Ventricular electrical delay as a predictor of arrhythmias in patients with cardiac resynchronization implantable cardioverter defibrillator.

BACKGROUND: Left ventricular (LV) remodeling and clinical response to cardiac resynchronization therapy (CRT) is inversely related to electrical dyssynchrony, measured as LV lead electrical delay (QLV). Presence of atrial or ventricular arrhythmia is correlated with worsening heart failure and LV remodeling. OBJECTIVE: We sought to assess the association of QLV with arrhythmic events in CRT recipients. METHODS: We identified patients implanted with a CRT device at our center. QLV interval was measured and corrected for baseline QRS (cQLV). We performed multivariable Logistic regression to assess the effect of cQLV on the occurrence of atrial/ventricular arrhythmic events. RESULTS: Sixty-nine patients were included in analyses. The cQLV was significantly shorter in patients with atria tachycardia/supraventricular tachycardia (AT/SVT) events compared to patients without AT/SVT events (43.4 ± 22% vs. 60.3 ± 26.7%, p = .006). In contrast, no significant difference in cQLV was observed between patients with and without ventricular tachycardia/fibrillation (VT/VF) events (46.2 ± 25.4% vs. 56 ± 25.7%, p = .13). cQLV was significantly shorter in patients with new onset AT/SVT events compared to those without (38.3 ± 22.2% vs. 55.7 ± 25.7%, p = .028). In contrast, no significant difference in cQLV was observed between patients with and without new onset VT/VF events (44.2 ± 25.2% vs. 56.3 ± 25.5%, p = .069). Following adjusted analyses, cQLV was a significant predictor of AT/SVT, but not for VT/VF. CONCLUSION: cQLV is a simple measure that can identify a vulnerable cohort of CRT patients at increased risk for atrial tachyarrhythmias, and hence can predict reverse remodeling and clinical response to CRT treatment.

Effect of an Educational Intervention on the Accuracy of Data Submitted to a National Quality Registry.

BACKGROUND: We hypothesize that data-entry errors within the National Cardiovascular Data Registry® (NCDR) ICD Registry™ may be an important reason behind labeling many cases as nonevidence-based. OBJECTIVE: To describethe frequency of data-entry errors in implantable cardioverter-defibrillator (lCD) implant data from our institution and develop a plan for quality improvement using the Deming cycle. METHODS AND RESULTS: We assessed data of patient report forms from2007to 2010 and compared these data with forms submitted from 2011 to 2012 after implementation of a continuous multicomponent staff education and training program. Of 211 ICD implants between 2007 and 2010, 36 (17%) were labeled nonevidence-based. Twenty-four (11.4%) resulted from misclassification due to data entry errors and 12 (5.7%) were actual nonevidence-based. Postintervention, review of 97 submitted patients' data revealed one (1%) data-entry error and three (3.1%) actual nonevidence-based implants. CONCLUSIONS: Multicomponent educational intervention was effective in reducing errors in data sub- mitted to the NCDR ICD Registry.

Managing hypertension with ambulatory blood pressure monitoring.

There has been a dramatic shift in the manner in which blood pressure (BP) is measured to provide far more comprehensive clinical information than that provided by a single set of office BP readings. Extensive clinical and epidemiological research shows an important role of ambulatory BP monitoring (ABPM) in the management of hypertensive patients. A 24-h BP profile helps to determine the absence of nocturnal dipping status and evaluate BP control in patients on antihypertensive therapy. The ability to detect white-coat or masked hypertension is enhanced by ambulatory BP monitoring. In 2001, the Center for Medicare and Medicaid Services approved ABPM for reimbursement for the identification of patients with white-coat hypertension. In 2011, the National Institute for Health and Clinical Excellence (NICE) in the UK published guidelines that recommended the routine use of ABPM in all patients suspected of having hypertension. The European Society of Hypertension (ESH) 2013 guidelines also support greater use of ABPM in clinical practice. While the advantages of ABPM are apparent from a clinical perspective, its use should be considered in relation to its cost, the complexity of data evaluation, as well as patient inconvenience. In this review, we evaluate the clinical importance of ABPM, highlighting its role in the current management of hypertension.

The role of radionuclide imaging in heart failure.

The incidence of heart failure (HF) is increasing and it remains the only area in cardiovascular disease wherein hospitalization rates and mortalities have worsened in the past 25 years. This review is provided to assess the role of radionuclide imaging in HF. The focus is on three aspects: the value of nuclear imaging to distinguish ischemic from non-ischemic etiologies; risk stratification of patients with HF with evaluation of candidates for specific treatment strategies; and the role of cardiac neuronal imaging in patients with HF. Distinguishing ischemic from non-ischemic cardiomyopathy is important because patients with ischemic cardiomyopathy can potentially have dramatic improvement with revascularization. Single photon emission computed tomography (SPECT) has excellent reported sensitivity and negative predictive value in the detection of coronary artery disease in HF patients. SPECT imaging is also useful in establishing treatment strategies in patients with HF, including those with new onset CHF. Cardiac neuronal imaging of mIBG is particularly helpful in risk stratification of patients with HF. The modality can be used to monitor the response to therapy as dysfunctional mIBG uptake may show improvement with pharmacological treatment.

Contribution of medical colleges to tuberculosis control in India under the Revised National Tuberculosis Control Programme (RNTCP): lessons learnt & challenges ahead.

Medical college faculty, who are academicians are seldom directly involved in the implementation of national public health programmes. More than a decade ago for the first time in the global history of tuberculosis (TB) control, medical colleges of India were involved in the Revised National TB Control Programme (RNTCP) of Government of India (GOI). This report documents the unique and extraordinary course of events that led to the involvement of medical colleges in the RNTCP of GOI. It also reports the contributions made by the medical colleges to TB control in India. For more than a decade, medical colleges have been providing diagnostic services (Designated Microscopy Centres), treatment [Directly Observed Treatment (DOT) Centres] referral for treatment, recording and reporting data, carrying out advocacy for RNTCP and conducting operational research relevant to RNTCP. Medical colleges are contributing to diagnosis and treatment of human immunodeficiency virus (HIV)-TB co-infection and development of laboratory infrastructure for early diagnosis of multidrug-resistant and/or extensively drug-resistant TB (M/XDR-TB) and DOTS-Plus sites for treatment of MDR-TB cases. Overall, at a national level, medical colleges have contributed to 25 per cent of TB suspects referred for diagnosis; 23 per cent of 'new smear-positives' diagnosed; 7 per cent of DOT provision within medical college; and 86 per cent treatment success rate among new smear-positive patients. As the Programme widens its scope, future challenges include sustenance of this contribution and facilitating universal access to quality TB care; greater involvement in operational research relevant to the Programme needs; and better co-ordination mechanisms between district, state, zonal and national level to encourage their involvement.

Profile of micro-organisms in intensive care unit of a level-1 trauma centre: A retrospective study.

BACKGROUND: Patients with trauma usually require highly specialized care in ICU and many times their recovery is complicated by infections. Aim of this study was to determine the profile of pathogens and their impact on outcome among these patients. MATERIALS AND METHODS: The clinical records of 101 consecutive patients who were admitted for more than 48-hrs in ICU during Jun-Dec 2007 were analyzed. RESULTS: Total of 953 samples from blood, urine, BAL or pus/collection were subjected to cultures. From 276 samples, 299 organisms were isolated. Among pathogens Candida Spp. [89 (29%)] were the most common, followed by Acinetobacter Spp. [69 (23%)], Pseudomonas Spp. [63 (21%)], Klebsiella Spp. [31 (10%)], coagulase negative Staphylococcus aureus [16 (5%)], E coli [12 (4%)], Enterobacter Spp. [7 (2%)], S aureus [6 (2%)], Enterococcus Spp. [5 (2%)], Citrobacter Spp. [2 (0.6%)], S maltophila [1 (0.3%)] and Providentia Spp. [1 (0.3%)]. For gram negative pathogens drug-resistance rates were as follows: Fluoroquinolones, 76%; 3(rd) generation cephalosporins, 74%; aminoglycosides, 66%; ß-lactams/ß-lactamase inhibitors combinations, 64%; and carbapenems, 50%. Among these 27% of pathogens were resistant to all 5 classes of drugs. 58% of Staphylococcus aureus were methicillin-resistant whereas 85% of coagulase negative Staphylococcus were methicillin resistant. The mortality was higher among patients in whom pathogens were isolated [Odd's Ratio (OR) 0.185; 95% confidence interval (CI) 0.049-0.640; P = 0.002]. CONCLUSIONS: Isolation of multi-drug resistant pathogens is common among trauma patients admitted in ICU and is associated with increased mortality and could impact on the consumption of hospital resources. The importance of high rate of fungal isolation needs to be studied among these patients.

Clinical characteristics of tuberculosis-associated immune reconstitution inflammatory syndrome in North Indian population of HIV/AIDS patients receiving HAART.

BACKGROUND & OBJECTIVE: IRIS is an important complication that occurs during management of HIV-TB coinfection and it poses difficulty in diagnosis. Previous studies have reported variable incidence of IRIS. The present study was undertaken to describe the pattern of TB-associated IRIS using recently proposed consensus case-definitions for TB-IRIS for its use in resource-limited settings. METHODS: A prospective analysis of ART-naïve adults started on HAART from November, 2008 to May, 2010 was done in a tertiary care hospital in north India. A total 224 patients divided into two groups, one with HIV-TB and the other with HIV alone, were followedup for a minimum period of 3 months. The diagnosis of TB was categorised as ''definitive" and ''probable". RESULTS: Out of a total of 224 patients, 203 completed followup. Paradoxical TB-IRIS occurred in 5 of 123 (4%) HIV-TB patients while 6 of 80 (7.5%) HIV patients developed ART-associated TB. A reduction in plasma viral load was significantly (P = .016) associated with paradoxical TB-IRIS. No identifiable risk factors were associated with the development of ART-associated TB. CONCLUSION: The consensus case-definitions are useful tools in the diagnosis of TB-associated IRIS. High index of clinical suspicion is required for an early diagnosis.

Pattern & correlates of neurocognitive dysfunction in Asian Indian adults with severe obstructive sleep apnoea.

BACKGROUND & OBJECTIVES: No published data are available on neurocognitive dysfunction in Asian Indians with obstructive sleep apnoea (OSA). We therefore, studied the pattern and correlates of neurocognitive dysfunction in Indian adults with severe OSA. METHODS: Fifty patients aged 25-65 yr with severe OSA (apnoea-hypopnoea index>30) and 25 age, sex, and education level-matched normal controls were studied. Both groups were administered a standardized battery of neurocognitive tests. RESULTS: Patients with severe OSA had significantly impaired performance on tests of alertness, working memory, response inhibition, problem solving, and executive function. However, the difference in executive function between the groups disappeared after adjusting for delayed information processing. The test scores did not correlate with apnoea-hypopnoea index, arousal index, or Epworth sleepiness score. However, the percentage of time spent at <90 per cent oxygen saturation had a weak correlation with the number of stroop errors (Spearman's rho=0.64; P=0.033), number of trials required (rho=0.05; P=0.02), and perseverative errors on Wisconsin card sorting test (rho=0.36; P=0.02). INTERPRETATION & CONCLUSIONS: Our results suggested that delayed information processing rather than impaired abstract thinking was probably the cause of impaired performance on composite tests of neurocognitive function in patients with severe OSA.

Obesity, and not obstructive sleep apnea, is responsible for increased serum hs-CRP levels in patients with sleep-disordered breathing in Delhi.

OBJECTIVE: The present study was conducted to evaluate serum levels of high-sensitivity C-reactive protein (hs-CRP) in newly diagnosed patients with obstructive sleep apnea (OSA). SUBJECTS AND METHODS: Between April 2005 and March 2006, a total of 231 consecutive adult habitual snorers underwent polysomnography (PSG) in the sleep laboratory. Ninety-seven subjects were found suitable for hs-CRP measurement after application of the following exclusion criteria: patients with diabetes mellitus, hypertension, coronary artery disease, acromegaly, hypothyroidism, chronic renal failure, congestive cardiac failure, or smoking history, patients who were pregnant, on steroid treatment, on hormone replacement therapy, or with chronic use of drugs such as non-steroidal anti-inflammatory drugs, oral anticoagulants and lipid-lowering drugs and patients having undergone upper airway surgery. Patients were classified as apneic [apnea-hypopnea index (AHI)>5], obese non-apneic [body mass index (BMI)>25, AHI<5] and non-obese non-apneic (BMI<25, AHI<5). C-reactive protein levels were measured in stored sera by high-sensitivity enzyme immunoassay (Biocheck, Inc. Foster City, CA, USA). After checking normality with the Kolmogorov-Smirnov test and using a square-root transformation, Pearson's and partial correlation coefficients were calculated for identified risk factors and confounders. A multiple linear regression model was used to identify variables that were independently associated with hs-CRP. RESULTS: The mean serum levels of hs-CRP were found to be 0.25+/-0.23, 0.58+/-0.55, and 0.51+/-0.37 mg/dl in non-obese non-apneics (n=23), obese non-apneics (n=45) and apneics (obese and non-obese, n=29), respectively. Pearson's correlation coefficient of hs-CRP with BMI was found to be 0.25 (p=0.01), and with AHI 0.16 (p=0.12). Partial correlation analysis showed that hs-CRP levels correlated significantly with BMI after adjustment for AHI and age (r=0.22, p=0.03), while correlation with disease severity as assessed by AHI after adjustment for BMI and age was not significant (r=0.10, p=0.33). After stepwise multiple linear regression, only BMI was found to be significantly associated with serum hs-CRP levels (beta=0.02, p=0.01). CONCLUSIONS: In this first comprehensive cross-sectional study on Indian subjects, we found that obesity, and not obstructive sleep apnea, is associated with elevated serum levels of hs-CRP. No independent correlation was found between severity of OSA and hs-CRP in the present study.

Visceral leishmaniasis: acute liver failure in an immunocompetent Asian-Indian adult.

Fulminant liver failure due to visceral leishmaniais is very rare, and has been described only in children. We report an immunocompetent adult man who developed acute liver failure due to leishmaniais and dramatically recovered with amphotericin-B therapy.

Cardiac involvement in hemochromatosis.

Cardiac hemochromatosis or primary iron-overload cardiomyopathy is an important and potentially preventable cause of heart failure. This is initially characterized by diastolic dysfunction and arrhythmias and in later stages by dilated cardiomyopathy. Diagnosis of iron overload is established by elevated transferrin saturation (>55%) and elevated serum ferritin (>300 ng/mL). Genetic testing for mutations in the HFE (high iron) gene and other proteins, such as hemojuvelin, transferrin receptor, and ferroportin, should be performed if secondary causes of iron overload are ruled out. Patients should undergo comprehensive 2D and Doppler echocardiography to evaluate their systolic and diastolic function. Newer modalities like strain imaging and speckle-tracking echocardiography hold promise for earlier detection of cardiac involvement. Cardiac magnetic resonance imaging with measurement of T2* relaxation times can help quantify myocardial iron overload. In addition to its value in diagnosis of cardiac iron overload, response to iron reduction therapy can be assessed by serial imaging. Therapeutic phlebotomy and iron chelation are the cornerstones of therapy. The average survival is less than a year in untreated patients with severe cardiac impairment. However, if treated early and aggressively, the survival rate approaches that of the regular heart failure population.

Novel Approaches for the Treatment of the Patient with Resistant Hypertension: Renal Nerve Ablation.

Sympathetic innervation of the kidneys plays a major role in the pathogenesis of hypertension through modulation of renin secretion, glomerular filtration rate and renal absorption of sodium. Targeted interventions for renal nerve ablation are being developed for treatment of drug resistant hypertension in the USA and rest of the world. Early studies with the use of radiofrequency based renal denervation systems have shown encouraging results with significant reduction of blood pressure in patients inadequately controlled despite nearly maximal drug therapy regimens. Thus far, the renal denervation procedure has been associated with minimal side effects. Long term efficacy and safety beyond 3 years needs to be determined for renal nerve ablation. This review focuses on the physiology of the renal sympathetic system, the rationale for renal nerve ablation and current evidence in support of the available therapeutic renal denervation systems.

Review of the state of renal nerve ablation for patients with severe and resistant hypertension.

Through modulation of renin secretion, glomerular filtration rate, and renal absorption of sodium, the sympathetic innervation of the kidneys plays an important role in the pathogenesis of hypertension. Renal nerve ablation technology is being developed for treatment of drug-treatment-resistant hypertension worldwide. Preliminary research with the use of radiofrequency-based renal denervation systems have demonstrated encouraging results with significant reduction of blood pressure in patients inadequately controlled despite nearly maximal drug therapy regimens. From work done thus far, the renal denervation procedure has not been associated with serious adverse effects. Long-term efficacy and safety still needs to be established for renal nerve ablation. This review focuses on the impact of the renal sympathetic system on blood pressure regulation, the clinical rationale for renal nerve ablation in severe and drug-treatment-resistant hypertension, and current evidence from the more advanced renal denervation devices.

Differential properties of enantiomers of commercially available racemates.

The existence of left- or right-handedness of a compound is referred to as chirality. Each form (left- or right-handed) of a chiral compound is called an 'enantiomer' or an 'isomer'. A collection containing only one enantiomeric form of a chiral molecule is called an optically pure, chirally pure, enantiomerically pure or unichiral compound while collection of equal amounts of the two enantiomeric forms (R and S) is called a racemate. Many of the drugs currently used in medical practice are racemates. However it is well documented that the two enantiomers of a racemate can differ in their pharmacokinetic/pharmacodynamic and efficacy/ safety profiles. Replacing existing racemates with unichiral drugs may result in improved safety and/or efficacy profile of various racemates. This article presents an overview of differential properties of enantiomers of some commercially available racemates.