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Adverse cardiac remodeling refers to progressive structural and functional modifications in the heart because of increased wall stress in the myocardium, loss of viable myocardium, and neurohormonal stimulation. The guideline-directed medical therapy for Heart failure (HF) includes Angiotensin receptor-neprilysin inhibitor (ARNI) (sacubitril/valsartan), ?-blockers, sodium-glucose co-transporter 2 (SGLT2) inhibitors, and mineralocorticoid receptor antagonists (MRA). ARNI is under-prescribed in India despite its attractive safety and efficacy profile. Therefore, the consensus discusses objectives and topics related to ARNI in the management of cardiac remodeling, and experts shared their views on the early timely intervention of effective dosage of ARNI to improve the diagnosis and enhance mortality and morbidity benefits in cardiac reverse remodeling (CRR).
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Iron deficiency (ID) with or without anemia is frequently observed in patients with heart failure (HF). Uncorrected ID is associated with higher hospitalization and mortality in patients with acute HF (AHF) and chronic HF (CHF). Hence, in addition to chronic renal insufficiency, anemia, and diabetes, ID appears as a novel comorbidity and a treatment target of CHF. Intravenous (IV) ferric carboxymaltose (FCM) reduces the hospitalization risk due to HF worsening and improves functional capacity and quality of life (QOL) in HF patients. The current consensus document provides criteria, an expert opinion on the diagnosis of ID in HF, patient profiles for IV FCM, and correct administration and monitoring of such patients.
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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.
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Background & objectives: High mortality has been observed in the cancer population affected with COVID-19 during this pandemic. We undertook this study to determine the characteristics and outcomes of cancer patients with COVID-19 and assessed the factors predicting outcome. Methods: Patients of all age groups with a proven history of malignancy and a recent diagnosis of SARS-CoV-2 infection based on nasal/nasopharyngeal reverse transcriptase (RT)-PCR tests were included. Demographic, clinical and laboratory variables were compared between survivors and non-survivors groups, with respect to observed mortality. Results: Between May 11 and August 10, 2020, 134 patients were included from the three centres and observed mortality was 17.1 per cent. The median age was 53 yr (interquartile range 39-61 yr) and thirty four patients (25%) were asymptomatic. Solid tumours accounted for 69.1 per cent and breast cancer was the most common tumour type (20%). One hundred and five patients (70.5%) had received chemotherapy within the past four weeks and 25 patients (19.3%) had neutropenia at presentation. On multivariate analysis, age [odds ratio (OR) 7.99 (95% confidence interval [CI] 1.18-54.00); P=0.033], haemoglobin [OR 6.28 (95% CI 1.07-37.04); P=0.042] neutrophil–lymphocyte ratio [OR 12.02 (95% CI 2.08-69.51); P=0.005] and baseline serum albumin [OR 18.52 (95% CI 2.80-122.27); P=0.002], were associated with higher mortality. Recent chemotherapy, haematological tumours type and baseline neutropenia did not affect the outcome. Interpretation & conclusions: Higher mortality in moderate and severe infections was associated with baseline organ dysfunction and elderly age. Significant proportion of patients were asymptomatic and might remain undetected
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Background: Although dermatology is mostly an outpatient specialty, some patients with severe skin disease need hospital admission for management. There is a paucity of data regarding the profile of these dermatology in-patient admissions. Aims: We studied the profile of patients admitted to the dermatology ward of our tertiary care government hospital in North India. Methods: This was a retrospective analysis of discharge sheets of patients admitted in the dermatology ward from January 1, 2014 to December 31, 2017. Results: Discharge sheets of 2032 admissions for 1664 patients were analyzed. The most common diagnoses in the admitted patients were immunobullous disorders (576, 28%), connective tissue diseases (409, 20%), infections, including leprosy and sexually transmitted infections (179, 8.8%), psoriasis (153, 7.5%) and reactive arthritis (92, 4.5%). The mean duration of admission was 13.95±11.67 days (range 1-118 days). Two hundred and fifty-six patients (15.38%) were re-admitted, accounting for 368 (18.11%) re-admissions. Patients with immunobullous disorders (OR 1.72, 95% CI 1.29-2.28) and psoriasis (OR 1.62, 95% CI 1.02-2.55) were more likely to be re-admitted. Adult patients, those who were admitted for more than four weeks, those who had comorbidities, and those who developed a complication during the hospital stay also had a greater likelihood of being re-admitted. Limitations: The retrospective design of the study, and the non-availability of data regarding transfers to other specialties or intensive care units and deaths were the main limitations of this study. Conclusion: This study describes the profile of patients admitted in a dermatology ward of a tertiary care centre center in North India. The patient profile and admission characteristics associated with a higher probability of re-admission were identified.
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Prevalence of non-communicable diseases were considered to be rare in children. But they have increased recently in developing countries, with increase in the prevalence of paediatric overweight and obesity. Body Mass Index (BMI) is commonly used to define overweight and obesity. Positive associations have been repeatedly reported between BMI and Hypertension.METHODSWe have conducted an observational cross sectional study of hypertension in 1250 students in the age group of 10-18 years studying in class 6 to 12 during school hours from July 2013 to June 2014. The values were recorded in multiples of 2 mmHg and levels greater than 95th percentile of age and gender were considered using the definition of the fourth report of NHBPEP. The association of risk factors were also evaluated.RESULTSOut of a total 1250 children, 239 (19.1%) had systolic hypertension, and 216 (17.3%) has diastolic hypertension. Prevalence of overweight and obesity were 11.8% and 7.5% respectively. Highly significant statistical association was found between body mass index (BMI) and both systolic and diastolic hypertension (p value 0.001).CONCLUSIONSPrevalence of both systolic and diastolic hypertensions were significantly high in overweight and obese children in comparison to normal weight children. Strong positive association was found between body mass index (BMI) and both systolic and diastolic hypertension. Association of other risk factors such as sex, family history, dietary habits like junk food intake and extra salt intake, were also observed
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Chronic respiratory diseases(CRD) remain a formidable challenge for public health experts acrossthe world due to their ever increasing morbidity and mortality. This study investigated various riskfactors for CRD among rural adults aged 20 years and above. The study was conducted in fourvillages under sub-health centre Domana in Kot Balwal health block and these villages wereselected randomly. For this cross-sectional population based study, a pre-tested respiratory healthquestionnaire was used. Those respondents who were found to be diagnosed cases of CRD werefurther enquired in detail about various risk factors for CRD. Out of 2018 respondents surveyed,177confirmed cases of CRD were detected.Various risk factors like being male, smoking, overcrowding,recurrent chest infections and use of non-clean fuel (wood, cow dung) were found to bestatistically significant. Among other risk factors, ventilation and history of allergy were found tobe highly significant statistically (p< 0.000). Smoking, recurrent chest infections, use of biomass fuel,ventilation and history of allergy were risk factors for CRD in rural adults aged 20 years andabove.
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Introduction: Posterior fossa tumours are common inpaediatric population; however their occurrence in adults is notrare. They form a major cause of morbidity and mortality ineither population. Some of these tumours like pilocyticastrocytomas are rewarding, others, like medulloblastomasmay have a poor outcome. This study aims to analyse theepidemiology and surgical outcomes of posterior fossa lesions.Materials and Methods: This is a retrospective study done atDepartment of neurosurgery S.M.S Medical college Jaipur fromJanuary 2017 to December 2017. It included 32 patients withposterior fossa lesions. Cerebellopontine angle lesionsschwannomas, epidermoids were excluded. Only lesionsinvolving the cerebellum or occupying the fourth ventricle wereincluded in the study. Their surgical outcome in terms ofcomplications and mortality were analysed.Results: Thirty –two patients, in the age group of 2years to 68years were included in the study. Cerebello-pontine anglelesions were excluded. Only lesions involving the cerebellum oroccupying the fourth ventricle were included in the study. Mostcommon lesion was medulloblastoma, followed by pilocyticastrocytoma, cerebellar abscess, haemangioblastoma,arachnoid cyst, exophytic tectal gliomas, tuberculoma,metastasis, epidermoid. They underwent surgery dependingupon the nature of lesion. Overall mortality was found in 9 of 32patients. Mortality was especially high in medulloblastomapatients (54.55%).Conclusions: Various lesions may affect the posterior fossa,varying from neoplastic malignant or benign lesions to infectiveand developmental lesions. Medulloblastoma is a commontumour in the paediatric population and carries a badprognosis.
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Background: Available options for correction of facial volume loss, such as synthetic fillers, autologous fat and cultured fibroblasts, have limitations viz. temporary effect and high cost. Aim: To assess the use of a novel technique, autologous non-cultured dermal cell suspension transplantation, for correction of localized facial volume loss due to inflammatory pathologies. Methods: It was a pilot study conducted in the Dermatology Outpatient Department, All India Institute of Medical Sciences (AIIMS), New Delhi, India. Autologous non-cultured dermal cell suspension was transplanted in a total of 10 patients, out of which 5 had predominantly dermal loss and the rest had predominantly lipoatrophy. The donor tissue from the gluteal region was digested into a single cell suspension using collagenase-1 and injected into the recipient area. The outcome was assessed subjectively by patients and investigators and objectively using ultrasonography. Cell count, viability testing and measurement of mesenchymal stem cells were also done. Results: On assessment of patients, the median improvement in the predominantly dermal atrophy group at 3 and 6 months was 70% (range: 10–90%) and 80% (range: 0–90%), respectively, and in the predominantly lipoatrophy group, 0% (range: 0–40) and 0% (range: 0–50), respectively. Mean thickness of dermis + subcutis at the baseline was 1.835 mm (range: 0.89–6.04 mm), which increased to 2.912 mm (range: 0.88–7.07 mm, P = 0.03) at 6 months. Limitations: Our pilot study has some limitations such as small sample size and heterogeneity of the recruited patients. Conclusions: Autologous non-cultured dermal cell suspension transplantation appears to be safe and effective in localized facial dermal defects because of inflammatory pathologies, but not effective in deeper defects.
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Background: Trichoscopy is an office tool used in the diagnosis of alopecia but its utility has not been assessed. Objectives: To compare the trichoscopic characteristics of different types of alopecia, identify features of diagnostic value, and to determine the utility of trichoscopy in the diagnosis of alopecia. Methods: A descriptive cross‑sectional study was performed in patients with alopecia. After clinical assessment and relevant investigations, trichoscopy was performed using a non‑polarized trichoscope (×10). The utility of trichoscopy in difficult cases of alopecia was assessed statistically. Results: One hundred and twenty patients of alopecia (90 non-cicatricial, 30 cicatricial) were recruited. The diagnosis was made on the basis of a detailed history and clinical examination, and confirmed by biopsy and relevant investigations in difficult cases. Yellow dots (63.3%) were the most common trichoscopic feature followed by thin hair (40.8%). Among the 21 difficult cases of alopecia, trichoscopy was diagnostic in 19 (90.5%). Statistically significant features on intergroup comparison included black dots (Fischer’s exact test, P < 0.001), cadaverized hair (P = 0.024), exclamation mark hair (P < 0.001) in alopecia areata; diameter diversity more than 20% (P < 0.001) and thin hair (P < 0.001) in androgenetic alopecia; broken hair of different lengths (P < 0.001), frayed hair (P < 0.001), split ends (P < 0.001) in trichotillomania; comma hair (P < 0.001) in tinea capitis and arborizing blood vessels in discoid lupus erythematosus (P = 0.012). Limitations: The small number of patients in some types of alopecia was a limiting factor. Conclusions: Trichoscopy is useful in the differential diagnosis of alopecia. Among the various trichoscopic findings, those of diagnostic value were identified.
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Background: Previous epidemiological studies suggest an association between psoriasis and metabolic syndrome and risk of subclinical atherosclerosis. However, there is a paucity of data in the Indian population on these associations. Objectives: To evaluate the prevalence of metabolic syndrome and subclinical atherosclerosis in patients with chronic plaque psoriasis compared to healthy controls and to correlate the prevalence of metabolic syndrome with severity of psoriasis. Methods: A hospital-based cross-sectional study was performed on 140 patients with chronic plaque psoriasis and 140 controls. Psoriasis was categorized as mild, moderate and severe based on psoriasis area and severity index (<10, 10–14 and ≥15, respectively) and as disease of short (<1 year), intermediate (1–3 years) and long duration (>3 years). In all patients and controls, body mass index was calculated, blood pressure and waist circumference were measured and fasting blood sugar and lipid profi le were estimated. Metabolic syndrome was diagnosed by the presence of 3 or more of the modifi ed National Cholesterol Education Program’s Adult Treatment Panel III criteria. A subset of 30 psoriatic patients and 30 healthy controls were selected by the systematic sampling method for cardiac evaluation including electrocardiography, echocardiography and carotid intima-media thickness measurement. Results: The prevalence of metabolic syndrome was signifi cantly more in psoriatic patients than in controls (39.3% vs. 17.1%, odds ratio = 3.13). Psoriatic patients also had a signifi cantly higher prevalence of hypertension, abdominal obesity and diabetes. There was a signifi cant trend to increase in prevalence of metabolic syndrome, hypertension and type 2 diabetes with increased severity and longer duration of the psoriasis. Patients with psoriasis had signifi cantly higher carotid intima-media thickness (mean 0.61 mm ± 0.01 mm vs. 0.37 mm ± 0.01 mm) than controls. Limitation: This was a hospital-based cross-sectional study with a relatively small sample size. A prospective study with a larger sample would have validated the results further. Conclusion: There is a signifi cantly higher prevalence of metabolic syndrome in psoriasis patients as compared to controls; the prevalence of metabolic syndrome and its components increases with severity and duration of psoriasis. There is a higher prevalence of subclinical atherosclerosis in patients with psoriasis thus increasing the risk of cardiovascular disease. We suggest that patients with moderate to severe psoriasis be screened routinely for metabolic syndrome and cardiovascular disease and encouraged to correct modifi able cardiovascular risk factors.
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Background: Pulsed corticosteroids have been used successfully for the management of pemphigus. However, prolonged use of glucocorticoids may be associated with adverse effects and some patients show a poor response to conventional therapy. Biologics have shown a promising role in such cases; however, there is limited data from the Indian subcontinent. Objective: The primary objective was to assess the effi cacy and adverse effects of rituximab in pemphigus. The secondary objective was to measure the cumulative doses of corticosteroids required for these patients. Methods: We undertook a retrospective review of records of 25 pemphigus patients (pemphigus vulgaris: 21, pemphigus foliaceus: 4) who had received rituximab infusion (rheumatoid arthritis protocol in 21 patients, modifi ed in 4). Oral prednisolone was administered in dosages up to 0.5 mg/kg of body weight and tapered over the next 3–4 months according to the disease activity. However, other immunosuppressive agents such as cyclophosphamide and azathioprine were continued for one year after clinical remission was achieved. Results: Complete remission was observed in 22 (88%) patients. The mean time to disease control and complete remission was 1.10 and 4.36 months, respectively. Four (16%) patients experienced relapse after a mean duration of 11.75 months. The mean total dose of oral steroids administered was equivalent to 3535.64 mg of prednisolone. Exacerbation of disease was noted in two patients after the fi rst dose of rituximab and infectious complications, pneumonia and cellulitis, developed in one patient each. Limitations: A small sample size, the retrospective nature of the study and unavailability of follow-up anti-desmoglein autoantibodies levels were limitations. Conclusion: Rituximab is an effective agent in the treatment of pemphigus. The use of rituximab enabled use of a lower initial dose of oral prednisolone in pemphigus and hence reduced its total cumulative dose. Severe side effects were rare.