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.

Spot urine cortisol-creatinine ratio - A useful screening test in the diagnosis of Cushing's syndrome.

INTRODUCTION: Although, there are several tests available, not one of them fulfils the criteria of being an ideal screening test. Continuing the search for an ideal screening test, we explored the use of urine spot cortisol-creatinine ratio as a novel method of evaluating patients with Cushing's syndrome. METHOD: A total of 35 subjects were studied and divided into 3 groups - 15 having cushings syndrome, 15 patients with obesity and 5 normal weight subjects. All patients with cushings syndrome were positive for the other screening tests. RESULTS: The mean (standard deviation) of cortisol:creatinine ratio among the 3 groups (cushings, obese and control subjects) was 36.00(24.74), 7.01(2.73) and 3.49(2.68) respectively. Using the cutoff of 12.27 nano mol/ micro mol(based on data of normal subjects) for the urine cortisol creatinine ratio we get a sensitivity of 93.75% and a specificity of 100%. Also the positive and negative predictive value as calculated with this cutoff is 100% and 93.3% respectively. CONCLUSION: In this study we found that UCCR is similar in both Obese and Non Obese subjects who did not have cushings syndrome. UCCR is significantly elevated in individuals with Cushing's syndrome as compared to those who do not have cushings syndrome. Also when a cut off of 12.27 nano mol/ micro mol was used this test had a higher sensitivity, however this test had a higher specificity at a cut off of 15.35.

Oxidative stress in hemodialysis--postdialytic changes.

BACKGROUND: There is evidence for production of free oxygen radicals during hemodialysis. Hemodialysis is an intervention that is intermittent and is usually undertaken once in two or three days. It is known that the free oxygen radicals are short lived. Hence, it is necessary to know how long the effects of this oxidative stress are seen in the postdialytic period and whether they are carried over to the next dialysis. Review of the literature showed that there is no information in this area. Hence, this study was undertaken in order to learn whether oxidative stress due to a dialysis session is carried over to next dialysis session or not. METHODS: The effects were studied after four different types of membrane and dialysate--Polysulphone-Bicarbonate (PB), Polysulphone-Acetate (PA), Cuprophan-Acetate (CA) and Cuprophan-Bicarbonate (CB). Two consecutive dialysis sessions were studied to know the effect of re-use of the membrane. For each dialysis session, blood samples were collected at 0 (immediately prior to dialysis or preHD), 4 (immediate postdialysis), 6, 12, 24 and 48 hours (start of next session). Lipid peroxides, SOD and GP were determined in erythrocytes. Vitamins A and E and lipid peroxides were estimated in plasma. RESULTS: In the postdialytic phase there was an increase in plasma lipid peroxide levels. Plasma vitamin E levels increased significantly in all groups after first use dialysis, whereas the increase found after re-use dialysis was not statistically significant. Erythrocyte lipid peroxide levels showed a significant decrease. No significant changes were observed in the plasma vitamin A, erythrocyte SOD and GP levels. There was no significant change in any of the parameters between preHD and either 48-hour or 96-hour samples in all groups studied. CONCLUSIONS: Our results show that there is no carry-over of oxidative stress produced by dialysis to the next session regardless of the type of dialysis.

Oxidative stress in haemodialysis: immediate changes caused by passage of blood through the dialyser.

Oxygen free radicals have been implicated in the long-term complications of maintenance haemodialysis. Studies that have probed into the mechanisms of oxygen radical production have implicated the bio-incompatibility of dialysis membranes. Changes between the arterial (inlet) and venous (outlet) points of a dialyser may give a better picture of blood membrane interaction. There are very few studies on changes across the dialyser. Hence, it was planned to study the immediate changes that occur due to passage of blood through the dialyser. Changes between the arterial and venous ends of the dialyser after 1 h of dialysis were studied in four combinations of dialysate and membrane. There was a significant decrease in plasma vitamin E concentrations in all the groups during first-use dialysis. This was not observed with re-use dialysis. A decrease in plasma lipid peroxides was also observed in all the groups with both first and re-use dialysis. There was no significant difference in the parameters studied among the four types of dialysis. A less severe, reactive oxygen radical generation was observed with re-use of membranes.

Oxidative stress in haemodialysis--intradialytic changes.

Oxidative stress is likely to be involved in the development of complications due to haemodialysis. Though there is evidence for production of oxygen free radicals during haemodialysis, reports on net oxidative imbalance due to a single dialysis session are conflicting. Hence, a time-course analysis of changes in lipid peroxides (LPO) along with antioxidant enzymes and vitamins was carried out. Hourly changes in LPO and antioxidants were studied during a first-use cuprophan membrane and acetate dialysis in 20 patients on regular haemodialysis treatment. Data were corrected for haemoconcentration and standardised to measure the rate of change before statistical evaluation using analysis of variance for repeated measures. The results of the study showed a net oxidative stress due to a single dialysis session in the form of increased plasma and erythrocyte lipid peroxidation, decrease in plasma vitamin E, slight increase in plasma superoxide dismutase and erythrocyte glutathione peroxidase and no change in plasma glutathione peroxidase. erythrocyte superoxide dismutase and plasma vitamin A levels. The oxygen radical production was found to be maximum in the first hour of dialysis.

The psychiatric aspects of wilson's disease-a study from a neurology unit.

A series of 31 cases of Wilson's disease (WD) were assessed retrospectively on a range of variables including psychiatric, neurologic and biochemical data recorded at index admission over a period of 7 years. 18 patients (58%) showed psychopathological features. 5 patients (16.1%) were reported to have poor scholastic performance at the onset of illness and 1 patient (3.2%) had abnormal behaviour (mania like) many years prior to the appearance of neurological symptoms. The most common psychiatric features were cognitive impairment (45.2%), affective symptomatology (41.9%) and behavioural abnormalities (29%). Only one patient had a schizophrenia like psychosis. The psychiatric manifestation of Wilson's disease as they present in our setting and their clinical relevance are discussed.