Costs & outcomes of hospitalized scrub typhus infection in a tertiary hospital in south India.

Background & objectives: Scrub typhus is a rickettsial infection seen along the Asian-Pacific rim and imposes a considerable burden on affected people in low- and middle-income countries. The present study was aimed to determine the direct cost of hospitalization of scrub typhus and its trend over six years. Methods: This was a retrospective, observational, hospital based study of individuals admitted to the hospital, diagnosed with scrub typhus over six years, from January 2013 to December 2018. The potential out of pocket expenditure was evaluated. Results: A total of 198 patients were included in the study. The median cost of admission (adjusted to INR 2020) for the six years (2013 to 2018) was found to be ₹ 37,026 (US $ 490) [interquartile range (IQR) 22,996-64,992]. The median cost for patients admitted to the intensive care unit (ICU) was ₹ 128,046 (US $ 1695) (IQR 71,575-201,171), while the cost for patients admitted to the ward-alone was ₹ 33,232 (US $ 440) (IQR 19,609-45,373). The multivariable analysis showed that ARDS and SOFA score were the independent predictors of ICU admission. Interpretation & conclusions: Hospitalisation for scrub typhus is associated with a substantial healthcare expense. The predictors of increased cost were the presence of acute respiratory distress syndrome (ARDS), shock, increasing sequential organ failure assessment (SOFA) score and duration of hospital stay.

Infections precipitating Takotsubo cardiomyopathy, an uncommon complication of a common infection.

Takotsubo cardiomyopathy (TTC) is a non-ischemic cardiomyopathy precipitated by stress. Various infections are reported to precipitate this form of cardiomyopathy. We report a patient presenting with TTC secondary to influenza.  In this article, we also discuss the various infections reported to precipitate this form of reversible cardiomyopathy in literature. We have also included the recent reports of TTC among patients with COVID-19.

Endocrinological abnormalities and Takotsubo cardiomyopathy.

Dear Editor, We read with much excitement in the article "Takotsubo syndrome and pheochromocytoma: an insidious combination" published by Maffé et al. in your esteemed journal...

ProtekDuo percutaneous ventricular support system-physiology and clinical applications.

The ProtekDuo (LivaNova, London, UK) cannula is a dual-lumen device, typically inserted into the right internal jugular (IJ) vein through a percutaneous approach, with fluoroscopy or ultrasound guidance. When connected to a pump, such as the TandemHeart (LivaNova, London, UK) or CentriMag (Abbott, Pleasanton, CA, USA), it can function as a right ventricular (RV) mechanical circulatory support (MCS). When an oxygenator is also added [veno-pulmonary (V-P)], it can provide extracorporeal membrane oxygenation (ECMO) support. This review aims to provide a comprehensive overview of the device's physiology and clinical applications. In the setting of RV failure (RVF), the ProtekDuo cannula, with its outflow in the main pulmonary artery (PA), can bypass the failing RV, improving pulmonary flow, left atrial (LA) filling pressures, and left ventricular (LV) preload. This can also reduce ventricular interdependence and leftward shift of the interventricular septum that occurs in RVF. In this review, the key sections expand on the use of the ProtekDuo cannula in the management of critically ill patients, specifically, the use of ProtekDuo for RV myocardial infarction (MI) RVF, LV assist device (LVAD) implantation-associated RVF, RVF post-heart transplantation, temporary biventricular MCS as bridge to recovery (ECpella 2.0 or PROpella), biventricular support as bridge to recovery or decision, isolated LV failure, post lung transplantation (LT) care, and other miscellaneous clinical scenarios. ProtekDuo is an important tool in the armory of RVF management. The ProtekDuo system is expected to gain more popularity given its clear advantages such as groin-free approach allowing for mobility, easy percutaneous deployment, compatibility with various pumps and oxygenators, and the versatility to be integrated in numerous configurations. In an era of expanding MCS options, further research is needed to better understand the optimal tool for specific patient subsets.

Burden of firearm-related injuries as associated secondary diagnosis in the United States from National Inpatient Sample Dataset.

There is little known about the differences, from the point of view of healthcare resource utilization, between non-fatal versus fatal firearm-related injuries. We undertook this research project utilizing the National Inpatient Sample (NIS) database to address this critical knowledge gap. Our aims for this study were to describe the patterns of FRI in the United States during the period of 2016-2019 and to evaluate the patient-centered outcomes in the survivor (non-fatal injuries) versus the non-survivor (fatal injuries) groups. We used the National Inpatient Sample (NIS) Database, 2016-2019 (5) (~ 20% of United States hospitalizations) to identify patients with an associated diagnosis of firearm-related injuries (FRI) [Gibson T et al (2016) in Agency for Healthcare Research and Quality 2016-02]. We found that the individuals from the lowest quartile of annual household income, males, young Americans, and racial minorities were disproportionally affected The non-survivor (fatal injuries) group had a shorter length of stay in the hospital by 5.1 days (95% CI - 5.64 to - 4.58, p value = < 0.01), the higher median cost of hospitalization by $8903 (95% confidence interval $311.9 to $17,494.2, p value = 0.04), and a higher median cost of hospitalization per day by $41,576.74 (95% confidence interval $ 40,333.1 to $42,820.3, p value = < 0.01). In conclusion, the individuals from the lowest quartile of annual household income, males, young Americans and racial minorities were disproportionally affected. Firearm-related injuries pose a persistent healthcare cost burden with the cumulative and per day cost of hospitalization for fatal injuries being significantly higher than the non-fatal injuries despite a shorter hospital LOS.

Takotsubo cardiomyopathy following envenomation: An updated review.

BACKGROUND: Takotsubo cardiomyopathy (TTC) can be diagnosed in patients presenting with clinical features of acute coronary syndrome (ACS) by using Mayo clinic criteria. Multiple precipitators have been attributed to causing TTC. Rarely it has been reported to occur following an acute envenomation. AIM: This review describes the various patterns, mechanisms, and outcomes of envenomation induced TTC. METHODS: In this review, we included all studies on "TTC" and "envenomation "published in the various databases before June 2022. To be included in the review articles had to have a distinct diagnosis of TTC and an envenomation. RESULTS: A total of 20 patients with envenomation induced TTC were identified. Most episodes of envenomation induced TTC were reported following a bee sting, scorpion sting, and snake envenomation. Fear and anxiety related to the sting, direct catecholamine toxicity and administration of exogenous beta-adrenergic agents have been commonly postulated to precipitate TTC in these patients. 95% of these patients presented with a clinical picture of ACS. Most of these patients also fulfill at least 3 out of 4 criteria of Mayo clinic criteria for TTC. Echocardiographic evidence of Apical TTC was noted in 72% of patients. 94% of these patients had clinical improvement following optimal management and 35% of these patients were treated with guideline directed medications for heart failure. CONCLUSION: Envenomation following multiple insect stings and reptile bites can precipitate TTC. Most reported envenomation related TTC has been due to bee stings and scorpion bites. Common mechanisms causing TTC were fear, anxiety, and stress of envenomation. Most of these patients present with clinical presentation of ACS, ST elevation, and elevated troponin. The most common type of TTC in these patients is Apical, which improved following medical management.

Cardiovascular complications following medical termination of pregnancy: An updated review.

BACKGROUND: Around 1 million cases of medical termination of pregnancy (MTP) take place yearly in the United States of America with around 2 percent of this population developing complications. The cardiovascular (CVD) complications occurring post MTP or after stillbirth is not very well described. AIM: To help the reader better understand, prepare, and manage these complications by reviewing various cardiac comorbidities seen after MTP. METHODS: We performed a literature search in PubMed, Medline, RCA, and google scholar, using the search terms "abortions" or "medical/legal termination of pregnancy" and "cardiac complications" or "cardiovascular complications". RESULTS: The most common complications described in the literature following MTP were infective endocarditis (IE) (n = 16), takotsubo cardiomyopathy (TTC) (n = 7), arrhythmias (n = 5), and sudden coronary artery dissection (SCAD) (n = 4). The most common valve involved in IE was the tricuspid valve in 69% (n = 10). The most observed causative organism was group B Streptococcus in 81% (n = 12). The most common type of TTC was apical type in 57% (n = 4). Out of five patients developing arrhythmia, bradycardia was the most common and was seen in 60% (3/5) of the patients. All four cases of SCAD-P type presented as acute coronary syndrome 10-14 d post termination of pregnancy with predominant involvement of the right coronary artery. Mortality was only reported following IE in 6.25%. Clinical recovery was reported consistently after optimal medical management following all these complications. CONCLUSION: In conclusion, the occurrence of CVD complications following pregnancy termination is infrequently documented in the existing literature. In this review, the most common CVD complication following MTP was noted to be IE and TTC.

Application of Cardiogenic Shock Working Group-defined Society for Cardiovascular Angiography and Interventions (CSWG-SCAI) Staging of Cardiogenic Shock to the Medical Information Mart for Intensive Care IV (MIMIC-IV) database.

BACKGROUND: The optimal parameters for defining stages of cardiogenic shock (CS) are not yet known. The Cardiogenic Shock Working Group-defined Society for Cardiovascular Angiography and Interventions (CSWG-SCAI) staging of CS was developed to provide simple and specific parameters for risk-stratifying patients. OBJECTIVES: The purpose of this study was to test whether the Cardiogenic Shock Working Group-defined Society for Cardiovascular Angiography and Interventions (CSWG-SCAI) staging is associated with in-hospital mortality, using the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. METHODS: We utilized the open-access MIMIC-IV database, which includes >300,000 patients admitted between 2008 and 2019. We extracted the clinical profile of patients admitted with CS and stratified them into different SCAI stages at admission based on the CSWG criteria. We then tested the association between in-hospital mortality and parameters of hypotension, hypoperfusion, and overall CSWG-SCAI stage. RESULTS: Of the 2463 patients, CS was predominantly caused by heart failure (HF; 54.7 %) or myocardial infarction (MI; 26.3 %). Mortality was 37.5 % for the total cohort, 32.7 % for patients with HF, and 40 % for patients with MI (p < 0.001). Mortality was higher among patients with mean arterial pressure < 65 mmHg, lactate >2 mmol/L, ALT >200 IU/L, pH ≤ 7.2, and more than one drug/device support at baseline. Increasing CSWG-SCAI stages at baseline and maximum CSWG-SCAI stage achieved were significantly associated with in-hospital mortality (p < 0.05). CONCLUSIONS: The CSWG-SCAI stages are significantly associated with in-hospital mortality and may be used to identify hospitalized patients at risk of worsening cardiogenic shock severity. CONDENSED ABSTRACT: We analyzed data from 2463 patients with cardiogenic shock using the MIMIC-IV database to investigate the relationship between the Cardiogenic Shock Working Group-defined Society for Cardiovascular Angiography and Interventions (CSWG-SCAI) staging and in-hospital mortality. The main causes of cardiogenic shock were heart failure (54.7 %) and myocardial infarction (26.3 %). The overall mortality rate was 37.5 %, with a higher rate among patients with myocardial infarction (40 %) compared to those with heart failure (32.7 %). Mean arterial pressure < 65 mmHg, lactate >2 mmol/L, ALT >200 IU/L, and pH ≤ 7.2 were significantly associated with mortality. Increasing CSWG-SCAI stages at baseline and maximum achieved stages were strongly associated with higher mortality (p < 0.05). Therefore, the CSWG-SCAI staging system can be used to risk-stratify patients with cardiogenic shock.

Infective endocarditis and COVID -19 coinfection: An updated review.

With the rising number of COVID-19 patients, there have been reports of patients presenting with concomitant infective endocarditis.  In this retrospective review, we included all articles from Medline with COVID-19 and infective endocarditis coinfection.  Ten articles were identified from eight different countries over the world over the past 11 months.  All patients reported with the above coinfections were male with a mean age of 53 years.  Clinical features of COVID-19 and the presence of ground-glass opacity in CT thorax were predominant among patients with positive RT-PCR for COVID-19.  New-onset embolic infarct, pulmonary edema was a contributor to the diagnosis of endocarditis in most patients.  Involvement of the aortic valve was most common.  Delayed diagnosis and cardiac surgery were contributors to increased morbidity.

Nosocomial Infections in COVID-19 Patients Treated with Immunomodulators: A Narrative Review.

Nosocomial infections pose an imminent challenge to hospitalized Coronavirus disease-19 (COVID-19) patients due to complex interplay of dysregulated immune response combined with immunomodulator therapy. In the pre-pandemic era, immunomodulatory therapy has shown benefit in certain autoimmune conditions with untamed inflammatory response. Efforts to recapitulate these immunomodulatory effects in COVID-19 patients has gained impetus and were followed by NIH COVID-19 expert panel recommendations. The current NIH guideline recommends interleukin-6 inhibitors (tocilizumab and sarilumab) and Janus kinase inhibitors (baricitinib and tofacitinib). Several landmark research trials like COVAVTA, EMPACTA, REMDACTA, STOP-COVID and COV BARRIER have detailed the various effects associated with administration of immunomodulators. The historical evidence of increased infection among patients receiving immunomodulators for autoimmune conditions, raised concerns regarding administration of immunomodulators in COVID-19 patients. The aim of this review article is to provide a comprehensive update on the currently available literature surrounding this issue. We reviewed 40 studies out of which 37 investigated IL-6 inhibitors and 3 investigated JAK inhibitors. Among the studies reviewed, the reported rates of nosocomial infections among the COVID-19 patients treated with immunomodulators were similar to patients receiving standard of care for COVID-19. However, these studies were not powered to assess the side effect profile of these medications. Immunomodulators, by dampening the pyrogenic response and inflammatory markers may delay detection of infections among the patients. This underscores the importance of long-term surveillance which are necessary to discover the potential risks associated with these agents.

Utility of cardiac bioenzymes in predicting cardiovascular outcomes in SARS-CoV-2.

BACKGROUND: Cardiovascular complications have been increasingly recognized in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) associated coronavirus disease 2019 (COVID-19). Cardiac biomarkers are released because of this ongoing cardiovascular injury and can act as surrogate markers to assess the disease severity. AIM: To review the variation and utility of these biomarkers in COVID-19 to ascertain their role in diagnosis, prognosis and clinical outcomes of the disease. METHODS: We performed a literature search in PubMed, Medline and the Reference Citation Analysis (RCA), using the search terms "COVID-19" and "cardiac bioenzymes" or "cardiac biomarkers". Additionally, we also used the latest reference citation analysis tool to identify more articles. RESULTS: Cardiac troponin has been consistently elevated in patients with COVID-19 associated myocarditis, and strongly correlated with adverse prognosis. Natri-uretic peptides including brain natriuretic peptide (BNP) and pro-BNP is elevated in patients with COVID-19 associated cardiac injury, irrespective of their prior heart failure status, and independently correlated with worst outcomes. Alongside these traditional biomarkers, novel cardiac bioenzymes including presepsin, soluble ST2 and copeptin, are also increasingly recognized as markers of cardiovascular injury in COVID-19 and can be associated with poor outcomes. CONCLUSION: Assessment of cardiac bioenzymes at admission and their serial monitoring can help assess the severity of disease and predict mortality in patients with SARS-CoV-2 infection. Future studies are needed to elude the critical importance of novel biomarkers.

Heart failure in COVID-19 patients: Critical care experience.

Patients with heart failure (HF) may be at a higher risk of coronavirus disease 2019 (COVID-19) infection and may have a worse outcome due to their comorbid conditions and advanced age. In this narrative review, we aim to study the interaction between COVID-19 and HF from a critical care perspective. We performed a systematic search for studies that reported HF and critical care-related outcomes in COVID-19 patients in the PubMed and Medline databases. From a total of 1050 papers, we identified 26 that satisfied the eligibility criteria for our review. Data such as patient demographics, HF, intensive care unit (ICU) admission, management, and outcome were extracted from these studies and analyzed. We reported outcomes in heart-transplant patients with COVID-19 separately. In hospitalized patients with COVID-19, the prevalence of HF varied between 4% and 21%. The requirement for ICU admission was between 8% and 33%. HF patients with COVID-19 had an overall mortality rate between 20% and 40%. We identified that HF is an independent predictor of mortality in hospitalized COVID-19 patients, and patients with HF were more likely to require ventilation, ICU admission and develop complications. Patients with HF with reduced ejection fraction did worse than those with HF with midrange ejection fraction, and HF with preserved ejection fraction. COVID-19 patients with HF should be identified early and managed aggressively in an attempt to improve outcomes in this cohort of patients.

Central Variant Posterior Reversible Encephalopathy Syndrome in a Pregnant Woman With Eclampsia: A Case Report.

Posterior Reversible Encephalopathy Syndrome (PRES) is a clinico-radiological diagnosis characterized by acute or subacute neurological symptoms. A 27-year-old woman at 35 weeks of pregnancy, who presented with generalized tonic-clonic seizures had persistently low Glasgow Coma Scale (GCS) score after delivery of the baby. Magnetic Resonance Imaging (MRI) of the brain showed T-2 Fluid Attenuated Inversion Recovery (FLAIR) hyperintensities in the brainstem, bilateral medial cerebellar hemispheres, bilateral medial temporal lobes, bilateral thalami, lentiform and caudate nuclei, and bilateral fronto-parieto-occipital lobes. There was diffusion restriction in bilateral caudate nuclei, left thalamus and right frontal lobe, and microhemorrhages in the left thalamus. These findings were suggestive of central variant PRES. She improved with strict blood pressure control and anti-edema measures. A repeat MRI brain on day 10 showed significant improvement, and she had no residual neurological deficits. The central variant of PRES is a rare entity that has to be considered in a patient presenting with neurological deficits in the setting of uncontrolled blood pressure, eclampsia, immunomodulatory medication use, or renal failure. While most patients with PRES fully recover with timely therapy targeted at reversing the primary cause, some may have residual neurological deficits or rarely, die.

Clinical considerations for critically ill COVID-19 cancer patients: A systematic review.

BACKGROUND: The World Health Organization (WHO) on March 11, 2020, had declared the novel coronavirus disease 2019 (COVID-19) outbreak a global pandemic. The COVID-19 infection continues to be a pandemic and is currently causing overwhelming challenges to healthcare across the nations. Cancer patients represent a unique population vulnerable to COVID-19 infection due to their advanced age, intrinsic frailty, medical comorbidities, immunosuppression, and frequent health care visits for their underlying disease. Robust analysis of COVID-19 infection among cancer patients is crucial to aid in the optimal management of these patients. AIM: To identify contributors of worse outcomes in patients with malignancy and COVID-19 and to describe the role of critical care. METHODS: In this review, we summarized the information from seminal articles on the presentation and management of patients with COVID-19 and malignancy that were published before December 10, 2020. We searched the Pub Med and Medline database for "COVID-19" and "Cancer", "Malignancy". Studies published in English, including adults with malignancy and COVID-19 infection, were eligible to be included in this review. Studies on patients that provided details on malignancy, clinical presentation, management, and outcome were included. Various details of malignancy that were included are the site of cancer, histopathological type, stage, chemotherapy, and immunotherapy. Details of COVID-19 infection that were obtained are clinical presentation, the modality of testing, imaging, management, and outcome. Critical care details that were obtained were the type of the organ dysfunction and the requirement of organ support measures, requirement of noninvasive, invasive ventilation, management of vasopressor support, and outcome. Articles that did not have patient details, opinions, letters, and articles not published in English were excluded. All articles were reviewed by 2 independent clinicians. Articles were screened for the above terminologies by independent clinicians. RESULTS: We identified two thousand one hundred eighty-six articles, among which fifty-five were studies that had included patient details pertaining to COVID-19 and cancer (Figure 1). Among these, eighteen studies were eligible and were included in this review as shown in Table 1. A total of 5199 cancer patients were reported. The mean age of patients across all the studies was 64.3 years with male predominance was noted in 12 studies. The clinical presentation and diagnosis of these patients were similar to the general population. Most commonly reported malignancies with COVID-19 infection were hematological in 44% of patients, followed by thoracic malignancy in 11% of patients. The mean number of cancer patients with COVID-19 requiring critical care was 16%. The mean mortality reported was 27.4%. Among the studies that reported the presence of organ dysfunction, respiratory failure was reported in 52% of patients, of which 11.7% required mechanical ventilation. 72% of COVID-19 cancer patients required hospitalization across all the studies. The factors which are associated with the worse outcome from COVID-19 infections among the cancer patients were male gender, age ≥ 65 years, presence of higher comorbidity burden based on Charlson comorbidity index and cumulative illness reporting scale > 6, and smoking history. CONCLUSION: The majority of the cancer patients required intensive care due to respiratory failure and the need for mechanical ventilation. Appropriate contingency planning for these patients in terms of goals of care and judicious resource allocation in the resource-poor regions is the key. The factors associated with worse outcomes from COVID-19 infections were independent of oncological features such as tumor stage, disease status, or current provision of active anticancer therapy and it could be continued with caution.

Metronidazole-induced reversible cerebellar dysfunction.

A 73-year-old man who presented with fever and abdominal discomfort was diagnosed to have a liver abscess. He was treated with antimicrobials which included metronidazole. One month into treatment, he developed neurological symptoms and signs that were suggestive of cerebellar pathology. MRI of the brain showed T2/fluid attenuated inversion recovery hyperintensities involving bilateral dentate, fastigial and interpositus nuclei. After excluding common aetiologies, the possibility of metronidazole-induced neurotoxicity was considered. After stopping metronidazole, his symptoms and signs resolved. A subsequent MRI scan of the brain showed reversal of changes. Neurotoxicity caused by metronidazole is an uncommon adverse effect of a commonly used antimicrobial drug and should be considered in the appropriate clinical scenario.

A review of the presentation and outcome of sarcoidosis in coronavirus disease 2019.

BACKGROUND: In the setting of the current pandemic, concerns have arisen regarding the multisystemic involvement of sarcoidosis and the possible exacerbations in response to the exposure to severe acute respiratory syndrome coronavirus 2. AIM: This study aims to compare the differences in clinical presentation, management, and outcome of coronavirus disease 2019 (COVID-19) between patients with sarcoidosis and those in the general population. METHODS: A literature search was conducted by reviewing original research articles such as case reports, case series, observational studies, and questionnaire-based surveys published in PubMed/Medline, Web of Science, and Google scholar. Data from individual patients in case series and case reports have been pooled to create a data set that was compared with larger such cohorts obtained from several other observational studies. RESULTS: Twenty-seven patients were identified from 14 original articles. No significant differences were found in the clinical manifestations of patients with sarcoidosis presenting with COVID-19 as compared to the general population. The rate of hospitalization in our study was found to be 48.1%. The overall mortality in our study was 7.4%, which is higher than the global average of 2.1%. CONCLUSION: Our observations have reinforced the hypothesis that the presence of additional medical comorbidities is associated with a higher risk of intensive care unit admission. Furthermore, the presence of moderate to a severe limitation in pulmonary functions is an additional risk factor associated with increased hospital admissions and mortality in sarcoidosis. However, neither the diagnosis of sarcoidosis nor ongoing treatment with steroids, methotrexate, or other immunosuppressants was associated with a poorer prognosis in patients with sarcoidosis. RELEVANCE FOR PATIENTS: Patients with sarcoidosis must take added precautions to mitigate the risk of acquiring COVID-19 infection in view of the COVID-19-related mortality rate in this group of patients. Specifically, immunocompromised patients (on immunomodulator drugs and high dose steroids) have been found to have an increased risk of contracting COVID-19. Overall impact on prognostication and outcome in cases requiring hospitalization remains yet to be determined.

A review of the presentation and outcome of left ventricular thrombus in coronavirus disease 2019 infection.

BACKGROUND: Cardiovascular complications of the coronavirus disease 2019 (COVID-19), which is caused by the severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2), have been documented both in the acute phase and in convalescence. One such complication is the formation of the left ventricular (LV) thrombus. There is a lack of clarity regarding the incidence, risk factors, and management of this complication. AIM: The aim of the study is to identify the clinical presentation, risk factors and outcome of COVID-19 patients with left ventricular thrombus (LVT). METHODS: A literature search was conducted to identify all case reports of COVID-19 with LVT in PubMed/Medline, Embase, Web of Science, and Google Scholar. RESULTS: Among the 65 patients identified, 60 had LVT, either at admission, or during the acute phase of the illness. Six patients with mild symptoms during the acute phase of viral illness had only the COVID-19 antibody test positivity at the time LV thrombus was detected. Few of the patients (23.1%) had no comorbidities. The mean age of the patients was 52.8 years, and the youngest patient was 4 years old. This suggests that LVT formation can occur in young COVID-19 patients with no co-morbid conditions. Most of the patients (69.2%) had more than one site of thrombosis. A mortality rate of 23.1% was observed in our review, and ST-elevation myocardial infarction (STEMI) was diagnosed in 33.3% of those who died. CONCLUSIONS: A high degree of suspicion for LVT must be maintained in patients with known cardiac disease and those with new-onset arterial or venous thromboembolism, and such patients may benefit from a screening echocardiography at admission. RELEVANCE FOR PATIENTS: The patients with preexisting cardiovascular disease must take added precautions to prevent acquiring COVID-19 infection as there is a higher risk of developing LV thrombus. In patients who develop LVT in COVID-19, mortality rate is higher.

Clinical and Immunological Profile of Mixed Connective Tissue Disease and a Comparison of Four Diagnostic Criteria.

Mixed connective tissue disease (MCTD) was initially described as a chronic immune-mediated disease with overlapping features of systemic lupus erythematosus, scleroderma, and polymyositis. We conducted a cross-sectional study to describe the clinical and immunological profile of patients with MCTD and to compare the four diagnostic criteria, namely, Sharp, Kasukawa, Alarcón-Segovia, and Khan criteria. A total of 291 patients who were admitted from June 2007 to June 2017 and fulfilled the inclusion criteria were included in the study. A clinical diagnosis of MCTD was made in 111 patients, of whom 103 (92.8%) were women. The mean age at presentation was 39.3 years (SD ± 11.6). The most common organ systems that were involved were musculoskeletal system (95.5%), skin and mucosa (78.4%), and the gastrointestinal and hepatobiliary systems (56%). The maximum sensitivity was for the Kasukawa criteria with a sensitivity of 77.5% (95% CI 68.4-84.6) and specificity of 92.2% (95% CI 87-95.5). The Kahn criteria and Alarcón-Segovia criteria had the maximum specificity; the Alarcón-Segovia criteria had a sensitivity of 69.4% (95% CI 59.8-77.6) and a specificity of 99.4% (95% CI 96.5-99.9), while the Kahn criteria had a sensitivity of 52.3% (95% CI 42.6-61.7) and a specificity of 99.4% (95% CI 96.5-99.9). The sensitivity and specificity of Sharp criteria were 57.7% (95% CI 47.9-66.87) and 90% (95% CI 84.4-93.8), respectively.

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.

Cytomegalovirus ventriculoencephalitis presenting with hydrocephalus in a patient with advanced HIV infection.

A 38-year-old lady with advanced human immunodeficiency virus (HIV) infection presented to the emergency department with headache, vomiting and fluctuating alertness for 3 weeks. On examination, she had tachycardia, bilateral papilledema, restriction of upward gaze, gaze-evoked nystagmus and signs of meningeal irritation. Magnetic resonance imaging of the brain showed hydrocephalus and periventricular high T2-signal regions with restriction on diffusion-weighted imaging. Polymerase chain reaction done on the cerebrospinal fluid obtained after the insertion of an external ventricular drain was positive for cytomegalovirus (CMV). She was treated with intravenous ganciclovir followed by oral valganciclovir with which she made a dramatic recovery. CMV ventriculoencephalitis can present with hydrocephalus in HIV-infected individuals. A high index of suspicion must be maintained to diagnose this disease and start appropriate therapy on time.