to define the incidence, programming, patient characteristics, and factors associated with appropriate and inappropriate ICD shocks in persons with LVADs. METHODS: We performed a retrospective review at Duke University Hospital of all LVAD recipients implanted between January 1, 2013, to June 30, 2019, with a preexisting ICD. ICD shocks were adjudicated by the treating physician and a second reviewer for the purpose of this study. RESULTS: Among 421 patients with an ICD in situ undergoing LVAD implant, 147 (33.9%) had at least 1 shock after LVAD implantation. Among 134 patients with complete device history, a total of 330 shock episodes occurred: 255 (77.3%) appropriate and 75 (22.7%) inappropriate. Etiologies for inappropriate shocks included supraventricular tachycardia (n = 66 [20.0%]), physiological oversensing (n = 1 [0.3%]), and nonphysiological oversensing (n = 8 [2.4%]) including LVAD electromagnetic interference (n = 1 [0.3%]). ICD programming with shorter detection delay (P <.001) and absence of antitachycardia pacing programming (P = .001) in high-rate zones was seen more commonly in inappropriate shock than appropriate shock. CONCLUSIONS: The rate of inappropriate shocks in LVAD recipients is very high and most often is due to supraventricular arrhythmias. LVAD electromagnetic interference is a rare cause of ICD shock. Implementation of current consensus American Heart Association recommendations for LVAD programming with long detection delays and high rate cutoffs may help prevent inappropriate ICD shocks.

An ISHLT consensus statement on strategies to prevent and manage hemocompatibility related adverse events in patients with a durable, continuous-flow ventricular assist device.

Life expectancy of patients with a durable, continuous-flow left ventricular assist device (CF-LVAD) continues to increase. Despite significant improvements in the delivery of care for patients with these devices, hemocompatability-related adverse events (HRAEs) are still a concern and contribute to significant morbility and mortality when they occur. As such, dissemination of current best evidence and practices is of critical importance. This ISHLT Consensus Statement is a summative assessment of the current literature on prevention and management of HRAEs through optimal management of oral anticoagulant and antiplatelet medications, parenteral anticoagulant medications, management of patients at high risk for HRAEs and those experiencing thrombotic or bleeding events, and device management outside of antithrombotic medications. This document is intended to assist clinicians caring for patients with a CF-LVAD provide the best care possible with respect to prevention and management of these events.

Reflux Symptom Index (RSI), Videolaryngostroboscopy and Voice Analysis: A Triad of Non-Invasive Tools to Study Treatment Outcomes of Laryngopharyngeal Reflux Disease (LPRD).

Study post treatment improvement of Laryngopharyngeal Reflux Disease (LPRD) using non-invasive tools of Reflux symptom index (RSI), Reflux finding score (RFS) grading of videolaryngostroboscopy (VLS) and voice analysis. This study from December 2020 to April 2022 enrolled 100 adults with complaints suggestive of reflux symptoms and having Reflux Symptom Index (RSI) more than 13. All patients underwent VLS along with voice analysis. VLS findings were graded using Reflux Finding Score (RFS). Patients were advised for lifestyle modifications and proton pump inhibitors for 8 weeks when post treatment RSI, VLS and voice analyses were again documented. The age range was from 18 to 75 years. Males predominated. Lifestyle modification compliance was seen in 85% of the patients. We found a significant association (P = 0.001) for difference in pretreatment and posttreatment for both Reflux Symptom Index (RSI) parameters & Reflux Finding Score Index (RFS) parameters. Voice analysis pre and post treatment showed a significant association (P = 0.001) for fundamental frequency, jitter, shimmer, harmonic-to-noise ratio and maximum phonation time. The gold standard of diagnosis of LPRD is 24 h pH monitoring but has many false negatives and false positives due to intermittent reflux and inaccurate probe placement. This costly, time consuming and invasive procedure is not widely available amongst our speciality. Excellent visualisation of VLS allowed accurate RFS calculation. Voice analysis permitted early diagnosis of LPRD induced hoarseness before it became clinically significant. It also documented the treatment outcome. We conclude that an 8-weeks proton pump inhibitor treatment combined with lifestyle modification resulted in a significant improvement in the parameters of the non-invasive tools of RSI and RFS and voice analysis.

Donor Heart Recovery and Preservation Modalities in 2024.

Historically, heart transplantation (HT) has relied on the use of traditional cold storage for donor heart preservation. This organ preservation modality has several limitations, including the risk for ischemic and cold-induced graft injuries that may contribute to primary graft dysfunction and poor post-HT outcomes. In recent years, several novel donor heart preservation modalities have entered clinical practice, including the SherpaPak Cardiac Transport System of controlled hypothermic preservation, and the Transmedics Organ Care System of ex vivo perfusion. Such technologies are altering the landscape of HT by expanding the geographic reach of procurement teams and enabling both donation after cardiac death and the use of expanded criteria donor hearts. This paper will review the emerging evidence on the association of these modalities with improved post-HT outcomes, and will also suggest best practices for selecting between donor heart preservation techniques.

Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure: The ARIES-HM3 Randomized Clinical Trial.

IMPORTANCE: Left ventricular assist devices (LVADs) enhance quality and duration of life in advanced heart failure. The burden of nonsurgical bleeding events is a leading morbidity. Aspirin as an antiplatelet agent is mandated along with vitamin K antagonists (VKAs) with continuous-flow LVADs without conclusive evidence of efficacy and safety. OBJECTIVE: To determine whether excluding aspirin as part of the antithrombotic regimen with a fully magnetically levitated LVAD is safe and decreases bleeding. DESIGN, SETTING, and PARTICIPANTS: This international, randomized, double-blind, placebo-controlled study of aspirin (100 mg/d) vs placebo with VKA therapy in patients with advanced heart failure with an LVAD was conducted across 51 centers with expertise in treating patients with advanced heart failure across 9 countries. The randomized population included 628 patients with advanced heart failure implanted with a fully magnetically levitated LVAD (314 in the placebo group and 314 in the aspirin group), of whom 296 patients in the placebo group and 293 in the aspirin group were in the primary analysis population, which informed the primary end point analysis. The study enrolled patients from July 2020 to September 2022; median follow-up was 14 months. Intervention: Patients were randomized in a 1:1 ratio to receive aspirin (100 mg/d) or placebo in addition to an antithrombotic regimen. MAIN OUTCOMES AND MEASURES: The composite primary end point, assessed for noninferiority (-10% margin) of placebo, was survival free of a major nonsurgical (>14 days after implant) hemocompatibility-related adverse events (including stroke, pump thrombosis, major bleeding, or arterial peripheral thromboembolism) at 12 months. The principal secondary end point was nonsurgical bleeding events. RESULTS: Of the 589 analyzed patients, 77% were men; one-third were Black and 61% were White. More patients were alive and free of hemocompatibility events at 12 months in the placebo group (74%) vs those taking aspirin (68%). Noninferiority of placebo was demonstrated (absolute between-group difference, 6.0% improvement in event-free survival with placebo [lower 1-sided 97.5% CI, -1.6%]; P < .001). Aspirin avoidance was associated with reduced nonsurgical bleeding events (relative risk, 0.66 [95% confidence limit, 0.51-0.85]; P = .002) with no increase in stroke or other thromboembolic events, a finding consistent among diverse subgroups of patient characteristics. CONCLUSIONS AND RELEVANCE: In patients with advanced heart failure treated with a fully magnetically levitated LVAD, avoidance of aspirin as part of an antithrombotic regimen, which includes VKA, is not inferior to a regimen containing aspirin, does not increase thromboembolism risk, and is associated with a reduction in bleeding events. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04069156.

Real-world Experiences in the Transplantation of Hepatitis C-NAAT-positive Organs.

Background: Hepatitis C virus (HCV) nucleic acid amplification test (NAAT)-positive donors have increased the organ pool. Direct-acting antivirals (DAAs) have led to high rates of treatment success and sustained virologic response (SVR) in recipients with donor-derived HCV infection without significant adverse effects, although variability remains in the timing and duration of antivirals. Methods: This retrospective study analyzed all adult HCV-NAAT-negative transplant recipients who received an organ from HCV-NAAT-positive donors from November 24, 2018, to March 31, 2022, at Duke University Medical Center with protocolized delay of DAA initiation until after hospital discharge, with at least 180-d follow-up on all patients. Transplant and HCV-related outcomes were analyzed. Results: Two hundred eleven transplants (111 kidneys, 41 livers, 34 hearts, and 25 lungs) were performed from HCV-NAAT-positive donors to HCV-NAAT-negative recipients. Ninety percent of recipients became viremic within 7 d posttransplant. Ninety-nine percent of recipients were initiated on pangenotypic DAAs in the outpatient setting a median of 52 d posttransplant, most commonly with 12-wk courses of sofosbuvir-velpatasvir (lungs) and glecaprevir-pibrentasvir (heart, kidney, and liver). Ninety-seven percent of recipients had SVR after a first-line DAA; all ultimately achieved SVR at 12 wk after subsequent treatment courses. The median peak HCV RNA for all organ systems was 2 436 512 IU/mL; the median time from antiviral to undetectable RNA was 48 d, although differences were noted between organ groups. No patient deaths or graft losses were directly attributable to HCV infection. Conclusions: One hundred percent of transplant recipients of HCV-NAAT-positive organs ultimately developed SVR without significant adverse effects when HCV antivirals were initiated in the outpatient setting after transplant hospitalization, suggesting that this real-world treatment pathway is a viable option.

Maternal and Pregnancy Outcomes Following Heart Transplantation in the United States.

BACKGROUND: Improved survival following heart transplantation (HT) has led to more recipients contemplating pregnancy, but data on outcomes are limited. OBJECTIVES: The authors used a national data set to investigate and describe outcomes of pregnancies and deliveries in the United States in HT recipients. METHODS: Diagnosis and procedure codes from the 2010-2020 Nationwide Readmissions Database identified delivery hospitalizations, history of HT, comorbid conditions, and outcomes. The authors compared rates of severe maternal morbidity (SMM), nontransfusion SMM, cardiovascular SMM (cSMM), and preterm birth from delivery hospitalization between HT recipients and no-HT recipients. The authors evaluated readmission to 330 days postpartum. Logistic and proportional hazard regressions were performed, adjusting for age, socioeconomic and facility characteristics, and clinical comorbidities. RESULTS: Among 19,399,521 deliveries, 105 were HT recipients. Compared with no-HT, HT recipients were at higher risk for all SMM (24.8% vs 1.7%), nontransfusion SMM (20.8% vs 0.7%), cSMM (7.3% vs 0.12%), and preterm birth (43.3% vs 8.2%), all P < 0.001. In adjusted analyses, HT recipients had 16-fold greater odds of SMM, 28-fold greater odds of nontransfusion SMM, 38-fold greater odds of cSMM, and 7-fold greater odds of preterm birth. HT recipients had higher morbidity rates during delivery hospitalization and higher readmission rates within 1 year following delivery (26.9% vs 3.8%; adjusted HR: 6.03 [95% CI: 3.73-9.75]). CONCLUSIONS: Delivery with history of HT is associated with significantly increased rates of SMM, preterm birth, and hospital readmission. These results provide data regarding pregnancy outcomes for use when counseling patients with HT history who are considering pregnancy or who are pregnant.

Seroprevalence and incidence of primary dengue infection and its correlation with fetomaternal prognosis in Western Rajasthan.

Background: Viral hemorrhagic fevers are becoming increasingly common in the tropics and subtropics. Dengue fever is currently the most important arthropod-borne viral disease because of its widespread distribution in more than 100 countries and its potential for extensive outbreaks of life-threatening disease. Material and Methods: This study was a hospital-based cross-sectional study conducted in the Microbiology Laboratory of Maternal and Child Tertiary Care Hospital in Western Rajasthan, India, between January 2021 and December 2021. Institutional Ethical Committee permission was obtained. All patients with clinical suspicion of dengue-like illness (DLI), attending outpatient department (OPD) or inpatient department (IPD), were included in the study after obtaining their written consent. A blood sample was collected, and the Dengue Duo rapid card test was conducted for the detection of nonstructural protein 1 (NS1) antigen and immunoglobulin (Ig) M or IgG antibody estimation. All positive samples were tested for IgM enzyme-linked immunosorbent assay (ELISA) test using MAC-ELISA. Results: Of 250 positive sample, the distribution of cases as per clinical features was as follows: all cases presented with fever (100%) followed by myalgia (24.5%), headache (16.06%), hemorrhagic manifestation (13.25%), rash (8.84%), and bleeding gums (2.01%). Thrombocytopenia was seen in 30.40% (76/250) of dengue fever cases. NS1 antigen was detected in 157 cases (62.80%) followed by IgG in 84 cases (33.60%), IgM in 77 cases (30.80%), NS1+IgG in 27 cases (10.80%), NS1 + IgM in 16 cases (6.40%), and NS1 + IgM + IgG in five cases (2%). Of 250 samples, 77 cases were IgM positive and 173 were IgM negative by the Dengue Duo card test. Among the 173 Dengue Duo IgM card negative, 131 cases (79.39%) were also detected negative by IgM ELISA and 42 cases (49.41%) were detected positive by IgM ELISA. The sensitivity was 50.59%, the specificity was 79.39%, the positive predictive value (PPV) was 55.84%, the negative predictive value (NPV) was 75.72%, and the diagnostic accuracy was 69.90%. The case fatality of the cases was 2.35%. Conclusion: Early diagnosis and treatment can prevent mortality in pediatric and pregnant females suffering from dengue and dengue-like illness. Facility and availability of ELISA kits should be adequate for early confirmation of suspected dengue patients by ELISA test.

A comparative study of vision-related quality of life (VRQoL) among glaucoma and nonglaucoma patients at a tertiary care center of North India.

Purpose: Glaucoma influences vision-related quality of life (VRQoL) of an individual in various ways. There are very limited studies on the Indian population and the northern part of India. Therefore, we conducted the present study to evaluate VRQoL in glaucoma patients as well as the association between the severity of glaucoma and VRQoL. Methods: An institution-based, cross-sectional, analytical study was conducted from August 2022 to October 2022 involving 190 participants (95 glaucoma patients and 95 controls). The glaucoma quality of life-15 (GQL-15) questionnaire was explained in their vernacular language by the interviewer. The scoring was given according to the validated scoring algorithm for the questionnaire. Results: Mean GQL score in the control group was 19.66 ± 5.5 and in glaucoma cases was 32.8 ± 10.2, whereas the mean score of mild glaucoma cases was 22.3 ± 4.83, moderate glaucoma cases was 36.3 ± 4.09, and severe glaucoma cases was 47.24 ± 3.03. Therefore, as the severity of glaucoma increases, the GQL score also increases, indicating poorer quality of life. Visual field loss was strongly positively correlated (correlation coefficient = 0.759, P < 0.01) with the GQL-15 score, while a weaker positive correlation was found with best corrected visual acuity (BCVA), cup disc ratio, and duration of treatment. Conclusion: Besides controlling or reducing intraocular pressure (IOP) to the target level, the goal of glaucoma treatment should be to provide an individual with good functional vision to maintain an acceptable quality of life. It would also help in providing patients with the best possible treatment, not only in terms of good vision but also in maintaining or improving their overall quality of life.

Pattern of Food Allergen Sensitivity Amongst Adult Allergic Rhinitis Patients: A Four Year Central Indian Study.

AIMS: Only limited Indian data is available regarding the food allergy pattern among allergic rhinitis patients in Indian population. This study aims to assess the pattern of food allergen sensitivity amongst allergic rhinitis patients in central India. MATERIAL AND METHODS: A total of 218 subjects with allergic rhinitis were enrolled in the study (from May 2018 to August 2022). Skin prick test was done in all subjects with proper technique and precautions by using 125 common food allergens and 75 aero allergens. The test readings were noted after 20 minutes by comparing the wheals so formed with the negative control of Saline and positive control of Histamine. Any reaction with a wheal diameter of 3mm or greater was considered as positive. RESULTS: While test results of both food and inhalant allergens were issued to individual patients, this study was restricted to detection and analysis of pattern of food allergens. Our study observed male preponderance with predominantly a third decade affliction. The most common food allergen in the study population was beetle nut (29.3%) followed by chilli powder and spinach (28.8% each). CONCLUSION: Along with aeroallergens, food allergens are also important provocateurs of allergic rhinitis. Diagnosing the offending food allergens and its avoidance reduces patient morbidity, need for pharmaceutical agents and subsequently drug dependence and its side effects. Offering subjects a replacement diet with food items of similar taste and nutritive character helps in sustainable avoidance therapy.

Metastatic Renal Cell Carcinoma: An Enigmatic Nasal Mass.

Metastatic Renal Cell Carcinoma rarely presents in head and neck and is even rarer in the sinonasal region. However, a sinonasal metastatic mass is usually of RCC origin. These metastases may present prior to the renal symptoms or may appear after primary treatment. Report a 60-year lady with epistaxis due to metastatic RCC. Calculate total published cases of sino-nasal metastasis of RCC. Classify according to sequence of primary and metastatic presentation. A computer aided search of PubMed and Google scholar databases was done using pertinent combinations of the keywords "renal cell carcinoma", "nose and paranasal sinus", "metastasis", "delayed metastasis" and "unusual presentation", revealing 1350 articles. 38 relevant articles were included in the review. Our case presented with epistaxis 3 years after primary RCC. She had a vascular left sided nasal mass which was excised enblock. Immunohistochemistry confirmed metastatic RCC. She is on oral chemotherapy and asymptomatic 1 year post excision. Literature search revealed 116 such cases. 19 patients presented within 10 years of RCC while 7 more were delayed metastasis. 17 cases presented primarily with nasal symptoms with subsequent incidental renal mass. Chronology of presentation was unavailable in the rest 73 cases. We recommend to consider the diagnosis of sinonasal metastatic RCC in a patient presenting with epistaxis or nasal mass, particularly with a past history of RCC. Also, any person with known diagnosis of RCC should undergo regular ENT examination for early diagnosis of sinonasal metastasis.