Serious Failure Modes After EVAR Are Device Specific.

OBJECTIVES: Type I and III endoleaks following endovascular aneurysm repair (EVAR) can lead to catastrophic events that require major re-interventions. We reviewed our experience with aortic endograft re-interventions for type I and III endoleaks and other serious failures among different devices. METHODS: We retrospectively reviewed patients with a prior EVAR who underwent open conversion (OC) or major endovascular intervention (MEI) (re-lining, cuff/limb extension, parallel graft) for type I/III endoleaks at our institution from 2002 to 2019. Baseline characteristics, procedural details, re-interventions, and outcomes were collected. RESULTS: A total of 229 patients (194 men) underwent re-interventions for type I and III endoleaks after EVAR (90 OC, 139 MEI) for devices implanted between 1997 and 2019. Average age at re-intervention was 78±8.5 years. A total of 135 (59%) were implanted at our institution, whereas 93 (41%) were referred. Median time to re-intervention was 4 years with 25% to 75% interquartile range (IQR) of 2.2-6.6 years. There was no significant difference in baseline demographics or type of re-interventions (OC/MEI) between device types. 42/229 (18%) presented with ruptured aneurysms, 20/229 (9%) were symptomatic, whereas the rest presented with asymptomatic radiographic findings. Type 1A endoleak was present in 146/229 (63.8%-72 with proximal migration), type IB in 46/229 (20.1%), type IIIA in 37/229 (16.6%), type IIIB in 15/229 (6.5%), and persistent aneurysm sac growth with no radiographic evidence of an endoleak in 6/229 (2.6%). Devices included most commercial products: AFX, Excluder, AneuRx, Ancure, Endurant, and Zenith. A smaller number of investigational devices accounted for the rest. Type 1A endoleak was the most common indication for re-intervention among all devices except for AFX and ancure devices, proximal migration was a frequent presentation with AneuRx. AFX devices more frequently presented with a type III and ancure devices more frequently presented with a type IB endoleak. CONCLUSIONS: Serious failure modes after EVAR differ between endografts and occur throughout the follow-up period. This is important to guide targeted interrogation of surveillance studies and follow-up schedules, even for discontinued devices, as well as comparisons between various series and estimation of EVAR failure rates. CLINICAL IMPACT: Surveillance after EVAR is critical for long term success of the repair, understanding of the differential modes of failure of every graft available is important in the longitudinal evaluation of these endografts. Equally important is the understanding of the modes of failure of legacy endografts that are no longer on the market but still being followed, in order to be able to tailor a surveillance regiemn and the evntual repair if needed.

Targeted (PCR-based) screening of antibiotic resistance genes' prevalence in the gut microbiota of tribal people of Nabarangpur, Odisha, India.

Antibiotic resistance is a major public health concern worldwide. The gut microbiota harbours multiple antibiotic resistant genes (ARGs) that contribute to the existing and future microbial population in a community or ecosystem. This study aimed to investigate the prevalence of 35 antibiotic resistance genes (ARGs) in the gut microbiota of the tribal people of Nabarangpur, Odisha, India. A total of 83 faecal samples were collected from three different tribes (Bhatra, Gond, and Paraja). Total faecal DNA was extracted, and the simplex polymerase chain reaction was performed to detect selected ARGs. Further analysis was done to estimate the incidence of these ARGs across these tribes based on alcohol consumption habits. We identified a higher prevalence of tetracycline resistance genes (tetW, tetQ and tetM) in the gut microbiota among three populations. Furthermore, a significant (P = 0·024) difference in ARG prevalence against vancomycin in individuals with and without alcohol consumption habits was noticed. The overall distribution of ARGs among the three major tribes of this location was found to be very similar. Together, irrespective of the tribes, the people of this location have gut microbiota harbouring different kinds of ARGs and tetracycline-resistant genes are the most commonly found ARGs.

Use of signals and systems engineering to improve the safety of warfarin initiation.

Warfarin-dosing algorithms combine clinical factors and dosing history with the current international normalized ratio (INR) to estimate the therapeutic warfarin dose. Unfortunately, these approaches can result in an overdose if the INR is spuriously low. Our goal was to develop an alert mechanism based on prior INRs in addition to the current INR. Using data from the Genetics InFormatics Trial (GIFT) of Warfarin to Prevent DVT, we analyzed warfarin dose estimates for days 3 through 11 that were ≥10 % higher than an average of the previous two dose estimates. We fit a stepwise mixed model to current and prior dose estimates, and subsequently compared the root-mean-square-error (RMSE) in predicting the final therapeutic dose using the GIFT algorithm versus the mixed model. From 861 dosing records (obtain from 556 patients), 646 dosing records (75 %) were randomly selected for the derivation cohort and 215 dosing records (25 %) for the validation cohort. Using one prior dose estimate improved the accuracy of the warfarin dose estimate. Compared to a dose estimate based on current INR (GIFT algorithm), the mixed model reduced the RMSE in the derivation cohort by 0.0015 mg/day (RMSE 0.2079 vs. 0.2094; p = 0.039). In the validation cohort, the RMSE reduction was not significant. A mixed model of dose estimates based on the current and most recent INRs shows potential to improve the safety of warfarin dosing. Clinicians should be cautious about aggressively escalating the warfarin dose after an INR that is lower than expected.

Resonance Raman spectroscopy of twisted interfaces in turbostratic multilayer graphene.

Turbostratic multilayer graphene presents a unique system with a large number of twisted interfaces with variable twist angles. In this work, we have systematically studied the laser excitation energy dependence of the Raman modes of turbostratic graphene. The combination of 4 different laser energies is shown to be important to reveal the twist angles ranging from 5∘to 30∘present at the same lateral position of the sample. Rotational or R-modes and D-like modes are observed, which directly arise from additional momentum transfer from the potential of corresponding superlattices. Trends in their dispersion and intensity are discussed. The resonant window for laser excitation indicates lowered positions of the van Hove singularities. Furthermore, an anomalous broadening factor of 0.17-0.265 eV is estimated for the resonance window when compared to the literature on isolated twisted bilayer graphene. Interestingly, a weak dependence of the R-modes on the laser wavelength is also observed. Finally, the dispersion of the 2D modes is also presented.

TB disease patterns by HIV and diabetes status.

BACKGROUND: TB is commonly categorised as pulmonary (PTB) or extrapulmonary TB (EPTB). Knowledge of TB disease patterns (PTB and/or EPTB) and determining risk factors remains limited.METHODS: This was a prospective cohort study using point-of-care ultrasound (POCUS) in Indian patients with presumed TB. Clinical and imaging data were used to develop refined case definitions for PTB, concurrent PTB and EPTB (PTB + EPTB) and EPTB without PTB (EPTB). These groups were analysed by HIV (HIV+/-) and diabetes mellitus (DM+/-) status.RESULTS: Of 172 HIV-/DM- patients with TB, 48% had PTB, 23% PTB + EPTB and 29% had EPTB, totalling 52% with any EPTB (PTB + EPTB or EPTB). In HIV+/DM- patients with TB (n = 35), 6% had PTB, 40% had PTB + EPTB and 54% had EPTB, accounting for 94% with EPTB. In HIV-/DM+ patients with TB (n = 61), 61% had PTB, 28% had PTB + EPTB and 11% had EPTB, representing 39% with EPTB.CONCLUSION: Refined case definitions revealed high proportions of EPTB even without HIV or DM. HIV further altered the TB disease pattern towards EPTB and DM towards PTB. Therefore, the dichotomy between PTB or EPTB does not represent the actual spectrum of TB disease. EPTB should receive higher priority in research and clinical practice.

Multiple supernumerary teeth associated with bony malformations.

Full blown cases of cleidocranial dysplasia (CCD) have been reported earlier but a case with a rarity of 60 teeth associated with bony malformations, is seldom observed Because of the oral findings this condition has been diagnosed at an early age, thus helping to achieve a better oral harmony. This article reports an atypical case with 16 supernumerary teeth associated with bony malformations.

Thermal transport across wrinkles in few-layer graphene stacks.

Wrinkles significantly influence the physical properties of layered 2D materials, including graphene. In this work, we examined thermal transport across wrinkles in vertical assemblies of few-layer graphene crystallites using the Raman optothermal technique supported by finite-element analysis simulations. A high density of randomly oriented uniaxial wrinkles were frequently observed in the few-layer graphene stacks which were grown by chemical vapor deposition and transferred on Si/SiO2 substrates. The thermal conductivity of unwrinkled regions was measured to be, κ ∼ 165 W m-1 K-1. Measurements at the wrinkle sites revealed local enhancement of thermal conductivity, with κ ∼ 225 W m-1 K-1. Furthermore, the total interface conductance of wrinkled regions decreased by more than an order of magnitude compared to that of the unwrinkled regions. The physical origin of these observations is discussed based on wrinkle mediated decoupling of the stacked crystallites and partial suspension of the film. Wrinkles are ubiquitous in layered 2D materials, and our work demonstrates their strong influence on thermal transport.

Comparison of enteric methane yield and diversity of ruminal methanogens in cattle and buffaloes fed on the same diet.

An in vivo study was conducted to compare the enteric methane emissions and diversity of ruminal methanogens in cattle and buffaloes kept in the same environment and fed on the same diet. Six cattle and six buffaloes were fed on a similar diet comprising Napier (Pennisetum purpureum) green grass and concentrate in 70:30. After 90 days of feeding, the daily enteric methane emissions were quantified by using the SF6 technique and ruminal fluid samples from animals were collected for the diversity analysis. The daily enteric methane emissions were significantly greater in cattle as compared to buffaloes; however, methane yields were not different between the two species. Methanogens were ranked at different taxonomic levels against the Rumen and Intestinal Methanogen-Database. The archaeal communities in both host species were dominated by the phylum Euryarchaeota; however, Crenarchaeota represented <1% of the total archaea. Methanogens affiliated with Methanobacteriales were most prominent and their proportion did not differ between the two hosts. Methanomicrobiales and Methanomassillicoccales constituted the second largest group of methanogens in cattle and buffaloes, respectively. Methanocellales (Methanocella arvoryza) were exclusively detected in the buffaloes. At the species level, Methanobrevibacter gottschalkii had the highest abundance (55-57%) in both the host species. The relative abundance of Methanobrevibacter wolinii between the two hosts differed significantly. Methanosarcinales, the acetoclastic methanogens were significantly greater in cattle than the buffaloes. It is concluded that the ruminal methane yield in cattle and buffaloes fed on the same diet did not differ. With the diet used in this study, there was a limited influence (<3.5%) of the host on the structure of the ruminal archaea community at the species level. Therefore, the methane mitigation strategies developed in either of the hosts should be effective in the other. Further studies are warranted to reveal the conjunctive effect of diet and geographical locations with the host on ruminal archaea community composition.

Congenital absence of multiple primary teeth.

Idiopathic agenesis of primary dentition is very rare. This is a case report of a 2-year and 6-month-old girl child who presented with 14 missing primary teeth. A review of the previous case reports is done and the management of these cases is discussed.

Mother's knowledge about pre-school child's oral health.

Children under the age of 5 years generally spend most of their time with their parents and guardians, especially mothers, even when they attend pre-schools or nurseries. It has been found that young children's oral health maintenance and outcomes are influenced by their parent's knowledge and beliefs. This study was done to assess the mother's knowledge about the oral health of their pre-school children in Moradabad, India. Mothers of children aged 1-4 years, attending the hospital for vaccination or regular checkups in the pediatric division of government hospitals, were invited to participate in the study. A 20-item questionnaire covering socio-demographic characteristics, dietary practices, oral hygiene practices and importance of deciduous teeth, was distributed to their mothers, during their visit to the hospital. Responses of the mothers were recorded on a Likert Scale. The sample comprised 406 mothers, with the mean age of children being 3.8 years. Three hundred (73.8%) mothers had a good knowledge about diet and dietary practices, while only 110 (27.1%) and 103 (25.4%) mothers were found to have a good knowledge about the importance of oral hygiene practices and importance of deciduous teeth, respectively. Mothers with higher educational qualification and information gained through dentist had a better knowledge about child's oral health. Oral hygiene habits and dietary habits are established during pre-school days and the parents, especially mothers, function as role models for their children.

Magnetic Stimulus Responsive DDS Based on Chitosan Microbeads Embedded with Magnetic Nanoparticles.

In this paper, we have presented a novel Drug Delivery Substrate (DDS) that that is responsive to external stimuli of high-frequency alternating magnetic fields. The DDS is constituted of chitosan crosslinked with PEGDMA (polyethylene glycol dimethacrylate), loaded with Fe3O4 magnetic nanoparticles and vancomycin. In another experiment, a 19-hour elution was observed where three magnetic stimuli of 25 mT, 109.9 kHz were given for 60 min to the test samples. The stimuli were separated by several hours. After excitation span, it was observed that the stimulated samples released a significantly higher amount of vancomycin by as much as 21% compared to non-stimulated samples. In another study, preliminary results showing the effect of different PEGDMA chain lengths have been discussed. These results show evidence of a smart, controllable DDS that allows modulation of its normal passive antibiotic elution by applying external stimuli per personalized needs.

Occult Hepatitis B virus Infection (OBI) predominated by genotype D among chronic liver disease patients: The first report from Odisha, Eastern India.

Detection of Occult hepatitis B infection (OBI) has higher significance for treatment and management. There is no information available about the OBI and its genotype associated with chronic hepatitis patients in Odisha, India. We aimed to determine the association of OBI and its genotype among the chronic hepatitis patients in Odisha. In a hospital based study, 175 serum samples of chronic hepatitis patients were screened for Hepatitis surface antigen (HBsAg). All the HBsAg - negative samples were tested for hepatitis B core antibodies (HBcAb). HBcAb-positive samples were tested further for Hepatitis surface antibodies (HBsAb), hepatitis B virus HBV-DNA and HBV genotyping. Of the 89 HBsAg negative samples, 79 (88.8%) were found positive for HBcAb and these patients were presumed to have OBI. Among the total HBcAb positive samples, 22 (27.8%) were positive and 57 (72.2%) were negative for HBsAb. Detection of HBV- DNA from 45 out of 79 HBcAb positive samples (57.0%) yielded positive results for OBI which was negative for HBsAb. Genotyping of all hepatitis B virus showed that all 45 (100%) were genotype-D. Detection of OBI among chronic hepatitis patients suggests testing for OBI for management and treatment.

Hemostatic Abnormalities in Severe Renal Failure: Do They Bark or Bite?

Abnormal primary hemostasis is believed to be the most significant contributor to uremic bleeding. This study aimed to describe the prevalence and profile of primary and secondary hemostatic disorders in patients with chronic kidney disease (CKD) Stages 4 and 5 and to determine their association if any, with degree of uremia. Stages 4 and 5 predialysis CKD patients attending nephrology outpatient clinic were prospectively recruited and the following bleeding parameters were measured in all patients: platelet count, bleeding time (BT), Factor VIII assay, von Willebrand factor antigen (vWF:Ag), vWF:ristocetin cofactor activity (vWF:RCo), ratio of vWF:ristocetin cofactor activity to vWF antigen (vWF:RCo/vWF:Ag), prothrombin time (PT), and activated partial thromboplastin time (aPTT). Forty-five patients (80%, males) with a mean age of 39.4 years, 82% (n = 37) in Stage 5 CKD, were recruited for the study. The prevalence of thrombocytopenia was significantly higher among patients from West Bengal (15/26, 57.7%) compared to other study patients (2/19, 10.5%; P = 0.001); however, all had macrothrombocytes with normal BT, suggestive of the Harris syndrome. Factor VIII, vWF:Ag, vWF:RCo, vWF:RCo/vWF:Ag ratio, BT, PT, and aPTT were abnormal in 0 (0%), 0 (0%), 0 (0%), 4 (8.8%), 1 (2.2%), 7 (15.6%), and 5 (11.1%) patients, respectively. Except for thrombocytopenia, the prevalence of hemostatic abnormalities did not differ between CKD Stages 4 and 5. Hemostatic abnormalities are uncommon in Stages 4-5 CKD and except for thrombocytopenia, are not associated with degree of uremia. Constitutional macrothrombocytopenia is associated with normal BT even in CKD.

Relationship of Creatinine and Cystatin C-based Estimated Glomerular Filtration rates with Measured Glomerular Filtration Rate in Healthy Kidney Donors from South Asia.

Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation is currently recommended for the estimation of glomerular filtration rate (GFR). This retrospective study aimed to evaluate the correlation between creatinine and cysC-based estimated GFRs and measured GFR in healthy adults. Consecutive healthy adults who were accepted as voluntary kidney donors at our center between January 2008 and December 2012 were included in the study. The 336 individuals who comprised the study population had a mean age of 41.6 ± 11.8 years, male:female ratio 1:1.7, mean creatinine 0.9 ± 0.1 mg/dl, and mean cysC 0.8 ± 0.1 mg/dl. Mean measured GFR by Tc-99m diethylenetriaminepentaacetic acid using Gates method was 98.4 ± 21.2 ml/min/1.73 m2. The mean ± standard deviation of eGFRs by various formulae were as follows: Cockcroft-Gault (CG) = 88.1 ± 15.9 ml/min/1.73 m2, Modification of Diet in Renal Disease (MDRD) = 78 ± 14.7 ml/min/1.73 m2, CKD-EPI creatinine = 88.1 ± 15.5 ml/min/1.73 m2, CKD-EPI cysC = 97 ± 19.9 ml/min/1.73 m2, CKD-EPI creatinine-cysC (CKD-EPI cr-cysC) = 92.5 ± 14.1 ml/min/1.73 m2. The CKD-EPI cr-cysC equation had the highest accuracy, with 43% and 72% of values lying within ±10% and ±20% of the measured GFR, respectively. Bland-Altman analyses for levels of agreement showed least bias with CKD-EPI cysC overall and among females, while among males, CKD-EPI creatinine equation had the least bias. The CKD-EPI equation showed a higher performance than the MDRD and CG equation in GFR estimation of a healthy population. Among CKD-EPI equations, CKD-EPI cr-cysC had the highest accuracy and CKD-EPI cysC the least bias.

Renoprotective and antioxidative effects of methanolic Paederia foetida leaf extract on experimental diabetic nephropathy in rats.

ETHNOPHARMACOLOGICAL RELEVANCE: Paederia foetida Linn. (Family: Rubiaceae) is widely used as a natural remedy for diabetes mellitus by the Nepali and Lepcha tribes of Sikkim and Darjeeling Himalayan region. The plant is administered to a diabetic individual in the form of leaf infusion for 2-3 weeks. Therefore, we investigated the effects of methanolic leaf extract of Paederia foetida (MEPF) on alloxan (ALX) induced diabetic renal oxidative stress and NF-kB dependent renoinflammatory events in rat. Method Effects of MEPF on blood glucose, glomerular filtration rate (GFR), serum and oxidative stress markers were evaluated in ALX induced diabetic wistar rats. Enzyme linked immunosorbent assay (ELISA) was carried out to estimate serum IL-6, IL-1ß, TNF-α and renal tissue NF-kB p65 levels. MEPF treatment was given to the diabetic rats at a dose of 250 and 500mg/kg body weight (b.w.). RESULTS & DISCUSSION: MEPF treatment significantly reduced hyperglycaemia, serum creatinine, blood urea nitrogen (BUN), bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), triglycerides (TRIGs), and total cholesterol (TCHOL) levels in the diabetic rats, whereas it significantly restored GFR and serum albumin level. The activity of enzymatic and non-enzymatic antioxidant machineries was remarkably augmented by MEPF treatment. Likewise, it also significantly lowered lipid peroxidation which was evidenced by decreased concentration of thiobarbituric reactive substances (malondialdehyde, MDA) in the renal tissue of treated diabetic groups. Moreover, MEPF treated animals exhibited low serum concentrations of IL-6, IL-1ß and TNF-α compared to the diabetic control rats. It showed a dose dependent inhibition of NF-kB activation in the diabetic kidney, but the effects were more prominent at a dose of 500mg/kg. Histopathological examinations also confirmed its nephroprotective action during diabetes. CONCLUSION: MEPF treatment mitigates oxidative stress and suppresses renal inflammation via inhibition of NF-kB in diabetic kidney in early progressive diabetic nephropathy.

Effect of Double Filtration Plasmapheresis on Various Plasma Components and Patient Safety: A Prospective Observational Cohort Study.

Double filtration plasmapheresis (DFPP) was historically used for blood group incompatible renal transplantation. Very few studies are available worldwide regarding its efficiency in removing specific plasma components, and safety. We conducted a prospective observational cohort study over 1 year on patients undergoing DFPP for various renal indications. There were 15 patients with 39 sessions. The pre- and post-procedure plasma samples of serum IgG, IgA, IgM, fibrinogen, calcium, phosphate, potassium, and magnesium were analyzed. The effluent albumin concentration was also measured, and complications during the hospital stay were recorded. Cumulative removal of serum IgG, IgA, IgM, fibrinogen, and albumin at the end of four sessions were 72%, 89%, 96%, 88.5%, and 21.3%, respectively and effluent albumin concentration was 1.75 - 2.0 times (range: 6.3 g/dl - 7.2 g/dl; mean ± standard deviation (SD) - 7 g/dl ± 0.3 g/dl) the preprocedural serum albumin (mean ± SD - 3.5 g/dl ± 0.5 g/dl). Removal of other plasma components were not statistically significant. Hypotensive episodes were observed only 16.6%, with the usage of effluent concentration albumin as replacement fluid despite an average 2.4 (mean ± SD - 2.4 ± 0.4 l) liters of plasma volume processing each session. DFPP removes IgG, IgA, IgM, fibrinogen, and albumin. The cumulative removal IgG (72%) is suboptimal, whereas IgA (89%) and IgM (96%) are comparable to historical controls. We observed lesser episodes (12.5%) of hypotension with effluent albumin concentration as replacement fluid, and all bleeding complications were observed when serum fibrinogen level was <50 mg/dl.

Neonatal sepsis in rural India: timing, microbiology and antibiotic resistance in a population-based prospective study in the community setting.

OBJECTIVE: To examine the timing and microbiology of neonatal sepsis in a population-based surveillance in the Indian community setting. STUDY DESIGN: All live born infants in 223 villages of Odisha state were followed at home for 60 days. Suspect sepsis cases were referred to study hospitals for further evaluation including blood culture. RESULTS: Of 12 622 births, 842 were admitted with suspected sepsis of whom 95% were 4 to 60 days old. Culture-confirmed incidence of sepsis was 6.7/1000 births with 51% Gram negatives (Klebsiella predominating) and 26% Gram positives (mostly Staphylococcus aureus). A very high level of resistance to penicillin and ampicillin, moderate resistance to cephalosporins and extremely low resistance to Gentamicin and Amikacin was observed. CONCLUSION: The bacterial burden of sepsis in the Indian community is not high. Judicious choice of empiric antibiotics, antibiotic stewardship and alternate modalities should be considered for the management or prevention of neonatal sepsis in India.