Subclinical hepatitis E virus genotype 1 infection: The concept of "dynamic human reservoir".

Hepatitis E virus (HEV) is hyperendemic in South Asia and Africa accounting for half of total Global HEV burden. There are eight genotypes of HEV. Among them, the four common ones known to infect humans, genotypes 1 and 2 are prevalent in the developing world and genotypes 3 and 4 are causing challenge in the industrialized world. Asymptomatic HEV viremia in the general population, especially among blood donors, has been reported in the literature worldwide. The clinical implications related to this asymptomatic viremia are unclear and need further exploration. Detection of viremia due to HEV genotype 1 infection, apparently among healthy blood donors is also reported without much knowledge about its infection rate. Similarly, while HEV genotype 3 is known to be transmitted via blood transfusion in humans and has been subjected to screening in many European nations, instances of transmission have also been documented albeit without significant clinical consequences. Epidemiology of HEV genotype 1 in endemic areas often show waxing and waning pattern. Occasional sporadic occurrence of HEV infection interrupted by outbreaks have been frequently seen. In absence of known animal reservoir, where HEV exists in between outbreak is a mystery that needs further exploration. However, occurrence of asymptomatic HEV viremia due to HEV genotype 1 during epidemiologically quiescent period may explain that this phenomenon may act as a dynamic reservoir. Since HEV genotype 1 infection cannot cause chronicity, subclinical transient infection and transmission of virus might be the reason it sustains in interepidemic period. This might be the similar phenomenon with SARS COVID-19 corona virus infection which is circulating worldwide in distinct phases with peaks and plateaus despite vaccination against it. In view of existing evidence, we propose the concept of "Dynamic Human Reservoir." Quiescent subclinical infection of HEV without any clinical consequences and subsequent transmission may contribute to the existence of the virus in a community. The potential for transmitting HEV infection by asymptomatic HEV infected individuals by fecal shedding of virus has not been reported in literature. This missing link may be a key to Pandora's box in understanding epidemiology of HEV infection in genotype 1 predominant region.

The Role of Mechanical Thrombectomy for Acute Massive Pulmonary Embolism in a Patient With Unilateral Lung Transplant and Atrial Septal Defect.

PURPOSE: The risk of thromboembolic disease is high in patients with lung transplantation and is associated with significant morbidity and mortality with single healthy transplanted lung. We present a case involving successful endovascular management of life-threatening acute massive pulmonary embolism (PE) in a patient with single lung transplant and atrial septal defect (ASD). CASE REPORT: A 65-year-old man with a history of interstitial lung disease status post single left orthotopic lung transplant in 2012 presented with acute massive PE and clot burden in the pulmonary arteries of the transplanted left lung. Severe right heart dysfunction, hemodynamic instability, and requirement for vasopressors persisted post systemic thrombolytic therapy. As a result, the patient underwent successful endovascular mechanical thrombectomy with immediate improvement in oxygen saturation and hemodynamic status. The procedure was performed without adverse outcomes or paradoxical embolization despite the presence of ASD. The right heart dysfunction resolved, the patient was extubated the next day, and was discharged to home 2 days post procedure. CONCLUSIONS: Endovascular mechanical thrombectomy was safely used to treat acute massive PE in a single transplanted lung in the presence of ASD. CLINICAL IMPACT: Endovascular mechanical thrombectomy could be safely utilized to treat patients with lung transplant and acute massive or submassive pulmonary embolism. However, safely of mechanical thrombectomy should be determined in case-based scenarios and based on time interval from transplantation to when the thrombectomy is required.

Thirty-day hospital readmission rate amongst older adults correlates with an increased number of medications, but not with Beers medications.

AIM: We sought to explore the relationship between the number of medications at hospital discharge and 30-day rehospitalization in older adults aged >65 years. METHODS: This was a multicenter cohort study to determine whether an increased number of medications was associated with 30-day rehospitalization in patients aged >65 years. We explored the relationship between rehospitalization and other risk factors. Data were collected from a large health system in the New York metropolitan area from September 2011 to January 2013. The primary outcome was 30-day hospital readmission from the index hospitalization. RESULTS: Patients had a mean ± SD age of 78 ± 9 years; 55% were women. The average length of stay after discharge from the hospital was 6 days. An increased number of medications was significantly associated with unplanned 30-day hospital readmission (P < 0.05). For each medication, the risk of rehospitalization increased by 4% (OR 1.04, 95% CI 1.03, 1.05). Patients discharged to rehabilitation centers were 32% more likely to be readmitted than patients discharged home (OR 1.39, 95% CI 1.27-1.51). Other risk factors significantly associated with 30-day rehospitalization were: cancer, intensive care unit, chronic heart failure, renal diseases and peripheral vascular diseases. Hypertension was negatively associated with 30-day unplanned rehospitalization (OR 0.88, 95% CI 0.82-0.95). No significant association between the number of Beers medications and 30-day rehospitalization was observed, after controlling for the number of medications and other covariates. CONCLUSIONS: The number of discharge medications was significantly associated with 30-day hospital readmission among older adult patients. Important risk factors for 30-day rehospitalization were discharge location, cancer, intensive care unit, chronic heart failure, renal diseases and peripheral vascular diseases. Geriatr Gerontol Int 2018; 18: 1513-1518.

Trends in Survival After In-Hospital Cardiac Arrest During Nights and Weekends.

BACKGROUND: Survival after in-hospital cardiac arrest (IHCA) is lower during nights and weekends (off-hours) compared with daytime during weekdays (on-hours). As overall IHCA survival has improved over time, it remains unknown whether survival differences between on-hours and off-hours have changed. OBJECTIVES: This study sought to examine temporal trends in survival differences between on-hours and off-hours IHCA. METHODS: We identified 151,071 adults at 470 U.S. hospitals in the Get with the Guidelines-Resuscitation registry during 2000 to 2014. Using multivariable logistic regression with generalized estimating equations, we examined whether survival trends in IHCA differed during on-hours (Monday to Friday 7:00 am to 10:59 pm) versus off-hours (Monday to Friday 11:00 pm to 6:59 am, and Saturday to Sunday, all day). RESULTS: Among 151,071 participants, 79,091 (52.4%) had an IHCA during off-hours. Risk-adjusted survival improved over time in both groups (on-hours: 16.0% in 2000, 25.2% in 2014; off-hours: 11.9% in 2000, 21.9% in 2014; p for trend <0.001 for both). However, there was no significant change in the survival difference over time between on-hours and off-hours, either on an absolute (p = 0.75) or a relative scale (p = 0.059). Acute resuscitation survival improved significantly in both groups (on-hours: 56.1% in 2000, 71% in 2014; off-hours: 46.9% in 2000, 68.2% in 2014; p for trend <0.001 for both) and the difference between on-hours and off-hours narrowed over time (p = 0.02 absolute scale, p < 0.001 relative scale). In contrast, although post-resuscitation survival also improved over time in both groups (p for trend < 0.001 for both), the absolute and relative difference persisted. CONCLUSIONS: Despite an overall improvement in survival, lower survival in IHCA during off-hours compared with on-hours persists.

Metformin therapy and postoperative atrial fibrillation in diabetic patients after cardiac surgery.

BACKGROUND: Postoperative atrial fibrillation (AF) commonly occurs in cardiac surgery patients. Studies suggest inflammation and oxidative stress contribute to postoperative AF development in this patient population. Metformin exerts an anti-inflammatory effect that reduces oxidative stress and thus may play a role in preventing postoperative AF. METHODS: We conducted a matched, retrospective cohort study of diabetic patients' age ≥18 undergoing a coronary artery bypass graft (CABG) and/or cardiac valve surgery from January 1, 2009, to November 30, 2014. We extracted data from The Society of Thoracic Surgeons National Adult Cardiac Surgery Database. Primary exposure was ongoing metformin use at a dose of ≥ 500 mg in effect before cardiac surgery as captured before admission. Primary study outcome was postoperative AF incidence. Matching was used to reduce selection bias between metformin and non-metformin groups. Comparison between the groups after matching was accomplished using the McNemar test or paired t test. RESULTS: Out of the 4177 patients with cardiac surgery (CABG and/or valve surgery), 1283 patients met our study criteria. These patients were grouped into metformin [n = 635 (49.5%)] and non-metformin [n = 648 (50.5%)] users. Pre-matching, postoperative AF was found in 149 (23.5%) patients in the metformin group and 172 (26.5%) in the non-metformin group (p = 0.2088). Matching resulted in a total of 114 patients in each group (metformin vs. non-metformin). We found no statistically significant difference for postoperative AF between the two groups after matching (p = 0.8964). CONCLUSIONS: Prior use of metformin therapy in diabetic patients undergoing cardiac surgery was not associated with decreased rate of postoperative AF.

Metformin and Myocardial Injury in Patients With Diabetes and ST-Segment Elevation Myocardial Infarction: A Propensity Score Matched Analysis.

BACKGROUND: Although animal studies have documented metformin's cardioprotective effects, the impact in humans remains elusive. The study objective was to explore the association between metformin and myocardial infarct size in patients with diabetes presenting with ST-segment elevation myocardial infarction. METHODS AND RESULTS: Data extraction used the National Cardiovascular Data CathPCI Registry in all patients with diabetes aged >18 years presenting with ST-segment elevation myocardial infarction at 2 academic medical centers from January 2010 to December 2013. The exposure of interest was ongoing metformin use before the event. Propensity score matching was used for the metformin and nonmetformin groups on key prognostic variables. All matched pairs had acceptable D scores of <10%, confirming an efficient matching procedure. The primary outcome was myocardial infarct size, reflected by peak serum creatine kinase-myocardial band, troponin T, and hospital discharge left ventricular ejection fraction. Of all 1726 ST-segment elevation myocardial infarction cases reviewed, 493 patients had diabetes (28.5%), with 208 metformin users (42.1%) and 285 nonusers. Matched pairs analysis yielded 137 cases per group. The difference between metformin and nonmetformin groups was -18.1 ng/mL (95% CI -55.0 to 18.8; P=0.56) for total peak serum creatine kinase-myocardial band and -1.1 ng/mL (95% CI -2.8 to 0.5; P=0.41) for troponin T. Median discharge left ventricular ejection fraction in both groups was 45, and the difference between metformin and nonmetformin users was 0.7% (95% CI -2.2 to 3.6; P=0.99). CONCLUSIONS: No statistically significant association of cardioprotection was found between metformin and myocardial infarct size in patients with diabetes and acute ST-segment elevation myocardial infarction.

Mercury concentrations in commercial fish species of Lake Phewa, Nepal.

Mercury (Hg) concentrations in four commercial fish species (Tilapia Oreochromis niloticus, Spiny Eel Mastacembelus armatus, African catfish Clarias gariepinus, and Sahar Tor putitora), were investigated in Lake Phewa, Nepal. Mean values of total mercury (THg mg kg(-1), ww) in these fishes were 0.02, 0.07, 0.05, and 0.12 respectively. Methylmercury contributed 82 % of THg. The lowest value was detected in O. niloticus, an exclusive plant feeder. The biomagnification rate of Hg through the fish community was 0.041 per δ(15)N (‰). The present investigation produced an important baseline data of Hg pollution in the fish community in this region.