Paradoxical Hemodynamic Instability After Pericardial Window.

Paradoxical hemodynamic instability (PHI), also called postoperative low cardiac output syndrome (LCOS), is a rare but fatal complication after drainage of a pericardial effusion (PEf). This condition usually develops within hours postprocedure and appears unrelated to the method of drainage. The exact mechanism of this condition is not well understood. We present a case of an 84-year-old patient with no previous cardiac or cancer history who presented with acute shortness of breath (SOB). Computed tomography (CT) ruled out pulmonary embolism and echocardiography confirmed early tamponade. Following emergent subxiphoid pericardiectomy, the patient developed hemodynamic instability and shock and subsequent multiorgan failure. Repeat echocardiography revealed left ventricular (LV) hypercontractility and new right ventricular (RV) dilatation with akinesis. The patient's condition continued to deteriorate in spite of maximal doses of pressors. The patient died after the family's request to discontinue further extraordinary measures.

Resurgence of hypertension and cardiovascular diseases in patients recovered from COVID-19: An Indian perspective.

Objective: The aim of this study was to understand the prevalence, extent, clinical approach of hypertension and cardiovascular disease (CVD) in patients recovered from COVID-19. Methods: The round table meetings (RTMs) and survey convened a diverse panel of specialists including cardiologists, endocrinologists, diabetologists, consultant physicians, and family physicians from various geographical zones of India. A standard questionnaire including 10 questions was developed pertaining to the resurgence of hypertension and CVD in patients recovered from COVID-19. The RTMs and survey were held virtually. The collected opinions and recommendations were compiled to derive a consensus document. Results: A total of 3066 health-care practitioners (HCPs) participated. Hypertension was the most prevalent comorbidity in patients recovered from COVID-19 followed by diabetes, dyslipidemia, and coronary artery disease. Almost two-thirds of HCPs reported that 10%-30% newly diagnosed hypertension in patients recovered from COVID-19. Uncontrolled hypertension in 10-20% of COVID-19 recovered patients opined by 45% of the HCPs. About, 35% HCPs reported CV complications in 10-20% of Covid-19 recovered patients and 63% HCPs reported exacerbations of CAD in 10-30% of patients. Majority of HCPs preferred to switch to dual combination therapy from monotherapy for hypertension management (52.0%) and ARBs and its combination is most preferred combination for hypertension control (60%). Majority of the HCPs suggested follow-up after 1-2 weeks (39.0%). Close monitoring on symptoms including chest pain and breathlessness (45.0%), adherence to medication and regular monitoring of lab parameters (25%) is recommended for these patients. Conclusion: Overall observations indicate an increased incidence of hypertension and CVDs post recovery from COVID-19. A dual therapy of ARBs was the preferred choice for management of hypertension. Regular follow-up and close monitoring of symptoms to prevent further CV complications in COVID-19 recovered patients is recommended.

The Relative Survival Impact of Guideline-Concordant Clinical Staging and Stage-Appropriate Treatment of Potentially Curable Non-Small Cell Lung Cancer.

BACKGROUND: Lung cancer management guidelines strive to improve outcomes. Theoretically, thorough staging promotes optimal treatment selection. We examined the association between guideline-concordant invasive mediastinal nodal staging, guideline-concordant treatment, and non-small cell lung cancer survival. RESEARCH QUESTION: What is the current practice of invasive mediastinal nodal staging for patients with lung cancer in a structured multidisciplinary care environment? Is guideline-concordant staging associated with guideline-concordant treatment? How do they relate to survival? STUDY DESIGN AND METHODS: We evaluated patients with nonmetastatic non-small cell lung cancer diagnosed from 2014 through 2019 in the Multidisciplinary Thoracic Oncology Program of the Baptist Cancer Center, Memphis, Tennessee. We examined patterns of mediastinal nodal staging and stage-stratified treatment, grouping patients into cohorts with guideline-concordant staging alone, guideline-concordant treatment alone, both, or neither. We evaluated overall survival with Kaplan-Meier curves and Cox proportional hazards models. RESULTS: Of 882 patients, 456 (52%) received any invasive mediastinal staging. Seventy-four percent received guideline-concordant staging; guideline-discordant staging decreased from 34% in 2014 to 18% in 2019 (P < .0001). Recipients of guideline-concordant staging were more likely to receive guideline-concordant treatment (83% vs 66%; P < .0001). Sixty-one percent received both guideline-concordant invasive mediastinal staging and guideline-concordant treatment; 13% received guideline-concordant staging alone; 17% received guideline-concordant treatment alone; and 9% received neither. Survival was greatest in patients who received both (adjusted hazard ratio [aHR], 0.41; 95% CI, 0.26-0.63), followed by those who received guideline-concordant treatment alone (aHR, 0.60; 95% CI, 0.36-0.99), and those who received guideline-concordant staging alone (aHR, 0.64; 95% CI, 0.37-1.09) compared with neither (P < .0001, log-rank test). INTERPRETATION: Levels of guideline-concordant staging were high, were rising, and were associated with guideline-concordant treatment selection in this multidisciplinary care cohort. Guideline-concordant staging and guideline-concordant treatment were complementary in their association with improved survival, supporting the connection between these two processes and lung cancer outcomes.

Incretins and thiazolidinediones in glucose homeostasis and cancer: role of common polymorphisms.

With growing epidemiologic and molecular evidence linking the pathogenesis of diabetes mellitus and oncogenesis, the role of anti-diabetic drugs as antineoplastic agents becomes a subject of intense investigation. Several trials are underway assessing the effect of adding metformin to the existing chemotherapy regimen in the treatment of cancers. This review has a focus on other commonly used drugs classified into two broad groups, incretins and thiazolidinediones. The aim of this review is to discuss the common genetic polymorphisms implicated in the pathogenesis of type 2 diabetes mellitus (type 2 DM) and how they are linked to molecular pathways involved in carcinogenesis.

Renal abscess after the Fontan procedure: a case report.

INTRODUCTION: The Fontan procedure is an intervention that helps to correct single ventricle physiology. There are many known long-term complications of 'Fontan physiology'. However, the occurrence of renal abscess in such patients has not yet been reported in the literature. The first generation of adults has now undergone the procedure and it is necessary to be aware of the long-term outcomes and complications associated with it. CASE PRESENTATION: We report the case of a 22-year-old South Indian man who had developed a staphylococcal renal abscess against a background of xanthogranulomatous pyelonephritis, nine years after Fontan surgery. He presented to our hospital with a high-grade fever of 25-days duration but with no other symptoms. Physical examination identified costovertebral angle tenderness and pedal edema. An ultrasound scan revealed a mass in his left kidney. The results of a computed tomography scan were consistent with a renal abscess. Despite treatment with the appropriate parenteral antibiotics, there was no change in the size of the abscess and a left nephrectomy was performed as a curative procedure. CONCLUSIONS: The learning points here are manifold. It is important to be aware of the possibility of renal abscess in a post-procedural patient. The early diagnosis of a septic focus in the kidneymay help to prevent the rare outcome of nephrectomy.

Ameliorative effect of caffeic acid against inflammatory pain in rodents.

The present study was designed to evaluate the antinociceptive profile of caffeic acid in mice and rats. Caffeic acid (5-100 mg/kg, p.o.), in a dose dependent manner inhibited acetic acid-induced writhing and late phase of formalin-induced pain in mice, with an ED(50) of 22.38 and 10.92 mg/kg, respectively. However, caffeic acid was ineffective in the hot plate and tail flick tests. Analgesic activity was also examined in carrageenan and lipopolysaccharide (LPS)-induced mechanical hyperalgesia in rats, where locally induced myeloperoxidase (MPO), malondialdehyde (MDA) and nitrite levels in foot pad were estimated by colorimetric assay. Oral administration of caffeic acid (200mg/kg, p.o.) showed analgesic activity similar to nimesulide (4 mg/kg, p.o.) and inhibited MPO, MDA and nitrite generation in the inflamed paw. Histological examination revealed reduction in neutrophil infiltration and protection of tissue damage by caffeic acid. These results suggest that caffeic acid exhibits peripheral analgesic effect in mice and rats and could be further examined for the treatment of chronic painful episodes.

Renal transplantation in the elderly: South Indian experience.

In developing countries, renal transplantation is offered to young end-stage renal disease (ESRD) patients, while the older ones face limitations due to higher mortality risk. We retrospectively analyzed 225 patients who underwent renal transplantation from living donors, aged 40-60 years (Group A) and >60 years (Group B), focusing on their survival outcome. Group A (n = 181) had mean creatinine (mg/dL) 1.41 ± 0.84, 1.30 ± 0.65 and 1.40 ± 0.60 and mean eGFR (mL/min/1.73 m(2)) of 65.32 ± 23.03, 69.14 ± 32.65 and 59.21 ± 22.79 at 0, 3 and 6 months post-transplantation. Death-censored graft survival was 93.1% in first year followed by 91.2% in subsequent 4 years. Patient survival was 92.5% in first year, 90.7% in the next 2 years, and 89.2% in 4th year. Highest cumulative graft survival was 86.7% in the first year with 83.4%, 82.7% and 82.4% during the subsequent 3 years. Group B (n = 44) had mean creatinine (mg/dL) of 1.46 ± 1.02, 1.29 ± 0.23 and 1.2 ± 0.29 with a mean eGFR (mL/min/1.73 m(2)) of 67.90 ± 23.48, 67.02 ± 12.76 and 75.23 ± 15.19 at 0, 3 and 6 months. Highest death-censored graft survival was 97.4% in the first year with 94.7% in next 3 years. Patient survival was 88.1% throughout 4 years post-transplantation. Cumulative graft survival was 84.1% during 4 years. Biopsy-proven acute rejection rate was 28.7% in group A and 15.9% in group B (P = 0.058). There was higher mortality rate in group B with death mainly due to infections and cardiovascular complication. Cardiovascular risk assessment, pre-transplant cancer screening and judicious use of immunosuppressive agents should help minimize adverse events, balanced with an inherently reduced risk of acute rejection, hence the graft survival advantage and is the way forward to maximize patient and renal allograft survival in elderly patients.

A fatal case of meningitis caused by Cryptococcus neoformans var. grubii in an immunocompetent male.

The incidence of cryptococcal infection is high in developing countries such as India. Cryptococcal meningitis is considered rare in immunocompetent patients and is mainly a disease of immunocompromised patients. Prognosis in immunocompetent patients is generally considered good. We report a fatal case of cryptococcal meningitis in an immunocompetent male caused by Cryptococcus neoformans var. grubii. Whether the patient is immunocompromised or immunocompetent, the outcome of the disease can be severe unless the disease is diagnosed early in the course of illness.

Community acquired methicillin-resistant Staphylococcus aureus pneumonia leading to rhabdomyolysis: a case report.

Community-acquired methicillin resistant Staphylococcus aureus (CA-MRSA) is considered an underreported entity in India. In this case report, the authors describe a thirty-five year old immunocompetent male presenting with severe respiratory distress requiring intubation. On further work up, a CT thorax showed features consistent with necrotizing pneumonia. The morphology and sensitivity pattern of the organism found in the bronchoalveolar lavage fluid and blood culture were consistent with MRSA. The patient's stay in the hospital was complicated by acute renal failure due to rhabdomyolysis with CPK levels of 9995 U/L. The patient was started on dialysis and improved there after. This case brings to light that CA-MRSA is becoming a problem in developing nations where antibiotics are frequently used empirically with little laboratory guidance. It also is a rare reporting of rhabdomyolysis due to CA-MRSA.

How to make peritoneal dialysis affordable in developing countries.

Peritoneal dialysis (PD) is an underutilized renal replacement therapy in the developing world. It offers advantages of simplicity, reduced need of training, lack of dependence on infrastructure and location. The population is extremely underserved by healthcare and means to achieve it. PD is unavailable in many African nations. We explore the logistics of PD, domestic manufacture of PD fluid and accessories and ways to sustain it. Realization of local factors, ways to reduce peritonitis, reduced dosage in patients with residual renal function and use of generics to treat anemia that help improve the logistics. The role of national government especially in countries where dialysis is rationed and its lack of involvement leaving the billions to fetch for themselves is discussed. Innovative schemes by private insurers have improved PD outcome locally. These include subsidized once-in-a-lifetime PD treatment payment and industry sponsored nurse and technician visits to patients. Finally, the factors preventing nephrologists in delivering PD such as lack of training, reimbursement, infrastructure and affordability are discussed.