Publications by authors named "Rajeev Malhotra"

122 Publications

Spectrum of Movement Disorders and Correlation with Functional Status in Children with Cerebral Palsy.

Indian J Pediatr 2021 Jun 7. Epub 2021 Jun 7.

Department of Pediatrics (Neurology Division), Lady Hardinge Medical College and Associated Hospitals, New Delhi, India.

Objectives: To detail the spectrum of movement disorders (MD) among children with cerebral palsy (CP) and assess impact on functional status.

Methods: In this cross-sectional study, children with CP were recruited and examined for various MDs. Tone abnormality was assessed using Hypertonia Assessment Tool (HAT), functional status using Gross Motor Function Classification System Expanded and Revised (GMFCS E&R), Manual Ability Classification System (MACS), and Communication Function Classification System (CFCS). These scores were classified into mild-moderate (level I-III)/severe (level IV-V) categories.

Results: A total of 113 children (mean age 4.9 ± 3.4 y, 66.4% boys) were enrolled. MDs were noted in 52 (46%) children; the most frequent were dystonia (28%), chorea (14%), choreoathetosis (8%). Of 64 children with quadriparetic CP, 27 (42.2%) demonstrated MDs. Of 19 children with hemiparetic CP, 2 (10.5%) had MDs. Of 16 children with dyskinetic CP, 15 (93%) had MDs. Children with dyskinetic CP had significantly higher frequency of MDs (p = 0.001). There was no difference in occurrence of all MDs or dystonia aloneamongst the two categories (mild-moderate/severe) of GMFCS E&R levels, CFCS levels or MACS levels.

Conclusion: Although diverse MDs occur frequently in CP, these do not correlate with the broad functional status of the child. The study is limited by small sample size.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12098-021-03785-7DOI Listing
June 2021

Prevalence of 'Hyperglycemia in pregnancy' remained stable between 2006 and 2015, despite rise in conventional risk factors: A hospital based study in Delhi, North India.

Diabetes Res Clin Pract 2021 May 26;177:108872. Epub 2021 May 26.

Department of Obstetrics and Gynaecology, St. Stephen's Hospital, Delhi, India.

Aims: Between 2006 and 2015, the trends in prevalence of Hyperglycemia in pregnancy (HIP); Gestational diabetes (GDM), Diabetes in Pregnancy (DIP), Pre existing diabetes (PDM) and GDM risk factors were studied in 30,692 pregnancies among Asian Indian women.

Methods: GDM (n = 4089) and DIP (n = 259) diagnoses were by 75 g OGTT, while PDM (n = 103) was identified by ICD code O24. Women with DIP and PDM were grouped together as pre-gestational diabetes (PGDM n = 362). Crude and age-adjusted prevalence trend analysis by Poisson and Jointpoint regression models respectively, were done in GDM and PGDM groups.

Results: During study years, the GDM prevalence by WHO 1999 and modified IADPSG criteria, showed decreasing and static trends respectively, while PGDM prevalence remained static. In a subgroup of 2560 women, mean BMI increased from 24.12 ± 4.16 in year 2011 to 25.18 ± 4.7 Kg/m in 2015 (p < 0.014), but this rise had no impact on GDM prevalence. GDM risk factors; maternal age, gravidity ≥3, previous GDM and abortion, high income, diabetes and hypertension in family, were higher in 2011-2015 than in 2006-2010 period. On multivariate analysis, BMI was not an independent GDM risk factor.

Conclusion: Despite rise in conventional GDM risk factors, HIP prevalence was static for a decade among pregnant Asian Indian women.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.diabres.2021.108872DOI Listing
May 2021

Patterns and Trends of Childhood Cancer Incidence (0-14 Years) in Delhi, India: 1990-2014.

Indian Pediatr 2021 May;58(5):430-435

Department of Radiotherapy, Dr BRAIRCH, AIIMS, New Delhi, India.

Objectives: To investigate the patterns and temporal trends of childhood cancer incidence (0-14 years) in Delhi from 1990 to 2014.

Methods: The new childhood cancer cases diagnosed between 1990 and 2014 were extracted from the Delhi population-based cancer registry (PBCR). Joinpoint regression analysis was performed to assess the temporal behaviour of new childhood cancer. The magnitude of temporal trend was assessed by estimated annual percentage changes (EAPCs).

Results: The Delhi PBCR registered 12,637 cases (8484 boys and 4153 girls) during 1990-2014. The overall childhood cancer was twice in boys than girls (5.62% vs. 2.78%). The age-standardised incidence rates (ASIRs) of childhood cancer adjusted to the WHO World standard population distribution (year 2000) was 163 per one million in boys and 92 per one million in girls; median age at diagnosis being 6 and 7 years, respectively. Five-top childhood cancer sites was leukaemia, lymphoma, central nervous system (CNS), bone and retinoblastoma. A decreasing linear trend in proportion of new childhood cancer cases to total all age-group cancer was observed in both sexes during this period. The percentage increase in childhood cancer is similar in both sexes from 1990-94 to 2010-14 (97% vs. 93%). Increasing trend in ASIRs of childhood cancer was observed.

Conclusions: The new childhood cancer cases observed increasing trend during 1990 to 2014. Boys had nearly double the number of childhood cancer cases than girls while population ratio of boys and girls during the same period was 1.14:1.
View Article and Find Full Text PDF

Download full-text PDF

Source
May 2021

Association of obesity-related inflammatory pathways with lung function and exercise capacity.

Respir Med 2021 Jul 30;183:106434. Epub 2021 Apr 30.

From the Cardiovascular Research Center, Division of Massachusetts General Hospital, Boston, MA, USA; Cardiology Division of Massachusetts General Hospital, Boston, MA, USA. Electronic address:

Background: Obesity has multifactorial effects on lung function and exercise capacity. The contributions of obesity-related inflammatory pathways to alterations in lung function remain unclear.

Research Question: To examine the association of obesity-related inflammatory pathways with pulmonary function, exercise capacity, and pulmonary-specific contributors to exercise intolerance.

Method: We examined 695 patients who underwent cardiopulmonary exercise testing (CPET) with invasive hemodynamic monitoring at Massachusetts General Hospital between December 2006-June 2017. We investigated the association of adiponectin, leptin, resistin, IL-6, CRP, and insulin resistance (HOMA-IR) with pulmonary function and exercise parameters using multivariable linear regression.

Results: Obesity-related inflammatory pathways were associated with worse lung function. Specifically, higher CRP, IL-6, and HOMA-IR were associated with lower percent predicted FEV and FVC with a preserved FEV/FVC ratio suggesting a restrictive physiology pattern (P ≤ 0.001 for all). For example, a 1-SD higher natural-logged CRP level was associated with a nearly 5% lower percent predicted FEV and FVC (beta -4.8, s.e. 0.9 for FEV1; beta -4.9, s.e. 0.8 for FVC; P < 0.0001 for both). Obesity-related inflammatory pathways were associated with worse pulmonary vascular distensibility (adiponectin, IL-6, and CRP, P < 0.05 for all), as well as lower pulmonary artery compliance (IL-6 and CRP, P ≤ 0.01 for both).

Interpretation: Our findings highlight the importance of obesity-related inflammatory pathways including inflammation and insulin resistance on pulmonary spirometry and pulmonary vascular function. Specifically, systemic inflammation as ascertained by CRP, IL-6 and insulin resistance are associated with restrictive pulmonary physiology independent of BMI. In addition, inflammatory markers were associated with lower exercise capacity and pulmonary vascular dysfunction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.rmed.2021.106434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8144063PMC
July 2021

Correction to: Tumor‑host interface in oral squamous cell carcinoma: Impact on nodal metastasis and prognosis.

Eur Arch Otorhinolaryngol 2021 May 4. Epub 2021 May 4.

Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00405-021-06853-yDOI Listing
May 2021

Oral Cancer in the Indian Subcontinent-Survival Outcomes and Risk Factors with Primary Surgery.

Laryngoscope 2021 Apr 1. Epub 2021 Apr 1.

Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India.

Objective: To assess the oncological outcome and prognostic factors for primary Oral Squamous Cell Cancer (OSCC) staged as per AJCC 8th pTNM, and treated by the contemporary standard of primary surgery and pathology directed adjuvant radiation-chemoradiation.

Methods: A single institution cohort from a tertiary care academic institution in North India. Case inclusion 2013 to 2016; n = 218, median follow-up 35 months. All patients were restaged as per the AJCC 8th pTNM classification. Analysis for Overall Survival (OS), Disease-free Survival(DFS), and factors impacting outcome (Cox proportionate model Multivariate analysis).

Results: AJCC pTNM 7th to 8th edition conversion led to upstaging in 16.5%. Stage-II demonstrated greatest stage migration and apparent improvement in OS and DFS (P < .09). Discordance was noted between the presurgical (clinico-radiologic) and postsurgical (pathological) nodal status in 40.3% (88/218; 54 pathologically upstaged;34 downstaged). Pathological downstaging was particularly significant with advanced stage Gingivo-Buccal Cancers (25/73-34.7%). Stage-I-II early cancers had 3 years. OS-86.7% and DFS-78.8%; Stage-III-IV advanced cancers had 3 years. OS-56.7% and DFS-46.6%. Multivariate analysis identified poorer OS and DFS for age < 40 years (HR-1.8; 2.0), skin involvement (HR-2.1; 2.6) and pN+ status (HR-2.4; 3.5). Bone involvement did not compromise survival in this surgically treated set of patients.

Conclusion: Age < 45 is newly identified as significantly compromising DFS and OS in Oral Cancer. Established factors of skin involvement and pN+ are confirmed as impacting DFS-OS. An apparent improvement in survival in Stage II Cancers is noted as consequent to adoption of AJCC 8th edition staging.

Level Of Evidence: II (OCEBM 2011-Inception Cohort Study for Prognosis) Laryngoscope, 2021.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.29537DOI Listing
April 2021

Comparison of Analgesic Efficacy of Ultrasound-Guided Interscalene Block Versus Continuous Subacromial Infusion for Postoperative Analgesia Following Arthroscopic Rotator Cuff Repair Surgeries: A Randomized Trial.

Cureus 2021 Feb 22;13(2):e13500. Epub 2021 Feb 22.

Onco-Anesthesiology and Palliative Medicine, All India Institute of Medical Sciences, Delhi, IND.

Background: Arthroscopic rotator cuff repair surgery may lead to significant postoperative pain. Interscalene block (ISB) is an effective analgesic technique in these surgeries but there is a risk of the phrenic blockade. Subacromial local anesthetic infiltration is a phrenic sparing alternative technique for postoperative analgesia. The primary aim of our study was to compare the ISB with a continuous subacromial infusion (SAC) with regard to postoperative analgesia.

Methods:  This prospective randomized, interventional parallel arm trial was conducted in 60 ASA grade I and II, adult patients (30 patients in each group) posted for arthroscopic rotator cuff repair surgery. Patients were randomly assigned to receive either ultrasound-guided ISB (Group ISB: 15 ml of 0.75% ropivacaine) or continuous SAC (Group SAC: 15 ml 0.75% ropivacaine as a subacromial injection by ultrasound guidance and infusion of 3 ml/hour of 0.5% ropivacaine through the catheter placed subacromial by the surgeon). Intraoperative hemodynamic parameters, visual analog scores (VAS), and rescue analgesic requirements for 24 hours, patient satisfaction, and complications were recorded.

Results: Rescue analgesic requirement was significantly higher in SAC at zero hours (P=0.000), while it was significantly higher in ISB at 12 hours (P=0.02). The VAS scores were comparable at all time points and patient satisfaction at 24 hours was similar. None of the patients had rated satisfaction related to pain relief as poor in any group. Complications like ptosis and motor weakness were seen only with ISB.

Conclusion: Both the techniques provided effective analgesia and comparable patient satisfaction with lesser incidence of complications in the SAC group. ISB provided more effective immediate postoperative pain relief while SAC was more effective in delayed analgesia for arthroscopic rotator cuff repair surgeries. SAC can be considered a reasonably safe alternative to ISB in patients with contraindications to the latter.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7759/cureus.13500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7990700PMC
February 2021

Hypoxia ameliorates brain hyperoxia and NAD deficiency in a murine model of Leigh syndrome.

Mol Genet Metab 2021 05 11;133(1):83-93. Epub 2021 Mar 11.

Anesthesia Center for Critical Care Research, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. Electronic address:

Leigh syndrome is a severe mitochondrial neurodegenerative disease with no effective treatment. In the Ndufs4 mouse model of Leigh syndrome, continuously breathing 11% O (hypoxia) prevents neurodegeneration and leads to a dramatic extension (~5-fold) in lifespan. We investigated the effect of hypoxia on the brain metabolism of Ndufs4 mice by studying blood gas tensions and metabolite levels in simultaneously sampled arterial and cerebral internal jugular venous (IJV) blood. Relatively healthy Ndufs4 and wildtype (WT) mice breathing air until postnatal age ~38 d were compared to Ndufs4 and WT mice breathing air until ~38 days old followed by 4-weeks of breathing 11% O. Compared to WT control mice, Ndufs4 mice breathing air have reduced brain O consumption as evidenced by an elevated partial pressure of O in IJV blood (PO) despite a normal PO in arterial blood, and higher lactate/pyruvate (L/P) ratios in IJV plasma revealed by metabolic profiling. In Ndufs4 mice, hypoxia treatment normalized the cerebral venous PO and L/P ratios, and decreased levels of nicotinate in IJV plasma. Brain concentrations of nicotinamide adenine dinucleotide (NAD) were lower in Ndufs4 mice breathing air than in WT mice, but preserved at WT levels with hypoxia treatment. Although mild hypoxia (17% O) has been shown to be an ineffective therapy for Ndufs4 mice, we find that when combined with nicotinic acid supplementation it provides a modest improvement in neurodegeneration and lifespan. Therapies targeting both brain hyperoxia and NAD deficiency may hold promise for treating Leigh syndrome.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ymgme.2021.03.005DOI Listing
May 2021

Tumor-host interface in oral squamous cell carcinoma: Impact on nodal metastasis and prognosis.

Eur Arch Otorhinolaryngol 2021 Mar 20. Epub 2021 Mar 20.

Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.

Purpose: To evaluate tumor-host interface in oral squamous cell carcinoma (OSCC) by the Brandwein-Gensler histological risk score (BG risk score); to assess its association with clinicopathological features and impact on survival outcomes in a contemporary cohort staged as per AJCC 8th edition pTNM classification.

Methods: This retrospective cohort study at a tertiary care centre included 178 cases of OSCC treated by primary surgical resection from 2013 to 2016. Pathological lymph node status, disease-free survival (DFS), overall survival (OS) were assessed.

Results: BG risk score assessment categorized 25 (14%) cases as low-risk, 93 (52%) as intermediate-risk, and 60 (34%) as high-risk. BG risk score category progression from low to intermediate to high risk was associated with an incremental risk of worsening pN status, DFS, and OS. BG risk score categories significantly demarcated 2-year DFS (96% in low-risk, 51.6% in intermediate-risk, 15% in high-risk; p < 0.001) and OS (96% in low-risk, 66.7% in intermediate-risk, 31.3% in high-risk; p < 0.001). On stratified analysis, BG risk score could further demarcate prognosis in early (I/II) and late (III/IV) stage subgroups (p < 0.001). Multivariate analysis indicated the prognostic impact of BG risk score categories to be additional to, and of equal magnitude to, impact of pTNM stage.

Conclusions: BG risk score is a powerful prognostic tool in OSCC additional to pTNM staging. It can enable risk stratification and inform decisions regarding post-surgical adjuvant treatment. It is undertaken with routine histopathological evaluation, with no increased expense or turnaround time. A case is made for its inclusion in OSCC reporting guidelines.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00405-021-06756-yDOI Listing
March 2021

Metabolic Cost of Exercise Initiation in Patients With Heart Failure With Preserved Ejection Fraction vs Community-Dwelling Adults.

JAMA Cardiol 2021 Jun;6(6):653-660

Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston.

Importance: Heart failure with preserved ejection fraction (HFpEF) is a joint metabolic and cardiovascular disorder with significant noncardiac contributions.

Objective: To define and quantify the metabolic cost of initiating exercise in individuals with and without HFpEF and its functional consequences.

Design, Setting, And Participants: This prospective cohort study included individuals with hemodynamically confirmed HFpEF from the Massachusetts General Hospital Exercise Study (MGH-ExS) and community-dwelling participants from the Framingham Heart Study (FHS). Analysis began April 2016 and ended November 2020.

Exposures: Internal work (IW), a measure of work equivalents required to initiate movement.

Main Outcomes And Measures: Using breath-by-breath oxygen uptake (V̇o2) measurements and V̇o2-work rate associations, cost of initiating exercise (IW) in patients with HFpEF (MGH-ExS) and in community-dwelling individuals (FHS) was quantified. Linear regression was used to estimate associations between IW and clinical/hemodynamic measures.

Results: Of 3231 patients, 184 (5.7%) had HFpEF and were from MGH-ExS, and 3047 (94.3%) were community-dwelling individuals from FHS. In the MGH-ExS cohort, 86 (47%) were women, the median (interquartile range) age was 63 (53-72) years, and the median (interquartile range) peak V̇o2 level was 13.33 (11.77-15.62) mL/kg/min. In the FHS cohort, 1620 (53%) were women, the median (interquartile range) age was 54 (48-60) years, and the median (interquartile range) peak V̇o2 level was 22.2 (17.85-27.35) mL/kg/min. IW was higher in patients with HFpEF and accounted for 27% (interquartile range, 21%-39%) of the total work (IW + measured external workload on the cycle), compared with 15% (interquartile range, 12%-20%) of that in FHS participants. Body mass index accounted for greatest explained variance in patients with HFpEF from MGH-ExS and FHS participants (22% and 18%, respectively), while resting cardiac output and biventricular filling pressures were not significantly associated with variance in IW in patients with HFpEF. A higher IW in patients with HFpEF was associated with a greater increase in left- and right-sided cardiac filing pressure during unloaded exercise, despite similar resting hemodynamic measures across IW.

Conclusions And Relevance: This study found that internal work, a new body mass index-related measure reflecting the metabolic cost of initiating movement, is higher in individuals with HFpEF compared with middle-aged adults in the community and is associated with steep, early increases in cardiac filling pressures. These findings highlight the importance of quantifying heterogeneous responses to exercise initiation when evaluating functional intolerance in individuals at risk for or with HFpEF.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamacardio.2021.0292DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970388PMC
June 2021

Design and rationale of an intelligent algorithm to detect BuRnoUt in HeaLthcare workers in COVID era using ECG and artificiaL intelligence: The BRUCEE-LI study.

Indian Heart J 2021 Jan-Feb;73(1):109-113. Epub 2020 Nov 24.

Indraprastha Institute of Information Technology, Delhi, India.

Background: There is no large contemporary data from India to see the prevalence of burnout in HCWs in covid era. Burnout and mental stress is associated with electrocardiographic changes detectable by artificial intelligence (AI).

Objective: The present study aims to estimate the prevalence of burnout in HCWs in COVID-19 era using Mini Z-scale and to develop predictive AI model to detect burnout in HCWs in COVID-19 era.

Methods: This is an observational and cross-sectional study to evaluate the presence of burnout in HCWs in academic tertiary care centres of North India in the COVID-19 era. At least 900 participants will be enrolled in this study from four leading premier government-funded/public-private centres of North India. Each study centre will be asked to recruit HCWs by approaching them through various listed ways for participation in the study. Interested participants after initial screening and meeting the eligibility criteria, will be asked to fill the questionnaire (having demographic and work related with Mini Z questionnaire) to assess burnout. The healthcare workers will include physicians at all levels of training, nursing staff and paramedical staff who are involved directly or indirectly in COVID-19 care. The analysis of the raw electrocardiogram (ECG) data and development of algorithm using convolutional neural networks (CNN) will be done by experts.

Conclusions: In Summary, we propose that ECG data generated from the people with burnout can be utilized to develop AI-enabled model to predict the presence of stress and burnout in HCWs in COVID-19 era.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ihj.2020.11.145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7683295PMC
March 2021

Estimating risk of mechanical ventilation and in-hospital mortality among adult COVID-19 patients admitted to Mass General Brigham: The VICE and DICE scores.

EClinicalMedicine 2021 Mar 25;33:100765. Epub 2021 Feb 25.

Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Yawkey 5700; 55 Fruit Street, Boston, MA 02114, United States.

Background: Risk stratification of COVID-19 patients upon hospital admission is key for their successful treatment and efficient utilization of hospital resources. We sought to evaluate the risk factors on admission (including comorbidities, vital signs, and initial laboratory assessment) associated with ventilation need and in-hospital mortality in COVID-19.

Methods: We established a retrospective cohort of COVID-19 patients from Mass General Brigham hospitals. Demographic, clinical, and admission laboratory data were obtained from electronic medical records of patients admitted to the hospital with laboratory-confirmed COVID-19 before May 19, 2020. Multivariable logistic regression analyses were used to construct and validate the Ventilation in COVID Estimator (VICE) and Death in COVID Estimator (DICE) risk scores.

Findings: The entire cohort included 1042 patients (median age, 64 years; 56.8% male). The derivation and validation cohorts for the risk scores included 578 and 464 patients, respectively. We found four factors to be independently predictive for mechanical ventilation requirement (diabetes mellitus, SpO:FiO ratio, C-reactive protein, and lactate dehydrogenase), and 10 factors to be predictors of in-hospital mortality (age, male sex, coronary artery disease, diabetes mellitus, chronic statin use, SpO:FiO ratio, body mass index, neutrophil to lymphocyte ratio, platelet count, and procalcitonin). Using these factors, we constructed the VICE and DICE risk scores, which performed with C-statistics of 0.84 and 0.91, respectively. Importantly, the chronic use of a statin was associated with protection against death due to COVID-19. The VICE and DICE score calculators have been placed on an interactive website freely available to healthcare providers and researchers (https://covid-calculator.com/).

Interpretation: The risk scores developed in this study may help clinicians more appropriately determine which COVID-19 patients will need to be managed with greater intensity.

Funding: COVID-19 Fast Grant (fastgrants.org).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eclinm.2021.100765DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906522PMC
March 2021

Exercise Intolerance in Heart Failure With Preserved Ejection Fraction: Arterial Stiffness and Aabnormal Left Ventricular Hemodynamic Responses During Exercise.

J Card Fail 2021 Jun 26;27(6):625-634. Epub 2021 Feb 26.

Corrigan Minehan Heart Center, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts. Electronic address:

Background: Arterial stiffness is thought to contribute to the pathophysiology of heart failure with preserved ejection fraction (HFpEF). We sought to examine arterial stiffness in HFpEF and hypertension and investigate associations of arterial and left ventricular hemodynamic responses to exercise.

Methods And Results: A total of 385 symptomatic individuals with an EF of ≥50% underwent upright cardiopulmonary exercise testing with invasive hemodynamic assessment of arterial stiffness and load (aortic augmentation pressure, augmentation index, systemic vascular resistance index, total arterial compliance index, effective arterial elastance index, and pulse pressure amplification) at rest and during incremental exercise. An abnormal hemodynamic response to exercise was defined as a steep increase in pulmonary capillary wedge pressure relative to cardiac output (∆PCWP/∆CO > 2 mm Hg/L/min). We compared rest and exercise measures between HFpEF and hypertension in multivariable analyses. Among 188 participants with HFpEF (mean age 61 ± 13 years, 56% women), resting arterial stiffness parameters were worse compared with 94 hypertensive participants (mean age 55 ± 15 years, 52% women); these differences were accentuated during exercise in HFpEF (all P ≤ .0001). Among all participants, exercise measures of arterial stiffness correlated with worse ∆PCWP/∆CO. Specifically, a 1 standard deviation higher exercise augmentation pressure was associated with 2.15-fold greater odds of abnormal LV hemodynamic response (95% confidence interval 1.52-3.05; P < .001). Further, exercise measures of systemic vascular resistance index, elastance index, and pulse pressure amplification correlated with a lower peak oxygen consumption.

Conclusions: Exercise accentuates the increased arterial stiffness found in HFpEF, which in turn correlates with left ventricular hemodynamic responses. Unfavorable ventricular-vascular interactions during exercise in HFpEF may contribute to exertional intolerance and inform future therapeutic interventions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cardfail.2021.02.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8180488PMC
June 2021

Errors in the use of Multivariable Logistic Regression Analysis: An Empirical Analysis.

Indian J Community Med 2020 Oct-Dec;45(4):560-562. Epub 2020 Oct 28.

Delhi Cancer Registry, Dr. BRA IRCH, AIIMS, Delhi, India.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/ijcm.IJCM_16_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7877407PMC
October 2020

Predictors for Rapid Progression of Coronary Calcification: An Optical Coherence Tomography Study.

J Am Heart Assoc 2021 Feb 26;10(3):e019235. Epub 2021 Jan 26.

Cardiology Division Massachusetts General HospitalHarvard Medical School Boston MA.

Background The role of coronary calcification in cardiovascular events and plaque stabilization is still being debated, and factors involved in the progression of coronary calcification are not fully understood. This study aimed to identify the predictors for rapid progression of coronary calcification. Methods and Results Patients with serial optical coherence tomography imaging at baseline and at 6 months were selected. Changes in the calcification index and predictors for progression of calcification were studied. Calcification index was defined as the product of the mean calcification arc and calcification length. Rapid progression of calcification was defined as an increase in the calcification index above the median value. Among 187 patients who had serial optical coherence tomography imaging, 235 calcified plaques were identified in 105 patients (56.1%) at baseline. After 6 months, the calcification index increased in 95.3% of calcified plaques from 132.0 to 178.2 (<0.001). In multivariable analysis, diabetes mellitus (odds ratio [OR], 3.911; <0.001), chronic kidney disease (OR, 2.432; =0.037), lipid-rich plaque (OR, 2.698; =0.034), and macrophages (OR, 6.782; <0.001) were found to be independent predictors for rapid progression of coronary calcification. Interestingly, rapid progression of calcification was associated with a significant reduction of inflammatory features (thin-cap fibroatheroma; from 21.2% to 11.9%, =0.003; macrophages; from 74.6% to 61.0%, =0.001). Conclusions Diabetes mellitus, chronic kidney disease, lipid-rich plaque, and macrophages were independent predictors for rapid progression of coronary calcification. Baseline vascular inflammation and subsequent stabilization may be related to rapid progression of calcification. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01110538.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.120.019235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955445PMC
February 2021

Comparison of two forced air warming systems for prevention of intraoperative hypothermia in carcinoma colon patients: a prospective randomized study.

J Clin Monit Comput 2021 Jan 16. Epub 2021 Jan 16.

Department of Onco-Anesthesia and Palliative Medicine, Dr.B.R. Ambedkar, IRCH, All India Institute of Medical Sciences, New Delhi, India.

Hypothermia is common occurrence in patients undergoing colonic surgeries. We hypothesized that the underbody forced air warming blankets will be better than conventional over-body forced air warming blankets for prevention of hypothermia during laparoscopic colon surgeries. After ethics approval, sixty patients undergoing elective laparoscopic colon surgeries were randomly divided into two groups to receive warming by underbody forced air warming blanket (n = 30) or over-body forced air warming blanket (n = 30). In the operating room, epidural catheter was inserted and thereafter warming was started with the forced air warmer with temperature set at 44 °C. Intraoperatively core temperature (using nasopharyngeal probe), vitals, incidence of postoperative shivering and time to reach Aldrete Score of 10 in the postoperative period were recorded. The core temperature was higher with an underbody blanket at 60 min (36.1 ± 0.5 °C vs. 35.7 ± 0.5 °C, P = 0.005), 90 min (35.9 ± 0.5 °C vs. 35.6 ± 0.5 °C, P = 0.009), 120 min (35.9 ± 0.5 °C vs. 35.5 ± 0.4 °C, P = 0.007), and 150 min (35.9 ± 0.5 °C vs. 35.6 ± 0.4 °C, P = 0.011). In the post anesthesia care unit, the time to reach an Aldrete score of 10 was also less in the underbody blanket group (14.3 ± 2.5 min vs. 16.8 ± 3.6 min) (P = 0.003). However, there were no clinically meaningful differences in any outcome. Underbody and over-body blankets were comparably effective in preventing hypothermia in patients undergoing laparoscopic colorectal surgery under general anaesthesia.Trial registration CTRI (2019/06/019,576). Date of Registration: June 2019, Prospectively registered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10877-020-00639-zDOI Listing
January 2021

Case 36-2020: A 72-Year-Old Woman with Dark Urine and Weakness.

N Engl J Med 2020 Nov;383(21):2066-2076

From the Departments of Medicine (R.M., M.N., J.J.P.), Radiology (B.B.G.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (R.M., M.N., J.J.P.), Radiology (B.B.G.), and Pathology (J.R.S.), Harvard Medical School - both in Boston, and the Department of Internal Medicine, Emerson Hospital, Concord, MA (P.A.H.).

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1056/NEJMcpc2027077DOI Listing
November 2020

Feasibility and Consistency of Results with Deployment of an In-Line Filter for Exercise-Based Evaluations of Patients With Heart Failure During the Novel Coronavirus Disease-2019 Pandemic.

J Card Fail 2021 01 21;27(1):105-108. Epub 2020 Oct 21.

Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Pulmonary Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address:

Background: Exercise testing plays an important role in evaluating heart failure prognosis and selecting patients for advanced therapeutic interventions. However, concern for severe acute respiratory syndrome novel coronavirus-2 transmission during exercise testing has markedly curtailed performance of exercise testing during the novel coronavirus disease-2019 pandemic.

Methods And Results: To examine the feasibility to conducting exercise testing with an in-line filter, 2 healthy volunteer subjects each completed 2 incremental exercise tests, one with discrete stages of increasing resistance and one with a continuous ramp. Each subject performed 1 test with an electrostatic filter in-line with the system measuring gas exchange and air flow, and 1 test without the filter in place. Oxygen uptake and minute ventilation were highly consistent when evaluated with and without use of an electrostatic filter with a >99.9% viral efficiency.

Conclusions: Deployment of a commercially available in-line electrostatic viral filter during cardiopulmonary exercise testing is feasible and provides consistent data compared with testing without a filter.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cardfail.2020.10.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7576320PMC
January 2021

Effect of Faculty Training on Quality of Multiple-Choice Questions.

Int J Appl Basic Med Res 2020 Jul-Sep;10(3):210-214. Epub 2020 Jul 11.

Department of Pediatrics and Medical Education, SGRD Institute of Medical Sciences and Research, Amritsar, Punjab, India.

Background: Multiple-choice question (MCQ) is frequently used assessment tool in medical education, both for certification and competitive examinations. Ill-constructed MCQs impact the utility of the assessment and thus the fate of examinee. We conducted this study to ascertain whether a short training session for faculty on MCQ writing results in desired improvement in their item-writing skills.

Methods: A 1-day workshop on constructing high-quality MCQs was conducted for the faculty as a before-after design, following training session of 3 h duration. 28 participants wrote preworkshop ( = 133) and postworkshop ( = 137) MCQs, which were analyzed and compared for 17 item-writing flaws. A mock test of 100 MCQs (selected by stratified random sampling from all the MCQs generated during the workshop) was conducted for MBBS-passed students for item analysis.

Results: Item-writing flaws reduced following the training (15% vs. 27.7%, < 0.05). Improvement mainly occurred in quality of options; heterogeneity dropped from 27.1% prior to the workshop to 5.8% postworkshop. The proportion of MCQs failing the cover test remained similarly high (68.4% vs. 60.6%), and there was no improvement in writing of the stem before and after the workshop. The item analysis did not reveal any significant improvement in facility value, discriminating index, and proportion of nonfunctioning distractors.

Conclusion: A single, short-duration faculty training session is not good enough to correct flaws in writing of the MCQs. There is a need of focused training of the faculty in MCQ writing. Courses with a longer duration, supplemented by repeated or continuous faculty development programs, need to be explored.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/ijabmr.IJABMR_30_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534721PMC
July 2020

Estimating Risk of Mechanical Ventilation and Mortality Among Adult COVID-19 patients Admitted to Mass General Brigham: The VICE and DICE Scores.

medRxiv 2020 Sep 16. Epub 2020 Sep 16.

Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA.

Background: Risk stratification of COVID-19 patients upon hospital admission is key for their successful treatment and efficient utilization of hospital resources.

Objective: To evaluate the risk factors associated with ventilation need and mortality.

Design, Setting And Participants: We established a retrospective cohort of COVID-19 patients from Mass General Brigham hospitals. Demographic, clinical, and admission laboratory data were obtained from electronic medical records of patients admitted to hospital with laboratory-confirmed COVID-19 before May 19th, 2020. Using patients admitted to Massachusetts General Hospital (MGH, derivation cohort), multivariable logistic regression analyses were used to construct the Ventilation in COVID Estimator (VICE) and Death in COVID Estimator (DICE) risk scores.

Measurements: The primary outcomes were ventilation status and death.

Results: The entire cohort included 1042 patients (median age, 64 years; 56.8% male). The derivation and validation cohorts for the risk scores included 578 and 464 patients, respectively. We found seven factors to be independently predictive for ventilation requirement (diabetes mellitus, dyspnea, alanine aminotransferase, troponin, C-reactive protein, neutrophil-lymphocyte ratio, and lactate dehydrogenase), and 10 factors to be predictors of in-hospital mortality (age, sex, diabetes mellitus, chronic statin use, albumin, C-reactive protein, neutrophil-lymphocyte ratio, mean corpuscular volume, platelet count, and procalcitonin). Using these factors, we constructed the VICE and DICE risk scores, which performed with C-statistics of at least 0.8 in our cohorts. Importantly, the chronic use of a statin was associated with protection against death due to COVID-19. The VICE and DICE score calculators have been placed on an interactive website freely available to the public (https://covid-calculator.com/).

Limitations: One potential limitation is the modest sample sizes in both our derivation and validation cohorts.

Conclusion: The risk scores developed in this study may help clinicians more appropriately determine which COVID-19 patients will need to be managed with greater intensity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1101/2020.09.14.20194670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523141PMC
September 2020

Metabolic Architecture of Acute Exercise Response in Middle-Aged Adults in the Community.

Circulation 2020 Nov 15;142(20):1905-1924. Epub 2020 Sep 15.

Cardiology Division and the Simches Cardiovascular Research Center, Department of Medicine, Harvard Medical School (M.N., R.V.S., J.B.B., M.T., R.M., N.E.H., J.E.H., A.L.B., G.D.L.), Massachusetts General Hospital, Boston.

Background: Whereas regular exercise is associated with lower risk of cardiovascular disease and mortality, mechanisms of exercise-mediated health benefits remain less clear. We used metabolite profiling before and after acute exercise to delineate the metabolic architecture of exercise response patterns in humans.

Methods: Cardiopulmonary exercise testing and metabolite profiling was performed on Framingham Heart Study participants (age 53±8 years, 63% women) with blood drawn at rest (n=471) and at peak exercise (n=411).

Results: We observed changes in circulating levels for 502 of 588 measured metabolites from rest to peak exercise (exercise duration 11.9±2.1 minutes) at a 5% false discovery rate. Changes included reductions in metabolites implicated in insulin resistance (glutamate, -29%; =1.5×10; dimethylguanidino valeric acid [DMGV], -18%; =5.8×10) and increases in metabolites associated with lipolysis (1-methylnicotinamide, +33%; =6.1×10), nitric oxide bioavailability (arginine/ornithine + citrulline, +29%; =2.8×10), and adipose browning (12,13-dihydroxy-9Z-octadecenoic acid +26%; =7.4×10), among other pathways relevant to cardiometabolic risk. We assayed 177 metabolites in a separate Framingham Heart Study replication sample (n=783, age 54±8 years, 51% women) and observed concordant changes in 164 metabolites (92.6%) at 5% false discovery rate. Exercise-induced metabolite changes were variably related to the amount of exercise performed (peak workload), sex, and body mass index. There was attenuation of favorable excursions in some metabolites in individuals with higher body mass index and greater excursions in select cardioprotective metabolites in women despite less exercise performed. Distinct preexercise metabolite levels were associated with different physiologic dimensions of fitness (eg, ventilatory efficiency, exercise blood pressure, peak Vo). We identified 4 metabolite signatures of exercise response patterns that were then analyzed in a separate cohort (Framingham Offspring Study; n=2045, age 55±10 years, 51% women), 2 of which were associated with overall mortality over median follow-up of 23.1 years (≤0.003 for both).

Conclusions: In a large sample of community-dwelling individuals, acute exercise elicits widespread changes in the circulating metabolome. Metabolic changes identify pathways central to cardiometabolic health, cardiovascular disease, and long-term outcome. These findings provide a detailed map of the metabolic response to acute exercise in humans and identify potential mechanisms responsible for the beneficial cardiometabolic effects of exercise for future study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCULATIONAHA.120.050281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8049528PMC
November 2020

Early lactate measurements for predicting in-hospital mortality in paediatric sepsis.

J Paediatr Child Health 2020 Oct 29;56(10):1570-1576. Epub 2020 Aug 29.

Environmental Biochemistry and Molecular Biology Laboratory, Department of Biochemistry, University College of Medical Sciences, Delhi, India.

Aim: We compared the performance of plasma lactate with high-sensitivity C-reactive protein (hs-CRP), and paediatric sepsis-related organ failure assessment (pSOFA) score for predicting mortality in septic children.

Methods: Serial plasma lactate and hs-CRP levels and pSOFA score was assessed during early hospital stay in septic children.

Results: Out of 149 participants, 45 died. Plasma lactate at 0 h and 6 h was significantly higher, and lactate clearance was significantly lower in non-survivors. The optimal cut-off of plasma lactate at 6h for identifying mortality was 2.5 mmol/L (sensitivity 85% and specificity 74%). pSOFA score had the best predictive ability for mortality (AUC 0.89) followed by hs-CRP at 0 h (AUC 0.86), hs-CRP at 48 h (AUC 0.83), plasma lactate levels at 6 h (AUC 0.83), and plasma lactate at 0 h (AUC 0.67).

Conclusion: pSOFA score, hs-CRP and hyperlactemia at 6 h can identify septic children at risk of dying.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jpc.15028DOI Listing
October 2020

Structural and functional analysis of female sex hormones against SARS-Cov2 cell entry.

bioRxiv 2020 Jul 29. Epub 2020 Jul 29.

Emerging evidence suggests that males are more susceptible to severe infection by the SARS-CoV-2 virus than females. A variety of mechanisms may underlie the observed gender-related disparities including differences in sex hormones. However, the precise mechanisms by which female sex hormones may provide protection against SARS-CoV-2 infectivity remains unknown. Here we report new insights into the molecular basis of the interactions between the SARS-CoV-2 spike (S) protein and the human ACE2 receptor. We further observed that glycosylation of the ACE2 receptor enhances SARS-CoV-2 infectivity. Importantly estrogens can disrupt glycan-glycan interactions and glycan-protein interactions between the human ACE2 and the SARS-CoV2 thereby blocking its entry into cells. In a mouse model, estrogens reduced ACE2 glycosylation and thereby alveolar uptake of the SARS-CoV-2 spike protein. These results shed light on a putative mechanism whereby female sex hormones may provide protection from developing severe infection and could inform the development of future therapies against COVID-19.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1101/2020.07.29.227249DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402040PMC
July 2020

The Role of Bone Morphogenetic Protein Signaling in Non-Alcoholic Fatty Liver Disease.

Sci Rep 2020 06 19;10(1):9831. Epub 2020 Jun 19.

Cardiovascular Research Center and Cardiology Division of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.

Non-alcoholic fatty liver disease (NAFLD) affects over 30% of adults in the United States. Bone morphogenetic protein (BMP) signaling is known to contribute to hepatic fibrosis, but the role of BMP signaling in the development of NAFLD is unclear. In this study, treatment with either of two BMP inhibitors reduced hepatic triglyceride content in diabetic (db/db) mice. BMP inhibitor-induced decrease in hepatic triglyceride levels was associated with decreased mRNA encoding Dgat2, an enzyme integral to triglyceride synthesis. Treatment of hepatoma cells with BMP2 induced DGAT2 expression and activity via intracellular SMAD signaling. In humans we identified a rare missense single nucleotide polymorphism in the BMP type 1 receptor ALK6 (rs34970181;R371Q) associated with a 2.1-fold increase in the prevalence of NAFLD. In vitro analyses revealed R371Q:ALK6 is a previously unknown constitutively active receptor. These data show that BMP signaling is an important determinant of NAFLD in a murine model and is associated with NAFLD in humans.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41598-020-66770-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7305229PMC
June 2020

Impaired Exercise Tolerance in Heart Failure With Preserved Ejection Fraction: Quantification of Multiorgan System Reserve Capacity.

JACC Heart Fail 2020 08 10;8(8):605-617. Epub 2020 Jun 10.

Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Pulmonary Critical Care Unit, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts. Electronic address:

Exercise intolerance is a principal feature of heart failure with preserved ejection fraction (HFpEF), whether or not there is evidence of congestion at rest. The degree of functional limitation observed in HFpEF is comparable to patients with advanced heart failure and reduced ejection fraction. Exercise intolerance in HFpEF is characterized by impairments in the physiological reserve capacity of multiple organ systems, but the relative cardiac and extracardiac deficits vary among individuals. Detailed measurements made during exercise are necessary to identify and rank-order the multiorgan system limitations in reserve capacity that culminate in exertional intolerance in a given person. We use a case-based approach to comprehensively review mechanisms of exercise intolerance and optimal approaches to evaluate exercise capacity in HFpEF. We also summarize recent and ongoing trials of novel devices, drugs, and behavioral interventions that aim to improve specific exercise measures such as peak oxygen uptake, 6-min walk distance, heart rate, and hemodynamic profiles in HFpEF. Evaluation during the clinically relevant physiological perturbation of exercise holds promise to improve the precision with which HFpEF is defined and therapeutically targeted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jchf.2020.03.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7395858PMC
August 2020

Predictors of mortality in hospitalized COVID-19 patients: A systematic review and meta-analysis.

J Med Virol 2020 10 11;92(10):1875-1883. Epub 2020 Jul 11.

Division of Cardiology, Department of Medicine, Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Mortality rates of coronavirus disease-2019 (COVID-19) continue to rise across the world. Information regarding the predictors of mortality in patients with COVID-19 remains scarce. Herein, we performed a systematic review of published articles, from 1 January to 24 April 2020, to evaluate the risk factors associated with mortality in COVID-19. Two investigators independently searched the articles and collected the data, in accordance with PRISMA guidelines. We looked for associations between mortality and patient characteristics, comorbidities, and laboratory abnormalities. A total of 14 studies documenting the outcomes of 4659 patients were included. The presence of comorbidities such as hypertension (odds ratio [OR], 2.5; 95% confidence interval [CI], 2.1-3.1; P < .00001), coronary heart disease (OR, 3.8; 95% CI, 2.1-6.9; P < .00001), and diabetes (OR, 2.0; 95% CI, 1.7-2.3; P < .00001) were associated with significantly higher risk of death amongst patients with COVID-19. Those who died, compared with those who survived, differed on multiple biomarkers on admission including elevated levels of cardiac troponin (+44.2 ng/L, 95% CI, 19.0-69.4; P = .0006); C-reactive protein (+66.3 µg/mL, 95% CI, 46.7-85.9; P < .00001); interleukin-6 (+4.6 ng/mL, 95% CI, 3.6-5.6; P < .00001); D-dimer (+4.6 µg/mL, 95% CI, 2.8-6.4; P < .00001); creatinine (+15.3 µmol/L, 95% CI, 6.2-24.3; P = .001); and alanine transaminase (+5.7 U/L, 95% CI, 2.6-8.8; P = .0003); as well as decreased levels of albumin (-3.7 g/L, 95% CI, -5.3 to -2.1; P < .00001). Individuals with underlying cardiometabolic disease and that present with evidence for acute inflammation and end-organ damage are at higher risk of mortality due to COVID-19 infection and should be managed with greater intensity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jmv.26050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280666PMC
October 2020

Clinical and Hemodynamic Associations and Prognostic Implications of Ventilatory Efficiency in Patients With Preserved Left Ventricular Systolic Function.

Circ Heart Fail 2020 05 4;13(5):e006729. Epub 2020 May 4.

Cardiology Division, Department of Medicine (M.N., M.T., J.B.B., R.V.S., M.S., J.S., R.F., R.M., N.E.H., A.L.B., J.E.H., G.D.L.), Massachusetts General Hospital, Harvard Medical School, Boston.

Background: Ventilatory efficiency (minute ventilation required to eliminate carbon dioxide, VE/VCO2) during exercise potently predicts outcomes in advanced heart failure with reduced ejection fraction, but its prognostic significance for at-risk individuals with preserved left ventricular systolic function is unclear. We aimed to characterize mechanistic determinants and prognostic implications of VE/VCO2 in a single-center dyspneic referral cohort (MGH-ExS [Massachusetts General Hospital Exercise Study]) and in a large sample of community-dwelling participants in the FHS (Framingham Heart Study).

Methods: Maximum incremental cardiopulmonary exercise tests were performed. VE/VCO2 was assessed as the slope pre- and post-ventilatory anaerobic threshold (VE/VCO2, VE/VCO2), the slope throughout exercise (VE/VCO2), and as the lowest 30-second value (VE/VCO2).

Results: In the MGH-ExS (N=493, age 56±15 years, 61% women, left ventricular ejection fraction 64±8%), higher VE/VCO2 was associated with lower peak exercise cardiac output and steeper increases in exercise pulmonary capillary wedge pressure (both <0.0001). VE/VCO2 (hazard ratio, 1.34 per 1-SD unit [95% CI, 1.10-1.62] =0.003) was associated with future cardiovascular hospitalization/death and outperformed classical VE/VCO2 measures used in heart failure with reduced ejection fraction (VE/VCO2). In FHS (N=1936, age 54±9 years, 53% women), VE/VCO2 measures taken in low-to-moderate intensity exercise (including VE/VCO2, VE/VCO2) were directly associated with cardiovascular risk factor burden (smoking, Framingham cardiovascular disease risk score, and lower fitness; all <0.001).

Conclusions: Impaired ventilatory efficiency is associated with cardiovascular risk in the community and with adverse hemodynamic profiles and future hospitalizations/death in a referral population, highlighting the prognostic importance of easily acquired submaximum exercise ventilatory gas exchange measurements in broad populations with preserved left ventricular systolic function.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCHEARTFAILURE.119.006729DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7224335PMC
May 2020

Impact of Using Different Growth References on Interpretation of Anthropometric Parameters of Children Aged 8-15 Years.

Indian Pediatr 2020 02;57(2):124-128

Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, India. Correspondence to: Dr Anju Seth, Director Professor, Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi 110 001, India.

Objective: To compare the effect of the application of three growth references (Agarwal, 1992; Indian Academy of Paediatrics (IAP), 2015; and World Health Organisation (WHO), 2007) on interpretation of anthropometric parameters in schoolchildren.

Setting: Cross-sectional school-based study.

Participants: Children 8-15 years studying in one government school and one private school of Delhi.

Procedure: The age- and gender-specific standard deviation scores of height-for-age and BMI-for-age were estimated for each student enrolled, using the three growth references independently.

Main Outcome Measure: The proportion of children with short stature, thinness and overweight/ obesity determined by each growth reference were compared.

Results: A total of 1237 students participated in the study. A significantly higher proportion of children (both sexes) were classified to have short stature using WHO 2007 reference (8.8%) as compared to the Agarwal (3.3%) charts and IAP, 2015 references (3.6%). The combined prevalence of overweight and obesity was highest (34.8%) by the IAP, 2015 reference as against 32% by Agarwal charts and 29.1% by WHO, 2007 reference. Good agreement existed between the IAP, 2015 reference and Agarwal charts in classifying subjects into different BMI categories (Kappa=0.82) and short stature (Kappa=0.99).

Conclusions: In view of differences noted, use of national population derived reference data is suggested to correctly define growth trajectories in children.
View Article and Find Full Text PDF

Download full-text PDF

Source
February 2020