Publications by authors named "Shivani Aggarwal"

25 Publications

  • Page 1 of 1

Migraine Characteristics, Comorbidities, Healthcare Resource Utilization, and Associated Costs of Early Users of Erenumab in the USA: A Retrospective Cohort Study Using Administrative Claims Data.

Pain Ther 2021 Sep 17. Epub 2021 Sep 17.

Global Health Economics, Amgen Inc., 1 Amgen Center Dr, Thousand Oaks, CA, 91320, USA.

Introduction: Erenumab is indicated for migraine preventive treatment in adults. The objective of this study was to provide descriptive information on real-world use of erenumab including patient profile and treatment patterns.

Methods: We completed a retrospective review of US data (through May 2019) from the IBM MarketScan Early View Databases, identifying adult patients newly treated with erenumab with a migraine claim in the year prior to first erenumab claim (index) and at least 1 year of continuous pre-index medical and pharmacy insurance coverage, to assess pre- and post-erenumab migraine characteristics, comorbidities, healthcare resource utilization, and associated costs. All data were summarized using descriptive statistics.

Results: A total of 9753 patients met inclusion criteria. The average (SD) age was 46 (12) years, 85% of patients were female, and 64% had at least one claim for chronic migraine; 70% of erenumab users had an initial dose of 70 mg; 77% of patients in the 6-month follow-up sample (n = 4437) remained on their initial erenumab dose. Persistence at 6-month follow-up was 47.3% with a mean (95% CI) proportion of days covered of 0.68 (0.67, 0.68). In the post-erenumab period, claims for comorbidities of non-migraine headaches and anxiety were reduced and there was a shift to decreased use of acute and preventive medications. Reductions in overall use and associated cost of healthcare resources such as inpatient hospitalization and outpatient office visits were minimal, with slightly more pronounced reductions in the subgroup of patients that were persistent to erenumab.

Conclusions: We observed reductions in claims for important migraine characteristics, comorbidities, and a shift to decreased use of acute and preventive migraine medications-observations indicative of the real-world effectiveness of erenumab. Further examination is required as persistence to erenumab, which may be influenced by dose titration, appears to be an important factor in changes to healthcare resource utilization and costs.
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http://dx.doi.org/10.1007/s40122-021-00319-zDOI Listing
September 2021

A retrospective observational study of the natural history of advanced non-small-cell lung cancer in patients with KRAS p.G12C mutated or wild-type disease.

Lung Cancer 2021 09 25;159:1-9. Epub 2021 May 25.

Department of Thoracic Oncology, Moffitt Cancer Center, 12902 Magnolia Dr, Tampa, FL, 33612, USA. Electronic address:

Introduction: The KRAS p.G12C mutation, prevalent in non-small-cell lung cancer (NSCLC), has only recently become a viable target. Here we present results of the largest retrospective observational study analyzing KRAS p.G12C in patients with advanced NSCLC.

Materials And Methods: Adults with advanced NSCLC (All Advanced NSCLC cohort) and subcohorts with different mutation profiles (KRAS p.G12C [G12C] and KRAS/EGFR/ALK wild type [Triple WT]) diagnosed January 2011 to March 2019 were selected from a US clinico-genomic database; treatment-related characteristics, molecular profiles, real-world overall (rwOS) and progression-free survival (rwPFS) were analyzed.

Results: Demographics were similar across cohorts, with more smokers and nonsquamous cell carcinoma histology in the G12C cohort. KRAS p.G12C was nearly mutually exclusive (≤1.2 %) with known actionable driver mutations, but non-driver co-mutations were common (STK11, 21.5 %; KEAP1, 7.0 %; TP53, 48.0 %). Among G12C patients, 20 % had no documentation of receiving systemic therapy. Across treated G12C patients, 67 % received immune checkpoint inhibitors; first-line usage increased from 0% (2014) to 81 % (2019). Among G12C patients, median (95 % CI) rwOS was 12.0 (9.6-15.3), 9.5 (8.1-13.1), and 6.7 (5.9-10.7) months after first, second, and third line of therapy, respectively; median (95 % CI) rwPFS was 5.0 (4.4-5.8), 4.0 (2.8-5.3), and 3.1 (2.4-4.3) months. Outcomes for the G12C subcohort were similar to those for all patients (All Advanced NSCLC cohort). Mutations in STK11/KEAP1 were associated with poorer survival across all cohorts.

Conclusion: The poor outcomes associated with KRAS p.G12C mutated advanced NSCLC indicate an unmet need for more effective novel treatments.
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http://dx.doi.org/10.1016/j.lungcan.2021.05.026DOI Listing
September 2021

Comparison of calretinin expression in dentigerous cysts and ameloblastoma: An immunohistochemical study.

Natl J Maxillofac Surg 2020 Jul-Dec;11(2):224-230. Epub 2020 Dec 16.

Department of Oral Pathology and Microbiology, Manav Rachna Dental College, Faridabad, Haryana, India.

Background: Calretinin is a calcium-binding protein of 29-kilodalton (kDa), which is widely expressed in normal human tissues and tumorigenic tissues. Its expression in the odontogenic epithelium during odontogenesis and in neoplastic odontogenic tissues has been demonstrated. Unicystic ameloblastoma poses a diagnostic challenge, as its histologic presentation can be sometimes mistaken for cystic odontogenic lesions. In the present study, an attempt is made to overcome the confusion encountered in the diagnosis of dentigerous cyst and unicystic ameloblastoma, using the expression of calretinin in both lesions and to compare this expression with conventional ameloblastoma to accurately diagnose and differentiate these lesions.

Materials And Methods: A total of eighty cases, in which twenty cases each of ameloblastoma, unicystic ameloblastoma, dentigerous cyst, and odontogenic keratocyst (OKC) were included in the study. Slides were made from the archival blocks of each case and were stained immunohistochemically with calretinin.

Results: Correlation between calretinin staining and histopathological diagnosis was done, and it was found that all twenty cases of ameloblastoma showed positivity for calretinin, whereas 17 of twenty cases of unicystic ameloblastoma showed positivity for calretinin staining. All the cases of OKC and dentigerous cyst were negative for calretinin.

Conclusion: Calretinin may serve as an important diagnostic adjunct in the differential diagnosis of ameloblastoma and cystic odontogenic lesions.
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http://dx.doi.org/10.4103/njms.NJMS_71_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051659PMC
December 2020

Management of ruptured sinus of valsalva for device closure in a patient with haemophilia.

Ann Card Anaesth 2020 Jan-Mar;23(1):82-86

Department of Cardiac Anaesthesia, AIIMS, New Delhi, India.

The association of Hemophilia A and ruptured aneurysm of sinus of valsalva (RSOV) has never been reported to the best of our knowledge. We report the case of a 29-year-old male patient with Hemophilia type A who presented with a RSOV into right atrium (RA). The patient underwent device closure off the RSOV and received Factor VIII infusions to decrease blood loss. The peri-procedural management is being presented in this case report.
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http://dx.doi.org/10.4103/aca.ACA_112_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7034198PMC
March 2021

Hypereosinophilia Associated With Risperidone in a Drug-Naive Patient: A Case Report.

J Clin Psychopharmacol 2019 Sep/Oct;39(5):521-523

All India Institute of Medical Sciences Tatibandh, Raipur Chhattisgarh, India Vidyasagar Institute of Mental Health Neuro and Allied Sciences Nehru Nagar New Delhi, India.

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http://dx.doi.org/10.1097/JCP.0000000000001100DOI Listing
April 2020

Burden of Valvular Heart Diseases in Hispanic/Latino Individuals in the United States: The Echocardiographic Study of Latinos.

Mayo Clin Proc 2019 08 3;94(8):1488-1498. Epub 2019 Jul 3.

Department of Epidemiology and Prevention, Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC. Electronic address:

Objective: To explore the burden and clinical correlates of valvular heart disease in Hispanics/Latinos in the United States.

Patients And Methods: A total of 1818 individuals from the population-based study of Latinos/Hispanics from 4 US metropolitan areas (Bronx, New York; Chicago, Illinois; San Diego, California; and Miami, Florida) underwent a comprehensive clinical and echocardiographic examination from October 1, 2011, through June 24, 2014. Logistic regression analysis was used to examine the associations of clinical and sociodemographic variables with valvular lesions.

Results: The mean age was 55.2±0.2 years; 57.4% were female. The prevalence of any valvular heart disease (AVHD) was 3.1%, with no considerable differences across sex, and a higher prevalence with increasing age. The proportion of US-born vs foreign-born individuals was similar in those with vs without AVHD (P=.31). The weighted prevalence of AVHD was highest in Central Americans (8.4%) and lowest in Mexicans (1.2%). Regurgitant lesions of moderate or greater severity were present in 2.4% of the population and stenotic lesions of moderate or greater severity in 0.2%. Compared with those without AVHD, individuals with AVHD were more likely to have health insurance coverage (59.6% vs 79.2%; P=.007) but similar income (P=.06) and educational status (P=.46). Univariate regression models revealed that regurgitant lesions were associated with lower body mass index whereas stenotic lesions were associated with higher body mass index.

Conclusion: Our data provide the first population-based estimates of the prevalence of valvular heart disease in Hispanic/Latinos. Valvular heart disease is fairly common in the Hispanic/Latino population and may constitute an important public health problem.
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http://dx.doi.org/10.1016/j.mayocp.2018.12.035DOI Listing
August 2019

State of the Art Management of Mechanical Heart Valves During Pregnancy.

Curr Treat Options Cardiovasc Med 2018 Nov 12;20(12):102. Epub 2018 Nov 12.

Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, BCH 3215, Boston, MA, 02115, USA.

Purpose Of The Review: To review the management of women with mechanical heart valves during pregnancy, from preconception counseling through delivery with a summary of the latest guidelines.

Recent Findings: The hypercoagulability of pregnancy combined with the imperfect choices of anticoagulant agents contribute to a high risk of complications in pregnant women with mechanical heart valves. Valve thrombosis remains a major concern, much of which occurs during the first trimester transition to heparin-based products. The safest method of anticoagulation, with the best balance of maternal and fetal risk, is use of low-dose vitamin K antagonists, but only if therapeutic anticoagulation can be achieved with warfarin doses of ≤ 5 mg/day. Management of mechanical heart valves in pregnancy remains fraught with difficult decisions involving balancing of maternal and fetal risks as well as a high risk of maternal and fetal complications. Preconception counseling and planning is imperative. A risk-benefit discussion with the patient will help guide the choice of anticoagulation and outline the plan for safe delivery options. A multidisciplinary approach to management is advisable with close follow-up and care in a tertiary center.
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http://dx.doi.org/10.1007/s11936-018-0702-3DOI Listing
November 2018

Mucoepidermoid carcinoma of hard palate.

Indian J Pathol Microbiol 2018 Jul-Sep;61(3):397-398

Department of Oral Pathology and Microbiology, Manav Rachna Dental College, Faridabad, Haryana, India.

Salivary gland tumors are clinically diverse group of neoplasms, of which pleomorphic adenoma and mucoepidermoid carcinoma (MEC) are most common benign and malignant tumors, respectively. Besides the major salivary glands, these tumors can affect the minor salivary gland tissues in the posterior part of the hard palate. Minor salivary gland tumor accounts for about 15% of all the salivary gland neoplasm, of which MEC accounts to about 35.9%. MEC appears as asymptomatic swellings and shows a variety of biological behaviors and variable natural history. This article reports a case of MEC involving the posterior part of the hard palate. The lesion was treated by wide surgical excision with a regular follow-up and no recurrence was noted.
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http://dx.doi.org/10.4103/IJPM.IJPM_617_17DOI Listing
November 2018

Management of iatrogenic pulmonary artery injury during pulmonary artery banding.

Ann Card Anaesth 2017 Jul-Sep;20(3):379-380

Department of Cardiac Anaesthesia, Cardiothoracic Centre, All Institute of Medical Sciences, New Delhi, India.

Pulmonary Artery banding (PAB) is limited to selected patients who cannot undergo primary repair due to complex anatomy, associated co-morbidities, as a part of staged univentricular palliation, and for preparing the left ventricle prior to an arterial switch operation. We report a catastrophic iatrogenic complication in which the pulmonary artery was injured during the PAB. We discuss its multi-pronged management.
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http://dx.doi.org/10.4103/aca.ACA_47_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5535589PMC
May 2018

The blalock and taussig shunt revisited.

Ann Card Anaesth 2017 Jul-Sep;20(3):323-330

Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India.

The systemic to pulmonary artery shunts are done as palliative procedures for cyanotic congenital heart diseases ranging from simple tetralogy of Fallots (TOFs)/pulmonary atresia (PA) to complex univentricular hearts. They allow growth of pulmonary arteries and maintain regulated blood flow to the lungs till a proper age and body weight suitable for definitive corrective repair is reached. We have reviewed the BT shunt with its anaesthtic considerations and management of associated complications.
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http://dx.doi.org/10.4103/aca.ACA_80_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5535574PMC
May 2018

Higher number of live births is associated with left ventricular diastolic dysfunction and adverse cardiac remodelling among US Hispanic/Latina women: results from the Echocardiographic Study of Latinos.

Open Heart 2017;4(1):e000530. Epub 2017 May 8.

Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.

Introduction: Female sex is a risk factor for heart failure with preserved ejection fraction (HFpEF). Previous literature suggests that some diastolic dysfunction (DD) develops during pregnancy and may persist postdelivery. Our objective was to examine the relationship between parity and cardiac structure and function in a population-based cohort.

Methods: Participants included 1172 Hispanic/Latina women, aged ≥45 years, enrolled in the Echocardiographic Study of Latinos from four US communities (Bronx, Miami, San Diego and Chicago). Standard echocardiographic techniques were used to measure cardiac volumes, left ventricular mass, systolic and diastolic function. Using sampling weights and survey statistics, multivariable linear and logistic regression models were constructed adjusting for age, body mass index, diabetes or prediabetes, systolic blood pressure, use of antihypertensive medications, smoking, total cholesterol and high-density lipoprotein cholesterol.

Results: In the target population, 5.0% were nulliparous (no live births) and 10.5% were grand multiparous (≥5 live births). Among the nulliparous women, 46% had DD as compared with 51%-58% of women with 1-4 live births and 81% of women with ≥5 live births (p<0.01). In full multivariate models, higher parity was significantly associated with greater left ventricular end-systolic volumes, end-diastolic volumes, left atrial volume indices and presence of DD (all p<0.01) but was not associated with ejection fraction. The log odds for having any grade of DD in grand-multiparous women was over three times that seen in nulliparous women (OR=3.4, 95% CI 1.5 to 7.9, p<0.01) in models further adjusted for income and education.

Conclusions: Higher parity is associated with increased cardiac mass, volumes and the presence of DD. Further studies are needed to elucidate this apparent deleterious relation and whether parity can help explain the increased risk of HFpEF in women.
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http://dx.doi.org/10.1136/openhrt-2016-000530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5471863PMC
May 2017

Diagnostic dilemma: Low oxygen saturation during cardiac surgery.

Ann Card Anaesth 2017 Apr-Jun;20(2):262-264

Department of Cardiothoracic and Vascular Surgery, CNC, AIIMS, New Delhi, India.

We report a case of rheumatic heart disease with severe mitral stenosis having cyanosis and low oxygen saturation on pulse oximetry. The findings of clinical examination and low values on pulse oximetry were inconsistent with the findings of normal partial pressure of oxygen and oxygen saturation on arterial blood gas analysis, leading to diagnostic dilemma. In such clinical scenario, the anesthesiologist should be aware and vigilant about the differential diagnosis of low oxygen saturation on pulse oximetry.
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http://dx.doi.org/10.4103/aca.ACA_34_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5408540PMC
November 2017

Pedal Edema as an Indicator of Early Heart Failure in the Community: Prevalence and Associations With Cardiac Structure/Function and Natriuretic Peptides (MESA [Multiethnic Study of Atherosclerosis]).

Circ Heart Fail 2016 12;9(12)

From the Heart and Vascular Center of Excellence (J.Y., W.Q., S.A.) and Department of Epidemiology (A.B.), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Cardiology and Radiology, Johns Hopkins University, Baltimore, MD (J.A.C.L.); Kantonsspital Graubuenden Clinic of Radiology, Loestrasse 170, 7000 Chur, Switzerland (N.K.-B.); National Institutes of Health Clinical Center, Bethesda, MD (D.A.B.); and Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.).

Background: The prevalence of pedal edema (PE) and its associations with abnormal cardiac structure/function, natriuretic peptides, and incident heart failure (HF) is unknown, especially in community-dwelling adults without a history of cardiovascular disease.

Methods And Results: Out of 5004 MESA (Multiethnic Study of Atherosclerosis) participants who had cardiac magnetic resonance imaging, 4196 had complete data and were included in this analysis (3501 for the right ventricle analysis). Logistic regression and Cox proportional hazard analyses were used to assess the associations among self-reported PE, 2-pillow orthopnea, paroxysmal nocturnal dyspnea, left and right ventricular structure and function, natriuretic peptide levels, and incident HF. PE was present in 28% of the participants. PE was not associated with overt left or right ventricular systolic dysfunction (ejection fraction <50%). PE was associated with 2-pillow orthopnea (odds ratio 1.66; 95% confidence interval [CI], 1.30-2.12), paroxysmal nocturnal dyspnea (odds ratio 1.95; 95% CI, 1.55-2.44), and abnormal N-terminal pro-B-type natriuretic peptide levels (defined as >400 pg/mL; odds ratio 1.80; 95% CI, 1.21-2.68) in adjusted models. After a mean of 10.2 years of follow-up, 184/4196 (4.4%) participants had an adjudicated incident HF hospitalization. PE was associated with incident HF hospitalization in models adjusted for age, sex, and race (hazard ratio 1.44; 95% CI, 1.05-1.97). This association persisted after adding additional covariates, including comorbidities, baseline left ventricular ejection fraction, and antecedent myocardial infarction (hazard ratio 1.43; 95% CI, 1.02-1.99). The association of PE with incident HF was attenuated by further adjustment for N-terminal pro-B-type natriuretic peptide.

Conclusions: PE is prevalent in community-dwelling adults without clinically recognized cardiovascular disease and associated with future hospitalized HF.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.116.003415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5147536PMC
December 2016

Googling endometriosis: a systematic review of information available on the Internet.

Am J Obstet Gynecol 2017 05 11;216(5):451-458.e1. Epub 2016 Nov 11.

Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, United Kingdom; Balliol College, University of Oxford, Oxford, United Kingdom. Electronic address:

Background: The demand for health information online is increasing rapidly without clear governance.

Objective: We aim to evaluate the credibility, quality, readability, and accuracy of online patient information concerning endometriosis.

Study Design: We searched 5 popular Internet search engines: aol.com, ask.com, bing.com, google.com, and yahoo.com. We developed a search strategy in consultation with patients with endometriosis, to identify relevant World Wide Web pages. Pages containing information related to endometriosis for women with endometriosis or the public were eligible. Two independent authors screened the search results. World Wide Web pages were evaluated using validated instruments across 3 of the 4 following domains: (1) credibility (White Paper instrument; range 0-10); (2) quality (DISCERN instrument; range 0-85); and (3) readability (Flesch-Kincaid instrument; range 0-100); and (4) accuracy (assessed by a prioritized criteria developed in consultation with health care professionals, researchers, and women with endometriosis based on the European Society of Human Reproduction and Embryology guidelines [range 0-30]). We summarized these data in diagrams, tables, and narratively.

Results: We identified 750 World Wide Web pages, of which 54 were included. Over a third of Web pages did not attribute authorship and almost half the included pages did not report the sources of information or academic references. No World Wide Web page provided information assessed as being written in plain English. A minority of web pages were assessed as high quality. A single World Wide Web page provided accurate information: evidentlycochrane.net. Available information was, in general, skewed toward the diagnosis of endometriosis. There were 16 credible World Wide Web pages, however the content limitations were infrequently discussed. No World Wide Web page scored highly across all 4 domains.

Conclusion: In the unlikely event that a World Wide Web page reports high-quality, accurate, and credible health information it is typically challenging for a lay audience to comprehend. Health care professionals, and the wider community, should inform women with endometriosis of the risk of outdated, inaccurate, or even dangerous information online. The implementation of an information standard will incentivize providers of online information to establish and adhere to codes of conduct.
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http://dx.doi.org/10.1016/j.ajog.2016.11.1007DOI Listing
May 2017

Racial Differences in the Association between Parity and Incident Stroke: Results from the REasons for Geographic and Racial Differences in Stroke Study.

J Stroke Cerebrovasc Dis 2017 Apr 7;26(4):749-755. Epub 2016 Nov 7.

Department of Epidemiology, UAB School of Public Health, Birmingham, Alabama.

Background: Circulatory and vascular changes across consecutive pregnancies may increase the risk of later-life cerebrovascular health outcomes.

Methods: The association between parity and incident stroke was assessed among 7674 white and 6280 black women, aged 45 years and older, and enrolled in the REasons for Geographic and Racial Differences in Stroke Study from 2003 to 2007. Parity was assessed at baseline, and incident stroke was ascertained from physician-adjudicated medical records through September 2014. Cox proportional hazards models were used to estimate hazard ratios (HR) for the association between parity and stroke, adjusting for baseline measures.

Results: At baseline, 12.7% of white women and 16.2% of black women reported 1 live birth, while 8.2% and 19.0%, respectively, reported 5 or more live births. Mean follow-up time was 7.5 years (standard deviation = 2.8); there were 447 incident strokes. A significant interaction between race and parity was detected (P = .05). Among white women, those with 5 or more live births had a higher stroke risk than those with 1 live birth (HR = 1.57; 95% confidence interval [CI] .93-2.65). However, the association was eliminated after adjustment for baseline characteristics (HR = 1.00, 95% CI .59-1.71). For black women, those with 5 or more live births had the highest stroke risk compared with those with 1 live birth (HR = 1.91, 95% CI 1.25-2.93), but the association was attenuated and no longer statistically significant after adjustment for confounders (HR = 1.40, 95% CI .89-2.18).

Conclusions: In adjusted models, no statistically significantassociations were observed between parity and stroke risk in a diverse cohort of U.S. women. Further studies are needed to elucidate the role of lifestyle and psychosocial factors in the race-specific associations that were observed.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2016.10.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5362279PMC
April 2017

Simulation in cardiac catheterization laboratory: Need of the hour to improve the clinical skills.

Ann Card Anaesth 2016 Jul-Sep;19(3):521-6

Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India.

Simulation is an effective teaching tool to decrease the learning curve for novices without compromising patient safety. Simulation helps interventionalist in mentally translating a two dimentional, black and white image into a usable three dimentional model. It also bridges the gap in training diverse team members on new procedures and products. All simulators have collision detection, i.e., virtual contact forces generated from collision which updates haptic output with new calculations.
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http://dx.doi.org/10.4103/0971-9784.185548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971983PMC
March 2017

Inverted left atrial appendage: a complication of de-airing during cardiac surgery.

Can J Anaesth 2015 Oct 3;62(10):1119-20. Epub 2015 Jul 3.

Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India,

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http://dx.doi.org/10.1007/s12630-015-0412-1DOI Listing
October 2015

Verruciform xanthoma of oral cavity- a case report.

J Clin Diagn Res 2014 Jul 20;8(7):FD11-2. Epub 2014 Jul 20.

Senior Lecturer, Department of Oral Pathology & Microbiology, Dasmesh Institute of Research and Dental Sciences , Faridkot,India .

Verruciform xanthoma is an uncommon benign lesion of undetermined aetiology. It is a superficial normo-lipemic xanthoma, probably reflecting a multifactorial reactive and dystrophic process. Its clinical and pathological recognition and correct diagnosis is critical because it can occur in conjunction with other systemic and cutaneous inflammatory diseases; therefore, it necessitates further clinical assessment. We, hereby report a rare case of verruciform xanthoma in 46-year-old male patient with history of leukemia with emphasis on need of vigilant comprehensive analysis of clinicopathological and immunohistohemical finding to arrive at definitive diagnosis and for better understanding of pathogenesis.
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http://dx.doi.org/10.7860/JCDR/2014/8822.4590DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4149079PMC
July 2014

Heart rate-corrected QT interval is an independent predictor of all-cause and cardiovascular mortality in individuals with type 2 diabetes: the Diabetes Heart Study.

Diabetes Care 2014 May 26;37(5):1454-61. Epub 2014 Feb 26.

Corresponding author: Donald W. Bowden,

Objective: Heart rate-corrected QT (QTc) interval is associated with mortality in the general population, but this association is less clear in individuals with type 2 diabetes. We assessed the association of QTc interval with all-cause and cardiovascular disease (CVD) mortality in the Diabetes Heart Study.

Research Design And Methods: We studied 1,020 participants with type 2 diabetes (83% European Americans; 55% women; mean age 61.4 years) who were free of atrial fibrillation, major ventricular conduction defects, and antiarrhythmic therapy at baseline. QT duration was automatically calculated from a standard 12-lead electrocardiogram (ECG). Following American Heart Association/American College of Cardiology Foundation recommendations, a linear scale was used to correct the QT for heart rate. Using Cox regression, risk was estimated per 1-SD increase in QTc interval as well as prolonged QTc interval (>450 ms) vs. normal QTc interval for mortality.

Results: At baseline, the mean (SD) QTc duration was 414.9 ms (18.1), and 3.0% of participants had prolonged QTc. After a median follow-up time of 8.5 years (maximum follow-up time 13.9 years), 204 participants were deceased. In adjusted multivariate models, a 1-SD increase in QTc interval was associated with an 18% higher risk for all-cause mortality (hazard ratio 1.18 [95% CI 1.03-1.36]) and 29% increased risk for CVD mortality (1.29 [1.05-1.59]). Similar results were obtained when QTc interval was used as a categorical variable (prolonged vs. normal) (all-cause mortality 1.73 [0.95-3.15]; CVD mortality 2.86 [1.35-6.08]).

Conclusions: Heart rate QTc interval is an independent predictor of all-cause and CVD mortality in this population with type 2 diabetes, suggesting that additional prognostic information may be available from this simple ECG measure.
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http://dx.doi.org/10.2337/dc13-1257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4182905PMC
May 2014

The complex nature of discordant severe calcified aortic valve disease grading: new insights from combined Doppler echocardiographic and computed tomographic study.

J Am Coll Cardiol 2013 Dec 24;62(24):2329-38. Epub 2013 Sep 24.

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota. Electronic address:

Objectives: With concomitant Doppler echocardiography and multidetector computed tomography (MDCT) measuring aortic valve calcification (AVC) load, this study aimed at defining: 1) independent physiologic/structural determinants of aortic valve area (AVA)/mean gradient (MG) relationship; 2) AVC thresholds best associated with severe aortic stenosis (AS); and 3) whether, in AS with discordant MG, severe calcified aortic valve disease is generally detected.

Background: Aortic stenosis with discordant markers of severity, AVA in severe range but low MG, is a conundrum, unresolved by outcome studies.

Methods: Patients (n = 646) with normal left ventricular ejection fraction AS underwent Doppler echocardiography and AVC measurement by MDCT. On the basis of AVA-indexed-to-body surface area (AVAi) and MG, patients were categorized as concordant severity grading (CG) with moderate AS (AVAi >0.6 cm²/m², MG <40 mm Hg), severe AS (AVAi ≤0.6 cm²/m², MG ≥ 40 mm Hg), discordant-severity-grading (DG) with low-MG (AVAi ≤0.6 cm(2)/m(2), MG <40 mm Hg), or high-MG (AVAi >0.6 cm(2)/m(2), MG ≥40 mm Hg).

Results: The MG (discordant in 29%) was strongly determined by AVA and flow but also independently and strongly influenced by AVC-load (p < 0.0001) and systemic arterial compliance (p < 0.0001). The AVC-load (median [interquartile range]) was similar within patients with DG (low-MG: 1,619 [965 to 2,528] arbitrary units [AU]; high-MG: 1,736 [1,209 to 2,894] AU; p = 0.49), higher than CG-moderate-AS (861 [427 to 1,519] AU; p < 0.0001) but lower than CG-severe-AS (2,931 [1,924 to 4,292] AU; p < 0.0001). The AVC-load thresholds separating severe/moderate AS were defined in CG-AS with normal flow (stroke-volume-index >35 ml/m(2)). The AVC-load, absolute or indexed, identified severe AS accurately (area under the curve ≥0.89, sensitivity ≥86%, specificity ≥79%) in men and women. Upon application of these criteria to DG-low MG, at least one-half of the patients were identified as severe calcified aortic valve disease, irrespective of flow.

Conclusions: Among patients with AS, MG is often discordant from AVA and is determined by multiple factors, valvular (AVC) and non-valvular (arterial compliance) independently of flow. The AVC-load by MDCT, strongly associated with AS severity, allows diagnosis of severe calcified aortic valve disease. At least one-half of the patients with discordant low gradient present with heavy AVC-load reflective of severe calcified aortic valve disease, emphasizing the clinical yield of AVC quantification by MDCT to diagnose and manage these complex patients.
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http://dx.doi.org/10.1016/j.jacc.2013.08.1621DOI Listing
December 2013

Comparison of the applicability of the 2006 and the 2010 cardiac CT angiography appropriate use criteria.

J Am Coll Radiol 2013 Apr 29;10(4):258-67. Epub 2013 Jan 29.

Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA.

Purpose: In a previous study, the 2006 appropriateness criteria (AC) for cardiac CT were applied to 251 patients. It was found that 46% of patients could not be classified, and two observers showed only fair agreement (κ = 0.31) on the assigned appropriateness rating (appropriate, inappropriate, uncertain, or not classifiable). The conclusion was that the 2006 AC were difficult to apply. The AC were revised in 2010. The aim of this study was to determine if the rate of patients not classifiable and interobserver variability had decreased to the point at which the AC could be reasonably applied.

Methods: Medical records of the 251 patients who were classified using the 2006 AC were reviewed by two observers, who attempted to assign the patients' indications using the 2010 AC. Patients for whom no indications could be found were deemed not classifiable. A third observer settled disagreements. The numbers of patients not classifiable using the 2006 and 2010 criteria and the number of patients on whom the two reviewers disagreed on indications were compared using McNemar's test.

Results: One hundred fifteen patients (46%) were not classifiable using the 2006 AC. With the 2010 AC, the number of patients not classifiable decreased to 39 (16%) (P < .001). With the 2006 criteria, the observers disagreed on specific indications for 152 patients (61%). With the 2010 criteria, the observers disagreed for 118 patients (47%) (P = .002).

Conclusions: Using the 2010 AC, the number of patients not classifiable and the number of disagreements decreased. Although the rate of patients not classifiable has decreased to an acceptable level, the interobserver variability remains concerning.
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http://dx.doi.org/10.1016/j.jacr.2012.07.014DOI Listing
April 2013

Juvenile ossifying fibroma: Psammamatoid variant.

Contemp Clin Dent 2012 Jul;3(3):330-3

Department of Oral and Maxillofacial Pathology, Manav Rachna Dental College, Faridabad, Haryana, India.

Juvenile ossifying fibroma is a rare fibro-osseous lesion containing variable amount of calcified masses, which resembles bone or cementum within a fibrocellular connective tissue stroma. It has variable clinical behavior, highly aggressive in nature including invasion and destruction of adjacent anatomic structures with a strong tendency to recur. We reported a 28-year-old female patient with a growth in the upper left vestibule region extending from canine to molar region with clinical, histopathological, and radiological features are presented. Surgical management was done, and regular follow-up was advised.
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http://dx.doi.org/10.4103/0976-237X.103630DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3532800PMC
July 2012

Sex differences in aortic valve calcification measured by multidetector computed tomography in aortic stenosis.

Circ Cardiovasc Imaging 2013 Jan 10;6(1):40-7. Epub 2012 Dec 10.

Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.

Background: Aortic valve calcification (AVC) is the intrinsic mechanism of valvular obstruction leading to aortic stenosis (AS) and is measurable by multidetector computed tomography. The link between sex and AS is controversial and that with AVC is unknown.

Methods And Results: We prospectively performed multidetector computed tomography in 665 patients with AS (aortic valve area, 1.05±0.35 cm(2); mean gradient, 39±19 mm Hg) to measure AVC and to assess the impact of sex on the AVC-AS severity link in men and women. AS severity was comparable between women and men (peak aortic jet velocity: 4.05±0.99 versus 3.93±0.91 m/s, P=0.11; aortic valve area index: 0.55±0.20 versus 0.56±0.18 cm(2)/m(2); P=0.46). Conversely, AVC load was lower in women versus men (1703±1321 versus 2694±1628 arbitrary units; P<0.0001) even after adjustment for their smaller body surface area or aortic annular area (both P<0.0001). Thus, odds of high-AVC load were much greater in men than in women (odds ratio, 5.07; P<0.0001). Although AVC showed good associations with hemodynamic AS severity in men and women (all r>0.67; P<0.0001), for any level of AS severity measured by peak aortic jet velocity or aortic valve area index, AVC load, absolute or indexed, was higher in men versus women (all P≤0.01).

Conclusions: In this large AS population, women incurred similar AS severity than men for lower AVC loads, even after indexing for their smaller body size. Hence, the relationship between valvular calcification process and AS severity differs in women and men, warranting further pathophysiological inquiry. For AS severity diagnostic purposes, interpretation of AVC load should be different in men and in women.
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http://dx.doi.org/10.1161/CIRCIMAGING.112.980052DOI Listing
January 2013

Implanon: subdermal single rod contraceptive implant.

J Obstet Gynaecol India 2011 Aug 28;61(4):422-5. Epub 2011 Sep 28.

Kasturba Hospital, Delhi, India.

Objectives: Study was conducted to determine acceptability, efficacy, safety, return of fertility with Implanon.

Methods: Volunteers having regular menstruation, requiring spacing formed study population. Implanon was inserted within 5 days of LMP or concurrent with MTP. Woman was asked to record bleeding pattern, side effects. Implanon duration was 3 years but Implanon was removed before, if patient wanted pregnancy/for side effects. Subjects who did not adopt family planning method after removal were followed up for return of ovulation and pregnancy.

Results: 200 subjects were enrolled (160 within 5 days of LMP, 40 concurrent with MTP). 74 implanon removals were done. (16 after tenure completion, 58 for other reasons.) 16% cases discontinued implanon for polymenorrhagia, 10% for irregular bleeding, 4.5% for amenorrhea. There was no failure of implanon. 40% had return of ovulation within one month, 95.8% conceived within 12 months.

Conclusions: Implanon is safe, effective, well accepted method of contraception.
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http://dx.doi.org/10.1007/s13224-011-0066-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3295879PMC
August 2011

Magnetic resonance elastography as a method to estimate myocardial contractility.

J Magn Reson Imaging 2012 Jul 14;36(1):120-7. Epub 2012 Feb 14.

Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.

Purpose: To determine whether increasing epinephrine infusion in an in vivo pig model is associated with an increase in end-systolic magnetic resonance elastography (MRE)-derived effective stiffness.

Materials And Methods: Finite element modeling (FEM) was performed to determine the range of myocardial wall thicknesses that could be used for analysis. Then MRE was performed on five pigs to measure the end-systolic effective stiffness with epinephrine infusion. Epinephrine was continuously infused intravenously in each pig to increase the heart rate in increments of 20%. For each such increase end-systolic effective stiffness was measured using MRE. In each pig, Student's t-test was used to compare effective end-systolic stiffness at baseline and at initial infusion of epinephrine. Least-square linear regression was performed to determine the correlation between normalized end-systolic effective stiffness and increase in heart rate with epinephrine infusion.

Results: FEM showed that phase gradient inversion could be performed on wall thickness ≈≥1.5 cm. In pigs, effective end-systolic stiffness significantly increased from baseline to the first infusion in all pigs (P = 0.047). A linear correlation was found between normalized effective end-systolic stiffness and percent increase in heart rate by epinephrine infusion with R(2) ranging from 0.86-0.99 in four pigs. In one of the pigs the R(2) value was 0.1. A linear correlation with R(2) = 0.58 was found between normalized effective end-systolic stiffness and percent increase in heart rate when pooling data points from all pigs.

Conclusion: Noninvasive MRE-derived end-systolic effective myocardial stiffness may be a surrogate for myocardial contractility.
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http://dx.doi.org/10.1002/jmri.23616DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3355216PMC
July 2012
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