Evaluation of management in acute coronary syndrome and extent of adherence to standard treatment guidelines

Background: India has the highest burden of acute coronary syndrome (ACS) in the world. This research is to evaluate prescriptions pattern and extent of adherence to American College of Cardiology (ACC)\American Heart Association (AHA) guidelines in the management of ACS with patient outcome.Methods: Case record form containing patient’s demographic, clinical profile, diagnosis, prescription drugs (with dose, duration and frequency) were noted. Pharmacotherapy was compared to ACC/AHA guidelines, to evaluate adherence, guideline adherence index (GAI-5) was used for 5 major drug groups for ACS. GAI was calculated as: number of patients using the prescribed medications/number of eligible patients multiplied by 100.Results: A total of 172 patients diagnosed with ACS. 64 (37.20%) Patients with the highest preponderance to ACS belonged to 51-60 years age group with a 4.73:1 male to female ratio. ST-elevation myocardial infarction (STEMI) (44.77%) was the most common diagnosis and an average of 14.66±4.34 drugs were prescribed. Majority of the patients opted for percutaneous coronary intervention (PCI) with or without having received fibrinolytic therapy at onset. Adherence to the ACC/AHA guidelines being 93.75% and 118 prescriptions being 100% adherent to the guidelines. A positive correlation between adherence and number of drugs was statistically significant.Conclusions: The success of evidence-based medicine (EBM) was well noted with a 0% in hospital mortality rate i.e. all of the 172 patients were discharged with therapeutic success. Despite the concept of EBM and its proven effectiveness, there is a paucity of availability of such guidelines in India, so this study, a first of its kind can serve as a starting point of generating national as well as local guidelines

Case Reports1. A Late Presentation of Loeys-Dietz Syndrome: Beware of TGFβ Receptor Mutations in Benign Joint Hypermobility

Background: Thoracic aortic aneurysms (TAA) and dissections are not uncommon causes of sudden death in young adults. Loeys-Dietz syndrome (LDS) is a rare, recently described, autosomal dominant, connective tissue disease characterized by aggressive arterial aneurysms, resulting from mutations in the transforming growth factor beta (TGFβ) receptor genes TGFBR1 and TGFBR2. Mean age at death is 26.1 years, most often due to aortic dissection. We report an unusually late presentation of LDS, diagnosed following elective surgery in a female with a long history of joint hypermobility. Methods: A 51-year-old Caucasian lady complained of chest pain and headache following a dural leak from spinal anaesthesia for an elective ankle arthroscopy. CT scan and echocardiography demonstrated a dilated aortic root and significant aortic regurgitation. MRA demonstrated aortic tortuosity, an infrarenal aortic aneurysm and aneurysms in the left renal and right internal mammary arteries. She underwent aortic root repair and aortic valve replacement. She had a background of long-standing joint pains secondary to hypermobility, easy bruising, unusual fracture susceptibility and mild bronchiectasis. She had one healthy child age 32, after which she suffered a uterine prolapse. Examination revealed mild Marfanoid features. Uvula, skin and ophthalmological examination was normal. Results: Fibrillin-1 testing for Marfan syndrome (MFS) was negative. Detection of a c.1270G > C (p.Gly424Arg) TGFBR2 mutation confirmed the diagnosis of LDS. Losartan was started for vascular protection. Conclusions: LDS is a severe inherited vasculopathy that usually presents in childhood. It is characterized by aortic root dilatation and ascending aneurysms. There is a higher risk of aortic dissection compared with MFS. Clinical features overlap with MFS and Ehlers Danlos syndrome Type IV, but differentiating dysmorphogenic features include ocular hypertelorism, bifid uvula and cleft palate. Echocardiography and MRA or CT scanning from head to pelvis is recommended to establish the extent of vascular involvement. Management involves early surgical intervention, including early valve-sparing aortic root replacement, genetic counselling and close monitoring in pregnancy. Despite being caused by loss of function mutations in either TGFβ receptor, paradoxical activation of TGFβ signalling is seen, suggesting that TGFβ antagonism may confer disease modifying effects similar to those observed in MFS. TGFβ antagonism can be achieved with angiotensin antagonists, such as Losartan, which is able to delay aortic aneurysm development in preclinical models and in patients with MFS. Our case emphasizes the importance of timely recognition of vasculopathy syndromes in patients with hypermobility and the need for early surgical intervention. It also highlights their heterogeneity and the potential for late presentation. Disclosures: The authors have declared no conflicts of interes

Multicentre evaluation of two multiplex PCR platforms for the rapid microbiologicalinvestigation of nosocomial pneumonia in UK ICUs: the INHALE WP1 study

Background Culture-based microbiological investigation of hospital-acquired or ventilator-associated pneumonia (HAP or VAP) is insensitive, with aetiological agents often unidentified. This can lead to excess antimicrobial treatment of patients with susceptible pathogens, while those with resistant bacteria are treated inadequately for prolonged periods. Using PCR to seek pathogens and their resistance genes directly from clinical samples may improve therapy and stewardship.Methods Surplus routine lower respiratory tract samples were collected from intensive care unit patients about to receive new or changed antibiotics for hospital-onset lower respiratory tract infections at 15 UK hospitals. Testing was performed using the BioFire FilmArray Pneumonia Panel (bioMérieux) and Unyvero Pneumonia Panel (Curetis). Concordance analysis compared machine and routine microbiology results, while Bayesian latent class (BLC) analysis estimated the sensitivity and specificity of each test, incorporating information from both PCR panels and routine microbiology.Findings In 652 eligible samples; PCR identified pathogens in considerably more samples compared with routine microbiology: 60.4% and 74.2% for Unyvero and FilmArray respectively vs 44.2% by routine microbiology. PCR tests also detected more pathogens per sample than routine microbiology. For common HAP/VAP pathogens, FilmArray had sensitivity of 91.7%–100.0% and specificity of 87.5%–99.5%; Unyvero had sensitivity of 50.0%–100.0%%, and specificity of 89.4%–99.0%. BLC analysis indicated that, compared with PCR, routine microbiology had low sensitivity, ranging from 27.0% to 69.4%.Interpretation Conventional and BLC analysis demonstrated that both platforms performed similarly and were considerably more sensitive than routine microbiology, detecting potential pathogens in patient samples reported as culture negative. The increased sensitivity of detection realised by PCR offers potential for improved antimicrobial prescribing.</p

Inflammatory risk and cardiovascular events in patients without obstructive coronary artery disease: the ORFAN multicentre, longitudinal cohort study

Background: Coronary computed tomography angiography (CCTA) is the first line investigation for chest pain, and it is used to guide revascularisation. However, the widespread adoption of CCTA has revealed a large group of individuals without obstructive coronary artery disease (CAD), with unclear prognosis and management. Measurement of coronary inflammation from CCTA using the perivascular fat attenuation index (FAI) Score could enable cardiovascular risk prediction and guide the management of individuals without obstructive CAD. The Oxford Risk Factors And Non-invasive imaging (ORFAN) study aimed to evaluate the risk profile and event rates among patients undergoing CCTA as part of routine clinical care in the UK National Health Service (NHS); to test the hypothesis that coronary arterial inflammation drives cardiac mortality or major adverse cardiac events (MACE) in patients with or without CAD; and to externally validate the performance of the previously trained artificial intelligence (AI)-Risk prognostic algorithm and the related AI-Risk classification system in a UK population. Methods: This multicentre, longitudinal cohort study included 40 091 consecutive patients undergoing clinically indicated CCTA in eight UK hospitals, who were followed up for MACE (ie, myocardial infarction, new onset heart failure, or cardiac death) for a median of 2·7 years (IQR 1·4-5·3). The prognostic value of FAI Score in the presence and absence of obstructive CAD was evaluated in 3393 consecutive patients from the two hospitals with the longest follow-up (7·7 years [6·4-9·1]). An AI-enhanced cardiac risk prediction algorithm, which integrates FAI Score, coronary plaque metrics, and clinical risk factors, was then evaluated in this population. Findings: In the 2·7 year median follow-up period, patients without obstructive CAD (32 533 [81·1%] of 40 091) accounted for 2857 (66·3%) of the 4307 total MACE and 1118 (63·7%) of the 1754 total cardiac deaths in the whole of Cohort A. Increased FAI Score in all the three coronary arteries had an additive impact on the risk for cardiac mortality (hazard ratio [HR] 29·8 [95% CI 13·9-63·9], p&lt;0·001) or MACE (12·6 [8·5-18·6], p&lt;0·001) comparing three vessels with an FAI Score in the top versus bottom quartile for each artery. FAI Score in any coronary artery predicted cardiac mortality and MACE independently from cardiovascular risk factors and the presence or extent of CAD. The AI-Risk classification was positively associated with cardiac mortality (6·75 [5·17-8·82], p&lt;0·001, for very high risk vs low or medium risk) and MACE (4·68 [3·93-5·57], p&lt;0·001 for very high risk vs low or medium risk). Finally, the AI-Risk model was well calibrated against true events. Interpretation: The FAI Score captures inflammatory risk beyond the current clinical risk stratification and CCTA interpretation, particularly among patients without obstructive CAD. The AI-Risk integrates this information in a prognostic algorithm, which could be used as an alternative to traditional risk factor-based risk calculators. Funding: British Heart Foundation, NHS-AI award, Innovate UK, National Institute for Health and Care Research, and the Oxford Biomedical Research Centre

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

Abstract Background Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. Methods All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. Results A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. Conclusion Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions. </jats:sec

Diagnostic outcome of fine needle aspiration cytology in 400 cases of head and neck masses in tertiary care center

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The objective of the study was to identify various lesions of neck swellings and to study their distributions according&lt;strong&gt; &lt;/strong&gt;to age, sex and site and to find out distribution of malignant, inflammatory and infective lesions in neck swellings.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The prospective study was conducted in the department of ENT, SCL General&lt;strong&gt; &lt;/strong&gt;Hospital, NHL MMC, Saraspur, Ahmedabad from July 2014 to July 2016. All indoor and outdoor 400 patients of SCL hospital presenting with palpable head and neck swellings were referred to the cytology section at SCL hospital for FNAC and included in present study.  &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In our study out of 400 cases, lymph nodes constituted 276 cases with female&lt;strong&gt; &lt;/strong&gt;preponderance. Among the inflammatory lesions, commonest lesion was tuberculosis which comprised of 147 cases followed by 64 cases of reactive lymphadenitis. In thyroid lesions the male: female ratio was 1:18, with maximum incidence in age group of 20-50 years. Total 95 cases were observed, out of which benign thyroid lesions (Bethesda grade II) were most common (92.63%). Salivary gland comprised of 11 cases, Out of 10 benign neoplastic lesions, 9 cases of pleomorphic adenoma and 1 cases of Warthin’s tumor were found.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; FNAC is a very simple and expeditious procedure which can be carried out without much&lt;strong&gt; &lt;/strong&gt;problem. It reduces the necessities to perform excisions biopsy in many cases. Thus, FNAC can be recommended as a first line of investigation in the diagnosis of neck swellings and can be adopted as an outpatient procedure, thus reducing the cost and time of hospitalization.&lt;/p&gt;</jats:p

A Retrospective Study of Covid-19 Disease in Confirmed Tuberculosis Patients from a Tertiary Care Centre in Ahmedabad

Background: Tuberculosis (TB) is long standing disease and SARS-COV-2 being global pandemic in current era. Interactions between SARS-COV-2 and TB needs analysis, as both has major infection-related morbidity and mortality worldwide. This study was conducted to evaluate impact of super imposing viral pandemic over chronic diseases like tuberculosis.&#x0D; Methodology: A Retrospective study done in 75 patients registered under RNTCP program at our centre. Epidemiological data, diagnostic timing of TB, duration of AKT, history of SARS-COV-2 symptoms and SARS-COV-2 diagnostic result were evaluated. Analysis conducted based on incidence of COVID-19 infection in active cases of TB.&#x0D; Results: Male: Female ratio was 1.88:1 with majority belongs to age group of 35 to 55years. Only 3 patients developed influenza like symptoms who tested negative for SARS-COV-2. None COVID-19 suspected or positive patient were reported amongst laboratory confirmed TB patients taking AKT, indicating TB drugs definitely have some impact on SARS-COV-2 virus.&#x0D; Conclusion: TB and COVID-19 co-infection has limited cases. Very few individuals who were exposed to SARS-COV-2 during AKT treatment developed influenza like symptoms, however tested negative for SARS-COV-2. A larger study is needed to understand any role played by TB infection or AKT drugs on covid-19 disease.</jats:p

Proceedings of the 14th annual RiboWest conference: perspectives and outcome

The RiboWest Conference brings together RNA researchers in Canada with the 2-fold goals of fostering internationally competitive RNA research and of training the next generation of scientists. The 14th Annual RiboWest conference (RiboWest 2018) was held at the University of Lethbridge (Lethbridge, Alberta) from June 10th to 13th, 2018. This meeting was focused on all major aspects of RNA research, ranging from understanding the cellular role of RNA, studying RNA interactions and structures, and employing them as a therapeutic tool. The invited keynote speakers (5) provided insights into the wide-range of RNA-based research. One of the unique features of this conference was that the majority of the oral presentations were given by the trainees (undergraduate/graduate students and postdoctoral researchers). Hosted by the Alberta RNA Research and Training Institute (ARRTI) at the University of Lethbridge as the leading center of RNA research in Western Canada, the RiboWest 2018 was well attended by researchers from across the country (&gt;110 attendees in total). This conference proceedings editorial presents the overview of the conference, and briefly introduces articles published in this special issue of Biochemistry and Cell Biology. </jats:p