Predictors of mortality, strategies to reduce readmission, and economic impact of acute decompensated heart failure: Results of the Vellore Heart Failure Registry.

AIM: Heart failure is a global problem that is increasing in prevalence. We undertook the initiative to compile the Vellore Heart Failure Registry (VHFR) to assess the clinical profile, mortality, risk factors and economic burden of heart failure by conducting a prospective, observational, hospital-based cohort study in Vellore, Tamil Nadu. METHODS AND RESULTS: This study was a prospective observational cohort study conducted at the Christian Medical College and Hospital, Vellore, between January 2014 and December 2016. A total of 572 patients who satisfied the Boston criteria for "definite heart failure" were included and the primary outcome was all-cause mortality. The median duration of hospital stay was eight days and the in-hospital, one, three and six month mortalities were 13.25%, 27.3%, 32.53% and 38.15%, respectively. The median duration of survival was 921 days. Readmission for heart failure constituted 42%, and the most common cause of decompensation was an infection(31.5%). The presence of cyanosis at admission, history of previous stroke or transient ischemic attack, and American College of Cardiology (ACC)/American Heart Association (AHA) stage D at the time of discharge were independently associated with mortality at six months. The median total direct cost of admission was INR 84,881.00 ($ 1232.34) CONCLUSION: The VHFR cohort had younger, more diabetic, and fewer hypertensive subjects than most cohorts. Admission for heart failure is a catastrophic health expenditure. Attempts should be made to ensure a reduction in readmission rates by targeting goal-directed therapy. As the most common cause of acute decompensation is pneumonia, vaccinating all patients before discharge may also help in this regard.

Antinuclear antibodies in scrub typhus: Transient occurrence during acute illness.

BACKGROUND & OBJECTIVES: The pathological hallmark of scrub typhus infection is focal or disseminated vasculitis. As with other infections, antinuclear antibodies (ANA) have been previously described in scrub typhus. However, the underlying mechanisms and implications of this immunological phenomenon is not well understood. In the present work it was assessed whether ANA is associated with illness severity and outcomes. METHODS: In this prospective study spanning one year, patients fulfilling the diagnostic criteria for scrub typhus were recruited. Patients with other acute infective febrile illnesses were taken as controls. ANA positivity was compared between the cases and controls. ANA in scrub typhus was assessed for correlation with disease severity, organ dysfunction and outcomes. RESULTS: The cohort comprised of 149 patients (scrub 89; controls 60) with mean age 46.5 (SD=16.9) yr; 48.3% were female. ANA was detected in 48 (53.9%) patients with scrub typhus and 9(15%) controls (p < 0.001). The ANA pattern was predominantly speckled (93.8%) in both scrub typhus patients and controls. In patients with scrub typhus, ANA positivity was associated with increasing APACHE-III score [Odds ratio (OR) 1.01; 95% CI 0.99-1.03; p = 0.09]. On bivariate analysis, ANA tended to be correlated with acute respiratory distress syndrome (OR 2.32; 95% CI 0.98-5.46; p = 0.06), hepatic dysfunction (OR 2.25; 95% CI 0.94-5.39, p = 0.06) and aseptic meningitis (OR 6.83; 95% CI 0.80-58.05, p = 0.08). The presence of these antibodies did not correlate with duration of hospitalization or mortality. Convalescent sera on 31 ANA positive scrub typhus patients demonstrated persistence of ANA in only 5 (16.1%) patients. INTERPRETATION & CONCLUSION: The disappearance of ANA during the convalescent phase suggests that ANA is expressed during the acute phase of scrub typhus infection. Its association with organ dysfunction warrants further study of the mechanisms and impact of autoantibody formation in scrub typhus.

Prognostic Factors of Malignant Pleural Effusion among Palliative Care Outpatients: A Retrospective Study.

BACKGROUND: Malignant pleural effusion (MPE) has varied survival and indicates advanced disease. LENT prognostic score is the first validated score used for MPE. This study assessed the role of LENT among palliative care cancer patients and assessed different patient, tumor, and treatment related factors that may affect survival. METHODS: A retrospective study of advanced cancer patients with MPE, seen in palliative care outpatient clinic (2013-2015) until death, was done. LENT prognostic score could be calculated in 15 patients. Patient, tumor, and treatment related factors that affect survival were assessed. RESULTS: The study included 48 patients (70.8% female; 29.2% male) with a median age of 53 years. Lung (41.7%) was the most common primary, and adenocarcinoma (44.7%) was the most common histology. The median overall survival (OS) was 14.5 months (interquartile range [IQR]: 5.25-32.75) and median survival time (ST) was 3 months (IQR: 1-7.75). ST was significantly low with poor Eastern Cooperative Oncology Group (ECOG) performance status (P = 0.002), bilateral effusion (P < 0.001), and with no oncological treatment after MPE diagnosis (P < 0.001). OS and ST were significantly low with lung primary (P = 0.006 and 0.02, respectively). Age, gender, breathlessness, tumor histology, lung metastasis, and interventions for MPE did not significantly affect survival. The median ST in the moderate and high risk LENT groups was 6 and 3 months, respectively (P = 0.16). CONCLUSION: ECOG performance status, bilateral effusion, and no oncological treatment after diagnosis of MPE were associated with poor ST. Lung primary was associated with shorter OS and ST. Small numbers precluded any definitive conclusion on the prognostic value of LENT in our group of patients, and hence larger studies are recommended.

Serum amyloid A as a marker of disease activity and treatment response in Takayasu arteritis.

Assessment of disease activity in Takayasu arteritis (TA) is challenging. We aimed to study utility of serum amyloid A (SAA) to assess disease activity and its association with SAA gene polymorphisms, if any, in our TA patients. Serum of 99 consecutive adult TA patients and 40 healthy controls were assayed for SAA. Depending on the ITAS2010 and ITAS-CRP score, patients were designated as having active disease if ITAS2010 ≥ 2 or ITAS-CRP ≥ 3 and stable disease if ITAS2010 = 0 or ITAS-CRP is ≤1. Clinical ITAS of 0 with raised inflammatory markers scoring a ITAS-CRP of 2 was considered as indeterminate for disease activity assessment. Repeat SAA levels for active group was measured after 6 months from baseline. SAA levels between active and stable disease as well as serial levels were compared. DNA of 40 patients and controls were genotyped for SAA polymorphisms (rs12218, rs2468844) and the allele frequencies were compared. At baseline, SAA levels were higher in patients as compared to controls (137.4 vs 100.8 ng/ml, p = 0.001) and higher in patients with active disease (166.4 ng/ml) than those with stable disease (98.2 ng/ml), p = 0.001. SAA decreased during follow-up in treatment responders (189.9 ng/ml at baseline vs 119.0 ng/ml at follow-up, p = 0.008); in contrast, there was no significant change among non-responders during follow-up. Allelic frequencies of SAA gene polymorphisms did not differ between cases and controls. SAA may be a reliable biomarker to assess disease activity and treatment response in TA.

Biochemical and clinical profile after organophosphorus poisoning--a placebo-controlled trial using pralidoxime.

BACKGROUND: Organophosphorus (OP) compounds are the most common suicidal poison in developing countries and mortality continues to be high. METHODS: A study was done to see butyryl cholinesterase (BuChE) profile after OP poisoning in pralidoxime (P2AM) and placebo treated cases. Highest recommended dose of P2AM was used to study the reactivation of cholinesterase. Clinical outcomes like, correlation of BuChE and severity of poisoning, mortality and complications like Type I and II paralysis, need for ventilation and ICU stay were also studied. RESULTS: Twenty one cases of moderate and severe poisoning with OP compounds were included in the study. Mean BuChE levels came up gradually over 6-7 days, some taking up to two weeks. There was no. difference between the treatment and placebo groups. BuChE levels did not correlate with severity of poisoning nor did it correlate with Type I or II paralysis, need for ventilation, ICU stay or mortality. CONCLUSIONS: Treatment with P2AM does not make any difference in BuChE reactivation or complications of moderate and severe OP poisoning. We have not been using P2AM for OP poisoning in our medical ICU with good patient outcomes.