Trends of Chronic Liver Disease in a Tertiary Care Centre in the Eastern Part of India: A Retrospective Study.

AIM OF THE STUDY: To assess the relationship between the severity of liver cirrhosis and its outcomes based on laboratory parameters, Child-Turcotte-Pugh (CTP) score, and upper gastrointestinal (UGI) endoscopy findings. BACKGROUND:  Cirrhosis is the end stage of chronic liver disease (CLD) and is characterised by progressive liver fibrosis and distortion of the liver architecture. It is a major cause of morbidity and mortality all over the world. Cirrhosis is compensated in the initial stages and later progresses to the decompensated stage with various complications. The CTP scoring system predicts mortality in patients with cirrhosis. MATERIALS AND METHODS: This retrospective study was done in the Department of Medicine and Gastroenterology of Tata Main Hospital (TMH), Jamshedpur, Jharkhand, India. It was conducted over a period of two years between 1 January 2019 and 31 December 2020, on 150 confirmed cases of cirrhosis. RESULTS: The most common age group was 41-60 years (86, 57.33%) and the mean age ± standard deviation (SD) for all patients was 49.82 ± 11.63 years. In a total of 150 CLD cases, males were 96 (64%). The most common cause of CLD was alcohol (76, 50.67%). Based on presenting symptoms, most CLD patients presented with generalized weakness (144, 96.00%). The most common signs were icterus (68, 45.33%) and ascites (44, 29.33%). Most patients belonged to CTP class A (77, 51.33%), followed by CTP class B (44, 29.33%) and class C (29, 19.34%). The most common UGI endoscopy finding was portal hypertensive gastropathy (mild or severe) (135, 75%). Total deaths were 24 (16.00%), with 17 deaths (70.83%) in patients belonging to CTP class C. CONCLUSION: CLD is a common entity in eastern India with male preponderance and affects mostly people of the middle age group. Alcohol intake is a major cause of CLD, followed by non-alcoholic fatty liver disease and chronic hepatitis B and C. A significant rise in morbidity and mortality due to alcoholic liver disease (ALD) was observed in the study and needs urgent social and medical intervention. The incidence of ALD in our study was 50.67%.

Getting paralysed after COVID: Guillain-Barre syndrome.

Neurological involvement after coronavirus disease (COVID-19) pneumonias is common and occurs in almost one-third of the patients. The commonest neurological symptoms are ageusia, anosmia, headache, nausea, vomiting, dizziness, and myalgia. Guillain-Barre syndrome (GBS) is a rare manifestation of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection; whereas the common neurological manifestations of the SARS-CoV-2 infection occur with the onset of the respiratory symptoms and may be due to the direct invasion of the nervous system by the virus, GBS in COVID-19 follows a time lag of 1-4 weeks and may be attributable to the immune mechanism of molecular mimicry. Here we report a case of GBS in a patient of COVID-19 which occurred on the 22nd day after the onset of the disease. The patient recovered completely and went home walking.

Outcomes of 1,090 consecutive, elective, nonselected percutaneous coronary interventions at a community hospital without onsite cardiac surgery.

We evaluated the efficacy and safety of elective percutaneous coronary intervention (PCI) at a hospital without onsite cardiac surgery. A growing number of hospitals without onsite cardiac surgery perform elective PCI. Few hospitals have reported outcomes, despite controversy surrounding this practice. From August 2003 to December 2005, 1,090 elective PCI were performed at Saint Luke's South Hospital (SLS), a hospital without onsite cardiac surgery, for which the referral center is the Mid America Heart Institute (MAHI). The elective PCI program used experienced interventionalists, technicians, and nurses; a tested helicopter transport protocol; a well-equipped catheterization laboratory; and a quality assurance process. Baseline characteristics, procedural success, and adverse clinical outcomes were compared. Observed frequencies of in-hospital death, a combined end point of Q-wave myocardial infarction (MI)/emergency coronary artery bypass grafting (CABG) surgery, and vascular complications were compared with prediction models. SLS, with lower risk characteristics than MAHI, had unadjusted frequencies of procedural success (93% vs 94%, p = NS), Q-wave MI (0.3% vs 0.3%, p = NS), emergency CABG surgery (0.2% vs 0.03%, p = 0.09), vascular complications (0.6% vs 0.6%, p = NS), and in-hospital death (0.1% vs 0.8%, p = 0.002) that compared favorably with MAHI. Two patients transferred from SLS to MAHI for emergency CABG surgery without adverse effects. Fewer in-hospital deaths and vascular complications were observed at SLS than predicted by models. In conclusion, favorable clinical outcomes were achieved for elective PCI at a hospital without onsite cardiac surgery that used strict program requirements.

Hemolysis induced pancreatitis after orbital atherectomy in a heavily calcified superficial femoral artery.

Orbital atherectomy represents a newly developed technology for the endovascular treatment of peripheral artery disease. There is currently limited data with regards to the safety and efficacy of this treatment. Herein, we describe a case where orbital atherectomy was utilized to treat a heavily calcified superficial femoral artery, and describe a previously unreported side effect of orbital atherectomy, hemolysis induced pancreatitis.

Utilization of distal embolic protection in saphenous vein graft interventions (an analysis of 19,546 patients in the American College of Cardiology-National Cardiovascular Data Registry).

In clinical trials, the use of a distal embolic protection device (EPD) during saphenous vein graft (SVG) percutaneous intervention (PCI) decreases the incidence of major adverse events. However, the frequency of EPD use during SVG PCI in clinical practice is unknown. We evaluated 19,546 SVG PCI procedures in the American College of Cardiology-National Cardiovascular Data Registry from January 1, 2004, through March 30, 2006. EPD use was the primary outcome. Univariate and multivariable analyses were used to assess for characteristics associated with EPD use and to determine the association between EPD use and 2 outcomes: no-reflow and in-hospital mortality. EPDs were used in 22% of patients who underwent SVG PCI. Characteristics independently associated with EPD use were age (odds ratio [OR] 1.04, p = 0.03), male gender (OR 1.12, p = 0.02), older grafts (p <0.001 for the group), longer lesions (OR 1.16, p <0.001), and American College of Cardiology/American Heart Association class C lesions (OR 1.41, p <0.001). Patients were less likely to receive an EPD if they had class <3 grade flow according to Thrombolysis in Myocardial Infarction classification (p <0.001) or previously treated lesions (OR 0.55, p <0.001). There was a weak correlation between annual hospital PCI volume and EPD use (r = 0.2, p <0.001). Nineteen percent of centers did not use EPDs and 41% used them in <10% of cases. EPD use was independently associated with a lower incidence of no-reflow (OR 0.68, p = 0.032), but not in-hospital mortality (1.0% vs 0.9%, p = NS). In conclusion, in current practice, EPDs are used in <25% of SVG PCI procedures.

Beta-blocker therapy in patients with heart failure in the urban setting: moving beyond clinical trials.

BACKGROUND: Despite their known benefits, beta-blockers (BBL) are not yet widely prescribed for heart failure, especially in the primary care setting. We wanted to identify patient characteristics that could guide primary care physicians in deciding whether they or a cardiologist should initiate BBL. A second objective was to determine the tolerability of BBL in clinical practice. METHODS: A retrospective chart review was conducted on a consecutive series of 551 patients with systolic dysfunction referred to a heart failure clinic in an urban public hospital. Patient responses to BBL were stratified into three categories: favorable (improvement of left ventricular ejection fraction by serial echocardiography), unfavorable (development of decompensated heart failure), or neither. Tolerability of BBL was assessed by the need to permanently discontinue BBL. RESULTS: Of 551 patients, 363 (66%) tolerated BBL. Among patients who had BBL initiated in the clinic, 48 had a favorable response, 34 had an unfavorable response, and 57 had neither a favorable or unfavorable response, as defined. A lower systolic blood pressure and higher diuretic dose were associated with development of decompensated heart failure as compared to improvement of ejection fraction. CONCLUSIONS: A majority of patients with heart failure in an urban public hospital can tolerate BBL. Easily measurable characteristics such as lower systolic blood pressure and higher diuretic dose may assist primary care physicians in triaging patients for referral to cardiologists for beta-blocker initiation.

Development of a depressed left ventricular ejection fraction in patients with left ventricular hypertrophy and a normal ejection fraction.

The progression from concentric left ventricular (LV) hypertrophy to heart failure has not been well defined. Of 159 predominantly hypertensive African-American patients with LV hypertrophy and a normal ejection fraction (EF), 28 (18%) developed a reduced EF after a median follow-up of approximately 4 years. Risk factors for this outcome included a history of coronary artery disease, pulmonary edema seen on a chest x-ray, or a subsequent myocardial infarction.

Therapy of heart failure in African Americans: lessons from an urban public hospital.

African-American patients with heart failure treated at urban public hospitals are at high risk for adverse outcomes likely due to complex socioeconomic factors. While establishing a heart failure disease management program at Parkland Memorial Hospital in Dallas, TX, the authors completed two studies that address the high rates of heart failure hospitalizations seen in this population. The first study found high rates of adverse outcomes following emergency department discharge for heart failure. The second identified important deficiencies in dietary sodium knowledge. Both 90-day outcomes (return emergency department visit or heart failure hospitalization) following an index emergency department discharge and dietary sodium knowledge represent new potential measures of quality of care of heart failure. Studies of this high-risk population of heart failure patients may offer insights that lead to improved outcomes both in the urban setting and elsewhere.

Primary systemic amyloidosis presenting with advanced heart failure.

Primary systemic amyloidosis (AL) is a rare, sporadic disease caused by deposition of immunoglobulin light chains in various tissues; symptoms vary based on which organs are infiltrated by the amyloid fibrils. Cardiac involvement occurs in up to 50% of patients with primary amyloidosis and is associated with a very poor prognosis. We report a case of a 57-year-old black man who presented with symptoms consistent with congestive heart failure. He was later found to have primary systemic amyloidosis, confirmed by abdominal fat pad biopsy.

Comparison of procedural complications with versus without interventional cardiology fellows-in-training during contemporary percutaneous coronary intervention.

Despite increasing complexity of contemporary procedures at tertiary care hospitals, the relationship between interventional cardiology fellows-in-training (ICFITs) and complications of percutaneous coronary intervention (PCI) has not been reported. We compiled logbooks of 6 ICFITs at an academic hospital and evaluated patient and procedural characteristics of PCIs performed with and without presence of an ICFIT. The primary end point was the composite of all in-hospital PCI complications defined by the American College of Cardiology's National Cardiovascular Data Registry: (1) catheterization laboratory events such as no-reflow and dissection/perforation, (2) general clinical events such as stroke or cardiogenic shock, (3) vascular and bleeding complications, and (4) miscellaneous complications such as peak troponin or creatinine levels. Logistic regression adjusted for differences in measured confounders between patients treated with and without presence of an ICFIT. All analyses were repeated after excluding PCI for ST-elevation myocardial infarction. Of 2,605 PCI procedures at the academic hospital between July 2007 and April 2010, an ICFIT was present for 1,638 procedures (63%). Despite having worse clinical and procedural characteristics, patients in the ICFIT group experienced similar rates of the composite end point (12.9% vs 14.5% without ICFIT, p = 0.27). Longer mean fluoroscopy times and greater number of stents were noted in the ICFIT group; however, hospital length of stay was shorter and no individual adverse events were increased in the ICFIT procedures. Presence of an ICFIT remained unrelated to the composite end point after multivariable adjustment (odds ratio 0.92, 95% confidence interval 0.71 to 1.20; p = 0.53), and findings were similar after excluding PCI for ST-elevation myocardial infarction. In conclusion, in contemporary practice at a large academic medical center, PCI complication rates were not adversely affected by the presence of an ICFIT.

Drug-eluting stents and the use of percutaneous coronary intervention among patients with class I indications for coronary artery bypass surgery undergoing index revascularization: analysis from the NCDR (National Cardiovascular Data Registry).

OBJECTIVES: Our purpose was to evaluate percutaneous coronary intervention (PCI) attempt rates in patients with class I indications for coronary artery bypass graft (CABG) surgery after the introduction of drug-eluting stents (DES). BACKGROUND: In patients with severe, multivessel coronary disease, CABG has historically been recommended over PCI. Practice guidelines for CABG were last updated before the emergence of data on DES efficacy. METHODS: We analyzed 265,028 procedures from the NCDR (National Cardiovascular Data Registry) meeting American College of Cardiology/American Heart Association class I indications for surgical revascularization. Temporal trends in PCI attempt rates were analyzed during 3 consecutive time periods: pre-DES (before April 1, 2003), DES diffusion (April 1, 2003 to December 31, 2004), and DES (January 1, 2005 to September 30, 2006). RESULTS: The attempted rate of PCI in patients with class I indications for CABG increased over the 3 time periods (pre-DES: 29.4%, DES diffusion: 33.4%, and DES era: 34.7%, p < 0.001). In a hierarchical multivariable logistic model adjusting for patient and PCI site characteristics, PCI attempts were more likely in the DES compared with pre-DES era (odds ratio: 1.44, 95% confidence interval: 1.40 to 1.48) and the DES diffusion era (odds ratio: 1.20, 95% confidence interval: 1.17 to 1.23). PCI attempt rates increased in all 3 time periods, although the average rate of increase during the DES era was 0.6% per quarter compared with 0.3% per quarter for both the DES diffusion and the pre-DES eras (p = 0.03). CONCLUSIONS: DES use in clinical practice was associated with a significant overall increase in PCI to treat patients with class I indications for CABG. Long-term follow-up of this cohort of patients is warranted.

Bleeding in patients undergoing percutaneous coronary intervention: the development of a clinical risk algorithm from the National Cardiovascular Data Registry.

BACKGROUND: Bleeding in patients undergoing percutaneous coronary intervention (PCI) is associated with increased morbidity, mortality, length of hospitalization, and cost. We identified baseline clinical characteristics associated with bleeding complications after PCI and developed a simplified, clinically useful algorithm to predict patient risk. METHODS AND RESULTS: Data were analyzed from 302 152 PCI procedures performed at 440 US centers participating in the National Cardiovascular Data Registry. As defined by the National Cardiovascular Data Registry, bleeding required transfusion, prolonged hospital stay, and/or a drop in hemoglobin >3.0 g/dL from any location, including percutaneous entry site, retroperitoneal, gastrointestinal, genitourinary, and other/unknown location. Bleeding complications occurred in 2.4% of patients. From the best-fitting model consisting of 15 clinical elements associated with post-PCI bleeding in a random 80% training cohort, we developed a parsimonious risk algorithm. Predictors of bleeding included age, gender, previous heart failure, glomerular filtration rate, peripheral vascular disease, no previous PCI, New York Heart Association/Canadian Cardiovascular Society Functional Classification class IV heart failure, ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and cardiogenic shock. The parsimonious model was validated in the remaining 20% of the population (c-statistic, 0.72) and in clinically relevant subgroups of patients. This simplified model was used to derive a clinical risk algorithm, with larger numbers corresponding with greater risk. In 3 categories, bleeding rates were greater in patients with higher estimates (or=18, 5.1%). CONCLUSIONS: This report identifies baseline clinical factors associated with bleeding and proposes a clinically useful algorithm to estimate bleeding risk. This model is potentially actionable in altering therapeutic decision making and improving outcomes in patients undergoing PCI.

Intravascular ultrasound measures of coronary atherosclerosis are associated with the Framingham risk score: an analysis from a global IVUS registry.

AIMS: In addition to an adjunctive imaging platform during coronary angiography, intravascular ultrasound (IVUS) with Virtual Histology (VH) is increasingly being used to quantify coronary atherosclerosis. The relationship between VH-IVUS measures of coronary atherosclerosis and traditional cardiovascular risk factors has not been completely described. The objective of this study was to determine if an association exists between VH-IVUS measures of coronary atherosclerosis and the Framingham risk score in a prospective, multinational registry. METHODS AND RESULTS: Patients enrolled from 2004-2006 at 37 multinational centres in the prospective VHIVUS Global Registry were analysed. All subjects underwent diagnostic coronary angiography followed by IVUS. A Framingham risk score (FRS) was calculated for each subject, then stratified into three exclusive estimates (<10%, 10-19%, or >or= 20%) for future coronary heart disease (CHD) event risk over 10 years. Among 531 patients, plaque volume of the most diseased 10 mm segment increased with increasing FRS (P=0.006, adjusted for multiple comparisons). Patients with higher FRS estimates of CHD risk had a higher proportion of plaque classified as thin cap fibroatheroma compared with patients in the middle and lower risk score categories (21.4% vs 15.2% and 11.3%, respectively, P=0.008, adjusted for multiple comparisons). CONCLUSIONS: Using data from a large, multinational VH-IVUS registry we describe an association between the Framingham risk score and VH-IVUS measures of atherosclerosis within the most diseased 10 mm segment, namely plaque volume and the proportion of thin cap fibroatheroma.

Low adiponectin levels are associated with atherogenic dyslipidemia and lipid-rich plaque in nondiabetic coronary arteries.

OBJECTIVE: The purpose of this study was to determine whether an association exists between adiponectin and plaque composition in human coronary arteries. RESEARCH DESIGN AND METHODS: Adiponectin is an adipocyte-derived protein with antiatherogenic and insulin-sensitizing properties. To date, the relationship between adiponectin and plaque composition is unknown. Fasting blood samples were collected from 185 patients undergoing coronary angiography and intravascular ultrasound (IVUS). Plaque composition was categorized as fibrous, fibrofatty, necrotic core, or dense calcium and further classified as IVUS-derived adaptive or pathological intimal thickening, fibroatheroma, fibrocalcific, or thin cap fibroatheroma. RESULTS: Adiponectin correlated with normalized plaque volume (r = -0.16, P = 0.025) and atheroma lipid content as measured by normalized fibrofatty volume (r = -0.19, P = 0.009). Low adiponectin levels were associated with IVUS-derived pathological intimal thickening (r = -0.18, P = 0.01). With increasing quartiles (Q) of adiponectin, the normalized volume of fibrofatty plaque decreased (P = 0.03), which was driven by reductions in the nondiabetic cohort (Q1 44.2 mm(3); Q2 28.2 mm(3); Q3 24.7 mm(3); and Q4 23.4 mm(3); P = 0.01). No similar association was present in diabetic patients. Low adiponectin levels were also associated with IVUS-derived pathological intimal thickening in nondiabetic (r = -0.20, P = 0.03) but not diabetic patients. CONCLUSIONS: Low adiponectin levels are associated with atherogenic lipoproteins (elevated triglycerides, small dense LDL cholesterol, and low HDL cholesterol), increased plaque volume, lipid-rich plaque, and IVUS-derived pathological intimal thickening in the total cohort that was driven by the nondiabetic population, suggesting an antiatherogenic role in the early stages of lesion development.

Suitability of saphenous vein graft lesions for the use of distal embolic protection devices.

The use of distal embolic protection devices (EPD) in saphenous vein graft percutaneous interventions (SVG-PCI) has been associated with a decrease in adverse events. Currently, there are limited data regarding the percentage of SVG lesions that are suitable for EPD deployment. We retrospectively reviewed 131 SVG-PCI procedures occurring over 18 months for suitability for EPD deployment, utilizing previously published suitability criteria. We found that 49% of cases were suitable for EPD use, which is similar to results from other studies. Given the data supporting the use of EPD use in SVG-PCI, we feel that these findings should motivate interventional operators to establish benchmark standards for employing EPDs to improve the care of patients undergoing SVG-PCI.

Intravascular ultrasound radiofrequency analysis of coronary atherosclerosis: an emerging technology for the assessment of vulnerable plaque.

Evaluation of atherosclerotic plaque composition and morphometry may yield insight into plaque biology and the mechanisms of plaque-associated thrombosis. Analysis of intravascular ultrasound radiofrequency (IVUS-RF) backscatter signal is one technology that provides in vivo assessment of both atherosclerotic plaque composition and morphometry. We summarize three different approaches to IVUS-RF and critique the studies using this technology. In addition, we address the potential application of IVUS-RF to assess vulnerable plaque.

Left ventricular hypertrophy, subclinical atherosclerosis, and inflammation.

To elucidate mechanisms by which left ventricular (LV) hypertrophy (LVH) increases the risk of atherosclerotic heart disease, we sought to determine whether LVH is independently associated with coronary artery calcium (CAC) and serum C-reactive protein (CRP) levels in the general population. The Dallas Heart Study is a population-based sample in which 2633 individuals underwent cardiac MRI to measure LV structure, electron beam CT to measure CAC, and measurement of plasma CRP. We used univariate and multivariable analyses to determine whether LV mass and markers of concentric LV hypertrophy or dilation were associated with CAC and CRP. Increasing quartiles of LV mass indexed to fat-free mass, LV wall thickness, and concentricity, but not LV volume, were associated with CAC in both men and women (P<0.001). After adjustment for traditional cardiovascular risk factors and statin use, LV wall thickness and concentricity remained associated with CAC in linear regression (P<0.001 for each). These associations were particularly robust in blacks. LV wall thickness and concentricity were also associated with elevated CRP levels (P=0.001 for both) in gender-stratified univariate analyses, although these associations did not persist in multivariable analysis. In conclusion, concentric LVH is an independent risk factor for subclinical atherosclerosis. LVH is also associated with an inflammatory state as reflected in elevated CRP levels, although this relationship appears to be mediated by comorbid conditions. These data likely explain in part why individuals with LVH are at increased risk for myocardial infarction.

Differentiating true versus pseudo left ventricular aneurysm: a case report and review of diagnostic strategies.

The differentiation of left ventricular pseudoaneurysm from true aneurysm is sometimes difficult. Given the propensity for pseudoaneurysms to rupture leading to cardiac tamponade, shock, and death, compared with a more benign natural history for true aneurysms, accurate diagnosis of these conditions is clinically important. Clinical symptoms, physical examination findings, electrocardiograms, and routine x-rays are not sensitive or specific for diagnosing left ventricular aneurysms nor for distinguishing true from pseudoaneurysm once detected. Our aim is to present a case report demonstrating these difficulties and to review the use of various cardiac imaging modalities in differentiating between these 2 entities.