Top Ten Tips for Palliative Care Clinicians Caring for Heart Failure Patients.

Heart failure (HF) is an increasingly prevalent condition with a very high symptom burden. To address challenges faced by palliative care clinicians, we assembled a team of experts to provide high-yield tips for the management of these patients. Prognosis is unpredictable in HF and many patients and physicians overestimate survival. Ejection fraction, notably, is not predictive of prognosis. It is important to have thorough discussions about implantable cardioverter defibrillators in terminally ill HF patients. Diuresis is the mainstay of managing volume overload and dyspnea in these patients and it is important to be aggressive and creative to achieve symptom relief. However, HF patients have a high burden of comorbidities and have many symptoms beyond dyspnea as well. Management in hospice remains challenging for these patients, with a significant risk for readmission to the hospital. Almost a quarter of HF patients discharged to hospice from the hospital die in less than three days.

Accuracy of physician prognosis in heart failure and lung cancer: Comparison between physician estimates and model predicted survival.

BACKGROUND: Anticipating adverse outcomes guides decisions but can be particularly challenging in heart failure. AIM: We sought to assess the accuracy and comfort of physicians in predicting prognosis in heart failure. DESIGN: Cross-sectional survey PARTICIPANTS/SETTING: Faculty and trainees in internal medicine, cardiology, and oncology estimated survival for three standardized patients: (1) 59-year-old patient with stage IV lung cancer; (2) 79-year-old woman with New York Heart Association class 4 heart failure symptoms and preserved ejection fraction; and (3) 40-year-old man with New York Heart Association class 3 heart failure symptoms and reduced ejection fraction of 20%. Survival predictions were derived from surveillance, epidemiology, and end results-Medicare database and the Seattle Heart Failure Model. Accuracy was defined as <2-fold difference between the clinician and model estimate. RESULTS: Totally, 79% (338/427) of participants responded. Physicians were more accurate in survival estimates for lung cancer than heart failure (74% vs 48%, respectively; p < 0.001). Cardiologists were more accurate in predicting survival in heart failure symptoms and reduced ejection fraction compared to generalists (67% vs 45%; p = 0.005) and oncologists (39%; p = 0.041) but no different at predicting heart failure symptoms and preserved ejection fraction. Cardiologists predicted longer survival in heart failure compared to others (p < 0.05). Physicians felt more uncomfortable discussing palliative care with heart failure patients compared to lung cancer. CONCLUSIONS: Less than half of physicians accurately estimate survival in heart failure. Cardiologists were more accurate than other specialties for heart failure symptoms and reduced ejection fraction but no different for heart failure symptoms and preserved ejection fraction.

Subclinical cardiovascular disease assessment in persons with diabetes.

Patients with diabetes mellitus are at particularly high risk for cardiovascular disease. Although global risk factor scoring systems, such as the Framingham Risk Score, are well established for screening asymptomatic adults, they are not as predictive in diabetics. Therefore, there has been considerable interest in new screening tests to establish cardiovascular risk in diabetics. Coronary artery calcium assessment, both baseline levels and progression, have been shown to be additive to risk factor scoring systems and are independently predictive of cardiovascular mortality in diabetics. Current American Heart Association/American College of Cardiology Foundation guidelines recommend coronary calcium scoring for asymptomatic diabetics. Myocardial perfusion studies are recommended for patients with a coronary calcium score >400 but the level of evidence is poor. The data for other screening tests is limited. Further research is required into assessing what would be an appropriate follow-up duration for serial coronary calcium scanning.

En face view of the mitral valve: definition and acquisition.

A 3-dimensional echocardiographic view of the mitral valve, called the "en face" or "surgical view," presents a view of the mitral valve similar to that seen by the surgeon from a left atrial perspective. Although the anatomical landmarks of this view are well defined, no comprehensive echocardiographic definition has been presented. After reviewing the literature, we provide a definition of the left atrial and left ventricular en face views of the mitral valve. Techniques used to acquire this view are also discussed.

Incidence and etiology of omphalitis in Pakistan: a community-based cohort study.

INTRODUCTION: Although omphalitis (umbilical infections) among newborns is common and a major cause of neonatal deaths in developing countries, information on its burden and etiology from community settings is lacking. This study aimed to determine the incidence and etiology of omphalitis in newborns in high neonatal mortality settings in Karachi, Pakistan. METHODOLOGY: Trained community health workers surveyed all new births in three low-income areas from September 2004 to August 2007. Pus samples from the umbilical stumps were obtained from babies with pre-defined signs of illness and subjected to culture and antimicrobial susceptibility testing. RESULTS: Among 6904 births, 1501 (21.7%) newborns were diagnosed with omphalitis. Of these, 325 (21.6%) were classified as mild, 1042 (69.4%) as moderate, and 134 (8.9%) as severe; 141 (9.3%) were associated with clinical signs of sepsis. The incidence of omphalitis was 217.4/1000 live births; moderate-severe omphalitis 170.3 per 1000 live births; and associated with sepsis 20.4 per 1000 live births. Of 853 infants with purulent umbilical discharge, 64% yielded 583 isolates. The most common pathogens were Staphylococcus aureus, of which 291 (95.7%) were methicillin-susceptible Staphylococcus aureus (MSSA) and 13 (4.2%) methicillin-resistant S. aureus (MRSA); Streptococcus pyogenes 105 (18%); Group B beta-hemolytic streptococci 59 (10 %); Pseudomonas spp., 52 (8.9 %); Aeromonas spp. 19 (3.2%); and Klebsiella spp. 12 (2%). CONCLUSIONS: A high burden of omphalitis can be associated with sepsis among newborns in low-income communities in Pakistan. S. aureus is the most common pathogen isolated from umbilical pus. Appropriate low-cost prevention strategies need to be implemented. 

Bench to bedside: dynamic mitral valve assessment.

PURPOSE: The authors analyze a commercially available software package capable of geometrically reconstructing the mitral valve (MV) dynamically throughout systole. DESCRIPTION: Three-dimensional echocardiography has revolutionized the understanding of MV geometry. Advanced quantification software can be used to assess geometric changes in the MV, which have been shown to have important implications for MV surgery. EVALUATION: The authors performed geometric analysis on 24 patients, with both anatomically normal and abnormal MVs to assess the feasibility of this new software. The application of this new software is briefly reviewed. CONCLUSION: This new software, despite its limitations, allows an improved perspective on MV geometry with implications for MV repair and surgical decision making.

Incidence of neonatal hyperbilirubinemia: a population-based prospective study in Pakistan.

OBJECTIVE: To estimate the incidence of neonatal jaundice and hyperbilirubinemia in a poor urban community in Karachi, where 70% of births occur at home. METHODS: Home-based pregnancy and newborn surveillance were conducted from September 2004 to July 2006 in a multi-ethnic population by trained community health workers. Newborns were visited several times at scheduled intervals until 59 days of life; any baby with jaundice was referred to the local clinic. Clinical assessments of jaundice were assigned by a physician and recorded using an adapted Kramer scale. Blood for plasma bilirubin was obtained if parents consented. RESULTS: Of a birth cohort of 1690 young infants during the study period, 466 infants (27.6%) were referred to our centre with jaundice. Of these, 64% were 0-6 days old. Bilirubin was measured in 125 of 466 (27%) jaundiced newborns. Overall detected rate of hyperbilirubinemia (bilirubin >5 mg/dl) among 1690 newborns was 39.7/1000 live births (95% CI 29.3-47.6). Rate of plasma bilirubin levels in the range of 15-20 mg/dl was 13/1000 live births (95% CI 7.6-18.4); levels >20 mg/dl were observed in 3.5/1000 live births (95% CI 0.4-5.5). The proportion of newborns with bilirubin > or =15 mg/dl was significantly higher among those assigned a Kramer score of 4-5 compared to those receiving a score of 1-3 (P-value 0.00004). CONCLUSION: A significant burden of untreated severe neonatal jaundice, causing potential neurological sequelae, exists in developing countries such as Pakistan. WHO guidelines are needed for screening and appropriate management of neonatal jaundice in developing countries.

Prevalence of obesity in school-going children of Karachi.

BACKGROUND: Obesity is an emerging problem in Pakistan. The authors sought to determine prevalence of obesity and malnutrition in school-going children, from grades 6(th) to 8(th) of different schools of Karachi and assess associations that affect the weight of the children. METHODOLOGY/PRINCIPAL FINDINGS: A cross sectional study design with children studying in grades 6(th) to 8(th) grade, in different schools of Karachi. We visited 10 schools of which 4 consented; two subsidized government schools and two private schools. A questionnaire was developed in consultation with a qualified nutritionist. Height and weight were measured on calibrated scales. A modified BMI criterion for Asian populations was used. Data was collected from 284 students. Of our sample, 52% were found to be underweight whereas 34% of all the children were normal. Of the population, 6% was obese and 8% overweight. Of all obese children, 70% belonged to the higher socio-economic status (SES) group, while of the underweight children, 63.3% were in the lower SES. Amongst obese children in our study, 65% ate meat every day, compared to 33% of normal kids. CONCLUSION: Obesity and undernutrition co-exist in Pakistani school-children. Our study shows that socio-economic factors are important since obesity and overweight increase with SES. Higher SES groups should be targeted for overweight while underweight is a problem of lower SES. Meat intake and lack of physical activity are some of the other factors that have been highlighted in our study.