Study protocol of DIVERGE, the first genetic epidemiological study of major depressive disorder in Pakistan

INTRODUCTION: Globally, 80% of the burdenof major depressive disorder (MDD) pertains to low- and middle-income countries. Research into genetic and environmental risk factors has the potential to uncover disease mechanisms that may contribute to better diagnosis and treatment of mental illness, yet has so far been largely limited to participants with European ancestry from high-income countries. The DIVERGE study was established to help overcome this gap and investigate genetic and environmental risk factors for MDD in Pakistan. METHODS: DIVERGE aims to enrol 9000 cases and 4000 controls in hospitals across the country. Here, we provide the rationale for DIVERGE, describe the study protocol and characterise the sample using data from the first 500cases. Exploratory data analysis is performed to describe demographics, socioeconomic status, environmental risk factors, family history of mental illness and psychopathology. RESULTS AND DISCUSSION: Many participants had severe depression with 74% of patients who experienced multiple depressive episodes. It was a common practice to seek help for mental health struggles from faith healers and religious leaders. Socioeconomic variables reflected the local context with a large proportion of women not having access to any education and the majority of participants reporting no savings. CONCLUSION: DIVERGE is a carefully designed case-control study of MDD in Pakistan that captures diverse risk factors. As the largest genetic study in Pakistan, DIVERGE helps address the severe underrepresentation of people from South Asian countries in genetic as well as psychiatric research

Study protocol of DIVERGE, the first genetic epidemiological study of major depressive disorder in Pakistan.

INTRODUCTION: Globally, 80% of the burdenof major depressive disorder (MDD) pertains to low- and middle-income countries. Research into genetic and environmental risk factors has the potential to uncover disease mechanisms that may contribute to better diagnosis and treatment of mental illness, yet has so far been largely limited to participants with European ancestry from high-income countries. The DIVERGE study was established to help overcome this gap and investigate genetic and environmental risk factors for MDD in Pakistan. METHODS: DIVERGE aims to enrol 9000 cases and 4000 controls in hospitals across the country. Here, we provide the rationale for DIVERGE, describe the study protocol and characterise the sample using data from the first 500 cases. Exploratory data analysis is performed to describe demographics, socioeconomic status, environmental risk factors, family history of mental illness and psychopathology. RESULTS AND DISCUSSION: Many participants had severe depression with 74% of patients who experienced multiple depressive episodes. It was a common practice to seek help for mental health struggles from faith healers and religious leaders. Socioeconomic variables reflected the local context with a large proportion of women not having access to any education and the majority of participants reporting no savings. CONCLUSION: DIVERGE is a carefully designed case-control study of MDD in Pakistan that captures diverse risk factors. As the largest genetic study in Pakistan, DIVERGE helps address the severe underrepresentation of people from South Asian countries in genetic as well as psychiatric research

Racial and Socioeconomic Disparities in Cardiovascular Outcomes of Preeclampsia Hospitalizations in the United States 2004-2019

Background: Preeclampsia is associated with higher in-hospital cardiovascular events and mortality with known disparities by race/ethnicity, but data on the interaction between income and these outcomes remain limited. Objectives: This study investigated racial and socioeconomic disparities in cardiovascular outcomes of preeclampsia at delivery hospitalizations. Methods: We analyzed National Inpatient Sample data using International Classification of Diseases-9th Revision/-10th Revision codes between 2004 and 2019. We identified a total of 2,436,991 delivery hospitalizations with preeclampsia/eclampsia as a primary diagnosis representing White (43.1%), Black (18.4%), Hispanic (18.7%), and Asian or Pacific Islander (A/PI; 3.3%) women. We stratified the population based on median household income (low income, medium income, and high income). Logistic regression and propensity-matched analysis were used for reporting outcomes adjusted for age, hospital region, and baseline comorbidities. Results: Black Hispanic, and A/PI women with preeclampsia had higher in-hospital mortality compared with White women across all groups of income. Hispanic women had lower odds of peripartum cardiomyopathy (PPCM) compared with White women. A significant interaction effect was observed with race/ethnicity and median household income for in-hospital mortality and PPCM with preeclampsia. Furthermore, high-income Black women had higher odds of PPCM, stroke, acute kidney injury, heart failure, cardiac arrhythmia, and venous thromboembolism compared with low-income White women. Conclusions: Women with preeclampsia experience significant racial/ethnic and socioeconomic disparities in inpatient mortality and cardiovascular outcomes at delivery. Across all income groups, Black, Hispanic, and A/PI women experience higher odds of in-hospital mortality compared with White women. Furthermore, high-income Black women had greater odds of many CV complications compared with low-income White women

Amidst COVID-19 pandemic: the catastrophic sequelae of an inadvertent carotid artery insertion during central venous catheter placement – a case report

Introduction: Central venous catheter (CVC) placement is one of the most commonly performed procedures in the intensive care unit for the institution of high-risk medications and nutrients. Despite the frequent use of ultrasound, inadvertent placement of CVC into the carotid artery is still possible. It carries significant morbidity due to the incidence of bleeding, arteriovenous fistula, and stroke. Methods: We present a case of accidental placement of CVC into the right carotid artery, which led to the right-sided temporoparietal stroke. Case Summary: A 71-year-old male was admitted to hospital with symptoms of cough, fatigue, and shortness of breath. He was diagnosed with coronavirus disease-19 and did require mechanical ventilation due to progressive hypoxic respiratory failure. The patient developed distributive shock and underwent CVC placement at the day of admission. On the 24th day of intubation, the patient was unable to move his left upper and lower extremities. Computed tomography (CT) head revealed showed a large temporoparietal stroke. CT Angiogram of head and neck revealed a misplaced CVC within the right common carotid artery . He was transferred to the Neuro ICU at our hospital where the patient underwent catheter removal and carotid artery sheath placement followed by dual antiplatelet therapy. Although the patient survived, he still required long-term facility placement due to the stroke. Conclusion: We reiterate that an experienced clinician must perform the CVC placement with ultrasound guidance and verify its placement with multiple confirmation techniques afterwards. Providers must manage unintentional carotid artery placement promptly to prevent long-term sequelae associated with it

A case of acquired immunodeficiency syndrome-related Kaposi sarcoma in a patient with COVID-19 - A brief review of HIV-COVID Co-infection and its Therapeutic challenges!

Barriers posed by the COVID-19 pandemic have led to reduced access to Human Immunodeficiency virus (HIV) care, leaving untreated patients at risk for various superimposed infections and malignancies such as Kaposi sarcoma (KS). We recently encountered a 37-year-old African-American male with a past medical history of HIV who tested positive for SARS-CoV-2 and was diagnosed with AIDS-related disseminated KS, representing the first reported case of COVID-19 infection with a newly diagnosed concomitant KS. The patient experienced multi-organ failure requiring tracheostomy, renal replacement therapy, and a prolonged intensive care unit (ICU) stay. Goals of care were changed to comfort measures and the patient passed away shortly afterwards. He was made comfort measures and passed away shortly afterwards. AIDS-related KS is a vascular tumor seen in association wit

Trends, Predictors, and Outcomes of Major Bleeding after Transcatheter Aortic Valve Implantation, From National Inpatient Sample (2011-2018)

Introduction: Major bleeding remains one of the most frequent complications seen in transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate outcomes, trends, and predictors of major bleeding in patients undergoing TAVI. Methods: We utilized the National Inpatient Sample (NIS) data from the year 2011 to 2018. Baseline characteristics were compared using a Pearsonχ2 test for categorical variables and Mann-Whitney U-Test for continuous variables. A multivariable logistic regression model was used to evaluate predictors of major bleeding. Propensity Matching was done for adjusted analysis to compare outcomes in TAVI with and without major bleeding. Results: A total of 215,938 weighted hospitalizations for TAVI were included in the analysis. Of the patient undergoing the procedure, 20,102 (9.3%) had major bleeding and 195,836 (90.7%) patients did not have in-hospital bleeding events. Patients in the major bleeding cohort were older and had greater female gender representation. At baseline patients with thrombocytopenia (Odds Ratio [OR], 1.47[confidence interval (CI), 1.36-1.59]), colon cancer (OR, 1.70[CI, 1.27-2.28]), coagulopathy (OR, 1.17[CI, 1.08-1.27]), liver disease (OR, 1.31[CI, 1.21-1.41]), chronic obstructive pulmonary disease (OR, 1.29[CI, 1.25-1.33]), congestive heart failure (OR, 1.12[CI, 1.08-1.16]), and end-stage renal disease (ESRD) (OR, 1.47[CI, 1.38-1.57]) had higher adjusted rates of major bleeding. The percentage of adjusted in-hospital mortality (14.4% vs. 4.2%, P \u3c 0.01) was significantly higher in the major bleeding group Patients with major bleeding had higher median cost of stay ($235,274 vs.$177,920) and length of stay (7 vs 3 days). Conclusion: In conclusion, we report that mortality is higher in patients with major bleeding and that baseline comorbidities like ESRD, liver disease, coagulopathy and colonic malignancy are important predictors of this adverse event

Trends, Predictors, and Outcomes of 30-Day Readmission With Heart Failure After Transcatheter Aortic Valve Replacement: Insights From the US Nationwide Readmission Database.

BACKGROUND Data on trends, predictors, and outcomes of heart failure (HF) readmissions after transcatheter aortic valve replacement (TAVR) remain limited. Moreover, the relationship between hospital TAVR discharge volume and HF readmission outcomes has not been established. METHODS AND RESULTS The Nationwide Readmission Database was used to identify 30-day readmissions for HF after TAVR from October 1, 2015, to November 30, 2018, using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. A total of 167 345 weighted discharges following TAVR were identified. The all-cause readmission rate within 30 days of discharge was 11.4% (19 016). Of all the causes of 30-day rehospitalizations, HF comprised 31.4% (5962) of all causes. The 30-day readmission rate for HF did not show a significant decline during the study period (Ptrend=0.06); however, all-cause readmission rates decreased significantly (Ptrend=0.03). HF readmissions were comparable between high- and low-volume TAVR centers. Charlson Comorbidity Index >8, length of stay >4 days during the index hospitalization, chronic obstructive pulmonary disease, atrial fibrillation, chronic HF, preexisting pacemaker, complete heart block during index hospitalization, paravalvular regurgitation, chronic kidney disease, and end-stage renal disease were independent predictors of 30-day HF readmission after TAVR. HF readmissions were associated with higher mortality rates when compared with non-HF readmissions (4.9% versus 3.3%; P<0.01). Each HF readmission within 30 days was associated with an average increased cost of $13 000 more than for each non-HF readmission. CONCLUSIONS During the study period from 2015 to 2018, 30-day HF readmissions after TAVR remained steady despite all-cause readmissions decreasing significantly. All-cause readmission mortality and HF readmission mortality also showed a nonsignificant downtrend. HF readmissions were comparable across low-, medium-, and high-volume TAVR centers. HF readmission was associated with increased mortality and resource use attributed to the increased costs of care compared with non-HF readmission. Further studies are needed to identify strategies to decrease the burden of HF readmissions and related mortality after TAVR