The Power and Promise of Angiotensin Receptor Neprilysin Inhibitor (ARNI) in Heart Failure Management: National Consensus Statement

Heart failure (HF) is a huge global public health task due to morbidity, mortality, disturbed quality of life, and major economic burden. It is an area of active research and newer treatment strategies are evolving. Recently angiotensin receptor-neprilysin inhibitor (ARNI), a class of drugs (the first agent in this class, Sacubitril–Valsartan), reduces cardiovascular mortality and morbidity in chronic HF patients with reduced left ventricular ejection fraction (LVEF). Positive therapeutic effects have led to a decrease in cardiovascular mortality and HF hospitalizations (HFH), with a favorable safety profile, and have been documented in several clinical studies with an unquestionable survival benefit with ARNI, Sacubitril–Valsartan. This consensus statement of the Indian group of experts in cardiology, nephrology, and diabetes provides a comprehensive review of the power and promise of ARNI in HF management and an evidence-based appraisal of the use of ARNI as an essential treatment strategy for HF patients in clinical practice. Consensus in this review favors an early utility of Sacubitril–Valsartan in patients with HF with reduced EF (HFrEF), regardless of the previous therapy being given. A lower rate of hospitalizations for HF with Sacubitril–Valsartan in HF patients with preserved EF who are phenotypically heterogeneous suggests possible benefits of ARNI in patients having 40–50% of LVEF, frequent subtle systolic dysfunction, and higher hospitalization risk.

Mortality of Elderly Patients Supported by Mechanical Ventilation at a General Critical Care Unit in a Tertiary Care Centre

Background : There has been a steady rise in the geriatric population in India and increasing number of elderly patients are being admitted in Critical Care Unit (CCU). They need mechanical ventilation during their hospital stay. Hence, there is continued need for evaluation and research to develop a validating scoring systems used to predict the outcome of CCU patients supported by mechanical ventilation. Objective : Analysis to predict the outcome (survival or mortality) of mechanically ventilated elderly patients in different age groups at the CCU. Material and Method : A Prospective observational study was done in CCU for a period of one year. A group of 40 elderly ventilated patients greater than 60 years of age (Group 1-elderly case group) and another group of 40 ventilated patients less than 60 years of age (Group-2- control group) were included in the study. A clinical database was collected which included age, sex, Acute Physiology and Chronic health Evaluation II (APACHE II) score and an Sequential Organ Failure Assessment (SOFA) scores were calculated in the first 24 hours of ventilation,indication of mechanical ventilation, co-morbidity, according to the Charlson Comorbidity Index (CCI), functional capacity according to the Barthel Index (BI). Patients outcome (survival or mortality) were analyzed. All the patients in two groups were on ventilation support. Result : In case group (n=40), mortality was 55%. In control group (n=40), mortality was 52.5%. On comparison of outcome between two groups (case with control group) the difference was not statistically significant (p= 0.8225). In case group, association of outcome to different age groups (60-65 years, 66-75years, more than75years) (p=0.3357) andto gender (p=0.3854) was not statistically significant. Multivariate logistic regression analysis of the study variables showed APACHE II score to be statistically significant for outcome (p=0.0229). Conclusion : Mortality of elderly patients supported by mechanical ventilation at CCU were slightly higher(55%) than in mechanically ventilated younger populations (52.5%) though the difference was not statistically significant between two groups (p=0.82). APACHE II, score measured within 24 hours of ventilation was a significant predictor of mortality in the patients on mechanical ventilation.

A Hospital based Observational Study of Clinical spectrum and Outcome of Mucormycosis during the COVID Pandemic

Background : Mucormycosis is a life threatening fungal disease caused by the filamentous fungi mucormycetes. Though a known entity for decades, it began to manifest in an unprecedented manner in the COVID scenario specially with the second wave in India. The objectives were to describe the demographic characteristics, clinical presentations, risk factors, therapy and in-hospital mortality of patients with Mucormycosis. Material and Methods : We conducted a retrospective observational study for a period of six months from March 2021 to August 2021. The data was collected for cases of mucormycosis from multiple centres all over West Bengal and analysed. All consecutive individuals with confirmed mucormycosis were enrolled in this study. The data documenting demographic particulars, presentation, predisposing factors and comorbiditieswere recorded in a pre validated case report form Details of investigation recording site and extent of disease, therapeutic intervention and outcome was mentioned . Statistical analysis was done using SPSS 21.0 for MS-Windows. Results : The total number of cases from March to August 2021 was 263 . There were 171 males and 92 females and the mean age of occurrence was 50.8±0.4 years .In West Bengal clusters of cases were being reported most commonly from the districts of North 24 Parganas, Kolkata, Jalpaiguri, Darjeeling and Hooghly. Some cases admitted here hailed from outside states like Bihar, Jharkhand, Odisha and Assam. The majority of the cases 74.22% (196)were COVID Associated Mucormycosis (CAM) while only 25.78% were non COVID associated. Diabetes mellitus was associated in 78.7 % and history of prolonged steroid therapy in 57.4% of cases. We encountered rhino orbital mucormycosis in 99.24 % of cases and cerebral involvement in 47.3%. They were treated with Amphotericin B deoxycholate along with endoscopic debridement. The most common side effects of Amphotericin B Deoxycholate were hypokalemia (93%), hypomagnesemia (32%) and AKI (74%) of the cases .The number of patients discharged was 16.7% and 10 left against medical advice (LAMA) . In hospital deaths were recorded to be 26.7%. Cause of death was commonly -AKI, septic shock and multiorgan failure . Conclusion : Prevention is better than cure of this devastating disease which is difficult todiagnose and treat .Awareness about mucormycosis and careful clinical evaluation of post-COVID patients is mandatory in this era in order to rapidly diagnose and treat mucormycosis

Myositis And Immune Reconstitution Inflammatory Syndrome In An Immuno Compromised Patient: A Therapeutic Conundrum

Microsporidia are ubiquitous fungi that may infect animals, fish, insects as well as humans. Human infection is uncommon and only seen in the immunocompromised individual. Here, we report the case of a 40-year-old known AIDS patient presented with severe myalgia and inability to walk. Investigations revealed microsporidial myositis. Her treatment was further complicated by the development of acute inflammatory demyelinating polyneuropathy (AIDP) 2 weeks later. However, treating human immunodeficiency virus, microsporidiosis, and AIDP as a consequence of immune reconstitution inflammatory syndrome concomitantly led to clinical improvement

A Cross-sectional Study of Undiagnosed Fever in a Rural Population at a Tertiary Care Hospital of West Bengal

Background:Undiagnosed fever has been a predicament to physicians all over the world for decades. This study was undertaken to evaluate the demographic and etiological pattern of a rural population in Eastern India. Objectives. 1. To study the spectrum of etiology of prolonged fever. 2. To evaluate the demographic characteristics of the patients. Methods: All patients with undiagnosed fever for more than three weeks attending the Medicine outpatient Department were included in the study. History and clinical examination were recorded in a proforma. All patients under went routine as well as relevant special investigations including RDT for Malaria, IgM ELISA for Leptospira and Chikungunya and Brucella. Blood, urine and other body fluid culture including BACTEC and CB NAAT (as required) were also done. Endoscopies, imaging studies and guided biopsies were performed where needed. Results were recorded and analysed using appropriate descriptive statistical methods using SPSS Software (version 20). Results:A total number of 110 patients were included in the study. Of them 52(47.2%) were male and 58 (52.7%) were female. The age of the patients varied from 15 years to 78 years mean age being 33.68±18.77. Conclusion: The patients were mainly from rural background, most common districts being Murshidabad (40%) followed by24 Parganas S (20%), Midnapur (14.5%) and Nadia (10.9%). Socioeconomic status of the patients varied from lower (47.2%) lower middle class (39%) to middle class(13.8%). 65.3% of the patients were literate of whom 10.9 % of the people were matriculate while 1.8% were graduates. The commonest etiology of prolonged fever were infections 76(69%) out of which Tuberculosis 44(40%), took the lions’ share. Tuberculosis was followed by chronic UTI (8.2%) enteric fever(5.5%) and malaria(4.5%). This was followed by various malignancies 14(12.7%) and inflammatory disorders 12(10.9%) It was notable that while prevalence of infections were comparable in males and females the prevalence of cancers (15.3%vs10.3%) and inflammatory disorders (7.6%vs 13.8%) varied. No diagnosis could be reached in 3.6% cases.

Appraisal of Phlebotomus argentipes habitat suitability using a remotely sensed index in the kala-azar endemic focus of Bihar, India

Visceral leishmaniasis, or kala-azar, is recognised as a serious emerging public health problem in India. In this study, environmental parameters, such as land surface temperature (LST) and renormalised difference vegetation indices (RDVI), were used to delineate the association between environmental variables and Phlebotomus argentipes abundance in a representative endemic region of Bihar, India. The adult P. argentipes were collected between September 2009-February 2010 using the hand-held aspirator technique. The distribution of P. argentipes was analysed with the LST and RDVI of the peak and lean seasons. The association between environmental covariates and P. argentipes density was analysed a multivariate linear regression model. The sandfly density at its maximum in September, whereas the minimum density was recorded in January. The regression model indicated that the season, minimum LST, mean LST and mean RDVI were the best environmental covariates for the P. argentipes distribution. The final model indicated that nearly 74% of the variance of sandfly density could be explained by these environmental covariates. This approach might be useful for mapping and predicting the distribution of P. argentipes, which may help the health agencies that are involved in the kala-azar control programme focus on high-risk areas.

Delimitation of kala-azar risk areas in the district of Vaishali in Bihar (India) using a geo-environmental approach

Remote sensing and geographical information technologies were used to discriminate areas of high and low risk for contracting kala-azar or visceral leishmaniasis. Satellite data were digitally processed to generate maps of land cover and spectral indices, such as the normalised difference vegetation index and wetness index. To map estimated vector abundance and indoor climate data, local polynomial interpolations were used based on the weightage values. Attribute layers were prepared based on illiteracy and the unemployed proportion of the population and associated with village boundaries. Pearson's correlation coefficient was used to estimate the relationship between environmental variables and disease incidence across the study area. The cell values for each input raster in the analysis were assigned values from the evaluation scale. Simple weighting/ratings based on the degree of favourable conditions for kala-azar transmission were used for all the variables, leading to geo-environmental risk model. Variables such as, land use/land cover, vegetation conditions, surface dampness, the indoor climate, illiteracy rates and the size of the unemployed population were considered for inclusion in the geo-environmental kala-azar risk model. The risk model was stratified into areas of "risk"and "non-risk"for the disease, based on calculation of risk indices. The described approach constitutes a promising tool for microlevel kala-azar surveillance and aids in directing control efforts.