Clinical Profile and Predictors of Mortality of Severe Pandemic (H1N1) 2009 Virus Infection Needing Intensive Care: A Multi-Centre Prospective Study from South India.

BACKGROUND: This multi-center study from India details the profile and outcomes of patients admitted to the intensive care unit (ICU) with pandemic Influenza A (H1N1) 2009 virus [P(H1N1)2009v] infection. MATERIALS AND METHODS: Over 4 months, adult patients diagnosed to have P(H1N1)2009v infection by real-time RT-PCR of respiratory specimens and requiring ICU admission were followed up until death or hospital discharge. Sequential organ failure assessment (SOFA) scores were calculated daily. RESULTS: Of the 1902 patients screened, 464 (24.4%) tested positive for P(H1N1)2009v; 106 (22.8%) patients aged 35±11.9 (mean±SD) years required ICU admission 5.8±2.7 days after onset of illness. Common symptoms were fever (96.2%), cough (88.7%), and breathlessness (85.9%). The admission APACHE-II and SOFA scores were 14.4±6.5 and 5.5±3.1, respectively. Ninety-six (90.6%) patients required ventilation for 10.1±7.5 days. Of these, 34/96 (35.4%) were non-invasively ventilated; 16/34 were weaned successfully whilst 18/34 required intubation. Sixteen patients (15.1%) needed dialysis. The duration of hospitalization was 14.0±8.0 days. Hospital mortality was 49%. Mortality in pregnant/puerperal women was 52.6% (10/19). Patients requiring invasive ventilation at admission had a higher mortality than those managed with non-invasive ventilation and those not requiring ventilation (44/62 vs. 8/44, P<0.001). Need for dialysis was independently associated with mortality (P=0.019). Although admission APACHE-II and SOFA scores were significantly (P<0.02) higher in non-survivors compared with survivors on univariate analysis, individually, neither were predictive on multivariate analysis. CONCLUSIONS: In our setting, a high mortality was observed in patients admitted to ICU with severe P(H1N1)2009v infection. The need for invasive ventilation and dialysis were associated with a poor outcome.

Rationale and design of the Rural Andhra Pradesh Cardiovascular Prevention Study (RAPCAPS): a factorial, cluster-randomized trial of 2 practical cardiovascular disease prevention strategies developed for rural Andhra Pradesh, India.

BACKGROUND: Developing countries are experiencing increasing levels of cardiovascular disease (CVD). Although there is a good understanding of how to deliver CVD prevention programs in developed countries, there are few data regarding strategies for CVD prevention in resource-poor settings. This study aimed to implement and evaluate a CVD prevention program in a rural area of India. METHODS: The 2 strategies of CVD prevention to be investigated are an algorithm-based care approach and a health-promotion campaign. A factorial, cluster-randomized trial design will be used to evaluate these, in which villages will be exposed to one, both, or neither of the interventions for a period of about 12 months. Surveys of households in every village will be used to assess outcomes in all high-risk individuals and a sample of the general adult population. RESULTS: The primary outcome of the algorithm-based component of this study will be the percentage of high-risk individuals that have been "identified"-defined as having received a cardiovascular-risk assessment in the last 12 months. The primary outcome for the health-promotion component will be the percentage of the adult population with correct knowledge about the effects of 6 behavioral determinants of cardiovascular risk (green-leafy vegetables, fruits, oily foods, salt, smoking, physical activity). Secondary outcomes include a range of measures defining uptake of different preventive strategies. CONCLUSIONS: This study will provide evidence about the effectiveness of a simple practical mechanism of CVD preventive care specifically designed for delivery in a resource-poor area in India.

Fatal and nonfatal cardiovascular disease and the use of therapies for secondary prevention in a rural region of India.

BACKGROUND: The rate of cardiovascular disease is widely considered to be increasing throughout India. Precise and reliable data on fatal and nonfatal cardiovascular disease, however, are few, and little is known about the use of preventive therapies. This is particularly true for rural regions. METHODS AND RESULTS: Data were collected from 53 villages in the Godavari region of Andhra Pradesh. Mortality data were obtained from a verbal autopsy-based mortality surveillance system during a 12-month period in 2003 to 2004. The prevalence of nonfatal cardiovascular disease and the use of preventive therapies were estimated from a stratified random sample of 4535 adults (> or =30 years of age) in 2005. Cardiovascular disease was the leading cause of mortality, accounting for at least 32% of all deaths. The average age at cardiovascular death was 65 years, and 51% of all cardiovascular deaths occurred in patients <70 years of age. Among adults, the prevalence of coronary heart disease was estimated to be 4.8% (95% CI, 4.1 to 5.5), and the prevalence of cerebrovascular disease was estimated at 2.0% (95% CI, 1.5 to 2.4). Among individuals with either diagnosis, 14% (95% CI, 10 to 18) reported taking aspirin, 41% (95% CI, 36 to 47) took a blood pressure-lowering medication, and 5% (95% CI, 3 to 7) reported using a cholesterol-lowering medication. CONCLUSIONS: This region has a large disease burden attributable to cardiovascular disease with significant underuse of proven, low-cost preventive medications.

Greater adverse effects of cholesterol and diabetes on carotid intima-media thickness in South Asian Indians: comparison of risk factor-IMT associations in two population-based surveys.

Asian Indians appear particularly susceptible to coronary heart disease compared with other ethnic groups. We compared the effects of vascular risk factors on carotid intima-media thickness (IMT) in a population of South Asians from Andhra Pradesh, India with a population of Caucasians from Perth, Australia. Cardiovascular risk factors and ultrasound-assessed carotid IMT were measured in randomly selected adults from two villages in rural India (n=303) and compared to those for randomly sampled adults from Australia (n=1111). Regression models with interaction terms were used to compare the strengths of associations between risk factors and carotid IMT, in these two populations. There were stronger associations of cholesterol (p for interaction=0.009) and diabetes (p=0.04) with carotid IMT in the Indian compared to the Australian population. Also, while increasing HDL-cholesterol was associated with decreasing carotid IMT in the Australian population the reverse was true for the Indian population (p<0.001). The associations with IMT of blood pressure, triglycerides, age, HDL to total cholesterol ratio, glucose, BMI, waist, waist to hip ratio and smoking were not different between the populations. Greater adverse effects of total cholesterol and diabetes on atherosclerosis and no protective effect of HDL-cholesterol amongst Asian Indians provide a novel possible explanation for observed excess rates of cardiovascular disease amongst these populations.

Significant lipid, adiposity and metabolic abnormalities amongst 4535 Indians from a developing region of rural Andhra Pradesh.

BACKGROUND AND OBJECTIVE: Both migrant and local urban populations of Asian Indians have high rates of cardiovascular disease. Metabolic risk factors appear key to this phenomenon but data from rural India are few. We sought to determine the prevalence and distribution of lipids, obesity and metabolic syndrome in a rural region of Andhra Pradesh. METHODS: Sampling was done in 20 villages representative of the project area with an age- and sex-stratified group of 4535 adults > or =30 years selected at random from a local census list. The sample represented 13% of all adults > or =30 years in the 20 villages with a response rate of 81%. All participants had interviewer administered questionnaire, physical examination and fasting finger-prick glucose. Every fourth individual had venous blood testing for lipid profile (n=1085). Analysis was done using weighting to obtain estimates of risk factor levels for the adult population in the 20 villages. In addition to standard WHO and 2005 NCEP-ATPIII classifications, exploratory 'Asian' definitions were used for overweight and abdominal obesity. RESULTS: The population mean levels of total, LDL, HDL-cholesterol and triglycerides were 4.5 (4.4-4.6) mmol/L, 2.8 (2.7-2.9) mmol/L, 1.1 (1.06-1.13) mmol/L, 1.5 (1.4-1.6) mmol/L for men; and 4.8 (4.7-4.9) mmol/L, 3.0 (3.0-3.1) mmol/L, 1.2 (1.16-1.22) mmol/L, 1.3 (1.2-1.4) mmol/L for women. 18.4% of men and 26.3% of women were overweight rising to 32.4% of men and 41.4% of women if 'Asian' definitions were used. Criteria for NCEP-ATPIII metabolic syndrome were met by 26.9% of men and 18.4% of women with figures of 32.5% and 23.9%, respectively, if 'Asian' waist cut-offs were substituted. CONCLUSIONS: Dyslipidaemia, adiposity and metabolic syndrome were common in this rural Indian population and prevalence was much greater if proposed Asian definitions for adiposity were used. Metabolic risk factors likely play a major role in cardiovascular disease in this region.

Cardiovascular disease and risk factors among 345 adults in rural India--the Andhra Pradesh Rural Health Initiative.

BACKGROUND: Heart attack and stroke are problems already faced by some urban populations of India, but less is known about cardiovascular disease and risk factors in rural areas. The aim of the study was to investigate the levels and management of major cardiovascular risk factors and the prevalence of cardiovascular disease in two villages in rural Andhra Pradesh, India. METHODS: A cross-sectional survey was done by selecting a random sample stratified by age and gender from each village using census lists compiled in 2002. For each individual, trained study staff administered a Telugu-translation of a structured questionnaire, performed a brief physical examination and collected a fasting venous blood sample. Weighted estimates of mean (or percentages with) risk factor levels in the population were calculated and are reported with confidence intervals unless otherwise specified. RESULTS: Data was collected from 345 adults aged 20 to 90. The average household size was 4.2 and the mean combined household income was about Indian Rupees 25,454 (580 US dollars) per year. The mean systolic blood pressure was 116 (114-117) mm Hg, diastolic blood pressure 73 (114-120) mm Hg, total cholesterol 4.6 (4.5-4.7) mmol/L, HDL-cholesterol 0.8 (0.8-0.9) mmol/L, LDL-cholesterol 3.2 (3.1-3.3) mmol/L and triglyceride 1.3 (1.2-1.4) mmol/L. The prevalence of current smoking was 19.9% (15.4-24.4%), hypertension 20.3% (16.2-24.4%), diabetes 3.7% (1.8-5.5%), overweight 16.9% (12.3-21.5%) and obesity 4.4% (1.9-6.8%). A medical diagnosis of cardiovascular disease (previous heart attack, stroke or angina) was reported by 2.5% (1.1-3.9%) and a further 1.1% (0.1-2.1%) had angina by the 'Rose' classification. CONCLUSIONS: The possibility of increasing cardiovascular risk factors and prevalence of vascular disease in areas of rural India represent a public health concern. Larger and repeated epidemiological studies focusing on chronic diseases are required to inform treatment and prevention strategies suitable for use in these areas and other resource poor settings.

Congenital lipoblastoma of the scalp.

Lipoblastoma is a unique tumor of infancy and early childhood that can occur congenitally. It commonly occurs in trunk and extremities, but also rarely in head and neck. We have not encountered any report of congenital lipoblastoma of scalp in published literature. Here we describe the case of an infant who presented with a rapidly growing large scalp mass that measured 15 x 15 x 10 cm. At birth, the mass was located on the bregma but progressed to extend into the left upper eyelid and eyebrow. The mass was resected in two stages: the first stage consisted of resecting the scalp mass and the second stage consisted of excising the eyelid extension of the lesion. The histology of both resection specimens was similar and showed lobular adipose tissue separated by fibrous septae, which was consistent with a lipoblastoma. The child is free of recurrence at follow-up 3 years after the resection.