Mixed cryoglobulinaemia vasculitis secondary to marginal zone lymphoma in a patient with end-stage renal failure on haemodialysis.

Cryoglobulinaemia vasculitis can present with a variety of symptoms and there is limited data on the incidence and presentation of cryoglobulinaemia vasculitis in haemodialysis patients. We report a case of a 63-year-old male who had a series of presentations with rash, visual changes, abdominal pain, weight loss, fevers and digital ischaemia. This is on a background of a congenital single kidney with end-stage renal failure secondary to diabetes and hypertension, receiving haemodialysis for nearly 5 years. He initially experienced a leukocytoclastic vasculitis rash confirmed on skin biopsy, followed by multiple hospital presentations for undifferentiated abdominal pain and fever of unknown source. Jejunal biopsy revealed intestinal vasculitis. His peripheral blood flow cytometry and bone marrow biopsy were consistent with marginal zone lymphoma (indolent subtype, IgM kappa clone). Further testing revealed a type II cryoglobulinaemia consisting of an IgM kappa monoclonal band with polyclonal IgG (cryocrit 5%). A diagnosis of cryoglobulinaemia vasculitis was established and he was treated with pulsed methylprednisolone and rituximab therapy. However, after receiving three doses of rituximab the patient developed a presumed vasculitis-associated pulmonary haemorrhage for which he received treatment with five sessions of plasma exchange. His symptoms resolved and cryocrit reduced to < 1% after his final dose of rituximab. The clinical features of cryoglobulinaemia may be difficult to detect in chronic haemodialysis patients and vigilance is required.

Next-Generation Sequencing Highlights of Diffuse Large B-cell Lymphoma in a Tertiary Care Hospital in North India.

INTRODUCTION: Next-generation sequencing (NGS) elucidates the diffuse large B-cell lymphoma (DLBCL) genetic characteristics by finding recurrent and novel somatic mutations. This observational study attempted to create an NGS panel with a focus on identifying novel somatic mutations which could have potential clinical and therapeutic implications. This panel was created to look for mutations in 133 genes chosen on basis of a literature review and it was used to sequence the tumor DNA of 20 DLBCL patients after a centralized histopathologic review. METHODS: The study included 20 patients having DLBCL. The quality and quantity of tumor cells were accessed by H&E staining and correlated with histopathology and Immunohistochemistry (IHC) status. Patients were grouped as ABC (activated B-cell), PMBL (primary mediastinal large B-cell lymphoma), and other or unclassified subtypes. The lymphoma panel of 133 was designed on targeted sequencing of multiple genes for the coding regions through NGS. The libraries were prepared and sequenced using the Illumina platform. The alignment of obtained sequences was performed using Burrows-Wheeler Aligner and identification of somatic mutations was done using LoFreq (version 2) variant caller. The mutations were annotated using an annotation pipeline (VariMAT). Previously published literature and databases were used for the annotation of clinically relevant mutations. The common variants were filtered for reporting based on the presence in various population databases (1000G, ExAC, EVS, 1000Japanese, dbSNP, UK10K, MedVarDb). A custom read-depth-based algorithm was used to determine CNV (Copy Number Variants) from targeted sequencing experiments. Rare CNVs were detected using a comparison of the test data read-depths with the matched reference dataset. Reportable mutations were prioritized and prepared based on AMP-ASCO-CAP (Association for Molecular Pathology-American Society of Clinical Oncology-College of American Pathologists), WHO guidelines, and also based on annotation metrics from OncoMD (a knowledge base of genomic alterations). RESULTS: The informativity of the panel was 95 percent. NOTCH 1 was the most frequently mutated gene in 16.1% of patients followed by 12.9% who had ARID1A mutations. MYD88 and TP53 mutations were detected in 9.6% of the patient while 6.4% of patients had CSF3R mutations. NOTCH 1 and TP 53 are the most frequently reported gene in the middle age group (40-60). Mutation in MYD88 is reported in every age group. MYD88 (51%) is the most common mutation in ABC subtypes of DLBCL, followed by NOTCH 1 (44%) and SOCS 1 (33%) according to our findings. NOTCH 1 mutations are frequent in ABC and PMBL subtypes. Closer investigation reveals missense mutation is the most frequent mutation observed in the total cohort targeting 68.4% followed by frameshift deletion reported in 26.3%. Six novel variants have been discovered in this study. CONCLUSIONS: This study demonstrates the high yield of information in DLBCL using the NGS Lymphoma panel. Results also highlight the molecular heterogeneity of DLBCL subtypes which indicates the need for further studies to make the results of the NGS more clinically relevant.

Hepatic Plasmacytoma With DEL13q14 Positive on Fluorescent In Situ Hybridization (FISH) on Tissue Biopsy.

A 40-year-old male presented with abdominal distension and dyspnea. On evaluation found to have hepatic plasmacytoma without marrow clonal plasma cells. Fluorescent in situ hybridization (FISH) on tissue biopsy revealed myeloma-defining cytogenetics. After treating with novel agents, the patient had a complete response to therapy.

Prescribed Water Intake in Autosomal Dominant Polycystic Kidney Disease.

BACKGROUND: Arginine vasopressin promotes kidney cyst growth in autosomal dominant polycystic kidney disease (ADPKD). Increased water intake reduces arginine vasopressin and urine osmolality and may slow kidney cyst growth. METHODS: In this randomized controlled 3-year clinical trial, we randomly assigned adults with ADPKD who had a height-corrected total kidney volume in Mayo imaging subclass categories 1B to 1E and an estimated glomerular filtration rate of 30 ml/min/1.73 m2 or greater to (1) water intake prescribed to reduce 24-hour urine osmolality to 270 mOsmol/kg or less or (2) ad libitum water intake irrespective of 24-hour urine osmolality. The primary end point was the percentage annualized rate of change in height-corrected total kidney volume. RESULTS: A total of 184 patients participated in either the ad libitum water intake group (n=92) or the prescribed water intake group (n=92). Over 3 years, there was no difference in the annualized rate of change in height-corrected total kidney volume between the ad libitum (7.8% per year; 95% confidence interval [CI], 6.6 to 9.0) and prescribed (6.8% per year; 95% CI, 5.8 to 7.7) water intake groups (mean difference, −0.97% per year; 95% CI, −2.37 to 0.44; P=0.18). The difference in mean 24-hour urine osmolality between the ad libitum and prescribed water intake groups was −91 mOsmol/kg (95% CI, −127 to −54 mOsmol/kg), with 52.3% of patients achieving adherence to the target 24-hour urine osmolality and no reduction in serum copeptin over 3 years. The frequency of adverse events was similar between groups. CONCLUSIONS: For patients with ADPKD, prescribed water intake was not associated with excess adverse events and achieved the target 24-hour urine osmolality for half of the patients but did not reduce copeptin or slow the growth of total kidney volume over 3 years compared with ad libitum water intake. (Funded by the National Health and Medical Research Council of Australia [grant GNT1138533], Danone Research, PKD Australia, the University of Sydney, and the Westmead Medical Research Foundation; Australian New Zealand Clinical Trials Registry number, ACTRN12614001216606).

Surgical outcome of full-thickness macular hole secondary to tractional retinal detachment in proliferative diabetic retinopathy.

PURPOSE: To evaluate the surgical outcome of full-thickness macular hole (FTMH) secondary to active fibrovascular proliferation (FVP) and tractional retinal detachment (TRD) in eyes with proliferative diabetic retinopathy (PDR), and factors influencing the outcome. METHODS: This retrospective study included the patients who underwent vitrectomy for FTMH secondary to PDR TRD from 2016 to 2020. Anatomical and visual outcomes were analyzed after six months along with the factors predicting the final outcome and duration of subretinal fluid (SRF) resolution. RESULTS: Group A (macula-off combined RD, i.e., tractional and rhegmatogenous) included 10 eyes, while group B (macula-threatening TRD) included eight eyes. The mean best-corrected visual acuity improved from logMAR 1.21 (Snellen equivalent: 20/324) to logMAR 0.76 (Snellen equivalent: 20/115) (P = 0.008). Seventeen patients gained ≥1 line(s) of vision. Mean visual gain in groups A and B was 3.7 ± 1.9 and 1.9 ± 1.1 lines, respectively (P = 0.051). MH closed in 88.9% eyes. Type 1 anatomical closure was achieved in 88.9% of eyes. At 6 months, SRF and central macular thickness reduced from 479.6 ± 512.5 µm to 11.4 ± 23.5 µm (P = 0.002) and 874.3 ± 422.6 µm to 207.6 ± 81.7 µm (P = 0.0002), respectively. Finally, macular SRF resolved in all the patients. The mean duration for complete SRF resolution was 4.9 ± 3.2 months. Eyes with a shorter duration of diabetes mellitus (rho = -0.49, P = 0.040) and macula-off combined RD (P = 0.048) took a longer time for complete SRF resolution. CONCLUSION: Good anatomical and visual outcomes can be achieved in eyes with PDR TRD-associated FTMH. The residual macular SRF resolves slowly after the surgery and extra intervention is not required. Macula-off combined RD is associated with worse outcome and a slower SRF resolution rate.

Evaluation of retinal functional changes after macular hole surgery using heavy brilliant blue G dye for internal limiting membrane staining: A prospective, single blind, randomized controlled trial.

PURPOSE: To evaluate retinal functional changes after idiopathic macular hole (MH) surgery using heavy brilliant blue G (hBBG) dye for internal limiting membrane (ILM) staining. METHODS: Forty-four eyes with idiopathic MH were randomized into two groups - 24 eyes undergoing vitrectomy with ILM peeling using hBBG staining and 20 eyes without staining; anatomical and functional status (with microperimetry (MP)) at baseline and during postoperative follow-up were noted and compared. RESULTS: All eyes had closure of MH postoperatively and overall baseline MP indices (average threshold, AT; foveal sensitivity, FS) improved significantly at 6 weeks and 6 months of follow-up. AT and FS showed significant improvement at 6 weeks and 6 months from baseline in both individual groups (P < 0.001). Intergroup comparison showed that there was no statistically significant difference in AT and FS values at any point of time (baseline, 6 weeks, 6 months) between staining and no-stain group. No eyes in our cohort had any unexplained visual loss. CONCLUSION: Functional parameters of macula improved significantly after successful MH surgery using hBBG for staining the ILM.

Clinico-demographic profile and outcomes of 25-gauge vitrectomy in advanced stage 5 retinopathy of prematurity.

BACKGROUND: Stage 5 retinopathy of prematurity is a difficult condition to treat despite technological advances in vitreous surgery. METHODS: A retrospective chart review of all consecutive cases of stage 5 ROP was performed between December 2016 and December 2018, and 21 babies were included for assessment of surgical outcomes using a modified vitrectomy technique. Data extracted from documents included demography, ROP screening status, preoperative prophylactic therapy, clinical presentation, surgery performed, and postsurgical outcomes. RESULTS: Out of the 21 babies, ophthalmologist screening was done in 42.9%. Mean birth weight was 1185 ± 222.4 g with a mean gestational age of 29.86 ± 2.0 weeks and mean post-menstrual age of 44.55 ± 9.82 weeks. Lesser than stage 5 disease was seen in 16.7% of eyes and they were managed accordingly. Seventy percent of babies had bilateral disease. 21 eyes underwent 25-gauge pars plicata vitrectomy using a modified technique. After an average follow-up duration of 6.33 ± 2.18 months, the final macular attachment rate was 19%. Anteriorly closed-posteriorly closed type configuration of retinal detachments had a poorer outcome. Fix and follow visual acuity was achieved in 23.8% of eyes, while 57.1% of eyes had a perception of light. CONCLUSIONS: Management of stage 5 ROP is mostly surgical; however, the risk of ending up with a poor vision or vision loss is high, irrespective of whether surgery is performed. The modified surgical technique with a spacer described in this study may help in better manipulation of instruments inside the vitreous cavity.

Ten-year trends in the incidence, clinical profile and outcomes of acute-onset endophthalmitis following combined pars plana vitrectomy and sutureless, glueless and flapless scleral fixation of intraocular lenses.

PURPOSE: To evaluate the frequency and outcomes of acute-onset endophthalmitis following combined pars plana vitrectomy and scleral fixation of intraocular lens. METHODS: We evaluated patients undergoing a sutureless, glueless, flapless technique of scleral fixation of intraocular lenses (SFIOL) implantation for various causes of aphakia and documented the clinico-demographic data, microbiological profile and final outcome after acute endophthalmitis in this cohort of eyes. RESULTS: The frequency of suspected acute endophthalmitis diagnosed post-surgery was 0.112% (4/3541 eyes), with culture-positive endophthalmitis frequency being 0.028% (1 eye), showing growth of Pseudomonas aeruginosa. Mean age of patients with endophthalmitis was 51.75 ± 9.28 years, and mean interval between surgery and acute endophthalmitis presentation was 10.25 ± 9.6 days. Patients were managed with intravitreal antibiotics with or without core vitrectomy. Visual acuity of patients increased from baseline 1.43 ± 0.32 logMAR (Snellen equivalent = 6/150) to 0.79 ± 0.16 logMAR (Snellen equivalent = 6/36) after an average follow-up of 11 ± 2 weeks. CONCLUSION: Endophthalmitis is a rare complication following SFIOL surgery, and all ophthalmic surgeons must be aware of this inadvertent possibility, since SFIOLs are gaining wider acceptability recently. Moreover, these cases of endophthalmitis may show a different pattern of microorganisms than post-cataract surgery endophthalmitis; however, with prompt diagnosis and effective timely management, favorable outcomes can be achieved.

Two-staged surgery as an alternative to buckle-vitrectomy for rhegmatogenous retinal detachment complicated by choroidal detachment.

AIM: To evaluate the outcome and safety profile of short-term perfluorocarbon liquids (PFCL) tamponade in comparison with buckle-vitrectomy in case of rhegmatogenous retinal detachment (RRD) associated with choroidal detachment (CD). METHODS: Records of patients who underwent surgery for RRD/CD from January 2016 to July 2019 were reviewed retrospectively. The patients were allocated into two groups-group 1 patients underwent buckle-vitrectomy, while those in group 2 underwent a two-staged vitrectomy with short-term (5 days) PFCL tamponade. RESULTS: The study included 33 eyes (33 patients) with mean age of 50.3 ± 17.2 years. Group 1 included 15 patients, while group 2 included 18. The pre-operative characteristics were similar in both the groups. The mean pre-operative intraocular pressure in group 1 and 2 was 9.1 ± 4.0 and 8.6 ± 5.2 mmHg, respectively (p = 0.755). Retinal re-attachment after single surgery was achieved in 10 (66.7%) and 14 eyes (77.8%), respectively. All the eyes achieved retinal re-attachment after repeat surgery in both the groups (1.40 vs 1.39 surgeries, p = 0.963). Post-surgery visual improvement was seen in 13 (86.7%) and 17 eyes (94.4%), respectively (p = 0.579). Final visual acuity of ≥ 6/60 was obtained in 7 (46.7%) and 9 eyes (50.0%), respectively (p > 0.999). None of the patients needed retinectomy during repeat surgery. None of the patients experienced exaggerated inflammation or intractable raised IOP spike which could not be controlled with medications. CONCLUSION: Surgical outcomes were similar in both the groups. No clinically apparent toxicity was seen with post-operative short-term PFCL tamponade. Two-staged surgery is a good alternative to buckle-vitrectomy for eyes with RRD associated with CD.

Nodular posterior scleritis - The great masquerader.

We aim to report the management of a patient who presented with a choroidal mass masquerading as an amelanotic choroidal melanoma. A 57-year-old male presented with defective vision in his right eye, which was associated with mild periocular pain. Fundus examination showed a large dome-shaped yellowish-orange subretinal mass in the macular region and exudative retinal detachment (RD). Magnetic resonance imaging (MRI) showed a 16 mm × 8 mm choroidal mass, which was hyperintense on T1-weighted images and hypointense on T2-weighted images. B-scan ultrasonography revealed a dome-shaped mass with homogeneous echogenicity, inferior RD, and fluid collection in the sub-Tenon space. There was no choroidal excavation. He was diagnosed as nodular posterior scleritis (NPS) with exudative RD in the right eye. The lesion regressed completely after treatment with oral steroids. Choroidal mass can pose a diagnostic dilemma to ophthalmologists. Atypical MRI features can further augment the confusion. Despite its low incidence, NPS should always be kept as a differential in the presence of an amelanotic choroidal mass.

Preoperative COVID-19 testing for elective vitreoretinal surgeries: Experience from a major tertiary care institute in South India.

PURPOSE: To study the prevalence of asymptomatic SARS-CoV-2 virus infection (COVID-19) among patients undergoing elective vitreoretinal surgeries at a tertiary care eye hospital. METHODS: This cross-sectional, observational study was performed between July 16, 2020 and August 31, 2020, in the retina clinic of a tertiary care eye hospital in south India. All patients undergoing elective retinal surgical procedures underwent RT-PCR testing for SARS-CoV-2 before being posted for surgery and after obtaining informed consent. Patients planned for surgery under general anesthesia underwent additional computed tomography of the chest. Testing strategies and outcomes were documented. RESULTS: Out of a total of 413 patients who were given appointments for surgery during this period, nine patients (2.2%) were found to have positive RT-PCR for SARS-CoV-2, and their surgeries were postponed. The test positivity (prevalence) rate of asymptomatic COVID-19 infection among all elective vitreoretinal surgical patients in our hospital was 2.2%. None of the patients were symptomatic for COVID-19. CONCLUSION: Our results showed that among patients visiting high volume ophthalmic centers in the near future, approximately 1 in 45 patients may be asymptomatic, SARS-CoV-2 RT-PCR positive. Asymptomatic COVID-19 patients may lead to chances of transmission of the virus inside healthcare facilities among other visiting patients and healthcare workers.

Incidence and management of rhegmatogenous retinal detachment after pars plana vitrectomy and sutureless scleral-fixated intraocular lens.

Purpose: To evaluate the incidence, risk factor(s), and surgical outcomes of rhegmatogenous retinal detachment (RRD) in patients undergoing pars plana vitrectomy (PPV) with sutureless scleral-fixated intraocular lens implantation (SFIOL). Methods: Records of patients (1311 eyes, 1234 patients) who underwent PPV and sutureless SFIOL from 2017 to 2018 were retrospectively analyzed. Results: The indications SFIOL were subluxated lens (33.7%), dislocated IOL (21.7%), surgical aphakia (20.1%), congenital lens subluxation (11.1%), nucleus drop (6.9%), and post-open globe injury (OGI) repair (6.5%). History of closed-globe injury (CGI) was present in 27.2% eyes.Twenty-two eyes (1.7%) developed RRD. The incidence of RRD in eyes, which underwent SFIOL surgery for subluxated lens, dislocated IOL, surgical aphakia, congenital lens subluxation, nucleus drop, and post-OGI repair was 1.4% (n = 6), 2.5% (n = 7), 1.1% (n = 3), 3.4% (n = 5), 0 and 1.2% (n = 1), respectively (P = 0.382). The incidence of RRD in eyes with and without CGI was 1.7% each (P = 0.996).Twenty-one eyes underwent RD surgery. Retinal reattachment was achieved in 76.2% eyes, while 66.7% eyes required only one surgery. The eyes in which retina failed to reattach had a high grade of proliferative vitreoretinopathy present at the time of presentation. Final best-corrected visual acuity of ≥20/60 and <20/60 to ≥20/200 and <20/200 was seen in 38.1%, 19.0%, and 42.9% eyes. Conclusion: Eyes with the congenital subluxated lens are at a marginally higher risk of developing post-SFIOL RRD. The surgical outcome of RD surgery in these eyes is good.

Clinical presentation and prognostic factors affecting surgical outcomes of secondary macular holes after retinal vein occlusions.

PURPOSE: To describe clinical presentation, morphological features and surgical outcomes of macular hole (MH) secondary to retinal vein occlusion (RVO). METHOD: This prospective interventional study evaluated eight eyes with atypical MH (secondary to RVO) and data regarding medical management, pars plana vitrectomy, postoperative anatomical hole closure, visual acuity improvement, morphological features of hole were noted till the last follow-up. RESULTS: Eight eyes with full-thickness MH in an RVO eye were followed-up for a minimum period of 3 months postoperatively. Five subjects had a RVO episode which occurred more than 6 months before the onset of the recent symptoms (Group 1; 4 branch RVO and 1 central RVO), and 3 subjects had a recent onset branch RVO within 6 months (Group 2). All FTMH cases except one showed closure at the last follow-up. Visual acuity of all eyes improved from 0.91 ± 0.57 logMAR to 0.5 ± 0.3 logMAR (p = 0.093). At baseline, visual acuities of the two groups had no significant difference. Postoperatively, group 1 holes had better visual prognosis, than Group 2 holes, further substantiated by persistence of subretinal fluid in Group 2 eyes till last follow-up. Minimum hole diameter was higher in the recent RVO group, although anatomical closure was obtained in all of these eyes. Most holes had favorable morphological hole features like raised configuration with rounded edges. CONCLUSION: In the presence of favorable morphological features, secondary macular holes associated with retinal vein occlusion may show optimal outcomes after surgery. It is not clear whether acutely created holes in recent onset RVO should be operated early. Older holes may have better prognosis.

Portal venous pulsatility fraction, a novel transesophageal echocardiographic marker for right ventricular dysfunction in cardiac surgical patients.

Background: Right ventricular (RV) has a vital role in maintaining optimal tissue perfusion. Assessment of portal venous flow characteristics can be alternative and emerging technique to assess RV function. Aims: To investigate if portal venous pulsatility fraction (PF) could serve as effective and complementary tool in identifying RV dysfunction. Materials and Methods: Thirty adult patients aged 18-65 years undergoing cardiac surgery under general anesthesia were enrolled in study. Intraoperative transesophageal echocardiographic examination was performed. Tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (FAC), RV ejection fraction (EF), and portal vein flow pulsatility were assessed. Portal vein PF was used to quantify degree of pulsatility. Results: Portal vein was demonstrated in 27 patients (90%). 27 values of portal vein PF, RV EF, FAC, and TAPSE were analyzed. Portal vein PF demonstrated significant linear correlation with TAPSE (r = -0.55, P = 0.003), RV FAC (r = -0.44, P = 0.02), and RV EF (r = -0.53, P = 0.004). ROC curve was constructed to calculate sensitivity and specificity of portal vein PF for assessing RV function. Portal vein PF value of ≥45% indicated RV dysfunction with sensitivity of 92.3%, specificity of 71.4%, positive predictive value of 75%, and negative predictive value of 90.9%. Area under ROC curve was 0.819 (95% confidence interval = 0.624 - 0.939, P = 0.0006). Conclusion: Portal vein PF is simple and feasible method for assessment of RV function. It complements the existing echocardiographic measures to diagnose RV dysfunction.

Sutureless Scleral-Fixated Intraocular Lens Implantation for Refractive Rehabilitation in Eyes With Spherophakia.

Purpose: Spherophakia is a rare, debilitating congenital ocular disorder. Methods: This institution-based, retrospective, interventional study evaluated medical records of 16 patients with spherophakia with a median age of 19.5 years. Twenty-six eyes underwent scleral-fixated intraocular lens implantation. The technique involved 2 parallel-to-limbus scleral tunnels fashioned using a microincision vitrectomy blade, followed by lensectomy, core vitrectomy, externalization of haptics through 2 separate diametrically opposite sclerotomies, and tucking in of the haptics into the tunnels. Anterior and posterior segment examination, visual acuity, and intraocular pressure (IOP) were noted at baseline and final follow-up. Results: Baseline best-corrected visual acuity (BCVA) of all eyes was 0.49 ± 0.51 logarithm of the minimum angle of resolution (logMAR) (Snellen equivalent, 6/18). BCVA of more than 6/60 was present in 28 of 32 (87.5%) eyes, and 13 of 26 (50%) eyes that were operated on had a baseline BCVA of more than 6/18. Postoperative BCVA in 26 eyes improved from 0.43 ± 0.32 logMAR to 0.19 ± 0.21 logMAR (Snellen equivalent, 6/9) (P = .002). Postoperative BCVA was more than 6/18 in 20 of 26 (76.9%) operated-on eyes (P = .046), and all eyes had a final BCVA of more than 6/60. In 20 of 26 (76.9%) eyes, BCVA improved from preoperative status. Postoperatively, spherical equivalent improved from -9.55 ± 5.17 diopters to -0.29 ± 1.45 diopters (P < .001). Apart from 2 patients with Marfan syndrome, 1 with Weill-Marchesani syndrome, and 1 with homocystinuria, the remaining patients had isolated spherophakia. Six eyes presented with an IOP greater than 21 mm Hg, and 50% of these eyes had a final IOP that decreased to less than 15 mm Hg after lensectomy. Conclusions: Lensectomy with pars plana vitrectomy and scleral-fixated intraocular lens is an effective method of refractive rehabilitation for patients with spherophakia presenting with visual disability.

Evaluation of risk scores in predicting perioperative blood transfusions in adult cardiac surgery.

Objective: Allogeneic blood product transfusions are associated with an increased morbidity and mortality risk in cardiac surgery. At present, a few transfusion risk scores have been proposed for cardiac surgery patients. The present study is aimed to develop a new score and to compare with preexisting scores - Transfusion Risk and Clinical Knowledge (TRACK) and Transfusion Risk Understanding Scoring Tool (TRUST) score. Methodology: A total of 1014 adult patients undergoing cardiac surgery were enrolled in the retrospective study. Independent predictors of allogeneic blood transfusions were selected from TRACK and TRUST scores. A predictive score was developed from six variables using logistic regression analysis, and new score was compared to the other existing scores - TRACK and TRUST. Results: The new score had following predictors: age >58 years, weight <63 kg for males and <49 kg for females, gender (female), complex surgery, hemoglobin <13.5 g/dl, and creatinine >1.36 mg/dl. Validation of new score demonstrated an acceptable predictive power (area under the curve [AUC] 0.749) and a good calibration at the Hosmer-Lemeshow test. New score was comparable with TRACK score with P = 0.578 (AUC of TRACK 0.756 and AUC of new score 0.749). There was a significant difference between new score and TRUST score, P = 0.01 (AUC of TRUST 0.72 and AUC of new score 0.749). Conclusion: New score is a simple risk model based on six predictors having a similar accuracy and calibration in predicting the transfusion rate in cardiac surgery as compared to TRACK score.

Efficacy of bilateral pectoralis nerve block for ultrafast tracking and postoperative pain management in cardiac surgery.

BACKGROUND: Good postoperative analgesia in cardiac surgical patients helps in early recovery and ambulation. An alternative to parenteral, paravertebral, and thoracic epidural analgesia can be pectoralis nerve (Pecs) block, which is novel, less invasive regional analgesic technique. AIMS: We hypothesized that Pecs block would provide superior postoperative analgesia for patients undergoing cardiac surgery through midline sternotomy compared to parenteral analgesia. MATERIALS AND METHODS: Forty adult patients between the age groups of 25 and 65 years undergoing coronary artery bypass grafting or valve surgeries through midline sternotomy under general anesthesia were enrolled in the study. Patients were randomly allocated into two groups with 20 in each group. Group 1 patients did not receive Pecs block, whereas Group 2 patients received bilateral Pecs block postoperatively. Patients were extubated once they fulfilled extubation criteria. Ventilator duration was recorded. Patients were interrogated for pain by visual analog scale (VAS) scoring at rest and cough. Inspiratory flow rate was assessed using incentive spirometry. RESULTS: Pecs group patients required lesser duration of ventilator support (P < 0.0001) in comparison to control group. Pain scores at rest and cough were significantly low in Pecs group at 0, 3, 6, 12, and 18 h from extubation (P < 0.05). At 24 h, VAS scores were comparable between two groups. Peak inspiratory flow rates were higher in Pecs group as compared to control group at 0, 3, 6, 12, 18, and 24 h (P < 0.05). Thirty-four episodes of rescue analgesia were given in control group, whereas in Pecs group, there were only four episodes of rescue analgesia. CONCLUSION: Pecs block is technically simple and effective technique and can be used as part of multimodal analgesia in postoperative cardiac surgical patients for better patient comfort and outcome.

Randomised controlled trial to determine the efficacy and safety of prescribed water intake to prevent kidney failure due to autosomal dominant polycystic kidney disease (PREVENT-ADPKD).

INTRODUCTION: Maintaining fluid intake sufficient to reduce arginine vasopressin (AVP) secretion has been hypothesised to slow kidney cyst growth in autosomal dominant polycystic kidney disease (ADPKD). However, evidence to support this as a clinical practice recommendation is of poor quality. The aim of the present study is to determine the long-term efficacy and safety of prescribed water intake to prevent the progression of height-adjusted total kidney volume (ht-TKV) in patients with chronic kidney disease (stages 1-3) due to ADPKD. METHODS AND ANALYSIS: A multicentre, prospective, parallel-group, open-label, randomised controlled trial will be conducted. Patients with ADPKD (n=180; age ≤65 years, estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m2) will be randomised (1:1) to either the control (standard treatment+usual fluid intake) or intervention (standard treatment+prescribed fluid intake) group. Participants in the intervention arm will be prescribed an individualised daily fluid intake to reduce urine osmolality to ≤270 mOsmol/kg, and supported with structured clinic and telephonic dietetic review, self-monitoring of urine-specific gravity, short message service text reminders and internet-based tools. All participants will have 6-monthly follow-up visits, and ht-TKV will be measured by MRI at 0, 18 and 36 months. The primary end point is the annual rate of change in ht-TKV as determined by serial renal MRI in control vs intervention groups, from baseline to 3 years. The secondary end points are differences between the two groups in systemic AVP activity, renal disease (eGFR, blood pressure, renal pain), patient adherence, acceptability and safety. ETHICS AND DISSEMINATION: The trial was approved by the Human Research Ethics Committee, Western Sydney Local Health District. The results will inform clinicians, patients and policy-makers regarding the long-term safety, efficacy and feasibility of prescribed fluid intake as an approach to reduce kidney cyst growth in patients with ADPKD. TRIAL REGISTRATION NUMBER: ANZCTR12614001216606.

Transesophageal Echocardiographic Assessment of Pulmonary Artery-to-Ascending Aorta Ratio for the Detection of Pulmonary Hypertension in Cardiac Surgical Patients.

OBJECTIVE: The objective of the study was to investigate if the main pulmonary artery (mPA)-to-ascending aorta (AscAo), (mPA:AscAo) ratio could serve as a screening tool in identifying pulmonary artery hypertension (PAH). DESIGN: A prospective observational study. SETTING: Tertiary care center, university hospital. PARTICIPANTS: Fifty-four adult patients undergoing off-pump coronary artery bypass grafting surgery (OPCAB). INTERVENTIONS: mPA and AscAo transverse diameters were measured by transesophageal echocardiography (TEE) and the mean pulmonary arterial pressures (mPAP) were recorded simultaneously using a pulmonary artery catheter. MEASUREMENTS AND MAIN RESULTS: mPA:AscAo ratio demonstrated significant linear correlation with mPAP measured by pulmonary artery catheterization (ie, r = 0.61, confidence interval [CI] = 0.5352-0.6736, p < 0.0001). Receiver operating characteristic curves were performed to evaluate sensitivity and specificity of mPA:AscAo ratio ≥1 for diagnosing PAH (mPAP ≥25 mmHg). Area under the curve for mPA:AscAo ratio was 0.91 (95% CI, 0.869-0.936, p < 0.0001), with a sensitivity of 84.27%, specificity of 83.92%, positive-predictive value of 87.6% and negative-predictive value of 81.1% for a mPAP ≥25 mmHg. CONCLUSIONS: The ratio of mPA:AscAo is a simple, reliable, and reproducible method that can be obtained through TEE, which guides the clinician to screen patients with PAH.