In-Hospital Outcomes of Percutaneous Coronary Intervention in America's Safety Net: Insights From the NCDR Cath-PCI Registry.

OBJECTIVES: This study compared risk-adjusted percutaneous coronary intervention (PCI) outcomes of safety-net hospitals (SNHs) and non-SNHs. BACKGROUND: Although risk adjustment is used to compare hospitals, SNHs treat a disproportionate share of uninsured and underinsured patients, who may have unmeasured risk factors, limited health care access, and poorer outcomes than patients treated at non-SNHs. METHODS: Using the National Cardiovascular Data Registry CathPCI Registry from 2009 to 2015, we analyzed 3,746,961 patients who underwent PCI at 282 SNHs (hospitals where ≥10% of PCI patients were uninsured) and 1,134 non-SNHs. The relationship between SNH status and risk-adjusted outcomes was assessed. RESULTS: SNHs were more likely to be lower volume, rural hospitals located in the southern states. Patients treated at SNHs were younger (63 vs. 65 years), more often nonwhite (17% vs. 12%), smokers (33% vs. 26%), and more likely to be admitted through the emergency department (48% vs. 38%) and to have an ST-segment elevation myocardial infarction (20% vs. 14%) than non-SNHs (all p < 0.001). Patients undergoing PCI at SNHs had higher risk-adjusted in-hospital mortality (odds ratio: 1.23; 95% confidence interval: 1.17 to 1.32; p < 0.001), although the absolute risk difference between groups was small (0.4%). Risk-adjusted bleeding (odds ratio: 1.05; 95% confidence interval: 1.00 to 1.12; p = 0.062) and acute kidney injury rates (odds ratio: 1.01; 95% confidence interval: 0.96 to 1.07; p = 0.51) were similar. CONCLUSIONS: Despite treating a higher proportion of uninsured patients with more acute presentations, risk-adjusted PCI-related in-hospital mortality of SNHs is only marginally higher (4 additional deaths per 1,000 PCI cases) than non-SNHs, whereas risk-adjusted bleeding and acute kidney injury rates are comparable.

Femoral micropuncture or routine introducer study (FEMORIS).

OBJECTIVES: The Micropuncture® 21-gauge needle may reduce complications related to vessel trauma from inadvertent venous or posterior arterial wall puncture. METHODS: This was a single-center, multiple-user trial. Four hundred and two patients undergoing possible or definite percutaneous coronary intervention (PCI) were randomized 1:1 to an 18-gauge versus a 21-gauge needle. Patients and personnel pulling the sheaths and performing the follow-up were blinded. The primary end point was a composite of access bleeding. Events were tabulated following sheath removal, ≤ 24 h after the procedure and at the follow-up (at 1-2 weeks). End points were blindly adjudicated. RESULTS: The event rate overall was 12.4% and did not differ significantly between groups, although the 21-gauge needle was found to reduce events by more than one third. An exploratory subgroup analysis of prespecified variables indicated that: patients who did not undergo PCI or elective procedures, female patients and those with a final sheath size of ≤ 6 Fr all had a significant or near-significant reduction of complications with Micropuncture. CONCLUSIONS: Although no significant differences between the use of the 18- and 21-gauge needles were observed, there was a 50-75% reduction with Micropuncture in several subgroups. The study was terminated prematurely. Access site complications may be reduced by the use of the 21-gauge needle, particularly when the risk of bleeding is not high. Further multicenter data will be required to confirm these hypothesis-generating observations.

Efficacy of a new model for delivering integrated TB and HIV services for people living with HIV/AIDS in Delhi -- case for a paradigm shift in national HIV/TB cross-referral strategy.

Under National TB/HIV framework, all TB patients are referred by Revised National Tuberculosis Programme (RNTCP) service providers to Integrated Counseling and Testing Centers (ICTCs) for voluntary counseling and testing (C&T) and ICTC "TB-suspects" are referred to RNTCP facilities for TB diagnosis and treatment. HIV-TB coinfected patients are then referred to Anti Retroviral Treatment (ART) center for initiation of ART between two weeks and two months of initiating TB treatment. During the third phase of National AIDS Control Programme (NACP-III, April 2007-April 2012), 30749/130503 (23.6%) TB/HIV cross-referrals were lost to follow up (LTFU) and there was missed opportunity for 940/1884 (49.9%) HIV-TB coinfected patients for initiation of ART during TB treatment. This motivated Delhi State AIDS Control Society (DSACS) and State TB Cell (STC) to revise existing cross-referral strategy. The new strategy was launched in May 2012, wherein HIV-TB coinfected and HIV-positive "TB-suspects" were referred to nearest ART center for HIV care and investigations of TB at Chest Clinic/Designated Microscopy Centre (DMC) located within the same hospital instead of referral to area RNTCP facility. Outcome of the strategy was evaluated in March 2013. The new HIV-TB cross-referral strategy in Delhi has shown advantage over national strategy: first, improved retention of coinfected clients in HIV care; second, ensured timely initiation of TB-treatment and ART; and third, significantly improved survival of HIV-TB coinfected patients.

Label-free route to rapid, nanoscale characterization of cellular structure and dynamics through opaque media.

We report a novel technique for label-free, rapid visualization of structure and dynamics of live cells with nanoscale sensitivity through traditionally opaque media. Specifically, by combining principles of near-infrared (NIR) spectroscopy and quantitative phase imaging, functional characterization of cellular structure and dynamics through silicon substrates is realized in our study. We demonstrate the efficacy of the new approach by full-field imaging of erythrocyte morphology in their native states with a nm path length sensitivity. Additionally, we observe dynamic variations of human embryonic kidney cells, through a silicon substrate, in response to hypotonic stimulation with ms temporal resolution that also provides unique insight into the underlying biophysical changes. The proposed technology is fundamentally suited for high-performance investigations of biological specimens and significantly expands the options for visualization in complex microfluidic devices fabricated on silicon.

Early diagnosis of HIV in children below 18 months using DNA PCR test--assessment of the effectiveness of PMTCT interventions and challenges in early initiation of ART in a resource-limited setting.

This study was conducted to assess efficacy of the current Indian Prevention of Mother-to-Child Transmission (PMTCT) protocol in 217 HIV-exposed infants, and to assess challenges in the early initiation of antiretroviral treatment (ART) in 18 (8.3%) infants with HIV, as determined by the HIV-1 DNA polymerase chain reaction (PCR) test at ≥ 6 weeks to <18 months of age. The mother-to-child transmission (MTCT) rate in 154 mother-baby pairs fully compliant with the PMTCT protocol was 5.2%. However, if 25 pairs who were positive using dried blood spot (DBS) DNA PCR and who did not undergo whole blood testing are included in the analysis, then the overall MTCT rate would be 19.8%. The current protocol is 50% effective considering an MTCT rate of 35-40% without any intervention. ART was initiated in 10 (55.6%) HIV-infected children at a mean ± standard deviation (SD) age of 10.45 ± 4.9 (range: 4-17.5) months; delay resulted in opportunistic infections in one-third of the children. A single-dose nevirapine PMTCT regimen should be replaced by a triple antiretroviral regimen; DBS DNA PCR-positive infants may be given ART, and simultaneously a whole blood specimen should be taken to determine whether ART should be continued.

The genus Plectranthus in India and its chemistry.

Phytochemical constituents isolated from Indian species of the genus Plectranthus reported up to 2009 are compiled. In India, the genus Plectranthus is found in all the habitats and altitudes, particularly in the Himalaya, the Southern Ghats, and the Nilgiri region. P. amboinicus, P. barbatus, P. caninus, P. mollis, P. coetsa, and P. incanus are the most common species found in India. Phytochemical studies of the genus revealed that Indian Plectranthus species are rich in essential oil, and that the most abundant secondary metabolites are diterpenoids, i.e., labdanes, abietanes, and ent-kauranes, as well as triterpenoids.

The balance between anti-ischemic efficacy and bleeding risk of antithrombotic therapy in percutaneous coronary intervention: a Yin-Yang paradigm.

BACKGROUND: The development of newer and more potent antithrombotic agents and strategies has markedly reduced cardiovascular mortality and ischemic complications in patients with acute coronary syndromes and those undergoing percutaneous coronary intervention (PCI). With every approach to reduce coronary thrombosis, however, there is an accompanying risk of increasing bleeding complications elsewhere. Conversely, reducing bleeding complications may increase coronary thrombotic (ischemic) events. This is the Yin-Yang principle of antithrombotic therapy and strategies in PCI. Balancing both ends of the spectrum is essential, and an individualized approach to therapy is advocated. This article reviews the efficacy and bleeding risk profile of the different antithrombotic agents and strategies in PCI, including aspirin, thienopyridines, glycoprotein IIb/IIIa-inhibitors, heparin-based antithrombins, synthetic antithrombins and oral anticoagulants. Recommendations for reducing thrombotic and bleeding complications are also discussed.

Quassinoids from Ailanthus excelsa.

Three quassinoids, 1, 2 and 3, 4-dihydro excelsin 3 were isolated from the stem bark of Ailanthus excelsa, along with five known quassinoids excelsin, glaucarubine, ailanthinone, glaucarubinone and glaucarubolone. The glaucarubolone has been isolated for the first time from this plant. The structural elucidation is based on the analysis of spectroscopic data.