Avoidable emergency department visits among palliative care cancer patients: novel insights from Saudi Arabia and the Middle East.

BACKGROUND: Several studies emerging from developed countries have highlighted a significant number of potentially avoidable emergency department (ED) visits by cancer patients during the end-of-life period. However, there is a paucity of information from developing nations regarding palliative care practices and the utilization of the ED by palliative care patients. Herein, we aim to characterize ED admissions among patients receiving palliative care at our tertiary center in Saudi Arabia. METHODS: This is a retrospective, cross-sectional study evaluating ED visits amongst adult patients with advanced cancer who were receiving treatment under the palliative care department. This study took place over a period of 12 months from July 2021 through to July 2022. Three palliative care specialist physicians independently and blindly reviewed each patient's ED visits and determined whether the visit was avoidable or unavoidable. RESULTS: A total of 243 patients were included in the final analysis, of which 189 (78.1%) patients had unavoidable visits and 53 (21.9%) patient visits were classified as avoidable. A significantly higher proportion of breast cancer patients presented with unavoidable admissions (14.3% vs. 3.8%, P = 0.037) compared to other cancer types. The incidence of dyspnea (23.8% vs. 5.7%, P < 0.001) and fevers/chills (23.3% vs. 5.7%, P = 0.005) was significantly higher in patients with unavoidable visits. Patients with avoidable visits had a significantly greater proportion of visits for dehydration (13.2% vs. 2.1%, P = 0.002). Notably, although hospital stay was significantly longer in the unavoidable group (P = 0.045), mortality for palliative care patients-regardless of whether their ED visit was avoidable or unavoidable-was not statistically different (P=-0.069). CONCLUSION: To our knowledge, this is the largest and most comprehensive study from Saudi Arabia and the Middle East providing insights into the utilization of palliative care services in the region and the propensity of advanced cancer patients towards visiting the ED. Future studies ought to explore interventions to reduce the frequency of avoidable ED visits.

Factors Affecting Survival in Severe and Very Severe COPD after Admission in ICUs of Tertiary Care Centers of India (FAST COPD): Study Protocol for a Multicentric Cohort Study.

Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. However, there is a lack of comprehensive data from low- and middle-income countries (LMICs) regarding factors influencing COPD outcomes, particularly in regions where biomass exposure is prevalent. Objective: The Factors Affecting Survival in Severe and Very Severe COPD Patients Admitted to Tertiary Centers of India (FAST) study aims to address this gap by evaluating factors impacting survival and exacerbation rates among COPD patients in LMICs like India, with a specific focus on biomass exposure, clinical phenotypes, and nutritional status in patients admitted to the Intensive Care Unit (ICU). Methods: The FAST study is an observational cohort study conducted in university teaching hospitals across India. The study aims to enroll 1000 COPD patients admitted to the ICU meeting specific inclusion criteria, with follow-up assessments conducted every 6 months over a 2-year period. Data collection includes demographic information, clinical manifestations, laboratory investigations, pulmonary function tests, medications, nutritional status, mental health, and health-related quality of life. Adjudication of exacerbations and mortality will also be undertaken. The FAST study seeks to provide crucial insights into COPD outcomes in LMICs, informing more precise management strategies and mitigating the burden of COPD in these settings. By evaluating factors such as biomass exposure, clinical phenotypes, and nutritional status, the study aims to address key knowledge gaps in COPD research. How to cite this article: Arunachala S, Devapal S, Swamy DSN, Greeshma MV, Ul Hussain I, Siddaiah JB, et al. Factors Affecting Survival in Severe and Very Severe COPD after Admission in ICUs of Tertiary Care Centers of India (FAST COPD): Study Protocol for a Multicentric Cohort Study. Indian J Crit Care Med 2024;28(6):552-560.

Incidental left atrial appendage isolation after catheter ablation of persistent atrial fibrillation: Mechanisms and long-term risk of thromboembolism.

INTRODUCTION: Incidental left atrial appendage (LAA) isolation may occur during radiofrequency ablation of persistent atrial fibrillation (AF). The study aims to describe the mechanisms and long-term thromboembolic risk related to incidental LAA isolation. METHODS: Patients who experienced incidental LAA isolation after AF ablation were included. Culprit sites where ablation resulted in LAA isolation were identified. Thromboembolic risk despite oral anticoagulation (OAC) was compared to that in a propensity-matched control group without LAA isolation. RESULTS: Forty-one patients with LAA isolation, and 82 matched patients without LAA isolation were included. The patient age, ejection fraction, LA diameter, and CHA2 DS2 -VASc score were 64 ± 11 years, 55 ± 12%, 45.0 ± 7 mm and 2.62 ± 1.5, respectively. Culprit sites included the LAA base, mitral isthmus, inferior LA, Bachmann's bundle, coronary sinus, and Marshall vein. After 4.2 ± 3.6 years follow-up, thromboembolism occurred in 7 of 41 patients (17%) with LAA isolation versus 3 of 82 patients (4%) without isolation (log rank p < .009, HR 5.14, 95% CI [1.32-19.94], p = .02). Patients with and without thromboembolism had similar CHA2 DS2 -VASc scores (2.65 ± 1.3 vs. 2.71 ± 0.76, p = .89). Thromboembolism occurred during noncompliance with or temporary discontinuation of OAC in four of the seven patients. CONCLUSIONS: Incidental LAA isolation may occur during ablation of atrial arrhythmias in the vicinity of, or even at sites remote from the appendage. Patients with incidental LAA isolation had higher rates of thromboembolism compared to patients without isolation. Since thromboembolism may occur despite prescription for OAC, the risks of LAA isolation must be weighed against clinical benefit and appendage occlusion devices should be considered in vulnerable patients.

Three-dimensional-guided and ICE-guided transseptal puncture for cardiac ablations: A propensity score match study.

INTRODUCTION: Transseptal puncture (TSP) is routinely performed for left atrial ablation procedures. The use of a three-dimensional (3D) mapping system or intracardiac echocardiography (ICE) is useful in localizing the fossa ovalis and reducing fluoroscopy use. We aimed to compare the safety and efficacy between 3D mapping system-guided TSP and ICE-guided TSP techniques. METHODS: We conducted a prospective observational study of patients undergoing TSP for left atrial catheter ablation procedures (mostly atrial fibrillation ablation). Propensity scoring was used to match patients undergoing 3D-guided TSP with patients undergoing ICE-guided TSP. Logistic regression was used to compare the clinical data, procedural data, fluoroscopy time, success rate, and complications between the groups. RESULTS: Sixty-five patients underwent 3D-guided TSP, and 151 propensity score-matched patients underwent ICE-guided TSP. The TSP success rate was 100% in both the 3D-guided and ICE-guided groups. Median needle time was 4.00 min (interquartile range [IQR]: 2.57-5.08) in patients with 3D-guided TSP compared to 4.02 min (IQR: 2.83-6.95) in those with ICE-guided TSP (p = .22). Mean fluoroscopy time was 0.2 min (IQR: 0.1-0.4) in patients with 3D-guided TSP compared to 1.2 min (IQR: 0.7-2.2) in those with ICE-guided TSP (p < .001). There were no complications related to TSP in both group. CONCLUSIONS: Three-dimensional mapping-guided TSP is as safe and effective as ICE-guided TSP without additional cost.

Design of three-bit binary to gray converter based on metal-insulator-metal plasmonic waveguides.

Using the finite element method and COMSOL version 5.5, a three-bit binary to gray converter with three plasmonic substructures and five input and three output ports was designed. Using a 520n m×200n m metal-insulator-metal plasmonic structure, the plasmonic converter was developed. In this configuration, the transmission threshold (T t h r e s h o l d ) is set to 45% at an operating wavelength of 1310 nm. Utilizing the modulation depth, contrast ratio (CR), and insertion loss criteria, the effectiveness of the plasmonic converter is evaluated. For the first, second, and third output terminals, the CR has respective values of 40.1 dB, 9.3 dB, and 9.2 dB.

A comparison of clinical outcomes and cost of radiofrequency catheter ablation for atrial fibrillation with monitored anesthesia care versus general anesthesia.

INTRODUCTION: Monitored anesthesia care (MAC) or general anesthesia (GA) can be used during catheter ablation (CA) of atrial fibrillation (AF). However, each approach may have advantages and disadvantages with variability in operator preferences. The optimal approach has not been well established. The purpose of this study was to compare procedural efficacy, safety, clinical outcomes, and cost of CA for AF performed with MAC versus GA. METHODS: The study population consisted of 810 consecutive patients (mean age: 63 ± 10 years, paroxysmal AF: 48%) who underwent a first CA for AF. All patients completed a preprocedural evaluation by the anesthesiologists. Among the 810 patients, MAC was used in 534 (66%) and GA in 276 (34%). Ten patients (1.5%) had to convert to GA during the CA. RESULTS: Although the total anesthesia care was longer with GA particularly in patients with persistent AF, CA was shorter by 5 min with GA than MAC (p < 0.01). Prevalence of perioperative complications was similar between the two groups (4% vs. 4%, p = 0.89). There was no atrioesophageal fistula with either approach. GA was associated with a small, ~7% increase in total charges due to longer anesthesia care. During 43 ± 17 months of follow-up after a single ablation procedure, 271/534 patients (51%) in the MAC and 129/276 (47%) patients in the GA groups were in sinus rhythm without concomitant antiarrhythmic drug therapy (p = 0.28). CONCLUSION: With the participation of an anesthesiologist, and proper preoperative assessment, CA of AF using GA or MAC has similar efficacy and safety.

Preparation, characterization, in vitro drug release and anti-inflammatory of thymoquinone-loaded chitosan nanocomposite.

In this study, we formulated Thymoquinone-loaded nanocomposites (TQ-NCs) using high-pressure homogenizer without sodium tripolyphosphate. The TQ-NCs were characterized and their anti-inflammatory determined by the response of the LPS-stimulated macrophage RAW 264.7 cells in the production of nitric oxide, prostaglandin E2, tumor necrosis factor-α, interleukin-6, and interleukin-1ß. The physicochemical properties of TQ-NC were determined using different machines. TQ was fully incorporated in the highly thermal stable nanoparticles. The nanoparticles showed rapid release of TQ in the acidic medium of the gastric juice. In medium of pH 6.8, TQ-NC exhibited sustained release of TQ over a period of 100 h. The results suggest that TQ-NC nanoparticles have potential application as parenterally administered therapeutic compound. TQ-NC effectively reduce production of inflammatory cytokines by the LPS-stimulated RAW 264.7 cells, indicating that they have anti-inflammatory properties. In conclusion, TQ-NC nanoparticles have the characteristics of efficient carrier for TQ and an effective anti-inflammatory therapeutic compound.

Efficacy and tolerability of quinidine as salvage therapy for monomorphic ventricular tachycardia in patients with structural heart disease.

INTRODUCTION: Quinidine is an effective therapy for a subset of polymorphic ventricular tachycardia and ventricular fibrillation (VF) syndromes; however, the efficacy of quinidine in scar-related monomorphic ventricular tachycardia (MMVT) is unclear. METHODS AND RESULTS: Between 2009 and 2020 a single VT referral center, a total of 23 patients with MMVT and structural heart disease (age 66.7 ± 10.9, 20 males, 15 with ischemic cardiomyopathy, mean LVEF 22.2 ± 12.3%, 9 with left ventricular assist device [LVAD]) were treated with quinidine (14 quinidine gluconate; 996 ± 321 mg, 8 quinidine sulfate; 1062 ± 588 mg). Quinidine was used in combination with other antiarrhythmics (AAD) in 19 (13 also on amiodarone). All patients previously failed >1 AAD (amiodarone 100%, mexiletine 73%, sotalol 32%, other 32%) and eight had prior ablations (median of 1.5). Quinidine was initiated in the setting of VT storm despite AADs (6), inability to tolerate other AADs (4), or recurrent VT(12). Ventricular arrhythmias recurred despite quinidine in 13 (59%) patients at a median of 26 (4-240) days after quinidine initiation. In patients with recurrent MMVT, VT cycle length increased from 359 to 434 ms (p = .02). Six (27.3%) patients remained on quinidine at 1 year with recurrence of ventricular arrhythmias in all. The following adverse effects were seen: gastrointestinal side effects (6), QT prolongation (2), rash (1), thrombocytopenia (1), neurologic side effects (1). One patient discontinued due to cost. CONCLUSION: Quinidine therapy has limited tolerability and long-term efficacy when used in the management of amiodarone-refractory scar-related MMVT.

Lead damage after cardiac implantable device replacement procedure: Comparison between electrical plasma tool and electrocautery.

BACKGROUND: Lead damage is a complication caused by lead manipulation or heating damage from conventional electrocautery (EC) after cardiovascular implantable electronic device (CIED) replacement. Application of electrical plasma (PEAK PlasmaBlade) is a new technology that reportedly reduces this risk. OBJECTIVES: This study was designed to compare the effect of EC versus PEAK PlasmaBlade on lead parameters and complications after generator replacement procedures. METHODS: We retrospectively studied 410 consecutive patients (840 leads) who underwent CIED replacement using EC (EC group) and 410 consecutive patients (824 leads) using PEAK PlasmaBlade (PlamaBlade group). Pacing lead impedance, incidence of lead damage, and complications were compared between both groups. RESULTS: Lead impedance increased in 393 leads (46.8%) in the EC group versus 282 leads (34.2%) in the PlasmaBlade group (p < .01) with average percent changes of 6.7% and 4.0% (p < .01), respectively. Lead impedance decreased in 438 leads (52.1%) in the EC group versus 507 leads (61.5%) in the PlasmaBlade group (p < .01) with average percent changes of -5.7% and -7.1% (p < .01), respectively. Lead damage requiring lead revision occurred in five leads (0.6%) or after five procedures (1.2%) in the EC group compared to three leads (0.4%, p = .50) or after three procedures (0.7%, p = .48) in the PlasmaBlade group. There were no significant differences in the procedural-related complications between the EC group (nine patients, 2.2%) and the PlasmaBlade group (five patients, 1.2%, p = .28). CONCLUSION: Conventional electrocautery can potentially damage lead insulations. However, this study shows that when used carefully electrocautery is as safe as the PEAK PlasmaBlade™.

Effect of metformin on outcomes of catheter ablation for atrial fibrillation.

BACKGROUND: Diabetes mellitus (DM) is a risk factor for atrial fibrillation (AF). The effect of antidiabetic medications on AF or the outcomes of catheter ablation (CA) has not been well described. We sought to determine whether metformin treatment is associated with a lower risk of atrial arrhythmias after CA in patients with DM and AF. METHODS AND RESULTS: A first CA was performed in 271 consecutive patients with DM and AF (age: 65 ± 9 years, women: 34%; and paroxysmal AF: 51%). At a median of 13 months after CA (interquartile range: 6-30), 100/182 patients (55%) treated with metformin remained in sinus rhythm without antiarrhythmic drug therapy, compared with 36/89 patients (40%) not receiving metformin (p = .03). There was a significant association between metformin therapy and freedom from recurrent atrial arrhythmias after CA in multivariable Cox hazards models (hazard ratio [HR]: 0.66; ±95% confidence interval [CI]: 0.44-0.98; p = .04) that adjusted for age, sex, body mass index, AF type (paroxysmal vs. nonparoxysmal), antiarrhythmic medication, obstructive sleep apnea, chronic kidney disease, coronary artery disease, left ventricular ejection fraction, and left atrial diameter. A Cox model that also incorporated other antidiabetic agents and fasting blood glucose demonstrated a similar reduction in the risk of recurrent atrial arrhythmias with metformin treatment (HR: 0.63; ±95% CI: 0.42-0.96; p = .03). CONCLUSIONS: In patients with DM, treatment with metformin appears to be independently associated with a significant reduction in the risk of recurrent atrial arrhythmias after CA for AF. Whether this effect is due to glycemic control or pleiotropic effects on electroanatomical mechanisms of AF remains to be determined.

Baseline and decline in device-derived activity level predict risk of death and heart failure in patients with an ICD for primary prevention.

BACKGROUND: Implanted defibrillators are capable of recording activity data based on company-specific proprietary algorithms. This study aimed to determine the prognostic significance of baseline and decline in device-derived activity level across different device companies in the real world. METHODS: We performed a retrospective cohort study of patients (n = 280) who underwent a defibrillator implantation (Boston, Medtronic, St. Jude, and Biotronik) for primary prevention at the University of Michigan from 2014 to 2016. Graphical data obtained from device interrogations were retrospectively converted to numerical data. The activity level averaged over a month from a week postimplantation was used as baseline. Subsequent weekly average activity levels (SALs) were standardized to this baseline. SAL below 59.4% was used as a threshold to group patients. All-cause mortality and death/heart failure were the primary end-points of this study. RESULTS: Fifty-six patients died in this study. On average, they experienced a 50% decline in SAL prior to death. Patients (n = 129) who dropped their SAL below threshold were more likely to be older, male, diabetic, and have more symptomatic heart failure. They also had a significantly increased risk of heart failure/death (hazard ratio [HR] 3.6, 95% confidence interval [95% CI] 2.3-5.8, P < .0001) or death (HR 4.2, 95% CI 2.2-7.7, P < .0001) compared to those who had sustained activity levels. Lower baseline activity level was also associated with significantly increased risk of heart failure/death and death. CONCLUSION: Significant decline in device-derived activity level and low baseline activity level are associated with increased mortality and heart failure in patients with an ICD for primary prevention.

Comparing Precision Machine Learning With Consumer, Quality, and Volume Metrics for Ranking Orthopedic Surgery Hospitals: Retrospective Study.

BACKGROUND: Patients' choices of providers when undergoing elective surgeries significantly impact both perioperative outcomes and costs. There exist a variety of approaches that are available to patients for evaluating between different hospital choices. OBJECTIVE: This paper aims to compare differences in outcomes and costs between hospitals ranked using popular internet-based consumer ratings, quality stars, reputation rankings, average volumes, average outcomes, and precision machine learning-based rankings for hospital settings performing hip replacements in a large metropolitan area. METHODS: Retrospective data from 4192 hip replacement surgeries among Medicare beneficiaries in 2018 in a the Chicago metropolitan area were analyzed for variations in outcomes (90-day postprocedure hospitalizations and emergency department visits) and costs (90-day total cost of care) between hospitals ranked through multiple approaches: internet-based consumer ratings, quality stars, reputation rankings, average yearly surgical volume, average outcome rates, and machine learning-based rankings. The average rates of outcomes and costs were compared between the patients who underwent surgery at a hospital using each ranking approach in unadjusted and propensity-based adjusted comparisons. RESULTS: Only a minority of patients (1159/4192, 27.6% to 2078/4192, 49.6%) were found to be matched to higher-ranked hospitals for each of the different approaches. Of the approaches considered, hip replacements at hospitals that were more highly ranked by consumer ratings, quality stars, and machine learning were all consistently associated with improvements in outcomes and costs in both adjusted and unadjusted analyses. The improvement was greatest across all metrics and analyses for machine learning-based rankings. CONCLUSIONS: There may be a substantive opportunity to increase the number of patients matched to appropriate hospitals across a broad variety of ranking approaches. Elective hip replacement surgeries performed at hospitals where patients were matched based on patient-specific machine learning were associated with better outcomes and lower total costs of care.

Velogenic newcastle disease virus tissue tropism and pathogenesis of infection in chickens by application of in situ PCR, immunoperoxase staining and HE staining.

Limited deep studies are available in the field of early stages of pathogenesis of Newcastle disease virus (NDV) infection and tissue tropism of NDV. In this study, 24 specific pathogen free (SPF) chickens of white leghorn breed were infected with Newcastle disease (ND) by intranasal administration of 105 50% EID50/0.1 mL of velogenic NDV (vNDV). A second group of 15 chickens were kept as a control group. Chickens were monitored every day to record clinical signs. Infected chickens were euthanized by cervical dislocation at successive times, namely at hours (hrs) 2, 4, 6, 12, days 1, 2, 4, and 6 post-inoculation (pi). Whereas, control group chickens were euthanized on days 0, 1, 2, 4, and 6 pi. Tissues of brain, trachea, lung, caecal tonsil, liver, kidney, spleen, heart, proventriculus, intestine, and thymus were collected, fixed in 10% buffered formalin, embedded in paraffin, and sectioned. HS staining, immunoperoxidase staining (IPS) and in situ PCR were applied. It was concluded that at hr 2 pi, virus seemed to be inclined to trachea and respiratory tract. Meanwhile, it attacked caecal tonsils, intestine and bursa of Fabricus. While primary viraemia was ongoing, virus created footing in kidney and thymus. At hr 4 pi, proventriculus, liver, and spleen were attacked. However, at hr 6 pi, brain and heart were involved. Secondary viraemia probably started as early as hr 12 pi since all collected tissues were positive. Tissue tropism was determined in trachea, caecal tonsil, liver, bursa of Fabricius, intestine, proventriculus, lung, spleen, thymus, kidney, heart, and brain.

The Comparative Epidemiology of Pediatric Severe Sepsis.

OBJECTIVE: To determine whether the coding strategies used to identify severe sepsis in administrative data sets could identify cases with comparable case mix, hospitalization characteristics, and outcomes as a cohort of children diagnosed with severe sepsis using strict clinical criteria. METHODS: We performed a retrospective cohort study using data from 2005 to 2011 from the New York and Florida State Inpatient Databases, available from the US Healthcare Cost and Utilization Project. We compared 4 coding strategies: the single International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM) codes for (1) severe sepsis or (2) septic shock, and the algorithms developed by (3) Angus et al or (4) Martin et al, which use a combination of ICD-9-CM codes for infection and organ dysfunction. We compared the cases identified by each strategy with each other and with children enrolled in the REsearching severe Sepsis and Organ dysfunction in children: a gLobal perspectiVE (RESOLVE) trial. RESULTS: The Angus criteria was 9 times larger (n = 23 995) than the smallest cohort, identified by the "septic shock" code (n = 2 601). Cases identified by the Angus and Martin strategies had low mortality rates, while the cases identified by the "severe sepsis" and "septic shock" codes had much higher mortality at all time points (eg, 28-day mortality of 4.4% and 7.4% vs 15.4% and 16.0%, respectively). Mortality in the "severe sepsis" and "septic shock" code cohorts was similar to that presented in the RESOLVE trial. CONCLUSIONS: The ICD-9-CM codes for "severe sepsis" and "septic shock" identify smaller but higher acuity cohorts of patients that more closely resemble the children enrolled in the largest clinical trial of pediatric severe sepsis to date.

Ablation of paroxysmal atrial fibrillation using a second-generation cryoballoon catheter or contact-force sensing radiofrequency ablation catheter: A comparison of costs and long-term clinical outcomes.

INTRODUCTION: Although noninferiority of cryoballoon ablation (CBA) and radiofrequency catheter ablation for antral pulmonary vein isolation (APVI) has been reported in patients with paroxysmal atrial fibrillation (PAF), it is not clear whether contact force sensing (CF-RFA) and CBA with the second-generation catheter have similar procedural costs and long-term outcomes. The objective of this study is to compare the long-term efficacy and cost implications of CBA and CF-RFA in patients with PAF. METHODS AND RESULTS: A first APVI was performed in 146 consecutive patients (age: 63 ± 10 years, men: 95 [65%], left atrial diameter: 42 ± 6 mm) with PAF using CBA (71) or CF-RFA (75). Clinical outcomes and procedural costs were compared. The mean procedure time was significantly shorter with CBA than with CF-RFA (98 ± 39 vs. 158 ± 47 minutes, P < 0.0001). Despite a higher equipment cost in the CBA than the CF-RFA group, the total procedure cost was similar between the two groups (P = 0.26), primarily driven by a shorter procedure duration that resulted in a lower anesthesia cost. At 25 ± 5 months after a single ablation procedure, 51 patients (72%) in the CBA, and 55 patients (73%) in the CF-RFA groups remained free from atrial arrhythmias without antiarrhythmic drug therapy (P = 0.84). CONCLUSIONS: The procedure duration was approximately 60 minutes shorter with CBA than CF-RFA. The procedural costs were similar with both approaches. At 2 years after a single procedure, CBA and CF-RFA have similar single-procedure efficacies of 72-73%.

Quantitative Hepatitis B e Antigen: A Better Predictor of Hepatitis B Virus DNA than Quantitative Hepatitis B Surface Antigen.

BACKGROUND: Hepatitis B surface antigen is usually secreted by infected hepatocytes in the form of subviral particles rather than infectious virions, while the hepatitis B e antigen originates from the core gene and is modified and secreted by hepatocytes into the circulation and functions as a marker of active viral replication. This study aimed to study the relationship between HBV DNA and quantitative hepatitis B surface and e antigen in Malaysian patients. METHODS: A total of 82 chronic hepatitis B patients were recruited for this study from the Hepatology Department of Selayang Hospital. Quantitative hepatitis surface and e antigen was performed retrospectively on frozen plasma using enzyme linked immunosorbent assay according to the manufacturer's instructions. Hepatitis B viral DNA was extracted from all plasma samples and quantified using real-time PCR. RESULTS: Quantitative hepatitis B surface and e antigens were found be high in 54.9% and 52.4% of the patients, respectively, while hepatitis B virus DNA level was high in 70.7%. The median of the viral load of HBV was 8,934.89 IU/mL and both hepatitis B surface and e antigens were also found to be high on average for qHBsAg (M = 5.19 IU/mL, SD ± 4. 33) and qHBeAg (M = 4.74IU/mL, SD ± 4.20), with qHBeAg being more strongly correlated to HBV DNA than qHBsAg (r = 0.893; p < 0.01). CONCLUSIONS: This study revealed HBeAg to be the most appropriate marker that correlates well with HBV DNA, thus not completely novel but confirmative, and related to the Malaysian situation.

A Population-Based Assessment of Depression and Anxiety in Patients With Brachial Plexus Injuries.

PURPOSE: Reactive depression and anxiety are common after major life changes such as brachial plexus injuries (BPI). The purpose of this study was to evaluate the incidence and risk factors for coded depression and coded anxiety among patients with BPI using a national database of commercial insurance claims. METHODS: We used the Truven MarketScan database from 2007 to 2013 to identify commercially insured patients aged 18 to 64 years who underwent BPI surgery. For comparison, a control group without BPI was frequency-matched 10:1 by age group, sex, number of provider visits, and length of insurance enrollment. Using International Classification of Diseases, Ninth Revision diagnosis codes and pharmacy claims, we identified coded depression and coded anxiety in the 12 months before and 12 months after BPI surgery. Multivariable Cox regression models were used to determine risk factors for coded depression or coded anxiety, adjusting for known risk factors for depression or anxiety (eg, alcohol, substance abuse). RESULTS: We identified 1,843 patients with BPI and 18,430 controls. Within the 12 months preceding surgery, coded depression and coded anxiety were present in 38% and 42%, respectively, of the BPI group; both were present in 25% and either was present in 54%. The rate of new-onset/postoperatively coded depression among patients with BPI was 142.1/1,000 person-years (12%) and of new-onset/postoperatively coded anxiety was 273.6/1,000 person-years (20%). Patients with BPI were significantly more likely than controls to develop new-onset/postoperatively coded depression (hazard ratio = 1.3; confidence interval [CI], 1.1-1.5) and new-onset/postoperatively coded anxiety (HR = 2.1 [CI, 1.8-2.4]). CONCLUSIONS: Patients undergoing BPI surgery have a high prevalence of coded depression and coded anxiety in the 12 months before surgery and are at higher risk for developing new-onset/postoperatively coded depression and coded anxiety within 1 year after surgery. These findings can be used by BPI surgeons to inform perioperative counseling, guide emotional recovery from injury, and facilitate coordinated or colocated care with mental health professionals. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Diabetes Mellitus is Associated With Higher Risk of Developing Decompensated Cirrhosis in Chronic Hepatitis C Patients.

GOALS: To investigate the association of diabetes with risk of decompensated cirrhosis in patients with chronic hepatitis C (CHC). BACKGROUND: Direct-acting antivirals are highly effective in treating CHC but very expensive. CHC patients at high risk of progression to symptomatic liver disease may benefit most from early treatment. STUDY: We conducted a retrospective cohort study using the 2006 to 2013 Truven Health Analytics MarketScan Commercial Claims and Encounters database including inpatient, outpatient, and pharmacy claims from private insurers. CHC and cirrhosis were identified using ICD-9-CM diagnosis codes; baseline diabetes was identified by diagnosis codes or antidiabetic medications. CHC patients were followed to identify decompensated cirrhosis. Multivariable Cox proportional hazards regression was used to model the risk of decompensated cirrhosis by baseline cirrhosis. RESULTS: There were 75,805 CHC patients with median 1.9 years follow-up. A total of 10,317 (13.6%) of the CHC population had diabetes. The rates of decompensated cirrhosis per 1000 person-years were: 185.5 for persons with baseline cirrhosis and diabetes, 119.8 for persons with cirrhosis and no diabetes, 35.3 for persons with no cirrhosis and diabetes, and 17.1 for persons with no cirrhosis and no diabetes. Diabetes was associated with increased risk of decompensated cirrhosis in persons with baseline cirrhosis (adjusted hazard ratio=1.4; 95% confidence interval, 1.3-1.6) and in persons without baseline cirrhosis (adjusted hazard ratio=1.9; 95% confidence interval, 1.7-2.1). CONCLUSIONS: In a privately insured US population with CHC, the adjusted risk of decompensated cirrhosis was higher in diabetic compared with nondiabetic patients. Diabetes status should be included in prioritization of antiviral treatment.

Readmission and Late Mortality After Critical Illness in Childhood.

OBJECTIVES: Little is known about the ongoing mortality risk and healthcare utilization among U.S. children after discharge from a hospitalization involving ICU care. We sought to understand risks for hospital readmission and trends in mortality during the year following ICU discharge. DESIGN: Retrospective observational cohort study. SETTING: This study was performed using administrative claims data from 2006-2013 obtained from the Truven Health Analytics MarketScan Database. SUBJECTS: We included all children in the dataset admitted to a U.S. ICU less than or equal to 18 years old. INTERVENTIONS: The primary outcome was nonelective readmission in the year following discharge. Risk of rehospitalization was determined using a Cox proportional hazards model. MEASUREMENTS AND MAIN RESULTS: We identified 109,130 children with at least one ICU admission in the dataset. Over three quarters of the index ICU admissions (78.6%) had an ICU length of stay less than or equal to 3 days, and the overall index hospitalization mortality rate was 1.4%. In multivariate analysis, risk of nonelective readmission for children without cancer was higher with longer index ICU admission length of stay, younger age, and several chronic and acute conditions. By the end of the 1-year observation period, 36.0% of children with an index ICU length of stay greater than or equal to 14 days had been readmitted, compared with only 13.9% of children who had an index ICU length of stay equals to 1 day. Mortality in the year after ICU discharge was low overall (106 deaths per 10,000 person-years of observation) but was high among children with an initial index ICU admission length of stay greater than or equal to 14 days (599 deaths per 10,000 person-years). CONCLUSIONS: Readmission after ICU care is common. Further research is needed to investigate the potentially modifiable factors affecting likelihood of readmissions after discharge from the ICU. Although late mortality was relatively uncommon overall, it was 10-fold higher in the year after ICU discharge than in the general U.S. pediatric population.

Scopoletin, an active principle of tree tobacco (Nicotiana glauca) inhibits human tumor vascularization in xenograft models and modulates ERK1, VEGF-A, and FGF-2 in computer model.

We recently reported the antineovascularization effect of scopoletin on rat aorta and identified its potential anti-angiogenic activity. Scopoletin could be useful as a systemic chemotherapeutic agent against angiogenesis-dependent malignancies if its antitumorigenic activity is investigated and scientifically proven using a suitable human tumor xenograft model. In the present study, bioassay-guided (anti-angiogenesis) phytochemical investigation was conducted on Nicotiana glauca extract which led to the isolation of scopoletin. Further, anti-angiogenic activity of scopoletin was characterized using ex vivo, in vivo and in silico angiogenesis models. Finally, the antitumorigenic efficacy of scopoletin was studied in human colorectal tumor xenograft model using athymic nude mice. For the first time, an in vivo anticancer activity of scopoletin was reported and characterized using xenograft models. Scopoletin caused significant suppression of sprouting of microvessels in rat aortic explants with IC50 (median inhibitory concentration) 0.06µM. Scopoletin (100 and 200mg/kg) strongly inhibited (59.72 and 89.4%, respectively) vascularization in matrigel plugs implanted in nude mice. In the tumor xenograft model, scopoletin showed remarkable inhibition on tumor growth (34.2 and 94.7% at 100 and 200mg/kg, respectively). Tumor histology revealed drastic reduction of the extent of vascularization. Further, immunostaining of CD31 and NG2 receptors in the histological sections confirmed the antivascular effect of scopoletin in tumor vasculature. In computer modeling, scopoletin showed strong ligand affinity and binding energies toward the following angiogenic factors: protein kinase (ERK1), vascular endothelial growth factor A (VEGF-A), and fibroblast growth factor 2 (FGF-2). These results suggest that the antitumor activity of scopoletin may be due to its strong anti-angiogenic effect, which may be mediated by its effective inhibition of ERK1, VEGF-A, and FGF-2.