Background: The ISCHEMIA trial postulated that patients with stable coronary artery disease (CAD) and moderate or severe ischemia would benefit from revascularization. We investigated the relationship between severity of CAD and that of ischemia and trial outcomes, overall and by management strategy. Methods: 5,179 patients with moderate or severe ischemia were randomized to an initial invasive or conservative management strategy. Blinded, core-laboratory-interpreted coronary CT angiography (CCTA) was used to assess anatomic eligibility for randomization. Extent and severity of CAD were classified using the modified Duke Prognostic Index (n=2,475, 48%). Ischemia severity was interpreted by independent core laboratories (nuclear, echocardiography, magnetic resonance imaging, exercise tolerance testing, n=5,105, 99%). We compared 4-year event rates across subgroups defined by severity of ischemia and CAD. The primary endpoint for this analysis was all-cause mortality. Secondary endpoints were myocardial infarction (MI), cardiovascular (CV) death or MI, and the trial primary endpoint (CV death, MI, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest). Results: Relative to mild/no ischemia, neither moderate nor severe ischemia was associated with increased mortality (moderate ischemia hazard ratio (HR) 0.89, 95% confidence interval [CI] 0.61- 1.30, severe ischemia HR 0.83, 95% CI 0.57-1.21, p=0.33). Nonfatal MI rates increased with worsening ischemia severity (HR for moderate ischemia 1.20 (95% CI 0.86-1.69) vs. mild/no ischemia; HR for severe ischemia 1.37, 95% CI 0.98-1.91, p=0.04 for trend, p=NS after adjustment for CAD). Increasing CAD severity was associated with death (HR 2.27, 95% CI 1.37-3.75) and MI (HR 1.69, 95% CI 1.17-2.45) for the most vs. least severe CAD subgroup. Ischemia severity did not identify a subgroup with treatment benefit on mortality, MI, the trial primary endpoint, or CV death or MI. In the most severe CAD subgroup (n=659), the 4-year rate of CV death or MI was lower in the invasive strategy group (difference 6.3%, 95% CI 0.2%-12.4%), but 4-year all-cause mortality was similar. Conclusions: Ischemia severity was not associated with increased risk after adjustment for CAD severity. More severe CAD was associated with increased risk. Invasive management did not lower all-cause mortality at 4 years in any ischemia or CAD subgroup. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT01471522

A prospective study was done to evaluate the efficacy and safety of intravesical instillation of 1% alum solution in 12 cases of hematuria of vesical origin, uncontrolled by saline irrigation for 24 hours via a 3-way Foley catheter. There were 10 cases of transitional cell carcinoma and 2 of radiation cystitis. Complete response was noted in 6 patients and a partial response in 4. Local side effects included suprapubic pain and vesical tenesmus, which were controlled by antispasmodic and/or analgesic drugs. Transient low grade pyrexia (maximum up to 38.2C) was noted in 4 patients. Among the other various clinical and biochemical parameters, serum aluminum level and prothrombin time showed statistically highly significant changes. Serum aluminum increased from an average baseline value of 1.68 to 3.36 mumol./l. without clinical evidence of aluminum toxicity and with levels well below the recommended safe limit. Prothrombin time increased parallel with the increase in serum aluminum level to a maximum of 1 1/2 times the control. Prothrombin values, therefore, can be used clinically, since they are readily obtainable whereas serum aluminum levels are not. Vesical irrigation with 1% alum solution is a safe method to control hematuria of vesical origin in properly selected cases.

Infective endocarditis, a great masquerader, is a clinical entity which may present with a myriad of manifestations. Its changing epidemiological profile has been studied in the previous decades in both the developed and the developing nations. In this study, we strived to uphold the evolving clinical profile and its outcome from a government tertiary care hospital in Northern India. It was a descriptive, cross-sectional, observational study conducted over two years' period involving 44 patients diagnosed with definite infective endocarditis, according to modified Dukes' criteria. Demographic, clinical, microbiological, and echocardiographic data were analysed. Mean age of patients was 31 years. Rheumatic heart disease with regurgitant lesions was the commonest risk factor. Dyspnea and fever were the predominant symptom, and pallor and heart failure the commonest sign. Cultures were positive in 52% with Staphylococcus, the major isolate. Transesophageal echocardiography fared better than transthoracic one to define the vegetations. Mortality is reported in 4.5%. Prolonged duration of fever, pallor, hematuria, proteinuria, rheumatoid factor positivity, and large vegetations proved to be poor prognostic variables. Culture positive endocarditis, with persistent bacteremia, had higher incidence of acute renal failure. Right sided endocarditis was frequent in congenital lesions or IV drug user, whereas left sided endocarditis mostly presented with atrial fibrillation.

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