Ghanshyam Palamaner Subash Shantha

Sex differences in short-term and long-term all-cause mortality among patients with ST-segment elevation myocardial infarction treated by primary percutaneous intervention: a meta-analysis.

IMPORTANCE Although outcomes in patients with ST-segment elevation myocardial infarction (STEMI) have improved in the past 2 decades, a sex disparity exists in survival, with women having higher mortality than men. OBJECTIVE To conduct a meta-analysis of observational studies that examined differences in mortality by sex in patients with STEMI treated with primary percutaneous coronary intervention (PPCI). DATA SOURCES MEDLINE, EMBASE, Cochrane central, and electronic databases were searched for relevant studies in all languages and without time restriction. STUDY SELECTION Studies were included if (1) they studied patients who presented with STEMI, (2) primary percutaneous coronary intervention (PPCI) was the treatment for STEMI, (3) PPCI was performed within 12 hours of symptom onset, and (4) sex-specific in-hospital and/or 1-year mortality were reported. DATA EXTRACTION AND SYNTHESIS Two investigators independently reviewed retrieved citations and assessed eligibility. Discrepancies were resolved by consensus. Quality of included studies was assessed using Newcastle-Ottawa Quality Assessment Scale for cohort studies. Data were pooled using a random-effects model. MAIN OUTCOMES AND MEASURES Sex-specific in-hospital and 1-year all-cause mortality. Risk ratios (RRs) of mortality were used for these 2 time points, if reported. RESULTS Of the 149 studies identified, 35 met inclusion criteria, representing 18 555 women and 49 981 men. In the unadjusted analyses, women were at a higher risk for in-hospital (RR, 1.93; 95% CI, 1.75-2.14 [P < .001, I2 = 14%]) and 1-year all-cause mortality (RR, 1.58; 95% CI, 1.36-1.84 [P < .001, I2 = 51%]) compared with men. However, when adjusted RRs were used, the association between women and higher risk of all-cause mortality was attenuated but still significantly elevated for in-hospital mortality (RR, 1.48; 95% CI, 1.07-2.05 [P = .02, I2 = 56%]), but the higher risk for 1-year mortality in women was no longer significant (RR, 0.90; 95% CI, 0.69-1.17 [P = .42, I2 = 58%]). CONCLUSIONS AND RELEVANCE An increased mortality in women with STEMI treated with PPCI was detected in this large meta-analysis but is likely confounded by baseline cardiovascular risk factors and the differences in clinical profile of male and female patients with STEMI. Intensive cardiovascular risk modification efforts in women may help to reduce this sex disparity.

Progressive hemi facial atrophy - Parry Romberg syndrome presenting as severe facial pain in a young man: a case report

We present a 30-year-old South Indian man who presented with complaints of left sided headache and facial pain for past 3 months, severe for past 10 days. On physical examination, right side of the face appeared normal. Left side of the face showed signs of hemi atrophy with minimal drooping of left eyelid. All Systems were found to be normal. Routine blood and urine investigations results were within normal limits. X-ray chest revealed no abnormalities and x-ray skull showed both sides equal. Computerized tomogram of the brain showed left minimal sub dural hygroma with no midline shift, and no evidence of cerebral edema or cerebral atrophy. Nerve conduction study showed features suggestive of trigeminal neuralgia. MRI of the skull base was also normal and showed no evidence of trigeminal nerve compression. Interestingly, he had minimal response to analgesics, steroids, and propranolol, but showed immediate response to carbamazepine. Hence this patient indeed had Parry Romberg syndrome: Hemi facial atrophy with trigeminal neuralgia.

Cataract, Visual Impairment and Long-Term Mortality in a Rural Cohort in India: The Andhra Pradesh Eye Disease Study

Background A large-scale prevalence survey of blindness and visual impairment (The Andhra Pradesh Eye Diseases Study [APEDS1]) was conducted between 1996-2000 on 10,293 individuals of all ages in three rural and one urban clusters in Andhra Pradesh, Southern India. More than a decade later (June 2009-March 2010), APEDS1 participants in rural clusters were traced (termed APEDS2) to determine ocular risk factors for mortality in this longitudinal cohort. Methods and Findings Mortality hazard ratio (HR) analysis was performed for those aged >30 years at APEDS1, using Cox proportional hazard regression models to identify associations between ocular exposures and risk of mortality. Blindness and visual impairment (VI) were defined using Indian definitions. 799/4,188 (19.1%) participants had died and 308 (7.3%) had migrated. Mortality was higher in males than females (p<0.001). In multivariable analysis, after adjusting for age, gender, diabetes, hypertension, body mass index, smoking and education status the mortality HR was 1.9 (95% CI: 1.5-2.5) for blindness; 1.4 (95% CI: 1.2-1.7) for VI; 1.8 (95% CI: 1.4-2.3) for pure nuclear cataract, 1.5 (95% CI: 1.1-2.1) for pure cortical cataract; 1.96 (95% CI: 1.6-2.4) for mixed cataract, 2.0 (95% CI: 1.4-2.9) for history of cataract surgery, and 1.58 (95% CI: 1.3-1.9) for any cataract. When all these factors were included in the model, the HRs were attenuated, being 1.5 (95% CI: 1.1-2.0) for blindness and 1.2 (95% CI: 0.9-1.5) for VI. For lens type, the HRs were as follows: pure nuclear cataract, 1.6 (95% CI: 1.3-2.1); pure cortical cataract, 1.5 (95% CI: 1.1-2.1); mixed cataract, 1.8 (95% CI: 1.4-2.2), and history of previous cataract surgery, 1.8 (95% CI: 1.3-2.6). Conclusions All types of cataract, history of cataract surgery and VI had an increased risk of mortality that further suggests that these could be potential markers of ageing.

Association of vitamin D and incident statin induced myalgia--a retrospective cohort study.

Background and Objectives Evidence is conflicting with regards to the role of vitamin D in statin induced myalgia (SIM). Studies so far have assessed cross-sectional association and were limited by study sample selected predominantly from cardiology clinics. In this retrospective cohort study we assessed the association between vitamin D and SIM and attempted to establish a serum vitamin D cutoff to identify patients at risk for developing SIM. Methods Medical charts of 5526 consecutive patients from a primary care practice in Scranton, Pennsylvania from 2005–2012 were reviewed. Vitamin D level (25-hydroxy cholecalciferol) at statin initiation was considered “Exposure level”. Vitamin D levels were categorized into quartiles (≤ 10, 11–20, 21–30, >30 ng/ml). SIM was identified by patient report. Results 1160 out of 5526 patients were treated with statins. The mean age was 55.9 years. 276 (24%) developed SIM. Unadjusted 7-yr cumulative incidences of SIM for quartiles 1–4 of vitamin D were 32.3, 21.5, 18.3 and 14.6% respectively. The lowest quartile of vitamin D was independently associated with 1.21 times the hazard of the fourth quartile for developing SIM (95% CI: 1.09, 1.33; P-trend  = 0.001). Vitamin D cut-off ≤15 ng/ml, showed a positive predictive value, negative predictive value, likelihood ratio (LR) + and LR- of 81, 90, 5.1 and 0.1, respectively for predicting SIM. Conclusions Low vitamin D level at statin initiation is associated with SIM, levels ≤15 ng/ml have a high predictive accuracy for SIM. Randomized controlled trials are needed to validate our results.

Lactate and risk of incident diabetes in a case-cohort of the atherosclerosis risk in communities (ARIC) study

Background Oxidative capacity is decreased in type 2 diabetes. Whether decreased oxidative capacity is a cause or consequence of diabetes is unknown. Our purpose is to evaluate whether lactate, a marker of oxidative capacity, is associated with incident diabetes. Methods and Findings We conducted a case-cohort study in the Atherosclerosis Risk in Communities (ARIC) study at year 9 of follow-up. We evaluated lactate’s association with diabetes risk factors at baseline and estimated the hazard ratio for incident diabetes by quartiles of plasma lactate in 544 incident diabetic cases and 533 non-cases. Plasma lactate showed a graded positive relationship with fasting glucose and insulin (P<0.001). The relative hazard for incident diabetes increased across lactate quartiles (P-trend ≤0.001). Following adjustment for demographic factors, medical history, physical activity, adiposity, and serum lipids, the hazard ratio in the highest quartile was 2.05 times the hazard in the lowest quartile (95% CI: 1.28, 3.28). After including fasting glucose and insulin the association became non-significant. Conclusions Lactate, an indicator of oxidative capacity, predicts incident diabetes independent of many other risk factors and is strongly related to markers of insulin resistance. Future studies should evaluate the temporal relationship between elevated lactate and impaired fasting glucose and insulin resistance.

Population Based Outcomes of Cataract Surgery in Three Tribal Areas of Andhra Pradesh, India: Risk Factors for Poor Outcomes

Purpose To report visual outcomes and risk factors for poor outcomes of cataract surgery in three Integrated Tribal Development Agency (ITDA) areas of Andhra Pradesh, India. Methods and Results Using validated Rapid Assessment of Avoidable Blindness (RAAB) methodology, a population based cross-sectional study, was conducted in three ITDA areas. A two-stage sampling procedure was used to select 7281 participants aged 50 years and above. Vision assessment using a tumbling E chart and standard ocular examinations were completed. Visual outcomes and risk factors for poor outcomes were assessed among subjects undergoing cataract surgery (1548 eyes of 1124 subjects). Mean age at surgery was 67±8 years; Among the operated eyes, presenting visual acuity (PVA) and best corrected visual acuity (BCVA) worse than 6/18 was seen in 492 (31.8%; 95% CI, 29.5–34.2%) and 298 eyes (19.3%; 95% CI, 17.3–21.3%), respectively. Similarly, PVA and BCVA worse than 6/60 was seen in 219 (14.1%; 95% CI, 12.4–16%) and 147 eyes (9.5%; 95% CI, 8.1–11.1%), respectively. When either eye was taken into consideration, the PVA and BCVA worse than 6/18 was seen in 323 (20.1%; 95% CI, 18.9–23%) and 144 subjects (9.3%; 95% CI, 7.9–10.9%), respectively. PVA and BCVA worse than 6/60 was seen in 74 (4.8%; 95% CI, 3.8–6%) and 49 subjects (3.2%; 95% CI, 2.4–4.2%), respectively. Posterior capsular opacification was seen in 51 of 1316 pseudophakic eyes (3.9%; 95% CI, 2.9–5.1%). In multivariable analysis among pseudophakic subjects with PVA worse than 6/18, increasing age (p = 0.002) and undergoing free surgery (p = 0.05) were independent risk factors. Undergoing surgery before 2005 (p = 0.05) and being illiterate (p = 0.05) were independent risk factors for BCVA worse than 6/18. Conclusions There are changing trends with improved outcomes in cataract surgery among these tribal populations of India. However, post-operative refractive error correction remains an issue, especially for those undergoing free surgeries.

Comparative outcomes of manual small incision cataract surgery and phacoemulsification performed by ophthalmology trainees in a tertiary eye care hospital in India: a retrospective cohort design

Objective To compare the outcomes of manual small incision cataract surgery (MSICS) and phacoemulsification performed by ophthalmology trainees. Design Retrospective cohort design. Setting Tertiary eye care centre. Participants A total of 1029 subjects underwent cataract surgeries with MSICS technique or phacoemulsification by trainees during one quarter (July–September 2007). Only 484 (47%) subjects were males. Surgeries which were primarily large incision extracapsular or intracapsular cataract extraction and performed on patients less than 20 years of age were excluded. Outcome measures The postoperative best corrected visual acuity (BCVA) along with the rates and types of complications were compared between both the groups. Results A total of 1029 surgeries were performed by 22 resident surgeons. In all, 522 (50.7%) were done using MSICS technique and 507 (49.2%) were done by phacoemulsification. Those in the MSICS group were significantly older (age >70 years; 5.7% vs 3.4%; p<0.001) and had worse preoperative visual acuity (visual acuity <6/60; 69.3% vs 40.4%; p<0.001). Postoperatively, the number of patients having BCVA≥6/12 was similar in both the groups (84.3% vs 88%; p=0.09). The complication rates were higher in MSICS group (15.1% vs 7.1%, p<0.001). Most common risk factor for poor outcome (postoperative BCVA<6/60) in both the groups was presence of associated ocular pathologies (OR 7.4 95% CI 3.4 to 16.4) and having a complications (OR 5.7 95% CI 3.0 to 10.8). Conclusions Although the complication rate was higher in the MSICS group, there was no difference in BCVA in both the groups.

Rhabdomyolysis in community acquired bacterial sepsis--a retrospective cohort study.

Background and Objectives Rhabdomyolysis is often associated with sepsis and gram positive bacterial pathogens are reported to be the most frequent cause of sepsis induced rhabdomyolysis. We report the pattern of infecting bacterial pathogens and associated causal factors in a South-Indian cohort. Design, Setting, Participants & Measurements Retrospective cohort study of adult patients with community acquired bacterial sepsis complicated by rhabdomyolysis from March 2003 - August 2008. Rhabdomyolysis was defined as serum creatine kinase >2000 IU/L. The study population was divided into group-I (sepsis with gram positive pathogens), group–II (sepsis with gram negative pathogens) and group-III (culture negative sepsis). Results 103 patients (group I -15, group II- 34 and group III- 54) formed the study cohort. Mean age was 55 years and two-third had diabetes. Mean creatine kinase was 7114 IU/L and mean serum creatinine on admission was 2.4 mg/dl. Causative pathogen of sepsis was identified in 47.5%. Gram negative pathogens were more frequently (33%) associated with rhabdomyolysis than gram positive pathogens (14.5%). Lung was the commonest foci of sepsis (38.8%). 78.6% of the study population had one or more additional causal factor for rhabdomyolysis like statin intake, chronic alcoholism, hypokalemia, hypernatremia and hypophosphatemia. Mortality was 59%. Conclusions Gram negative bacterial pathogens were more frequently associated with rhabdomyolysis than gram positive pathogens. Rhabdomyolysis in patients with sepsis is multifactorial and is associated with high mortality.

Prevalence of Subclinical Hypothyroidism in Patients with End-Stage Renal Disease and the Role of Serum Albumin: A Cross-Sectional Study from South India

Background/Aim: Subclinical hypothyroidism (SCH) and end-stage renal disease (ESRD) are independent risk factors for cardiovascular mortality. We aimed to study the prevalence of SCH in ESRD patients and assessed its associated risk factors. Methods: This cross-sectional study was conducted at 2 tertiary-care centers in Chennai, India, over a 3-year period. The study group comprised 137 patients with ESRD on thrice weekly regular maintenance hemodialysis. Free thyroxine (FT4) and thyroid-stimulating hormone (TSH) were measured using an electrochemiluminescence immunoassay. SCH was defined as TSH ranging between 4.5 and 10 mIU/l with normal FT4 (0.93–1.7 ng/dl). Patients with overt hypothyroidism, SCH and overt hyperthyroidism, those on medications affecting thyroid function and pregnant women were excluded from the study. Results: Of 137 ESRD patients (mean age: 43 ± 13.38 years), 107 were males (78.1%), 45 diabetics (32.8%), 127 hypertensives (92.7%), and 38 smokers (27.7%). Prevalence of SCH was 24.8%. In unadjusted (OR: 3.37, 95% CI: 1.91–5.21) and adjusted (for age, gender, HbA1C, and albumin/creatinine ratio; OR: 3.11, 95% CI: 2.15–4.98) logistic regression analysis, serum albumin was significantly associated with SCH. Further, multiple linear regression identified that for every 1 g/dl drop in serum albumin TSH increased by 4.61 mIU/l (95% CI: 2.75–5.92). Conclusion: We observed a high prevalence of SCH in our ESRD patients. Also, serum albumin was significantly associated with SCH in our study.

Association between sleep-disordered breathing, obstructive sleep apnea, and cancer incidence: a systematic review and meta-analysis.

OBJECTIVE/BACKGROUND Via this systematic review and meta-analysis, we assessed the associatio between sleep-disordered breathing (SDB)/obstructive sleep apnea (OSA) and cancer incidence. METHOD Medline, Embase, Cochrane Central, and electronic databases were searched for relevant studies in any language. Studies were included based on the following criteria: (1) those on patients with SDB/OSA, (2) those reporting cancer incidence rates specific to patients with SDB/OSA, and (3) those defining SDB/OSA using sleep-study-based objective measures. The quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale (NOQA). RESULTS Of the 8766 retrieved citations, five studies that defined SDB/OSA using the apnea-hypopnea index (AHI) or the respiratory disturbance index (RDI) totaling 34,848 patients with SDB and 77,380 patients without SDB were pooled into a meta-analysis. All five studies were of good quality (NOQA ≥ 6). A total of 574 (1.6%) and 290 (0.37%) incident cancers were reported in patients with and without SDB, respectively. In the unadjusted analysis, patients with SDB/OSA were at an increased risk of incident cancer (relative risk [RR]: 1.53, 95% confidence interval [CI]: 1.31-1.79, P <0.001, I(2): 0, five included studies). When adjusted for traditional cancer risk factors, the association between SDB/OSA and cancer incidence, although attenuated (RR: 1.40, 95% CI: 1.01-1.95, P = 0.04, I(2): 60%, five included studies), remains significant. CONCLUSIONS SDB/OSA may increase the risk of incident cancer. Inferring an independent association is not possible from our analysis considering the retrospective cohort design of the included studies and high inter-study heterogeneity. An individual patient data meta-analysis would help validate our findings.