Role of Noninvasive Urinary Prothrombin Fragment 1 + 2 to Measure Blood Coagulation Indices and Dose of Acenocoumarol.

PF1 + 2 plasma levels are a crucial indicator for assessing anticoagulant action in individuals receiving anticoagulant treatment. Urine also has PF1 + 2 levels due to its molecular size. Hence, the present study aims to measure urinary prothrombin fragment 1 + 2 (uPF1 + 2) in patients taking anticoagulants in order to divulge a noninvasive surrogate marker of PT-INR of blood coagulopathy. A total of 205 people participated in the study: 104 patients on acenocoumarol (AC) and 101 healthy controls (HC). Clinical parameters, including PT-INR, urinary creatinine, etc., were measured in all subjects. To evaluate uPF1 + 2 in samples, MALDI-TOF-MS, Western blot analysis, and ELISA tests were used. The MALDI-TOF-MS results showed the presence of uPF1 + 2 in both AC and HC urine samples. The Western blot, ELISA experiment, and unpaired t test results displayed that the patients with AC had significantly increased levels of uPF1 + 2 compared to HC. A regression study showed a strong positive relation between blood-based PT-INR and uPF1 + 2. ROC validation also revealed the clinical efficacy of uPF1 + 2. For the goal to monitor anticoagulant medication, the present study highlights PF1 + 2, which describes the overall hemostatic capacity and might be utilized in addition to or instead of PT-INR.

Bronchial Carcinoid Tumor in an Adolescent Female: Diagnosis and Management by a Multi-Disciplinary Team.

Bronchial carcinoid is the most common primary malignant lung tumor in children; however, it remains a very rare diagnosis due to the overall low incidence of childhood lung malignancies. We report a case of a 17-year-old girl with respiratory symptoms who was initially misdiagnosed as a case of COVID pneumonia. She was later detected to have a right mainstem bronchial carcinoid which was managed successfully by a multi-disciplinary team.

Right ventricular dysfunction in rheumatic heart valve disease: A clinicopathological evaluation.

Background: . Dysfunction of the right ventricle (RV) in rheumatic heart disease (RHD) is a poor prognostic factor. We planned to observe the clinicopathological changes in the RV of patients with RHD. Methods: . We defined RV dysfunction by a myocardial performance index value of >0.4 on transthoracic echo-cardiography and included patients with isolated severe mitral stenosis in sinus rhythm with normal left ventricular (LV) function from April 2014 to April 2016. The patients were divided into two groups based on the absence (group I, n=21) and presence (group II, n=22) of RV dysfunction. RV muscle biopsy was evaluated for the presence of apoptosis, fibrosis and fat deposition apart from other clinical and echocardiography parameters. Results: . Patients in both the groups had a similar demographic profile and LV dimensions and function. The age of the patients in the two groups was the only clinical parameter that was significantly different; older patients were in group II. A higher value for RV systolic pressure (RVSP) and the grade of tricuspid regurgitation was seen in group II. Though there was no significant difference in the presence of fibrosis and intensity of apoptosis in the RV biopsy samples, the deposition of fat in the interstitial spaces was decreased in group II. Age at presentation had no significant difference or correlation with the deposition of fibrosis or fat in the RV myocardial biopsy. Conclusions: . Patients with RV dysfunction were older in age and their RVSP was raised at operation, suggesting that earlier intervention may help in preserving RV function.

Do practice gaps exist in evidence-based medication prescription at hospital discharge in patients undergoing coronary artery bypass surgery & coronary angioplasty?

BACKGROUND & OBJECTIVES: Prescription patterns of guideline-directed medical therapy (GDMT) after coronary artery bypass surgery [coronary artery bypass graft (CABG)] and percutaneous coronary intervention (PCI) at hospital discharge are often not optimal. In view of scarce data from the developing world, a retrospective analysis of medication advice to patients following CABG and PCI was conducted. METHODS: Records of 5948 patients (post-PCI: 5152, post-CABG: 796) who underwent revascularization from 2010 to 2014 at a single tertiary care centre in north India were analyzed. RESULTS: While age and gender distributions were similar, diabetes and stable angina were more frequent in CABG group. Prescription rates for aspirin 100 per cent versus 98.2 per cent were similar, while beta-blockers (BBs, 95.2 vs 90%), statins (98.2 vs 91.6%), angiotensin-converting enzyme inhibitors (89.4 vs 41.4%), nitrates (51.2 vs 1.1%) and calcium channel blockers (6.6 vs 1.6%) were more frequently prescribed following PCI. Despite similar baseline left ventricular ejection fraction (48.1 vs 51.1%), diuretics were prescribed almost universally post-CABG (98.2 vs 10.9%, P<0.001). Nearly all (94.4%) post-CABG patients received a prescription for clopidogrel. Patients undergoing PCI were much more likely to receive higher statin dose; 40-80 mg atorvastatin (72 vs <1%, P<0.001) and a higher dose of BB. INTERPRETATION & CONCLUSIONS: Significant differences in prescription of GDMT between PCI and CABG patients existed at hospital discharge. A substantial proportion of post-CABG patients did not receive BB and/or statins. These patients were also less likely to receive high-dose statin or optimal BB dose and more likely to routinely receive clopidogrel and diuretics. Such deviations from GDMT need to be rectified to improve quality of cardiac care after coronary revascularization.

Evidence of apoptosis in right ventricular dysfunction in rheumatic mitral valve stenosis.

BACKGROUND & OBJECTIVES: Right ventricular (RV) dysfunction is one of the causes of morbidity and mortality in valvular heart disease. The phenomenon of apoptosis, though rare in cardiac muscle may contribute to loss of its function. Role of apoptosis in RV in patients with rheumatic valvular heart disease is investigated in this study. METHODS: Patients with rheumatic mitral valve stenosis formed two groups based on RV systolic pressure (RVSP) as RVSP <40 mmHg (group I, n=9) and RVSP ≥40 mmHg (group II, n=30). Patients having atrial septal defect (ASD) with RVSP <40 mmHg served as control (group III, n=15). Myocardial performance index was assessed for RV function. Real-time polymerase chain reaction was performed on muscle biopsy procured from RV to assess expression of pro-apoptotic genes (Bax, cytochrome c, caspase 3 and Fas) and anti-apoptotic genes (Bcl-2). Apoptosis was confirmed by histopathology and terminal deoxynucleotide-transferase-mediated dUTP nick end labelling. RESULTS: Group II had significant RV dysfunction compared to group I (P=0.05) while caspase 3 (P=0.01) and cytochrome c (P=0.03) were expressed excessively in group I. When group I was compared to group III (control), though there was no difference in RV function, a highly significant expression of pro-apoptotic genes was observed in group I (Bax, P=0.02, cytochrome c=0.001 and caspase 3=0.01). There was a positive correlation between pro-apoptotic genes. Nuclear degeneration was present conforming to apoptosis in valve disease patients (groups I and II) while it was absent in patients with ASD. INTERPRETATION & CONCLUSION: Our findings showed evidence of apoptosis in RV of patients with valvular heart disease. Apoptosis was set early in the course of rheumatic valve disease even with lower RVSP, followed by RV dysfunction; however, expression of pro-apoptotic genes regressed.

A new classification of inferior vena cava thrombus in renal cell carcinoma could define the need for cardiopulmonary or venovenous bypass.

INTRODUCTION: Although the level of inferior vena cava (IVC) thrombus governs the type of surgical approach, there is no consistency in reporting the levels of IVC thrombus in the literature. This prospective study illustrates a simple three-level classification based on the need for clamping hepatoduodenal ligament and venovenous or cardiopulmonary bypass. MATERIALS AND METHODS: Between January 2010 and June 2014, 30 patients of renal mass with renal vein and/or IVC thrombus were treated after classifying the IVC thrombus into three levels on the basis of need for clamping the hepatoduodenal ligament. After excluding renal vein thrombi, level I was described as thrombus located caudal to the hepatic vein. Level II included all retrohepatic, suprahepatic infradiaphragmatic or supradiaphragmatic thrombi reaching till the right atrium. Atrial thrombi were categorized as level III. Level I and II thrombi were managed without venovenous or cardiopulmonary bypass. Level III thrombus required cardiopulmonary bypass. RESULTS: Of 26 patients with thrombus, 13 had level I thrombus. Of eight cases with level II thrombus, three were retrohepatic, three were suprahepatic infradiaphragmatic and two were supradiaphragmatic. All were removed successfully. Of five patients with level III thrombus, three were operated with cardiopulmonary bypass while the remaining two patients were too sick to be taken up for surgery. The median hepatoduodenal ligament clamp time was 10 min. One patient with level II thrombus had transient liver enzyme elevation. CONCLUSION: Renal vein thrombus should not be categorized as level I thrombus. Level II thrombus, irrespective of its relation to the diaphragm, could be managed without venovenous or cardiopulmonary bypass.

CYP4F2 1347 G > A & GGCX 12970 C > G polymorphisms: frequency in north Indians & their effect on dosing of acenocoumarol oral anticoagulant.

BACKGROUND & OBJECTIVES: CYP4F2 and γ-glutamyl carboxylase (GGCX) have small but significant roles in the maintenance dose of coumarinic oral anticoagulants (COAs). CYP4F2 1347 G > A and GGCX 12970 C > G polymorphisms have been used in the pharmacogenetic dosing algorithms of warfarin for Caucasians and Chinese populations. India has a large population with multiple ethnic groups but there are no reports about the frequencies of these polymorphisms in north Indians. In the present study, we aimed to find out the allelic frequencies of CYP4F2 1347 G > A and GGCX 12970 C > G polymorphisms in a north Indian population and relate these to daily maintenance drug dose requirements of COA. METHODS: CYP4F2 1347 G > A and GGCX 12970 C > G polymorphisms were genotyped by polymerase chain reaction - restriction fragment length polymorphism (PCR-RFLP) protocols and Taqman SNP discrimination assays in healthy volunteers (n=102) and patients (n=225) receiving acenocoumarol, an oral anticoagulant, after cardiac valve replacement surgery. RESULTS: In healthy volunteers, the allele frequencies for CYP4F2 1347 G > A and GGCX 12970 C > G were 43.14 and 1.43 per cent, respectively. No significant differences in mean weight normalized doses of acenocoumarol were found for these CYP4F2 and GGCX genotypes. Binary logistic regression analysis revealed no significant association of any of the genotypes or alleles with the dosing phenotypes for both the SNPs. INTERPRETATION & CONCLUSIONS: We report distinct frequencies of CYP4F2 1347 G > A and GGCX 12970 C > G polymorphisms in north Indians but these polymorphisms did not have significant bearing on maintenance dose of acenocoumarol oral anticoagulant in cardiac valve replacement patients.

Differential Release Kinetics of Cardiac Biomarkers in Patients Undergoing Valve Replacement Surgery.

BACKGROUND: Differential release kinetics of cardiac biomarkers including brain natriuretic peptide (BNP), Troponin-I, and CK-MB following valve replacement (VR) are not well characterized. METHODS AND RESULTS: We serially measured these biomarkers 24 hours prior, six hours, 24 hours, 48 hours, and one month following mitral/aortic VR in 100 patients. Baseline BNP, Tn-I, and CK-MB levels were 304.01 pg/mL, 0.03 ng/mL, and 0.99 ng/mL, respectively. While BNP levels decreased at six hours, and then peaked at 24 hours, Tn-I and CK-MB levels increased within six hours and then showed declining trends by 24 hours. While Tn-I and CK-MB levels normalized at one month, 33% patients still had BNP >200 pg/mL. Those with baseline BNP >200 pg/mL more commonly had AF, higher RV systolic pressure, longer inotrope and ventilator duration, and longer mean ICU/hospital stay as compared to those with lower BNP, although echocardiographic left ventricular ejection fraction and Tn-I/CK-MB levels were similar. Inotrope duration >42 hours, ventilation time >29 hours, and ICU stay >4 days was seen in 42% versus 19%, 30% versus 9%, and 33% versus 14%, respectively, in those with BNP >/<200 pg/mL. Baseline BNP had a significant positive correlation with mean inotrope duration, ICU, and hospital stay. Baseline BNP was also a significant predictor of inotrope duration (odds ratio [OR]=5.9, 95% confidence interval [CI]=1.20-29.68, p=0.01) and ventilation time (OR=4.7, 95% CI=1.76-17.21, p=0.02). CONCLUSION: Release kinetics of cardiac biomarkers is significantly different following VR; BNP levels increase following an initial transient decline. Only BNP was a predictor of postoperative variables.

Factors affecting response variables with emphasis on drug release and loading for optimization of liposomes.

Drug delivery through Liposomes has shown tremendous potential in terms of the therapeutic application of nanoparticles. There are several drug-loaded liposomal formulations approved for clinical use that help mitigate harmful effects of life-threatening diseases. Developments in the field of liposomal formulations and drug delivery have made it possible for clinicians and researchers to find therapeutic solutions for complicated medical conditions. A key aspect in the development of drug-loaded liposomes is a careful review of optimization techniques to improve the overall formulation stability and efficacy. Optimization studies help in improving/modulating the various properties of drug-loaded liposomes and are vital for the development of this class of delivery systems. A comprehensive overview of the various process variables and factors involved in the optimization of drug-loaded liposomes is presented in this review. The influence of different independent variables on drug release and loading properties with the application of a statistical experimental design is also explained in this article.

Periodically, liposomes have shown tremendous potential as drug carriers as they are multifunctional nanoparticles with a unique ability to deliver drugs and other therapeutic moieties to target sites in the body. The use of statistical experimental designs and optimization models to develop drug-loaded liposomes is considered the most effective step in formulation development. A careful consideration of various factors and variables in optimizing liposome formulations has been specifically described in this review article. Thorough understanding of different factors that affect drug loading and release in liposomes provides deeper insights in achieving a stable, efficacious drug formulation. There are several new aspects and concepts which need to be explored as part of formulation development and optimization of drug-loaded liposomes and this article hopes to shed light on some important aspects in this scientific journey.

Bilateral Renal Cell Carcinoma in the Horseshoe Kidney With Metastasis in Gallbladder, Pancreas and Duodenum: A Report of a Rare Case and Literature Review.

Horseshoe kidney is the most common renal fusion anomaly and is associated with various complications, ranging from infections to neoplasms. While renal cell carcinoma (RCC) is the most frequent renal neoplasm in adults, its occurrence in a horseshoe kidney is rare, and bilateral involvement is rarer. Furthermore, RCC metastasizing to organs is known and rare sites of metastasis are also documented. The report presents a unique case of bilateral RCC in a horseshoe kidney with synchronous metastasis to the gallbladder, pancreas, and duodenum. This presentation, involving metastasis to these specific organs, is exceedingly uncommon, making it a rarest of rare possibilities. The current case report underscores the importance of vigilant monitoring and comprehensive evaluation in patients with horseshoe kidneys, as they may be predisposed to unusual complications like RCC and rare site metastasis.

Does high dose statin pretreatment affect global strains in patients undergoing valve replacement.

Purpose: To study the effect of rosuvastatin 40 mg (initiated 7 days prior to surgery) in patients undergoing valve replacement (VR) for rheumatic mitral valve disease on left ventricular (LV) strain and biomarker release kinetics. Methods: In this randomized study, cardiac biomarkers viz. troponin I (TnI), Creatine kinase MB (CK-MB), N-terminal pro B-type natriuretic peptide (NTPBNP) were measured before surgery; and 8, 24 and 48 h postoperatively. Global LV (circumferential, global circumferential strain (GCS); longitudinal, GLS; radial, global radial strain (GRS)) strains were measured preoperatively; and 48 h and 30 days postoperatively. Results: Following VR, Global Longitudinal Strain (GLS), Global Circumferential Strain (GCS) and Global Radial Strain (GRS) declined at 48 h in both statin loaded (SL) and non loaded (NL) groups. The %decline in strain was significantly lower in SL group (% change in GLS 35.8% vs 38.8%, GCS 34% vs 44.1%, GRS 45.7% vs 52.6%; p < 0.001).All strain values improved at 30 days with higher improvement in SL group (GLS -15.92 ± 2.00% vs -12.6 ± 1.66%, GCS -15.12 ± 2.93% vs -13.04 ± 2.44%; GRS 22.12 ± 6.85% vs 19.32 ± 6.48%). While TnI, CKMB, NTPBNP increased following surgery, values at 8, 24 and 48 h were lower in the SL vs. NL group. Mean change (baseline to peak biomarker value) was also significantly lower in SL group.The SL group had shorter hospital and Intensive Care Unit (ICU) stay. On Receiver Operating Characteristic Curve (ROC) analysis, baseline GCS ≤ 14% best predicted postoperative 30 day Left Ventricular Ejection Fraction (LVEF) ≤ 50%. Conclusion: Pre-operative high dose rosuvastatin was "cardioprotective" with favorable effect on LV global strain and release kinetics of biomarkers. These cut-offs (described for the first time for rheumatic VR) can be used as prognostic predictors.

Myocardial ischemia-reperfusion injury released cellular fibronectin containing domain A (CFN-EDA): A destructive positive loop amplifying arterial thrombosis formation and exacerbating myocardial reperfusion injury.

Previous research has identified intravascular platelet thrombi in regions affected by myocardial ischemia-reperfusion (MI/R) injury and neighbouring areas. However, the occurrence of arterial thrombosis in the context of MI/R injury remains unexplored. This study utilizes intravital microscopy to investigate carotid artery thrombosis during MI/R injury in rats, establishing a connection with the presence of prothrombotic cellular fibronectin containing extra domain A (CFN-EDA) protein. Additionally, the study examines samples from patients with coronary artery disease (CAD) both before and after coronary artery bypass grafting (CABG). Levels of CFN-EDA significantly increase following MI with further elevation observed following reperfusion of the ischemic myocardium. Thrombotic events, such as thrombus formation and growth, show a significant increase, while the time to complete cessation of blood flow in the carotid artery significantly decreases following MI/R injury induced by ferric chloride. The acute infusion of purified CFN-EDA protein accelerates in-vivo thrombotic events in healthy rats and significantly enhances in-vitro adenosine diphosphate and collagen-induced platelet aggregation. Treatment with anti-CFN-EDA antibodies protected the rat against MI/R injury and significantly improved cardiac function as evidenced by increased end-systolic pressure-volume relationship slope and preload recruitable stroke work compared to control. Similarly, in a human study, plasma CFN-EDA levels were notably elevated in CAD patients undergoing CABG. Post-surgery, these levels continued to rise over time, alongside cardiac injury biomarkers such as cardiac troponin and B-type natriuretic peptide. The study highlights that increased CFN-EDA due to CAD or MI initiates a destructive positive feedback loop by amplifying arterial thrombus formation, potentially exacerbating MI/R injury.

Association of angiotensin I-converting enzyme gene insertion/deletion polymorphism with rheumatic heart disease in Indian population and meta-analysis.

Rheumatic heart disease (RHD) is one of the most severe consequences of rheumatic fever. It has been suggested that angiotensin I-converting enzyme (ACE) may be involved in the increased valvular fibrosis and calcification in the pathogenesis of RHD. We conducted a case-control study to look for association of ACE I/D polymorphism with RHD in Indian population. The study incorporated 300 patients (170 males and 130 females) with RHD, and 200 controls (118 males and 82 females). We also subgrouped RHD patients into mitral valve lesion (MVL) and combined valve lesion (CVL). ACE I/D polymorphism was identified using polymerase chain reaction method. We also performed a meta-analysis of three published studies and the present study (636 RHD cases and 533 controls) to evaluate the association between the ACE I/D polymorphisms and RHD risk. A significant difference in ACE ID and DD genotypes distribution between RHD cases (OR = 1.62, 95% CI = 1.11-2.36 and OR = 2.08, 95% CI = 1.02-4.15, respectively) and corresponding controls was observed. On comparing the ACE genotypes of MVL and CVL subgroups with controls, ID and DD genotypes were also significantly associated with CVL (FDR Pcorr = 0.009, OR = 2.19 and FDR Pcorr = 0.014, OR = 3.29, respectively). Meta-analysis also suggested association of the ACE D allele (FDR Pcorr = 0.036, OR-1.22, 95% CI 1.02-1.45) with RHD. In conclusion, ACE ID and DD genotypes are associated with an increased risk of RHD, particularly CVL. This suggests that the ACE I/D gene polymorphism may play an important role in the pathogenesis of RHD.

Liposomes for drug delivery: review of vesicular composition, factors affecting drug release and drug loading in liposomes.

Liposomes are considered among the most versatile and advanced nanoparticle delivery systems used to target drugs to specific cells and tissues. Structurally, liposomes are sphere-like vesicles of phospholipid molecules that are surrounded by equal number of aqueous compartments. The spherical shell encapsulates an aqueous interior which contains substances such as peptides and proteins, hormones, enzymes, antibiotics, antifungal and anticancer agents. This structural property of liposomes makes it an important nano-carrier for drug delivery. Extrusion is one of the most frequently used technique for preparing monodisperse uni-lamellar liposomes as the technique is used to control vesicle size. The process involves passage of lipid suspension through polycarbonate membrane with a fixed pore size to produce vesicles with a diameter near the pore size of the membrane used in preparing them. An advantage of this technique is that there is no need to remove the organic solvent or detergent from the final preparation. This review focuses on composition of liposome formulation with special emphasis on factors affecting drug release and drug-loading.

Liposomes are among the most effective and multifunctional nanocarriers. However, they possess certain prevalent limitations such as lack of targeting strategies, production challenges and slow overall transition of approved therapies into clinic. Improving drug loading and release capabilities of liposomal drug formulations with efficient delivery optimisation can be the most effective path in designing this class of nanoparticle drugs. Considering the numerous applications of liposomes, the drug delivery research community must utilise these nanocarriers to their maximum potential in an attempt to introduce novel medications against life threatening diseases.

The lytic skeletal lesions: A rare presentation of carcinoma prostate on 18F-fluorodeoxyglucose positron emission tomography/computed tomography.

ABSTRACT: We describe the 18F-fluorodeoxyglucose positron emission tomography/contrast enhanced computed tomography (FDG PET/CECT) images of a 63-year-old male who complained of back pain and was suspected of multiple myeloma based on magnetic resonance imaging. PET/CECT suggested the FDG avid lesion involving prostate, accompanied by multiple lytic skeletal lesions with no evidence to suggest other possible primary site. A bone marrow biopsy suggested a metastatic adenocarcinoma of primary prostatic origin. Post anti-androgen therapy follow-up FDG PET/CT revealed reductions in the metabolic activities and soft tissue components of most of the metastatic skeletal lesions. These images highlight the possible indication of FDG PET/CT in evaluation of prostatic malignancy in era of 68Ga-PSMA.

Primary Mesenchymal Chondrosarcoma of the Mediastinum with Adrenal Metastasis: A Rare Scenario.

Mesenchymal chondrosarcoma (MC) is a rare malignant tumor that represents <3% of all chondrosarcomas. Herein, we describe extraskeletal MC involving the mediastinum in a 24-year-old gentleman with a rare phenomenon of adrenal metastasis.

Flecainide for conversion and maintenance of sinus rhythm after mitral valve replacement in rheumatic atrial fibrillation.

BACKGROUND: Despite successful mitral valve replacement (MVR), many patients remain in AF. Flecainide can be useful in these patients but has not been used because of underlying structural heart disease. METHODS: We assessed oral flecainide for conversion and maintenance of SR in 25 patients of chronic rheumatic AF following MVR (age 34.4 yrs, mean AF duration: 3.6 yrs). Non-converters underwent DC cardioversion at 24 h and 4 weeks. Patients received flecainide and bb/diltiazem at discharge. RESULTS: Single oral dose of Flecainide achieved SR in 6/25 (24%) while 19/25 achieved SR after DCC; at24 h 21/25 (84%) were in SR. With mean flecainide dose (93.10 ± 9.40 mg), successful maintenance of SR at 6 months was seen in 16/23 (69.5%). No significant changes in PR interval, QRS duration or QTc were noted; flecainide was well tolerated. Patients in SR had significantly better functional status, QOL scores and higher LA strain at 6 months (25.25 vs 17.43%, p < .0001). Baseline LA diameter ≤ 61 mm predicted SR at 6 months (sensitivity/specificity 93.7% and 85.71%) while the values for AF duration ≤ 4 years and LA strain > 21% for predicting SR were 87.5/71.43% and 100/85.71% respectively. CONCLUSION: Oral flecainide was safe and effective in post MVR rheumatic AF patients; maintenance of SR was achieved in 76% of initial converters and 64% of overall population, with better LA strain values. More studies are needed to validate these results.

Factors predicting emergency surgery in severe mitral regurgitation following mitral balloon valvotomy.

BACKGROUND AND AIM OF THE STUDY: Acute mitral regurgitation (MR) may cause adverse hemodynamics following mitral balloon valvotomy (MBV). Some patients become severely hemodynamically unstable and require emergency mitral valve replacement (MVR), while others remain relatively stable with medical management. The study aim was to identify factors that would predict severe acute MR leading to severe hemodynamic compromise requiring emergency MVR. METHODS: Between January 2001 and July 2009, a total of 46 patients developed acute severe MR following MBV at the authors' institution. Of these patients, 11 developed severe hemodynamic compromise and required emergency MVR within 6 h of the procedure (group I), while 35 were relatively stable, improved with time, and were discharged with advice to undergo an early MVR (group II). RESULTS: The demographic profile and routine echocardiographic parameters were comparable between the two groups. In group I, the right ventricular systolic pressure (RVSP) before and after MBV was significantly higher, and a significantly higher level of calcium was present in the mitral valve leaflets. Univariate analysis of the RVSP before and after MBV predicted the occurrence of hemodynamic instability leading to emergency MVR. The receiver operating characteristic (ROC) curve for RVSP before and after MBV had a significant area under the curve (0.944, p < 0.005 and 0.940, p < 0.005, respectively). Based on the ROC data, the pre- and post-MBV RVSPs of 76 mmHg and 77 mmHg, respectively, predicted the possibility of emergency MVR, with sensitivities and specificities of 72% and 63%, and 100% and 90%, respectively. CONCLUSION: Patients undergoing MBV with an RVSP >76 mmHg and the presence of non-commissural calcium on the mitral valve leaflet, or those who develop an RVSP of 77 mmHg following the procedure will very likely require emergency MVR.

Long-term performance of untreated fresh autologous pericardium as a valve substitute in pulmonary position.

Background: Pulmonary regurgitation is imminent after transannular patch (TAP). We analyze the long-term performance of untreated autologous pericardium (UAP) as valve substitute at pulmonary position in patients requiring TAP. Material and Methods: This cross-sectional study include patients operated between 2007 and 2012 (n = 92). A sample of 19 patients was selected for this study which had a follow-up of more than 3 years. This includes patients with no TAP (n = 4) and with TAP and valve substitute, a monocusp (n = 11) or a tricuspid valve (n = 4) at neopulmonary annulus. Patients underwent echocardiography for assessment of right ventricle function and 18 fluoro-deoxyglucose PET CT scan for measurements of valve substitute at neopulmonary annulus. The target to blood ratio (TBR) of uptake of glucose by monocusp was measured at the cooptation edge of the neopulmonary valve. Results: The median age of the patients is 14 (9 - 37). RV function is preserved (TAPSE 18.9 (10.6 - 22.8)) at a mean follow-up of 4 years (3-9). The measurements of monocusp shows a shrinkage in height of the cusp by 35.5% (70% - 1.0%) and length by 7% (-44% - +104%). There was less shrinkage observed in patients below 15 years of age. The TBR of monocusp was 0.945 (0.17 - 3.35) with a strong correlation between the TBR values of aortic valve leaflet and monocusp leaflet of same patient. Conclusion: The UAP is functional and successful as a valve substitute at neo pulmonary annulus at long-term follow-up. It has resisted calcification and has shown uptake of glucose in physiological limits.

Routine hematology parameters in COVID-19: A predictor of disease severity and mortality.

Background: Our understanding of the pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is still evolving and is limited for prognostication. The study was performed to predict severity and mortality based on hematology parameters in coronavirus disease (COVID-19). Material and Methods: The study was a single-center retrospective analysis of 240 patients with COVID-19. The hematological parameters were compared between different grades of severity. The receiver operating characteristics (ROC) curve along with the Classification and Regression Trees (CART) methods were used for the analysis. Result: The total leukocyte count, absolute neutrophil count, neutrophil-lymphocyte ratio (NLR), and neutrophil-monocyte ratio (NMR) were increasing along with an increase in severity; while the absolute lymphocyte count and lymphocyte-monocyte ratio (LMR) were decreasing (P < 0.001). For prediction of severity and mortality on admission, the NLR, NMR, and LMR were significant (P < 0.001). The NLR, NMR, and LMR had an area under the receiver operating characteristics curve (AUROC) of 0.86 (95% CI of 0.80-0.91), 0.822 (95% CI of 0.76-0.88), and 0.69 (95% CI of 0.60-0.79), respectively, for severity. While the NLR, NMR, and LMR had an AUROC value of 0.85 (95% CI of 0.79-0.92), 0.83 (95% CI of 0.77-0.89), and 0.67 (95% CI of 0.57-0.78), respectively, for mortality. Conclusion: With the increase in severity there was an increase in the total leukocyte count and absolute neutrophil count while the absolute lymphocyte count decreased. On admission, the cut-off value of NLR >5.2, NMR >12.1, while LMR <2.4 may predict severity and mortality in COVID-19.