Factors associated with unexplained sudden deaths among adults aged 18-45 years in India - A multicentric matched case-control study.

BACKGROUND OBJECTIVES: In view of anecdotal reports of sudden unexplained deaths in India's apparently healthy young adults, linking to coronavirus disease 2019 (COVID-19) infection or vaccination, we determined the factors associated with such deaths in individuals aged 18-45 years through a multicentric matched case-control study. METHODS: This study was conducted through participation of 47 tertiary care hospitals across India. Cases were apparently healthy individuals aged 18-45 years without any known co-morbidity, who suddenly (<24 h of hospitalization or seen apparently healthy 24 h before death) died of unexplained causes during 1 st October 2021-31 st March 2023. Four controls were included per case matched for age, gender and neighborhood. We interviewed/perused records to collect data on COVID-19 vaccination/infection and post-COVID-19 conditions, family history of sudden death, smoking, recreational drug use, alcohol frequency and binge drinking and vigorous-intensity physical activity two days before death/interviews. We developed regression models considering COVID-19 vaccination ≤42 days before outcome, any vaccine received anytime and vaccine doses to compute an adjusted matched odds ratio (aOR) with 95 per cent confidence interval (CI). RESULTS: Seven hundred twenty nine cases and 2916 controls were included in the analysis. Receipt of at least one dose of COVID-19 vaccine lowered the odds [aOR (95% CI)] for unexplained sudden death [0.58 (0.37, 0.92)], whereas past COVID-19 hospitalization [3.8 (1.36, 10.61)], family history of sudden death [2.53 (1.52, 4.21)], binge drinking 48 h before death/interview [5.29 (2.57, 10.89)], use of recreational drug/substance [2.92 (1.1, 7.71)] and performing vigorous-intensity physical activity 48 h before death/interview [3.7 (1.36, 10.05)] were positively associated. Two doses lowered the odds of unexplained sudden death [0.51 (0.28, 0.91)], whereas single dose did not. INTERPRETATION CONCLUSIONS: COVID-19 vaccination did not increase the risk of unexplained sudden death among young adults in India. Past COVID-19 hospitalization, family history of sudden death and certain lifestyle behaviors increased the likelihood of unexplained sudden death.

Prevalence and follow-up of subclinical rheumatic heart disease among asymptomatic school children in a north-western district of India based on the World Heart Federation echocardiographic criteria.

BACKGROUND: The present study is based on the World Heart Federation (WHF) echocardiographic criteria to assess the prevalence of subclinical rheumatic heart disease (RHD) and elucidate evolution of the disease when the cases were placed on appropriate antibiotic prophylaxis and regular follow-up. The prevalence of subclinical RHD reported by previous active surveillance studies among asymptomatic school children is not comparable to our study because of major differences in screening methods. METHODS: A random inclusion strategy was adopted to recruit urban and rural school children of Bikaner district in the state of Rajasthan, India. The diagnosis of RHD was based on the echocardiographic criteria proposed by the WHF. All studies were reported on-site by a single experienced cardiologist and the digitally preserved studies were reported by a second cardiologist off-site. The final diagnosis was made by consensus. The second echocardiogram was performed for cases diagnosed with RHD after two years from start of study to document early evolution of the disease with ongoing antibiotic prophylaxis. RESULTS: A high prevalence of subclinical RHD was observed in the study population. Pathological mitral and/or aortic valve regurgitation was the commonest lesion, and a significant proportion of cases improved while on regular antibiotic prophylaxis. No case showed fixity of leaflets/ stenosis. CONCLUSION: The prevalence of subclinical RHD is high in the study population, and the disease seems to regress over time in the presence of appropriate antibiotic prophylaxis.

Continuing Burden of Rheumatic Heart Disease in India.

Rheumatic heart disease (RHD) disables millions in Asia and Africa. Epidemiological data and clinical studies in India have reported a significant decline in its prevalence in last century. Global Burden of Disease (GBD) study estimated that RHD in India led to 395/100000 disability adjusted life years (DALYs) and 9.2/100000 deaths in 1990. This declined to 270/100000 and 7.9/100000, respectively, in 2017. School-based epidemiological studies in India have reported decline in clinically diagnosed RHD. On the other hand, GBD study has reported that in terms of absolute numbers, India contributes to one-third of global RHD burden. RHD in 1990 led to 3.44 million DALYs and 80,470 deaths which has increased to 3.73 million DALYs and 108,460 deaths in 2017. India Disease Burden Initiative has reported high RHD burden in many less developed states of the country, e.g., Bihar, Odisha, Assam, Chhattisgarh, Uttar Pradesh, etc. Echocardiographic epidemiology studies have reported high burden of subclinical RHD. Significant proportions of patients in hospital-based echocardiographic clinics have RHD and it contributes to 25-45% of cardiac surgeries in government hospitals. The continuing burden of RHD needs proper public health and clinical response.

Clinical Profile and Prognostic Indicators in Adults Hospitalized with Severe Malaria Caused by Different Plasmodium Species.

INTRODUCTION: Severe malaria remains a major cause of death and morbidity among adults in the Asiatic tropics. This study was planned to evaluate clinical profile and prognostic indicators of severe malaria in adults so as to improve insight into this highly prevalent disease. MATERIALS AND METHODS: This prospective observational study was conducted on 60 confirmed cases of malaria. Cases were divided into two groups: (a) study group: suffering from severe malaria and (b) control group: no severe manifestations. All cases were thoroughly studied for clinical features, laboratory evaluation, and outcome. Prognostic evaluation was also done by different score systems. RESULTS: In all, 40 cases suffer from severe malaria (study group), while 20 cases belong to the control group. The majority of our cases were males of age 21-40 years. The most common species of malaria in the study group was vivax (52.5%), followed by falciparum (25%) and mixed malaria species (22.5%). The clinical predictors for severe malaria were rural habitat, longer duration of fever, marked chills, tiredness, giddiness, nausea, vomiting, decreased urine output, jaundice, and altered sensorium. Extreme weakness (80%), jaundice (55%), renal failure (50%), and severe anemia (27.5%) were the most common presenting features in severe malaria. Two patients died of severe mixed malaria. The mortality rate was significantly associated with lower hemoglobin level (P = 0.002); higher total leukocyte count (P = 0.006), blood urea (P < 0.001), serum creatinine (P < 0.001), SGOT (P = 0.001), SGPT (P < 0.007), serum bilirubin (P = 0.003), and parasite density (P = 0.033); lower platelet count (P = 0.043); and those who had more APACHE II score (P = 0.003), SOFA score (P = 0.04), and Multiple Organ Dysfunction Score (P < 0.001) and lower Glasgow Coma Scale (P < 0.001). CONCLUSIONS: Manifestations of severe malaria is becoming increasingly more prevalent specifically in vivax and mixed malaria cases. Our study proposes that there are certain clinical predictors and prognostic indicators that should be kept in mind for better management of severe malaria.

Geographic epidemiology of cardiometabolic risk factors in middle class urban residents in India: cross-sectional study.

OBJECTIVE: To determine epidemiology of cardiovascular risk factors according to geographic distribution and macrolevel social development index among urban middle class subjects in India. METHODS: We performed cross-sectional surveys in 11 cities in India during years 2005-2009. 6198 subjects aged 20-75 years (men 3426, women 2772, response 62%) were evaluated for cardiovascular risk factors. Cities were grouped according to geographic distribution into northern (3 cities, n = 1321), western (2 cities, n = 1814), southern (3 cities, n = 1237) and eastern (3 cities, n = 1826). They were also grouped according to human social development index into low (3 cities, n = 1794), middle (5 cities, n = 2634) and high (3 cities, n = 1825). Standard definitions were used to determine risk factors. Differences in risk factors were evaluated using χ(2) test. Trends were examined by least squares regression. FINDINGS: Age-adjusted prevalence (95% confidence intervals) of various risk factors was: low physical activity 42.1% (40.9-43.3), high dietary fat 49.9% (47.8-52.0), low fruit/vegetables 26.9% (25.8-28.0), smoking 10.1% (9.1-11.1), smokeless tobacco use 9.8% (9.1-10.5), overweight 42.9% (41.7-44.1), obesity 11.6% (10.8-12.4), high waist circumference 45.5% (44.3-46.7), high waist-hip ratio 75.7% (74.7-76.8), hypertension 31.6% (30.4-32.8), hypercholesterolemia 25.0% (23.9-26.9), low HDL cholesterol 42.5% (41.3-43.7), hypertriglyceridemia 36.9% (35.7-38.1), diabetes 15.7% (14.8-16.6), and metabolic syndrome 35.7% (34.5-36.9). Compared with national average, prevalence of most risk factors was not significantly different in various geographic regions, however, cities in eastern region had significantly lower prevalence of overweight, hypertension, hypercholesterolemia, diabetes and metabolic syndrome compared with other regions (P < 0.05 for various comparisons). It was also observed that cities with low human social development index had lowest prevalence of these risk factors in both sexes (P < 0.05). CONCLUSIONS: Urban middle-class men and women in eastern region of India have significantly lower cardiometabolic risk factors compared to northern, western and southern regions. Low human social development index cities have lower risk factor prevalence.

Educational status-related disparities in awareness, treatment and control of cardiovascular risk factors in India.

OBJECTIVE: To determine association of socioeconomic status, defined by educational status (ES), with awareness, treatment and control of cardiovascular risk factors. METHODS: We performed an epidemiological study at 11 cities in India using cluster sampling. 6198 subjects (3426 men, 2772 women, response 62%, age 48±10 years) were evaluated for sociodemographic, lifestyle, anthropometric and biochemical factors. ES was categorised according to years of schooling into low (≤10 years), medium (11-15 years) and high (>15 years). Risk factors were diagnosed according to current guidelines. Awareness, treatment and control status were determined for hypertension, diabetes and hypercholesterolaemia. For smoking/tobacco use, quit rate was determined. Descriptive statistics are reported. RESULTS: Age-adjusted and sex-adjusted prevalence (%) of various risk factors in low, medium and high ES subjects was hypertension 31.8, 29.5 and 34.1, diabetes 14.5, 15.3 and 14.3, hypercholesterolaemia 24.0, 23.9 and 27.3, and smoking/tobacco use 24.3, 14.4 and 19.0. Significantly increasing trends with low, medium and high ES were observed for hypertension awareness (30.7, 37.8, 47.0), treatment (24.3, 29.2, 35.5) and control (7.8, 11.6, 15.5); diabetes awareness (47.2, 51.5, 56.4), treatment (38.3, 41.3, 46.0) and control (18.3, 15.3, 22.8); hypercholesterolaemia awareness (8.9, 22.4, 18.4), treatment (4.1, 6.2, 7.9) and control (2.8, 3.2, 6.9), as well as for smoking/tobacco quit rates (1.6, 2.8, 5.5) (χ(2) for trend, p<0.05). CONCLUSIONS: Low ES subjects in India have lower awareness, treatment and control of hypertension, diabetes and hypercholesterolaemia and smoking quit rates.

Clinical and histopathological profile of acute renal failure caused by falciparum and vivax monoinfection: an observational study from Bikaner, northwest zone of Rajasthan, India.

BACKGROUND & OBJECTIVES: Acute renal failure (ARF) is a known manifestation of severe Plasmodium falciparum (Pf) malaria but recently it has also been observed with P. vivax (Pv) monoinfection. A clinical observational study has been conducted to evaluate the clinical and histopathological profile of ARF in malaria. METHODS: This study was conducted on 288 consecutive cases of malaria with monoinfection (Pf 191 and Pv 97) diagnosed by peripheral blood film examination and rapid card test. ARF was diagnosed as per WHO criterion (serum creatinine >3 mg%). The data were analysed by Standard t-test using ANOVA software. RESULTS: ARF was seen in 52 cases of Pf and 14 cases of Pv malaria. Mean age was 32.58 yr (ranging 15-65; Pf 33.37 and Pv 29.14) and male to female ratio was 2:1 (Pf 3:1 and Pv 1:1). Most of the cases developed ARF within 10 days of onset of the disease. Associated severe manifestations were jaundice (53 cases: Pf 44 and Pv 9), cerebral malaria (28 cases: Pf 25 and Pv 3), severe anemia (18 cases: Pf 17 and Pv 1), hypotension (16 cases: Pf 11 and Pv 5), bleeding manifestations (16 cases: Pf 14 and Pv 2), multiorgan failure (12 cases: Pf 9 and Pv 3) and ARDS (6 cases: Pf 5 and Pv 1). Kidney biopsy (16 Pf and 2 Pv) showed acute tubular necrosis (5 Pf and 1 Pv), mesangioproliferative glomerulonephritis (2 Pf) or both (9 Pf and 1 Pv). Haemodialysis was done in 7 (Pf 4 and Pv 3) cases, out of which four survived. Most of the cases (48.49%) recovered within two weeks (range 3-20 days). Total mortality was 27.27% (Pf 28.85% and Pv 21.43%). INTERPRETATION & CONCLUSION: ARF can also be caused by vivax monoinfection with similar clinical and histopathological features although outcome is less severe as compared to falciparum monoinfection.

Normotension, prehypertension, and hypertension in urban middle-class subjects in India: prevalence, awareness, treatment, and control.

OBJECTIVE: We conducted a multisite study to determine the prevalence and determinants of normotension, prehypertension, and hypertension, and awareness, treatment, and control of hypertension among urban middle-class subjects in India. METHODS: We evaluated 6,106 middle-class urban subjects (men 3,371; women, 2,735; response rate, 62%) in 11 cities for sociodemographic and biological factors. The subjects were classified as having normotension (BP < 120/80), prehypertension (BP 120-139/80-89), and hypertension (documented or BP ≥ 140/90). The prevalence of other cardiovascular risk factors was determined and associations evaluated through logistic regression analysis. RESULTS: The age-adjusted prevalences in men and women of normotension were 26.7% and 39.1%, of prehypertension 40.2% and 30.1%, and of hypertension 32.5% and 30.4%, respectively. The prevalence of normotension declined with age whereas that of hypertension increased (P-trend < 0.01). A significant association of normotension was found with younger age, low dietary fat intake, lower use of tobacco, and low obesity (P < 0.05). The prevalence of hypercholesterolemia, diabetes, and metabolic syndrome was higher in the groups with prehypertension and hypertension than in the group with normotension (age-adjusted odds ratios (ORs) 2.0-5.0, P < 0.001). The prevalences in men and women, respectively, of two or more risk factors were 11.1% and 6.4% in the group with normotension, 25.1% and 23.3% in the group with prehypertension, and 38.3% and 39.1% in the group with hypertension (P < 0.01). Awareness of hypertension in the study population was in 55.3%; 36.5% of the hypertensive group were receiving treatment for hypertension, and 28.2% of this group had a controlled BP (< 140/90 mm Hg). CONCLUSIONS: The study found a low prevalence of normotension and high prevalence of hypertension in middle-class urban Asian Indians. Significant associations of hypertension were found with age, dietary fat, consumption of fruits and vegetables, smoking, and obesity. Normotensive individuals had a lower prevalence of cardiometabolic risk factors than did members of the prehypertensive or hypertensive groups. Half of the hypertensive group were aware of having hypertension, a third were receiving treatment for it, and quarter had a controlled BP.

Cardiovascular involvement in severe vivax and falciparum malaria.

BACKGROUND & OBJECTIVES: Recently, vivax malaria is also presenting as severe malaria causing multiorgan dysfunction similar to falciparum malaria. The present study was undertaken to evaluate the involvement of cardiovascular system in severe malaria. METHODS: This is a clinical prospective study conducted on the cases of severe malaria in S.P. Medical College and PBM Hospital, Bikaner, India. In total, 100 cases (45 males, 55 females; age range 13-75 yr) of severe malaria (P. vivax 60; P. falciparum 28; and mixed 12) diagnosed by peripheral blood smear examination, rapid card test and PCR were studied. Evaluation of cardiovascular system was done by clinical examination, chest Xray, ECG, high resolution transthoracic echocardiography and estimation of cardiac markers. RESULTS: In all, 17% cases (9 P. falciparum, 5 P. vivax and 3 mixed) were found to be suffering from cardiovascular involvement (11% circulatory failure, 7% congestive cardiac failure and 2% pulmonary edema). ECG showed sinus tachycardia in all the 17 patients, one had atrial ectopic and eight had non-specific ST-T changes. Cardiomegaly was seen in eight cases and pulmonary edema in two on X-ray chest. Echocardiography was within normal range but cardiac dimensions were increased in all the 17 cases. Troponin-I and CPK-MB were increased in 14 cases. Cardiovascular involvement in P. falciparum and mixed infection was associated with high parasite density but P. vivax infection was associated with relatively low parasite density. Involvement of cardiovascular system was associated with increased hospital stay (7.67 ± 2.23 vs 6.59 ± 0.87 days; p <0.001) and high mortality (5 died out of 17 patients). Significant ECG changes and cardiac markers indicate myocardial involvement in severe malaria. INTERPRETATION & CONCLUSION: The present study indicates involvement of cardiovascular system in severe malaria as evidenced by changes in ECG and cardiac markers (Trop 1 and CPK-MB). The present study also highlights that vivax malaria is no more benign and pathophysiology of vivax malaria should be re-evaluated.

Atherothrombotic risk factors & premature coronary heart disease in India: a case-control study.

BACKGROUND & OBJECTIVES: It was hypothesized that both thrombogenic and atherogenic factors may be responsible for premature coronary heart disease (CHD) in young Indians. A case-control study was performed to determine cardiovascular risk factors in young patients with CHD in India. METHODS: Successive consenting patients <55 yr with an acute coronary event or recent diagnosis of CHD were enrolled (cases, n=165). Age- and gender-matched subjects with no clinical evidence of CHD were recruited as controls (n=199). Demographic, anthropometric, clinical, haematological, and biochemical data were obtained in both groups. Univariate and multivariate logistic regression were performed to identify important risk factors. RESULTS: In cases vs. controls mean systolic BP, diastolic BP, platelet counts, LDL cholesterol, non-HDL cholesterol, triglycerides, and fibrinogen were higher and HDL cholesterol lower (P<0.001). The presence of current smoking, low fruit and vegetables intake, high fat intake, hypertension, diabetes, low HDL cholesterol, and high LDL cholesterol, total:HDL ratio, fibrinogen and homocysteine was significantly higher in cases (P<0.05). Multivariate logistic regression analysis (age adjusted odds ratio, 95% confidence intervals) revealed that smoking (19.41, 6.82-55.25), high fat intake (1.66, 1.08-2.56), low fruit and vegetables intake (1.99, 1.11-3.59), hypertension (8.95, 5.42-14.79), high LDL cholesterol [2.49 (1.62-3.84)], low HDL cholesterol (10.32, 6.30-16.91), high triglycerides (3.62, 2.35-5.59) high total:HDL cholesterol (3.87, 2.35-5.59), high fibrinogen (2.87, 1.81-4.55) and high homocysteine (10.54, 3.11-35.78) were significant. INTERPRETATION & CONCLUSIONS: Our results showed that thrombotic (smoking, low fruit/vegetables intake, fibrinogen, homocysteine) as well as atherosclerotic (hypertension, high fat diet, dyslipidaemia) risk factors were important in premature CHD. Multipronged prevention strategies are needed in young Indian subjects.

Echocardiographic Changes in Cases of Intermittent Acute Porphyria.

Intermittent acute porphyria (IAP) is an inborn metabolic disorder of biosynthesis of haeme, characterized by increased excretion of porphyrin or porphyrin precursor in urine and clinically by gastrointestinal, neuro-psychiatric and cardiovascular manifestations. Significant observations were made on echocardiographic examination of 25 IAP patients in our study. Significant decrease in ejection fraction (48.4 +/- 7.9, control group 63.0 +/- 7.5, P < 0.001) and percentage of fractional shortening (23.5% +/- 6.87%, control group = 36.4 +/- 4.26, P