Nirmanmoh Bhatia

Intrapulmonary shunt is a potentially unrecognized cause of ischemic stroke and transient ischemic attack.

BACKGROUND Ischemic stroke is a major cause of mortality and disability. Transient ischemic attack (TIA) is a harbinger of stroke. The etiology of stroke in as many as 40% of patients remains undetermined after extensive evaluation. It was hypothesized that intrapulmonary shunt is a potential facilitator of cerebrovascular accident (CVA) or TIA. METHODS Patients undergoing clinically indicated transesophageal echocardiography were prospectively enrolled. Comprehensive multiplane transesophageal echocardiographic imaging was performed and saline contrast done to assess for intrapulmonary shunt and patent foramen ovale. RESULTS Three hundred twenty-one patients with either nonhemorrhagic CVA (n = 262) or TIA (n = 59) made up the stroke group. Three hundred twenty-one age-matched and gender-matched patients made up the control group. Intrapulmonary shunt occurred more frequently in the stroke group (72 of 321) compared with the control group (32 of 321) (22% vs 10%, P < .0001). Intrapulmonary shunt was an independent predictor of CVA and/or TIA (odds ratio, 2.6; P < .0001). In subjects with cryptogenic CVA or TIA (n = 71), intrapulmonary shunt occurred more frequently (25 of 71) than in the control group (5 of 71) (35% vs 7%, P < .0001). Intrapulmonary shunt was an independent multivariate predictor of CVA or TIA in patients with cryptogenic CVA or TIA (odds ratio, 6.3; P < .005). CONCLUSIONS These results suggest that intrapulmonary shunt is a potentially unrecognized facilitator of CVA and TIA, especially in patients with cryptogenic CVA and TIA. Future studies assessing the prognostic significance of intrapulmonary shunt on cerebral vascular event recurrence rates in patients after initial CVA or TIA would be of great interest.

Urinary catheterization in medical wards

Aims: The study aims to determine the: 1. frequency of inappropriate catheterization in medical wards and the reasons for doing it. 2. various risk factors associated with inappropriate catheterization, catheter associated urinary tract infections (CAUTI) and bacterial colonization on Foleys catheters (BCFC). Settings and Design: Hospital-based prospective study. Materials and Methods: One hundred and twenty five patients admitted consecutively in the medical wards of a tertiary care hospital, who underwent catheterization with a Foleys catheter, at admission, have been included in the study. Patient profiles were evaluated using the following parameters: age, sex, diagnosis, functional status, mental status, indication, duration and place of catheterization, development of BCFC and CAUTI. Statistical tests used: Chi-square test. Results: Thirty-six out of 125 (28.8%) patients included were inappropriately catheterized. BCFC developed in 52.8% and 22.4% were diagnosed with a CAUTI. The most frequent indication for inappropriate catheterization was urinary incontinence without significant skin breakdown (27.8%). The risk factors for inappropriate catheterization were female sex (RR=1.29, 95% CI=0.99, 1.69, P<0.05) and catheterization in the emergency (RR=0.74, 95% CI=0.61, 0.90, P<0.05). The risk factors for developing a BCFC were age>60 years (RR=0.65, 95% CI=0.48, 0.89, P<0.05), non-ambulatory functional status (RR=0.57, 95% CI=0.39, 0.84, P<0.01), catheterization in the emergency (RR=2.01, 95% CI=1.17, 3.46, P<0.01) and duration of catheterization>3 days (RR=0.62, 95% CI=0.43, 0.89, P<0.01). The risk factors for acquiring a CAUTI were age>60 years (RR=0.47, 95% CI=0.25, 0.90, P<0.05), impaired mental status (RR=0.37, 95% CI=0.18, 0.77, P<0.01) and duration of catheterization>3 days (RR=0.24, 95% CI=0.10, 0.58, P<0.01). Conclusions: Inappropriate catheterization is highly prevalent in medical wards, especially in patients with urinary incontinence. The patients catheterized in the medical emergency and female patients in particular are at high risk. Careful attention to these factors can reduce the frequency of inappropriate catheterization and unnecessary morbidity.

Cardiovascular Effects of Androgen Deprivation Therapy for the Treatment of Prostate Cancer ABCDE Steps to Reduce Cardiovascular Disease in Patients With Prostate Cancer

Case Presentation: A 74-year-old man with a new diagnosis of locally advanced prostate cancer is referred to the cardio-oncology clinic for optimization of his cardiovascular health after treatment with degarelix, a gonadotropin-releasing hormone (GnRH) receptor antagonist, for his prostate cancer. Two years ago, he had a myocardial infarction resulting in placement of a drug-eluting stent in his proximal left anterior descending artery. He has had no recurrent symptoms but lives a sedentary lifestyle. An electrocardiogram showed normal sinus rhythm. His most recent echocardiogram demonstrated a structurally normal heart with normal left ventricular ejection fraction. He takes aspirin 81 mg daily. He has hypertension, with the last recorded blood pressure of 160/90 mm Hg, and he is currently treated with metoprolol 25 mg twice daily and lisinopril 40 mg daily. He has diabetes mellitus that is treated with glipizide 10 mg daily, and his last hemoglobin A1c level was 7.4 mg/dL. He is also treated with pravastatin 40 mg daily; his low-density lipoprotein was 120 mg/dL at his most recent clinic visit. He continues to smoke 1 pack of cigarettes daily, and his body mass index is 30 kg/m2. Prostate cancer is the most common noncutaneous cancer diagnosed in men in the United States and the second leading cause of cancer death.1 In 2015, there were an estimated 3 million prostate cancer survivors in the United States; this number will reach 4 million in the next decade.1 Because of the indolent, slowly progressive disease course of prostate cancer and advances in early detection and effective treatment, non–cancer-related deaths are the most common causes of mortality.2 In particular, given the prevalence of pre-existing and new cardiovascular disease (CVD), ischemic heart disease is the most common noncancer cause of death in patients with prostate cancer.2 Androgen …

Occupational stress amongst nurses from two tertiary care hospitals in Delhi.

Background Nursing is known to be a stressful profession. Nursing staff working at the bottom of the hierarchy and in public hospitals are the ones who are more stressed out. There is a paucity of data on prevalence of stress amongst nurses in the Indian setting. The individual contribution of various stressors, operational in nurse’s personal and professional life, to the overall stress levels also needs to be studied. Method A hospital based cross sectional study was carried out on 87 randomly selected staff nurses working in two tertiary care teaching hospitals of Central Delhi. Data was collected using pre-tested and self-administered questionnaire. Sociodemographic profile, stressors in daily life, stressors at workstation and total stress level was also assessed. The data was fed and analysed using WHO’s EPI-INFO 2005 software.

The role of implantable cardioverter-defibrillators in patients with continuous flow left ventricular assist devices — A meta-analysis

BACKGROUND Left ventricular assist devices (LVADs) and implantable cardioverter defibrillators (ICD) are each known to improve mortality in patients with advanced congestive heart failure (CHF). If ICDs contribute to improved survival specifically in recipients of LVADs is currently unknown. AIM To evaluate the impact of presence of ICD on mortality in continuous flow LVAD recipients. METHODS A meta- analysis of available literature was performed. PubMed, Embase and Google Scholar databases were searched for studies that compared mortality in continuous flow LVAD patients with ICDs (new implantation or no de-activation) and without ICDs (including de-activation of existing implant). Pooled analysis using a fixed effects model was used for outcomes of interest. RESULTS We included 3 observational studies for a total of 292 patients (203 (69.5%) with ICD versus 89 (30.5%) without ICD). The presence of an active ICD was not associated with improved survival [OR 0.63, 95% CI 0.33-1.18; p=0.15]. In bridge to transplantation [BT] patients (224 patients, 149 with ICD versus 75 without ICD), an active ICD was not associated with a higher probability of survivzal [OR 1.47, 95% CI 0.78-2.76; p=0.23]. There was no difference in the occurrence of severe right ventricular dysfunction or failure between two groups [OR 0.78, 95% CI 0.42-1.47; p=0.45]. The risk of LVAD related complications were similar [OR 0.68, 95% CI 0.35-1.31; P=0.25]. CONCLUSION This meta-analysis demonstrates that there is no survival benefit with ICD in heart failure patients supported with continuous flow LVAD. There is an urgent need of large-scale randomized trials to specifically address this issue.

Determination of the Optimum Number of Cardiac Cycles to Differentiate Intra‐Pulmonary Shunt and Patent Foramen Ovale by Saline Contrast Two‐ and Three‐Dimensional Echocardiography

Patent foramen ovale (PFO) and intra‐pulmonary shunt (IPS) are potential causes of stroke. The most optimum cardiac cycle cutoff for bubbles to appear in the left heart on saline contrast transthoracic echocardiography (TTE) as criteria to differentiate the 2 entities is unknown.

Staged versus index procedure complete revascularization in ST‐elevation myocardial infarction: A meta‐analysis

BACKGROUND Complete revascularization of patients with ST-elevation myocardial infarction and multivessel coronary artery disease reduces adverse events compared to infarct-related artery only revascularization. Whether complete revascularization should be done as multivessel intervention during index procedure or as a staged procedure remains controversial. METHOD We performed a meta-analysis of randomized controlled trials comparing outcomes of multivessel intervention in patients with ST-elevation myocardial infarction and multivessel coronary artery disease as staged procedure versus at the time of index procedure. Composite of death or myocardial infarction was the primary outcome. Mantel-Haenszel risk ratios were calculated using random effect model. RESULTS Six randomized studies with a total of 1126 patients met our selection criteria. At a mean follow-up of 13 months, composite of myocardial infarction or death (7.2% vs 11.7%, RR: 1.66, 95%CI: 1.09-2.52, P = 0.02), all cause mortality (RR: 2.55, 95%CI: 1.42-4.58, P < 0.01), cardiovascular mortality (RR: 2.8, 95%CI: 1.33-5.86, P = 0.01), and short-term (<30 days) mortality (RR: 3.54, 95%CI: 1.51-8.29, P < 0.01) occurred less often in staged versus index procedure multivessel revascularization. There was no difference in major adverse cardiac events (RR: 1.14, 95%CI: 0.88-1.49, P = 0.33), repeat myocardial infarction (RR: 1.14, 95%CI: 0.68-1.92, P = 0.61), and repeat revascularization (RR: 0.92, 95%CI: 0.66-1.28, P = 0.62). CONCLUSION In patients with ST-elevation myocardial infarction and multivessel coronary artery disease, a strategy of complete revascularization as a staged procedure compared to index procedure revascularization results in reduced mortality without an increase in repeat myocardial infarction or need for repeat revascularization.

Meta-Analysis of Aspirin Versus Dual Antiplatelet Therapy Following Coronary Artery Bypass Grafting

Although aspirin monotherapy is considered the standard of care after coronary artery bypass grafting (CABG), more recent evidence has suggested a benefit with dual antiplatelet therapy (DAPT) after CABG. We performed a meta-analysis of observational studies and randomized controlled trials comparing outcomes of aspirin monotherapy with DAPT in patients after CABG. Subgroup analyses were conducted according to surgical technique (i.e., on vs off pump) and clinical presentation (acute coronary syndrome vs no acute coronary syndrome). Random effects overall risk ratios (RR) were calculated using the DerSimonian and Laird model. Eight randomized control trials and 9 observational studies with a total of 11,135 patients were included. At a mean follow-up of 23 months, major adverse cardiac events (10.3% vs 12.1%, RR 0.84, confidence interval [CI] 0.71 to 0.99), all-cause mortality (5.7% vs 7.0%, RR 0.67, CI 0.48 to 0.94), and graft occlusion (11.3% vs 14.2%, RR 0.79, CI 0.63 to 0.98) were less with DAPT than with aspirin monotherapy. There was no difference in myocardial infarction, stroke, or major bleeding between the 2 groups. In conclusion, DAPT appears to be associated with a reduction in graft occlusion, major adverse cardiac events, and all-cause mortality, without significantly increasing major bleeding compared with aspirin monotherapy in patients undergoing CABG.

National Trends in the Incidence, Management, and Outcomes of Heart Failure Complications in Patients Hospitalized for ST-Segment Elevation Myocardial Infarction

Objective To analyze contemporary trends in the incidence, management, and clinical outcomes of heart failure (HF) complications in patients hospitalized for ST-segment elevation myocardial infarction (STEMI) in the United States. Patients and Methods Using the 2003 through 2010 Nationwide Inpatient Sample databases, all patients with STEMI who were 18 years and older with acute HF were identified. Overall trends in the incidence of HF, coronary intervention, and in-hospital mortality were analyzed. Results Of 1,990,002 hospitalizations with a primary diagnosis of STEMI, 471,525 (23.7%) had HF complication (decreasing from 25.4% [95% CI, 25.3%-25.6%] in 2003 to 20.7% [95% CI, 20.5%-20.8%]) in 2010 (P trend<.001). The incidence of cardiogenic shock in patients with HF-complicated STEMI increased from 13.9% (95% CI, 13.6%-14.1%) to 22.6% (95% CI, 22.2%-23.0%) during this period (P trend<.001). From 2003 through 2010, the use of diagnostic coronary angiography and percutaneous coronary intervention increased in patients with HF-complicated STEMI from 44.3% to 62.1% and from 25.0% to 48.1%, respectively. In-hospital mortality decreased significantly in patients with HF-complicated STEMI (from 18.1% to 15.1%) and in subgroups of those with (from 42.4% to 29.9%) and without (from 14.1% to 10.8%) cardiogenic shock (all P trend<.001). The adjusted odds ratio (AOR) (per year) of death was 0.992 (95% CI, 0.988-0.997; P<.001), which changed significantly after additional adjustment for coronary intervention (AOR [per year], 1.012; 95% CI, 1.008-1.017; P<.001). Conclusion The incidence and in-hospital mortality of HF-complicated STEMI has decreased significantly during recent times along with increased use of percutaneous coronary intervention and diagnostic coronary angiography.

Trends and Outcomes of Infective Endocarditis in Patients on Dialysis.

Dialysis patients are at high risk for infective endocarditis (IE); however, no large contemporary data exist on this issue. We examined outcomes of 44 816 patients with IE on dialysis and 202 547 patients with IE not on dialysis from the Nationwide Inpatient Sample database from 2006 thorough 2011. Dialysis patients were younger (59 ± 15 years vs 62 ± 18 years) and more likely to be female (47% vs 40%) and African‐American (47% vs 40%; all P < 0.001). Hospitalizations for IE in the dialysis group increased from 175 to 222 per 10 000 patients (P trend = 0.04). Staphylococcus aureus was the most common microorganism isolated in both dialysis (61%) and nondialysis (45%) groups. IE due to S aureus (adjusted odds ratio [aOR]: 1.79, 95% confidence interval [CI]: 1.73‐1.84), non‐aureus staphylococcus (aOR: 1.72, 95% CI: 1.64‐1.80), and fungi (aOR: 1.4, 95% CI: 1.12‐1.78) were more likely in the dialysis group, whereas infection due to gram‐negative bacteria (aOR: 0.85, 95% CI: 0.81‐0.89), streptococci (aOR: 0.38, 95% CI: 0.36‐0.39), and enterococci (aOR: 0.78, 95% CI: 0.74‐0.82) were less likely (all P < 0.001). Dialysis patients had higher in‐hospital mortality (aOR: 2.13, 95% CI: 2.04‐2.21), lower likelihood of valve‐replacement surgery (aOR: 0.82, 95% CI: 0.76‐0.86), and higher incidence of stroke (aOR: 1.08, 95% CI: 1.03‐1.12; all P < 0.001). We demonstrate rising incidence of IE‐related hospitalizations in dialysis patients, highlight significant differences in baseline comorbidities and microbiology of IE compared with the general population, and validate the association of long‐term dialysis with worse in‐hospital outcomes.