Procalcitonin Clearance, CD64, and HLA-DR as Predictors of Outcome in Febrile Neutropenic Children With Lymphoreticular Malignancies.

BACKGROUND: Febrile neutropenia (FN) is a dreaded complication of cancer chemotherapy. There has been a lot of improvement in supportive care in FN that has drastically reduced the infection-related mortality in these patients. The focus now is on reducing infection-related morbidity, healthcare costs and optimizing the quality of life of the child as well as their family during these episodes. In this study, biomarkers were studied as predictors of outcome so that outcome can be predicted earlier, and treatment modified accordingly. OBJECTIVE: To measure procalcitonin levels (at baseline and day 3), procalcitonin clearance, neutrophil CD64 expression levels (at baseline) and monocyte HLA-DR expression levels (at baseline), and their correlation with outcome. SETTING: Tertiary care hospital. STUDY TYPE: Cross-sectional observational study. POPULATION/PARTICIPANTS: Sixty-five episodes of FN in children below 12 years with lymphoreticular malignancies. Children receiving antibacterial and/or antifungal treatment within the last 7 days were excluded from the study. METHODS: The subjects recruited into the study had undergone complete clinical and laboratory evaluation as per hospital protocol. Procalcitonin (day 0 and 3), neutrophil CD64 expression, and monocytic HLA-DR expression levels were measured in these patients. RESULTS: Sixty-five episodes of FN were studied in children with lymphoreticular malignancy. It was found that procalcitonin and HLA-DR are very good markers of outcome, whereas CD64 although a good marker, was inferior to procalcitonin and HLA-DR in predicting outcome. Procalcitonin clearance was found to be superior to single value of procalcitonin. Furthermore, procalcitonin on day 3 was found to be a better predictor of outcome compared with its baseline value. Also, it was found that procalcitonin and HLA-DR had a significant correlation with baseline C-reactive protein levels. CONCLUSIONS: On the basis of the findings of the study we suggest that serial monitoring of procalcitonin levels be used in febrile neutropenic children with cancer. Procalcitonin levels on day 3 alone can be offered in resource poor setting. The role of HLA-DR and CD64 also seems promising and needs to be further explored in larger multicentric studies.

Scaling Hemodialysis Target Dose to Reflect Body Surface Area, Metabolic Activity, and Protein Catabolic Rate: A Prospective, Cross-sectional Study.

BACKGROUND: Women and small men treated by hemodialysis (HD) have reduced survival. This may be due to use of total-body water (V) as the normalizing factor for dialysis dosing. In this study, we explored the equivalent dialysis dose that would be delivered using alternative scaling parameters matching the current recommended minimum Kt/V target of 1.2. STUDY DESIGN: Prospective cross-sectional study. SETTING & PARTICIPANTS: 1,500 HD patients on a thrice-weekly schedule, recruited across 5 different centers. PREDICTORS: Age, sex, weight, race/ethnicity, comorbid condition level, and employment status. OUTCOMES: Kt was estimated by multiplying V by 1.2. Kt/body surface area (BSA), Kt/resting energy expenditure (REE), Kt/total energy expenditure (TEE) and Kt/normalized protein catabolic rate (nPCR) equivalent to a target Kt/V of 1.2 were then estimated by dividing Kt by the respective parameters. MEASUREMENTS: Anthropometry, HD adequacy details, and BSA were obtained by standard procedures. REE was estimated using a novel validated equation. TEE was calculated from physical activity data obtained using the Recent Physical Activity Questionnaire. nPCR was estimated using a standard formula. RESULTS: Mean BSA was 1.87m2; mean REE, 1,545kcal/d; mean TEE, 1,841kcal/d; and mean nPCR, 1.03g/kg/d. For Kt/V of 1.2, there was a wide range of equivalent doses expressed as Kt/BSA, Kt/REE, Kt/TEE, and Kt/nPCR. The mean equivalent dose was lower in women for all 4 parameters (P<0.001). Small men would also receive lower doses compared with larger men. Younger patients, those with low comorbidity, those employed, and those of South Asian race/ethnicity would receive significantly lower dialysis doses with current practice. LIMITATIONS: Cross-sectional study; physical activity data collected by an activity questionnaire. CONCLUSIONS: Current dosing practices may risk underdialysis in women, men of smaller body size, and specific subgroups of patients. Using BSA-, REE-, or TEE-based dialysis prescription would result in higher dose delivery in these patients.

The anesthetic implications of lumbar tattoos.

Lumbar and sacral tattoos are popular amongst all ages. Some physicians are concerned that passing a needle through a pigmented area during lumbar puncture may deposit toxic material into the central nervous system, resulting in late complications. In this review, we highlight the tattooing process with an emphasis on anatomy and physiology of the skin, and the pathophysiology and toxicology of tattoos. We conclude that there is perhaps no evidence yet to suggest that pigment can be transported into the central nervous system from a well healed tattoo. There is insufficient evidence to endorse placement of a needle through a tattoo into the neuraxis before it is completely healed. The Fermi paradox 'absence of evidence is not evidence of absence of effect' still holds in light of emerging evidence that tattoos may be linked to lymphoma.

The Closure of Grade 1 Coronary Perforation by the Snowplow Phenomenon.

We report an extremely rare case of spontaneous closure of grade 1 coronary perforation by the snowplow phenomenon during the revascularization of a subtotal occlusion in the left anterior descending coronary artery. Coronary artery perforation is usually a nightmare during coronary intervention in the cardiac catheterization laboratory. While large coronary perforation requires the deployment of a covered stent, small perforations require heparin reversal, prolonged balloon inflation, deployment of small coils, or gel foam closure. The coronary segment with a small perforation was stented with a drug-eluting stent (DES), which might have resulted in the shifting of the fatty plaque toward the perforation and subsequently sealing the coronary perforation.

Bleeding From Left Atrial Appendage During Atrial Septal Defect Closure Through Right Anterolateral Thoracotomy: An Unusual Complication.

Anterolateral thoracotomy is frequently used for the closure of ostium secundum atrial septal defect (ASD). The cosmetic result has become an important feature. There are various complications of anterolateral thoracotomy like persistent postoperative pain, phrenic nerve injury, atelectasis, and bleeding. We report a case of ASD closure through anterolateral thoracotomy who had bleeding of the left atrial appendage (LAA), which is an unusual and rare complication.

Non-Valvular Atrial Fibrillation in Young Adults in Eastern India: A Clinico-Aetiological Retrospective Analysis in a Tertiary Care Hospital.

BACKGROUND: The development of atrial fibrillation adds a lot to the morbidity and mortality of individual patients. The spectrum of non-valvular atrial fibrillation among young adults is less known. The present observational study aims to analyze the clinical-aetiological spectrum of non-valvular atrial fibrillation among young adults between 18 and 40 years of age. METHODS: A retrospective observational study was carried out to analyze the clinical-aetiological spectrum of non-valvular atrial fibrillation among young adults less than 40 years of age attending the cardiac outpatient department in a tertiary care hospital in Eastern India over a period of two years. Patients with any form of organic valvular heart disease and patients more than 40 years of age were excluded from the study. One hundred and seventeen patients under 40 years of age were analysed with respect to demographic, aetiological, and clinical profiles. RESULTS: Most common aetiologies behind non-valvular atrial fibrillation in young adults (<40 years) were hypertension (40%) and the presence of left ventricular systolic dysfunction (31%). Thyrotoxicosis, obesity, obstructive sleep apnoea, the presence of congenital heart disease, coronary artery disease, myopericarditis, chronic kidney disease, dyselectronemia, diabetes mellitus, and the presence of chronic obstructive pulmonary disease contributed towards the development of non-valvular atrial fibrillation in the young population in less proportion of cases. Most of the cases were symptomatic with palpitation, shortness of breath, or diaphoresis. Less number of cases (17%) had left atrial thrombus which may be due to early clinical attention with the proper therapeutic anticoagulation regimen. CONCLUSIONS: Hypertension and the presence of left ventricular systolic dysfunction contribute to the majority towards the development of non-valvular atrial fibrillation among young adults. Accurate measurement and monitoring of blood pressure among young adults and careful assessment of left ventricular systolic dysfunction with subsequent appropriate management of hypertension and left ventricular systolic dysfunction in young can decrease the burden of non-valvular atrial fibrillation among the young population.

The Rescuing Role of Aggressive Thrombosuction in Elective Coronary Angioplasty.

Thrombosuction plays a controversial role during primary percutaneous intervention (PCI). Landmark trials have demonstrated no additional role of thrombosuction during primary percutaneous intervention towards improving mortality and outcome during primary percutaneous intervention. We describe a rare elective coronary angioplasty where only aggressive thrombosuction (almost 150-200 mL) of blood from the coronary artery established the antegrade coronary flow and saved an octogenarian from impending sudden cardiac death (SCD). The present case describes the promising role of aggressive thrombosuction even during elective coronary intervention when a large dissection ends in acute total thrombotic occlusion of a coronary artery jeopardizing the antegrade coronary perfusion.

A Retrospective Study on Drug and Dietary Patterns in Patients With Severe Rheumatic Valvular Heart Disease in Eastern India.

Background India has a high prevalence of rheumatic valvular heart diseases. Empirical treatment in rheumatic heart disease curtails morbidity and mortality. Less is known about the drug and dietary management of severe rheumatic heart disease at the pretertiary care level, which forms the building stone in the management of rheumatic heart disease. The present study was carried out to evaluate the drug and dietary patterns of patients with severe rheumatic valvular heart disease at a pretertiary care level, which is the backbone of the management of rheumatic heart disease. Methodology This cross-sectional study was carried out in a tertiary care center in Eastern India between May 2020 and May 2022 across 1,264 study subjects. The drug and dietary patterns of the patients with severe rheumatic valvular heart disease during their index visit to the cardiac department were studied and analyzed. Patients aged less than 18 years; patients with mild or moderate rheumatic valvular heart diseases; patients with coexisting end-stage organ disease (chronic liver disease and chronic kidney disease), malignancy, and sepsis; and patients not willing to participate in the study were excluded. Results Most of the patients were on diuretic therapy, and diuretic therapy was overprescribed across the patients with mitral regurgitation, aortic stenosis, and aortic regurgitation. Most of the patients across each spectrum of rheumatic valvular heart disease were lacking the cornerstone therapy such as beta-blockers in mitral stenosis and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in mitral and aortic regurgitation. The recommended injectable benzathine penicillin prophylaxis was prescribed in a very small number of patients (5%), and most of the patients were on oral penicillin prophylaxis (95%) in spite of its reported high failure rate in prophylaxis. Empirical rationale prescriptions in severe rheumatic valvular heart disease were lacking in the pretertiary care level in Eastern India. Conclusion Each spectrum of severe valvular heart disease was lacking the cornerstone therapy such as beta-blockers in mitral stenosis and ACE inhibitors or angiotensin receptor blockers (ARBs) in mitral and aortic regurgitation along with recommended injectable benzathine penicillin prophylaxis. Diuretics and digoxin were overprescribed across the spectrum of rheumatic heart disease. Improvement of this essential gap in the treatment of severe rheumatic heart disease would bring down morbidity and improve mortality in the future.

Statins do not affect mineral metabolism in chronic kidney disease: a retrospective analysis.

It has recently been proposed that statins act as vitamin D analogs in binding the ubiquitously expressed vitamin D receptor, accounting for the perceived pleiotropic effects of statins (a reduction in cancer risk, prevention of organ transplant rejection and autoimmune disease). Chronic kidney disease (CKD) offers a useful test of this hypothesis: serum 25-hydroxyvitamin D levels are insufficient (<75 nmol/l) in as many as 76% of patients with advanced CKD, associated with secondary hyperparathyroidism and reduced bone mineralization. Vitamin D suppresses parathyroid hormone (PTH) secretion in part through its action on the vitamin D receptor. If statins act as vitamin D analogs, they may then be able to suppress PTH secretion in CKD. We examined data on 714 vitamin D analog naïve patients with stage 3-4 CKD. 404 patients were treated with a statin indicated almost exclusively for primary prevention of coronary heart disease, and 310 patients were not. Both groups were similar in characteristics. Statins had no effect on the intact PTH concentration, the percentage of patients achieving K/DOQI PTH targets, or on calcium or phosphate concentrations. In patients with stage 3-4 CKD, statins had no effect on secondary hyperparathyroidism. If the hypothesis contending that statins act as vitamin D analogs to exert pleiotropic effects is true, this is of no clinical benefit in the prevention of secondary hyperparathyroidism in CKD.

Disproportionately high rate of epileptic seizure in patients abusing dextropropoxyphene.

Dextropropoxyphene (DPP), a weak opioid, is often abused as a psychoactive substance. In this retrospective chart review to document, characterize and put in perspective the often-obtained history of epileptic seizures in patients with DPP abuse, we analyzed the case files of all patients with DPP abuse registered in our center (a tertiary-care drug de-addiction clinic in north India) from May 1, 2001 until April 30, 2007 and those with use of other opioids during the same period. Non-drug-related seizures were excluded from analysis. Out of 312 patients with DPP abuse, 63 (20.2%) had epileptic seizures related to DPP use, in contrast to 0.4% -4.2% of other opioid users. The seizures were mostly characterized as generalized tonic-clonic seizures (87.3%), occurring around two hours following a higher-than-usual dose of DPP. Those with seizures had significantly greater duration of DPP use and higher rates of medical comorbidity compared to patients without seizure. Age, duration of use and medical comorbidity were better predictors of seizure than dosage of drug or use of multiple drugs. Thus, DPP-induced epileptic seizures are common (one in five), and much more frequent than seizures in patients using other opioids. The awareness of this phenomenon has implications for diagnosis and management, as well as for drug regulation policy.

Haemodynamic effects of food intake during haemodialysis.

BACKGROUND: There is some doubt whether food intake during haemodialysis (HD) is detrimental to haemodynamic stability. METHODS: We studied 20 stable non-diabetic HD patients during a single session. A standard meal was given 45 min into dialysis. Relative blood volume (RBV), cardiac output (CO), systemic vascular resistance (SVR) and extracellular fluid (ECF) resistance were monitored continuously. Total protein and albumin were measured. RESULTS: There was a significant reduction in RBV after food ingestion (maximum reduction 3.4 +/- 1.1%; p < 0.001). There was no significant change in ECF resistance, heart rate, CO or SVR. Mean arterial pressure was significantly different from pre-food levels 30 min after food (p = 0.04). The rate of change of total protein and albumin concentration was significantly higher immediately after food ingestion. CONCLUSIONS: Food intake during HD caused significant reductions in RBV, possibly related to fluid shifts from intestinal microcirculation to interstitium. CO and SVR remained stable perhaps because of the opposing effects of food ingestion and UF.

Prevalence of depression and its effect on disability in patients with age-related macular degeneration.

AIMS: To estimate depression in patients with age-related macular degeneration (AMD) and study the relationships among depression, visual acuity, and disability. MATERIALS AND METHODS: It was a cross-sectional study with consecutive sampling (n = 53) of patients with AMD aged 50 years and above attending the retina clinic of a tertiary care hospital in North India. Depression, general disability and vision-specific disability were assessed in subjects meeting selection criteria. Assessments were done using the fourth edition of Diagnostic and Statistical Manual of mental disorders (DSM- IV) Geriatric Depression Scale (GDS), Structured Clinical Interview for DSM-IV Axis -I Disorders, Clinical Version (SCID-CV), World Health Organization Disability Assessment Schedule-II (WHODAS-II) and Daily Living Tasks dependent on Vision scale (DLTV). Non-parametric correlation analyses and regression analyses were performed. RESULTS: Out of 53 participants, 26.4% (n = 14) met DSM-IV criteria for the diagnosis of depressive disorder. Depressed patients had significantly greater levels of general and vision-specific disability than non-depressed patients. General disability was predicted better by depression and vision-specific disability than by visual acuity. CONCLUSION: Depression is a major concern in patients with AMD and contributes more to disability than visual impairment.

Ventriculo-peritoneal shunt infection in a patient on hemodialysis.

Sepsis is an important and serious complication in hemodialysis (HD) patients. Here we report on a case of spina bifida with ventriculo-peritoneal (VP) shunt infection who was on HD and underwent at least 5 months of investigations before a source of the infection was found and eventually treated successfully. We believe this to be the first reported case of VP shunt-associated sepsis in a patient on HD.

Indexing dialysis dose for gender, body size and physical activity: Impact on survival.

Current practice basing dialysis dose on urea distribution volume (V) has been questioned. We explored the impact on survival of scaling dialysis dose (Kt) to parameters reflective of metabolic activity. In a multicentre prospective cohort study of 1500 patients on thrice-weekly haemodialysis, body surface area (BSA) and resting energy expenditure (REE) were estimated using validated equations and physical activity by the Recent Physical Activity Questionnaire. Total energy expenditure (TEE) was estimated from REE and physical activity data. Kt was calculated from delivered (single-pool Kt/V)*Watson V. Kt/BSA, Kt/REE and Kt/TEE were then calculated at baseline and 6 monthly during follow-up for 2 years. In adjusted Cox models Kt/TEE, Kt/BSA, Kt/REE, in that order, had lower hazard ratios for death than single-pool Kt/V. On the basis of adjusted survival differences, putative minimum target doses were estimated for Kt/BSA as 27119 ml/m2 and Kt/TEE as 25.79 ml/kcal. We identified spKt/V values equivalent to these estimated targets, ranging from 1.4 to 1.8 in patient groups based on gender, body size and physical activity. For sedentary patients, the minimum target dose was 1.4 for large males, 1.5 for small males and 1.7 for women. For active patients the target was 1.8 irrespective of gender and body-weight. Patients achieving these individualised minimum targets had greater adjusted two-year survival compared to those achieving conventional minimum targets. Metabolic activity related parameters, such as Kt/TEE and Kt/BSA, may have a clinically important role in scaling haemodialysis dose. Using such parameters or their spKt/V equivalents to adjust minimum target doses based on gender, body size and habitual physical activity may have a positive impact on survival.

Ascites due to right atrial myxoma in a haemodialysis patient.

BACKGROUND: Persistent fluid overload in patients on renal replacement therapy despite good dialysis adequacy or obvious cardiac dysfunction should prompt a search for rarer causes. CASE PRESENTATION: We report here a rare cause of persistent peripheral oedema and ascites in a well-dialysed patient. CT scanning revealed a right atrial myxoma that was later confirmed on an echocardiogram. CONCLUSION: Fluid overload states are common in patients on dialysis. Common causes are inadequacy of dialysis and non-compliance. Where aetiology is not easily apparent further investigations into rarer causes should be sought.

Changing patterns of pericardial disease in patients with end-stage renal disease.

Pericarditis can occur in patients with chronic renal failure before initiation of dialysis. It is also described in established dialysis patients. Traditionally, the cause of pericarditis in such settings has been attributed to uremia and/or inadequate dialysis and it is consequently thought that intensifying the dialysis process in such patients could improve outcome. We report here 7 cases of acute pericarditis in patients with end-stage renal disease on renal replacement therapy. Only 3 of the patients gave any history of chest pain, and a pericardial friction rub was only noted in 2. Despite a period of intensive dialysis, none of the patients improved and all required pericardial drainage as the definitive curative procedure. The clinical presentation of acute pericarditis in dialysis patients therefore may be atypical and pericardial drainage should be considered early, as intensive dialysis alone may not lead to resolution.

Peritoneal dialysis catheter removal for acute peritonitis: a retrospective analysis of factors associated with catheter removal and prolonged postoperative hospitalization.

BACKGROUND: Most patients with acute peritoneal dialysis (PD) peritonitis respond to antibiotic therapy, but a significant minority of patients require surgical catheter removal to eradicate the infection. These patients may experience an adverse postsurgical course. METHODS: We retrospectively analyzed 64 episodes of acute peritonitis requiring PD catheter removal in comparison to 426 episodes treated with antibiotics alone. RESULTS: There were no differences between patients who required PD catheter removal and medically treated patients in sex (62% versus 60% men; P > 0.05), PD modality (31% versus 27% automated PD; P > 0.05), time spent on PD therapy (35 versus 26 months; P > 0.05), or cause of end-stage renal failure. Catheter removal was more likely to occur in elderly (mean age, 61 versus 54 years; P = 0.023) and South Asian patients (38% versus 22%; P = 0.020) and after peritonitis caused by Escherichia coli (16% versus 4%; P = 0.0005), Enterobacter species (5% versus 0.7%; P = 0.031), and Pseudomonas species (5% versus 0.7%; P = 0.031). The most significant correlation with requirement for surgical catheter removal was duration of peritonitis (mean, 7.5 versus 2.8 days; P = 1.3 x 10(-6)). Fifty-three percent of catheter removals resulted in postoperative hospitalization longer than 10 days. Delayed discharges were caused by multiple reasons. Compared with discharges within 10 days, prolonged hospitalization was associated with increased age (mean, 64 versus 58 years; P = 0.028) and delay in time to catheter removal (mean, 7.9 versus 5.3 days; P = 0.027). After catheter removal, only 4% of patients successfully returned to maintenance PD therapy. CONCLUSION: Increased age and duration of peritonitis are associated with both requirement for PD catheter removal and prolonged postoperative hospitalization.

Substance-induced psychotic disorders: 13-year data from a de-addiction centre and their clinical implications.

The relationship between substance use and psychotic disorder has been complex. Alcohol, cannabis, amphetamines, hallucinogens, and phencyclidine have been implicated as a causative factor for psychotic disorders. It is important to differentiate substance induced psychotic disorders (SIPDs) from primary psychotic disorders as management of the two conditions is different. There is paucity of research in the area of SIPD particularly from Asia. The present study was a retrospective study and it determines retrospectively the incidence rate and clinical characteristics of the SIPDs over a period of 13 years. The incidence of SIPDs was found to be 1.4% and all the subjects were males. In the present study, only alcohol and cannabis were implicated as causative agents for SIPDs. The most common type of psychosis was schizophrenia like psychosis, being more common in the cannabis group. The other forms of psychosis included delusional type, hallucinatory type and affective psychosis. 20% of the subjects had a change in diagnosis to either schizophrenia or affective psychosis on follow-up. The present study showed that the presentation of SIPDs is similar to the primary psychotic disorder and this has management implication.

Lanthanum associated abnormal liver function tests in two patients on dialysis: a case report.

Lanthanum (La) is a phosphate binder used in patients on dialysis in the UK. As it has only recently been in use, there are no long-term data about safety of this rare metal in human subjects with renal failure on renal replacement therapy. La has not been previously reported to cause any adverse reactions apart from nausea, sickness, dialysis graft occlusion and abdominal pain. We report here La induced abnormal liver function tests in a male and a female patient of 70 and 44 years old each, on peritoneal dialysis (PD) and haemodialysis (HD) respectively, the first report of such an adverse reaction to this agent.

Early intervention in schizophrenia.

Early intervention (EI) programs in schizophrenia and other psychoses are aimed at early detection (ED) of the disease; prevent conversion to manifested psychosis and phase-specific treatment to reduce development of chronic disabilities. EI strategies include targeting people at "high risk" for developing schizophrenia, intervening in prodromal phase of schizophrenia, and reducing the "duration of untreated psychosis" (DUP). Services are delivered by a specialized team and are usually resource intensive. Several strategies like treatment with antipsychotics, family interventions, and cognitive behavior therapy have been tried with modest success in prodromal patients. Significant ethical reservations exist regarding exposing prodromal patients to the stigma of labeling as "high risk for schizophrenia" and side effects of psychotropics in the absence of clear evidence of efficacy in favor of ED, intervention by specialist teams, and phase-specific interventions in prodrome of psychosis. More research is warranted to demonstrate the risk-benefit and cost-benefit of such interventions before these can be routinely recommended.