Patient-Reported Status and Heart Failure Outcomes in Asia by Sex, Ethnicity, and Socioeconomic Status

Background

In heart failure (HF), symptoms and health-related quality of life (HRQoL) are known to vary among different HF subgroups, but evidence on the association between changing HRQoL and outcomes has not been evaluated.

Objectives

The authors sought to investigate the relationship between changing symptoms, signs, and HRQoL and outcomes by sex, ethnicity, and socioeconomic status (SES).

Methods

Using the ASIAN-HF (Asian Sudden Cardiac Death in Heart Failure) Registry, we investigated associations between the 6-month change in a "global" symptoms and signs score (GSSS), Kansas City Cardiomyopathy Questionnaire overall score (KCCQ-OS), and visual analogue scale (VAS) and 1-year mortality or HF hospitalization.

Results

In 6,549 patients (mean age: 62 ± 13 years], 29% female, 27% HF with preserved ejection fraction), women and those in low SES groups had higher symptom burden but lower signs and similar KCCQ-OS to their respective counterparts. Malay patients had the highest GSSS (3.9) and lowest KCCQ-OS (58.5), and Thai/Filipino/others (2.6) and Chinese patients (2.7) had the lowest GSSS scores and the highest KCCQ-OS (73.1 and 74.6, respectively). Compared to no change, worsening of GSSS (>1-point increase), KCCQ-OS (≥10-point decrease) and VAS (>1-point decrease) were associated with higher risk of HF admission/death (adjusted HR: 2.95 [95% CI: 2.14-4.06], 1.93 [95% CI: 1.26-2.94], and 2.30 [95% CI: 1.51-3.52], respectively). Conversely, the same degrees of improvement in GSSS, KCCQ-OS, and VAS were associated with reduced rates (HR: 0.35 [95% CI: 0.25-0.49], 0.25 [95% CI: 0.16-0.40], and 0.64 [95% CI: 0.40-1.00], respectively). Results were consistent across all sex, ethnicity, and SES groups (interaction P > 0.05).

Conclusions

Serial measures of patient-reported symptoms and HRQoL are significant and consistent predictors of outcomes among different groups with HF and provide the potential for a patient-centered and pragmatic approach to risk stratification.

Bamboo for producing charcoal and biochar for versatile applications

Bamboo, the fastest-growing plant, has several unique characteristics that make it appropriate for diverse applications. It is low-cost, high-tensile, lightweight, flexible, durable, and capable of proliferating even in ineffectual areas (e.g., incline). This review discusses the unique properties of bamboo for making charcoal and biochar for diverse applications. To produce bamboo charcoal and biochar, this study reports on the pyrolysis process for the thermal degradation of organic materials in an oxygen-depleted atmosphere under a specific temperature. This is an alternative method for turning waste biomass into products with additional value, such as biochar. Due to various advantages, bamboo charcoal is preferred over regular charcoal as it has four times the absorption rate and ten times more surface area reported. According to the reports, the charcoal yield ranges from 24.60 to 74.27%. Bamboo chopsticks were the most useful source for producing charcoal, with a high yield of 74.27% at 300 °C in nitrogen, but the thorny bamboo species have a tremendous amount of minimal charcoal, i.e., 24.60%. The reported biochar from bamboo yield ranges from 32 to 80%. The most extensive biochar production is produced by the bamboo D. giganteus, which yields 80% biochar at 300 °C. Dry bamboo stalks at 400 °C produced 32% biochar. One of the sections highlights biochar as a sustainable solution for plastic trash management produced during the COVID-19 pandemic. Another section is dedicated to the knowledge enhancement about the broad application spectrum of the charcoal and biochar. The last section highlights the conclusions, future perspectives, and recommendations on the charcoal and biochar derived from bamboo.

Graphical Abstract

Preparation of nanolignin rich fraction from bamboo stem via green technology: assessment of its antioxidant, antibacterial and UV blocking properties

This work reports the preparation of nano lignin-rich fraction material via green technology from the holistic use of lignocellulosic biomass bamboo. The bamboo is first chemically treated, followed by acid precipitation to extract bamboo-derived macro lignin-rich fraction material. The nano lignin-rich fraction material was then prepared via ultrasonication technique from the extracted bamboo-derived macro lignin-rich fraction material. The confirmation of the distinct lignin functional groups in the extracted lignin-rich fractions has been done by FTIR. Surface morphology by FESEM and TEM revealed spherical nano-lignin-rich fraction materials from extracted bamboo-derived macro lignin-rich fraction materials. DPPH assays indicated that both the obtained fractions depict beneficial antioxidant characteristics. They were found to be effective in terms of their antibacterial activity against both gram-positive bacteria Staphylococcus aureus (S.aureus) and gram-negative bacteria Escherichia coli (E.coli), using the disc diffusion method. These fractions have UV blocking property, and nano-lignin-rich fraction material acts as a more potential UV blocking agent than others. Thus, the nano-lignin-rich fraction material has great potential as a high antioxidant, antibacterial, and UV blocking agent useful in biomedical applications.Highlights Extraction of macro-lignin rich fraction material using chemical treatment of lignocellulosic biomass bamboo via refluxing followed by acid precipitation.Preparation of nano-lignin rich fraction material from extracted bamboo-derived macro-lignin rich fraction material via ultrasonication technique as a green technology.Structural and surface morphology of the extracted macro-lignin & nano lignin-rich fraction materials have been analyzed by XRD, FTIR, EDX, SEM and TEM.The macro lignin & nano lignin-rich fraction materials showed good antioxidant, antibacterial activity and UV-blocking properties, but the nano-lignin rich fraction material exhibited more efficient properties.

294 Stem Cell Enriched Fat Grafts Versus Autologous Fat Grafts for Facial Reconstruction: A Systematic Review and Meta-Analysis

Aim

To compare the results of stem cell-enhanced fat grafting to autologous fat grafting for face reconstruction.

Method

A systematic review and meta-analysis were carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines, and an electronic search was carried out to identify all Randomised Controlled Trials (RCTs), case control studies, and cohort studies comparing the outcomes of stem cell-enrichment fat grafting versus routine fat grafting for facial reconstruction. The primary outcome measures were volume retention and infection rate. Secondary outcome measures included post-surgery patient satisfaction, redness and swelling, fat necrosis, cysts, and operation time. For the analysis, fixed and random effects modelling were utilised.

Results

Eight studies with a total of 275 participants were assessed. In terms of mean volume retention, there was a significant difference between the stem cell-enrichment fat grafting and routine grafting groups (standardised Mean Difference [MD] = 2.49, P 0.00001). However, there was no significant difference in infection rates between the two groups (OR = 0.36, P = 0.30). Except for the operation duration, which was shorter in the latter, the intervention group had similar results to the control group for all secondary outcomes.

Conclusions

When compared to conventional fat grafting, stem cell-enriched fat grafting is a better alternative for facial reconstruction surgery since it enhances mean volume retention and does not worsen patient satisfaction or surgical complications.

Transcatheter aortic valve implantation outcomes compared between bicuspid aortic and tricuspid aortic valve stenosis: an updated systematic review and meta-analysis

Background

TAVI has emerged as an attractive treatment modality based on promising recent trial data. Patients with BAV, a commonly encountered clinical condition have largely been excluded from a majority of trials.

Purpose

Elderly patients with BAV and severe AS are increasingly encountered in clinical practice. This meta-analysis compares clinical outcomes between bicuspid and tricuspid AV patients to address the current knowledge-gap and identify optimal management strategies of these patients.

Methods

A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify the available observational studies comparing outcomes of TAVI in BAV and TAV patients. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints.

Results

16 Observational studies met inclusion criteria, comprising 10,053 patients with BAV and 173,307 patients with TAV that underwent TAVI. No significant differences in 30-day and long-term mortality rates were observed. Patients with BAV had an increased risk of stroke (OR 1.23; 95% CI [1.06–1.44], p=0.007), re-intervention (OR 1.90; 95% CI [1.15–3.15], p=0.01), paravalvular leak (OR 1.42; 95% CI [1.25–1.61], p<0.ehab724.22251), conversion to open surgery (OR 1.93; 95% CI [1.21–3.07], p=0.006), and new pacemaker implantation (1.57; 95% CI (1.06 - 2.33, p=0.02). Adverse event rates are lower with the use of newer generation of valves. No significant difference in major vascular complications, major bleeding, or incidence of AKI was noted.

Conclusions

Complication rates for BAV TAVI are higher, but mortality is similar to TAV TAVI indicating TAVI is an appropriate alternative for intermediate-high risk patients with BAV. A better understanding of valve anatomy, physician expertise, the use of newer-generation valves can help reduce these complications.

Funding Acknowledgement

Type of funding sources: None.

Incidence and risk predictors analysis of adverse donor reactions in whole blood donation

OBJECTIVE

Adverse donor reactions in normal healthy blood donors is not unusual. However, these unpleasant effects have a negative impact on donor retention. Adverse event due to blood donation is multifactorial in origin. Therefore, the objective of this study was to determine the frequency and type of adverse donor reactions during or after blood donation. More importantly, this study also aimed at analyzing important risk predictors of adverse donor reaction.

MATERIAL AND METHODS

This was a retrospective study conducted from May 2017 to April 2019 in the department of Transfusion Medicine at a tertiary care center in eastern India. Data were stored in Microsoft excel 2016 by using a standardized format as per ISBT criteria and analyzed with software "R, version 3.5.3" to find out the various independent precipitating factor.

RESULTS

Overall, 107 donors (0.98%) experienced adverse events with 10,814 whole blood donations. The first time, females, younger age donors (18-30 years), and donors with a mean arterial blood pressure of less than 90mm of Hg were the most important independent risk factors predicting the possibility of adverse donor reaction. Donors' weight, hemoglobin, and the type of donation had not affected the frequency of adverse events.

CONCLUSION

Analysis of adverse donor reactions helps in selecting the blood donors who are at risk of donor reactions. Our study highlights the importance of proper predonation screening especially in terms of assessment of mean blood pressure, along with identification of first time and female blood donors in order to reduce untoward donor reaction.

Regulatable interleukin-12 gene therapy in patients with recurrent high-grade glioma: Results of a phase 1 trial

Human interleukin-12 (hIL-12) is a cytokine with anticancer activity, but its systemic application is limited by toxic inflammatory responses. We assessed the safety and biological effects of an hIL-12 gene, transcriptionally regulated by an oral activator. A multicenter phase 1 dose-escalation trial (NCT02026271) treated 31 patients undergoing resection of recurrent high-grade glioma. Resection cavity walls were injected (day 0) with a fixed dose of the hIL-12 vector (Ad-RTS-hIL-12). The oral activator for hIL-12, veledimex (VDX), was administered preoperatively (assaying blood-brain barrier penetration) and postoperatively (measuring hIL-12 transcriptional regulation). Cohorts received 10 to 40 mg of VDX before and after Ad-RTS-hIL-12. Dose-related increases in VDX, IL-12, and interferon-γ (IFN-γ) were observed in peripheral blood, with about 40% VDX tumor penetration. Frequency and severity of adverse events, including cytokine release syndrome, correlated with VDX dose, reversing promptly upon discontinuation. VDX (20 mg) had superior drug compliance and 12.7 months median overall survival (mOS) at mean follow-up of 13.1 months. Concurrent corticosteroids negatively affected survival: In patients cumulatively receiving >20 mg versus ≤20 mg of dexamethasone (days 0 to 14), mOS was 6.4 and 16.7 months, respectively, in all patients and 6.4 and 17.8 months, respectively, in the 20-mg VDX cohort. Re-resection in five of five patients with suspected recurrence after Ad-RTS-hIL-12 revealed mostly pseudoprogression with increased tumor-infiltrating lymphocytes producing IFN-γ and programmed cell death protein 1 (PD-1). These inflammatory infiltrates support an immunological antitumor effect of hIL-12. This phase 1 trial showed acceptable tolerability of regulated hIL-12 with encouraging preliminary results.

Deep venous thrombosis manifestation of common femoral vein leiomyoma

Deep vein thrombosis is a common clinical condition, with well-known risk factors. An unusual case of venous leiomyoma manifesting as a deep vein thrombosis in the left femoral vein of a 55-year-old man was managed successfully at our institution with anticoagulation, en-bloc excision and reconstruction of the femoral vein with spiral vein graft.

Establishing scald prevention measures in UK maternity units from takeaway drinks

AIM

To identify policies on the consumption of hot drinks by patients and visitors on all perinatal and postnatal wards in the United Kingdom, and to seek the opinions of members of the wider burns MDT as to whether standardised patient education or regulation of hot drinks around newborn babies is required.

METHODS

All maternity units with postnatal wards across the United Kingdom were surveyed to establish availability of hot drinks on site and whether these were permitted on postnatal wards around infants. An online questionnaire was distributed to members of the British Burn Association to ascertain opinions on hot drinks policies.

RESULTS

Hot takeaway drinks were permitted around newborn infants in 194 of surveyed postnatal wards and were only banned by two units. The online survey received 49 responses from different members of the British Burn Association. Thirty responders (61%) supported a takeaway hot drink ban, while those against the policy would alternatively encourage patient education, dedicated drinking areas and introduction of safety measures.

CONCLUSIONS

Almost every postnatal unit in the UK has access to hot drink retailers on site allowing parents and visitors to bring them into close contact with babies. With varying local regulations, this poses potentially serious consequences during feeding or carrying. We propose a standardised antenatal education be made available, together with standardised designated areas on wards for parents and visitors to consume hot drinks away from infants.

Regional Variation of Mortality in Heart Failure With Reduced and Preserved Ejection Fraction Across Asia: Outcomes in the ASIAN-HF Registry

Background

Data comparing outcomes in heart failure (HF) across Asia are limited. We examined regional variation in mortality among patients with HF enrolled in the ASIAN‐HF (Asian Sudden Cardiac Death in Heart Failure) registry with separate analyses for those with reduced ejection fraction (EF; <40%) versus preserved EF (≥50%).

Methods and Results

The ASIAN‐HF registry is a prospective longitudinal study. Participants with symptomatic HF were recruited from 46 secondary care centers in 3 Asian regions: South Asia (India), Southeast Asia (Thailand, Malaysia, Philippines, Indonesia, Singapore), and Northeast Asia (South Korea, Japan, Taiwan, Hong Kong, China). Overall, 6480 patients aged >18 years with symptomatic HF were recruited (mean age: 61.6±13.3 years; 27% women; 81% with HF and reduced rEF). The primary outcome was 1‐year all‐cause mortality. Striking regional variations in baseline characteristics and outcomes were observed. Regardless of HF type, Southeast Asians had the highest burden of comorbidities, particularly diabetes mellitus and chronic kidney disease, despite being younger than Northeast Asian participants. One‐year, crude, all‐cause mortality for the whole population was 9.6%, higher in patients with HF and reduced EF (10.6%) than in those with HF and preserved EF (5.4%). One‐year, all‐cause mortality was significantly higher in Southeast Asian patients (13.0%), compared with South Asian (7.5%) and Northeast Asian patients (7.4%; P<0.001). Well‐known predictors of death accounted for only 44.2% of the variation in risk of mortality.

Conclusions

This first multinational prospective study shows that the outcomes in Asian patients with both HF and reduced or preserved EF are poor overall and worst in Southeast Asian patients. Region‐specific risk factors and gaps in guideline‐directed therapy should be addressed to potentially improve outcomes.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01633398.

Temperature dissociation of liquids in reusable thermoplastic containers-An eco-friendly scald risk?

Recent global concern regarding the impact of plastic waste on the environment has resulted in efforts to utilise reusable drink containers. Research is lacking regarding temperature dissociation of drinks in reusable thermoplastic cups. This study aimed to compare the cooling time of two common hot drinks sold at a UK retailer, in the three vessels they are sold; ceramic, disposable paper (with and without lid) and reusable thermoplastic cups (with and without lid). All temperatures were collated from 250 ml volumes of black Americano coffee or café latte in the three different containers. The cooling time was measured every sixty seconds using a standardised digital thermocouple thermometer until a threshold liquid temperature of 43 °C was reached. All experiments were performed in triplicate and temperatures converted to a dimensionless logarithmic scale prior to statistical analysis. Cooling time was significantly slower for lidded cups irrespective of material. Unlidded thermoplastic cups significantly slowed cooling times for both black Americano coffee and café latte compared to ceramic and unlidded disposable paper cups. The growing trend in reusable cups does not in itself pose an increased risk of scald injury. However, we consider that the potentially increased ambulatory behaviour associated with using a lidded rather than unlidded cup may increase scald risk. We propose that further consumer guidance should be disseminated regarding the use of any lidded takeaway container to prevent scalds in both adults and children.

Acquired diaphragmatic hernia in a preterm low birth weight neonate

Iatrogenic diaphragmatic hernia is rare in children and we report a preterm low birth weight neonate with a presumably acquired diaphragmatic hernia due to trauma caused by treatment following pneumothorax.

Oral Ketamine or Midazolam or Low Dose Combination for Premedication in Children

This randomized controlled trial was designed to evaluate whether the combination of low dose oral midazolam (0.25 mg/kg) and low dose oral ketamine (3 mg/kg) provides better premedication than oral midazolam (0.5 mg/kg) or oral ketamine (6 mg/kg). Seventy-eight children of ASA physical status I or II scheduled for elective ophthalmic surgery were randomly divided into three groups and given premedication in the holding area 30 minutes before surgery. Two subjects from each group vomited the medication and were excluded, leaving 72 subjects for further analysis.

The onset of sedation was earlier in the combination group than the other two groups. At 10 minutes after premedication 12.5% in the combination group had an acceptable sedation score compared with none in the other two groups. After 20 minutes 54% in the combination group had an acceptable sedation score, 21% in the midazolam group and 16% in the ketamine group (P<0.05). There were no significant differences in the parental separation score, response to induction and emergence score. The mean time for best parental separation score was significantly less in the combination group (19±8 min) than either the midazolam (28±7) or ketamine (29±7 min) groups (P<0.05). Recovery was earlier in the combination group, as the time required to reach a modified Aldrete score of 10 was significantly less in the combination group (22±5 min) than in the oral midazolam (36±11 min) or ketamine (38±8 min) groups. The incidence of excessive salivation was significantly higher in the ketamine alone group (P<0.05). In conclusion, the combination of oral ketamine (3 mg/kg) and midazolam (0.25 mg/kg) has minimal side effects and gives a faster onset and more rapid recovery than ketamine 6 mg/kg or midazolam 0.5 mg/kg for premedication in children.

Consensus statement for implantation and follow-up of cardiac implantable electronic devices in India

Cardiac implantable electronic device (CIED) procedures are being done by many operators/centers and it is projected that this therapy will remarkably increase in India in the coming years. This document by IHRS, aims at guiding the Indian medical community in the appropriate use and method of implantation with emphasis on implanter training and center preparedness to deliver a safe and effective therapy to patients with cardiac rhythm disorders and heart failure.

Psychometric properties of the English version of the Oral Health Literacy Adults Questionnaire - OHL-AQ

Objective

To test the psychometric properties of the Oral Health Literacy Adult Questionnaire (OHL-AQ) in English. The OHL-AQ was designed to test functional oral health literacy in general populations and was initially validated in Iran.

Methods

The instrument was administered to 405 adult subjects (mean age 45 (SD 16) years and 67% female) attending the 2014 Minnesota State Fair. The OHL-AQ is composed of 17 items measuring four conceptual dimensions: reading comprehension, numeracy, listening, and decision-making. Participants selected the best answer for written or verbally administered items and entered answers on an electronic tablet. Item responses for each individual were combined into a summary score (range 0-17) with higher scores indicating better oral health literacy. Score dimensionality, reliability, and validity were investigated.

Results

For dimensionality, both exploratory factor analysis and a parallel analysis yielded evidence for scale unidimensionality. Reliability was sufficient indicated by a Cronbach's alpha ⟩0.74. Validity of scores was supported by "small" and "medium" effect sizes for construct validity. "Small" effect sizes were observed for global oral health self-report, OHIP-5 scores, treatment urgency, and having a regular dentist. "Medium" effect sizes were seen for presence of dentures, number of natural teeth present, and educational level.

Conclusions

Dimensionality, reliability and validity of the English version of the OHL-AQ in a general adult English-speaking population is supported, providing sufficient psychometric properties in an important target population of the instrument.

Under-utilization of pacemaker therapy for sinus node dysfunction - Real world data from South Asia

OBJECTIVE

Chronic symptomatic sinus node dysfunction (SND), the most common bradyarrhythmia, can be effectively managed by permanent cardiac pacing. Yet the care pathway and barriers to adoption of pacing therapy are not well understood - particularly in low volume implanting countries. The IMPROVE Brady study is a quality improvement initiative being conducted at centers in South Asia, Latin America, and Russia. We assessed the rates of SND diagnosis and pacemaker treatment for SND in the South Asia cohort.

METHODS

The prospective study enrolled patients with heart rate of  ≤50 beats per minute presenting with symptoms including syncope, dizziness, and/or dyspnea from ten centers in India and Bangladesh. Patients were followed to identify the proportion diagnosed with SND and subsequently treated with pacemaker therapy.

RESULTS

A total of 508 patients meeting criteria were enrolled and followed on average for 8.3±8.0months. Patients were on average 58 years of age, 77% were male, and 91% had completed at least primary education. An SND diagnosis was made in 368 (72%) of patients, with the majority (80%) of diagnoses occurring within 1 month of enrollment. Of the patients with an SND diagnosis, 63 (17%) were treated with a pacemaker. Reasons for not receiving treatment were: subject refusal or deferred decision (45%), unaffordability (34%), physician determined - not-indicated (20%), and other (1%). Older age, female gender, history of hypertension, lower resting heart rate, and syncopal or pre-syncopal symptoms were associated with a higher probability of implant.

CONCLUSIONS

In a care pathway assessment for the diagnosis and treatment of symptomatic SND in South Asia only 1 in 6 patients received pacemaker indicated therapy, largely due to patient refusal and physician decision. Phase II of the study will be aimed to improve this treatment rate.

A comparison of the effects of male pheromone priming and optogenetic inhibition of accessory olfactory bulb forebrain inputs on the sexual behavior of estrous female mice

Previous research has shown that repeated testing with a stimulus male is required for ovariectomized, hormone-primed female mice to become sexually receptive (show maximal lordosis quotients; LQs) and that drug-induced, epigenetic enhancement of estradiol receptor function accelerated the improvement in LQs otherwise shown by estrous females with repeated testing. We asked whether pre-exposure to male pheromones ('pheromone priming') would also accelerate the improvement in LQs with repeated tests and whether optogenetic inhibition of accessory olfactory bulb (AOB) projection neurons could inhibit lordosis in sexually experienced estrous female mice. In Experiment 1, repeated priming with soiled male bedding failed to accelerate the progressive improvement in LQs shown by estrous female mice across 5 tests, although the duration of each lordosis response and females' investigation of male body parts during the first test was augmented by such priming. In Experiment 2, acute optogenetic inhibition of AOB inputs to the forebrain during freely moving behavioral tests significantly reduced LQs, suggesting that continued AOB signaling to the forebrain during mating is required for maximal lordotic responsiveness even in sexually experienced females. Our results also suggest that pheromonal stimulation, by itself, cannot substitute for the full complement of sensory stimulation received by estrous females from mounting males that normally leads to the progressive improvement in their LQs with repeated testing.

Profiling cardiac arrhythmia and heart failure patients in India: The Pan-arrhythmia and Heart Failure Observational Study

Background

The PANARrhythMia and Heart Failure Registry (PANARM HF) characterized demographic, clinical and interventional therapy indication profiles of cardiac arrhythmia (CA) and heart failure (HF) patients in India.

Methods

Consulting Physicians (CP) who medically manage CA and HF patients enrolled patients with one or more of the following: syncope, pre-syncope, dyspnea, palpitation, fatigue and LV dysfunction. The CPs were trained by interventional cardiologists (IC) to identify CA/HF patients indicated for implantable device/radiofrequency ablation (RFA). 59 CP’s, 16 IC’s & 2205 patients from 12 cities participated. Demographic, clinical, device/RFA indication and referral-consultation profiles were created. IC’s provided device/RFA recommendations based on these profiles.

Results

The CA/HF distribution of patients was: HF – 58%, bradyarrhythmia – 15%, atrial fibrillation – 15%, other supraventricular tachyarrhythmia – 10% and ventricular tachycardia/fibrillation – 4.5%. 62% of the CA/HF population was male and 45% were below age 60. Coronary artery disease (52%), hypertension (44%), diabetes (30%) & myocardial infarction (20%) were prominent. 1011 (46%) of the CA/HF population were potential device/RFA candidates according to the IC’s. However, only 700 (69%) of these patients were referred to the IC by the CP. Of referred patients, only 177 (25%) consulted the IC and were recommended therapy. Thus, 824 (83%) of patients indicated for interventional therapy were not advised therapy or did not opt for it.

Conclusion

The India PANARM HF study provides new information and insights into the demographic, clinical, interventional therapy, referral and consultation pattern profiles of CA/HF patients in India.

Summer Temperature and Spatial Variability of all-Cause Mortality in Surat City, India

Background:

Ample information is available on extreme heat associated mortality for few Indian cities, but scant literature is available on effect of temperature on spatial variability of all-cause mortality for coastal cities.

Objective:

To assess the effect of daily maximum temperature, relative humidity and heat index on spatial variability of all-cause mortality for summer months (March to May) from 2014 to 2015 for the urban population of Surat (coastal) city.

Materials and Methods:

Retrospective analysis of the all-cause mortality data with temperature and humidity was performed on a total of 9,237 deaths for 184 summer days (2014-2015). Climatic and all-cause mortality data were obtained through Tutiempo website and Surat Municipal Corporation respectively. Bivariate analysis performed through SPSS.

Observations:

Mean daily mortality was estimated at 50.2 ± 8.5 for the study period with a rise of 20% all-cause mortality at temperature ≥ 40°C and rise of 10% deaths per day during extreme danger level (HI: > 54°C) days. Spatial (Zone wise) analysis revealed rise of 61% all-cause mortality for Southeast and 30% for East zones at temperature ≥ 40°C.

Conclusions:

All-cause mortality increased on high summer temperature days. Presence of spatial variation in all-cause mortality provided the evidence for high risk zones. Findings may be helpful in designing the interventions at micro level.

Cardiovascular risk profile and management of atrial fibrillation in India: Real world data from RealiseAF survey

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia with high risk for many cardiovascular (CV) complications. Adherence to recommended management guidelines is important to avoid complications. In India, there is little knowledge on how AF is managed in real world.

METHODS

This is a cross-sectional study of patients in India enrolled in RealiseAF survey between February 2010 and March 2010 with a diagnosis of AF within the last 12 months.

RESULTS

From 15 centers, 301 patients {mean age 59.9 years (14.4); 52.5% males} were recruited. AF was controlled in 50% of patients with 77 (26.7%) in sinus rhythm and 67 (23.3%) with heart rate <80beats/min. Hypertension (50.8%), valvular heart disease (40.7%), heart failure (25.9%), and diabetes (20.4%) were the most common underlying CV diseases. Increased risk for stroke (CHADS2 score≥2) was present in 36.6%. Most of the patients (85%) were symptomatic. AF was paroxysmal, persistent, and permanent in 28.7%, 22.7%, and 34.3% respectively. In 14%, AF was diagnosed as first episode. Forty-six percent of patients had rate control, 35.2% rhythm control, 0.3% both strategies, and 18.4% received no therapy for AF before the visit. At the end of the visit, adoption to rate control strategy increased to 52.3% and patients with no therapy decreased to 7%.

CONCLUSION

AF in India is not adequately controlled. Concomitant CV risk factors and risk of stroke are high. The study underscores the need for improved adoption of guideline-directed management for optimal control of AF and reducing the risk of stroke.

Clinical presentation, management, and outcomes in the Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF) registry

Aim

A national atrial fibrillation (AF) registry was conducted under the aegis of the Indian Heart Rhythm Society (IHRS), to capture epidemiological data-type of AF, clinical presentation and comorbidities, current treatment practices, and 1-year follow-up outcomes.

Methods

A total of 1537 patients were enrolled from 24 sites in India in the IHRS-AF registry from July 2011 to August 2012. Their baseline characteristics and follow-up data were recorded in case report forms and subsequently analyzed.

Results

The average age of Indian AF patients was 54.7 years. There was a marginal female preponderance – 51.5% females and 48.5% males. At baseline, 20.4% had paroxysmal AF; 33% had persistent AF; 35.1% had permanent AF and 11% had first AF episode. At one-year follow-up, 45.6% patients had permanent AF.

Rheumatic valvular heart disease (RHD) was present in 47.6% of patients. Hypertension, heart failure, coronary artery disease, and diabetes were seen in 31.4%, 18.7%, 16.2%, and 16.1%, respectively.

Rate control was the strategy used in 75.2% patients, digoxin and beta-blockers being the most frequently prescribed rate-control drugs. Oral anticoagulation (OAC) drugs were used in 70% of patients. The annual mortality was 6.5%, hospitalization 8%, and incidence of stroke 1%.

Conclusions

In India, AF patients are younger and RHD is still the most frequent etiology. Almost two-third of the patients have persistent/permanent AF. At one-year follow-up, there is a significant mortality and morbidity in AF patients in India.

Control of Heart Rate Versus Rhythm in Rheumatic Atrial Fibrillation: A Randomized Study

Background: Patients with rheumatic heart disease with atrial fibrillation incur significant morbidity and mortality. Which approach, ventricular rate control or maintenance of sinus rhythm, in this setting might be superior is not known. The role of amiodarone in this patient population for maintaining sinus rhythm has not been evaluated.

Methods and Results: We prospectively studied 144 patients with chronic rheumatic atrial fibrillation in a double-blind protocol in which rhythm control (group I), comprising 48 patients each with amiodarone (group Ia) and placebo (group Ib), were compared with each other and with patients in a ventricular rate control group (group II) in which the effects by diltiazem were determined (n = 48, open-label). Direct current cardioversion was attempted in group I. The mean age of the study population was 38.6 ± 10.3 years, left atrial size, 4.7 ±0.6 cm; atrial fibrillation duration, 6.1 ± 5.4 years; and 72.9% had valvular interventions performed. At 1 year, 45 patients with sinus rhythm in group I compared with 48 in group II demonstrated an increase in exercise time (2.6 ± 1.9 vs. 0.6 ± 2.5 min, P = .001), improvement in New York Heart Association class of 1 or more ( P = .002), and improvement in the quality-of-life score of one or greater ( P = 0.01) with no difference in hospitalizations, systemic bleeds, or thromboembolism. Five patients died in group II; none died in group I ( P =.02). In group I, 73 of 87 (83.9%) patients converted to sinus rhythm and 45 of 86 (52.3%) patients maintained the rhythm at 1 year. Conversion rates were 38 of 43 (88.4%) with amiodarone versus 34 of 44 (77.3%) with placebo ( P = .49); the corresponding rate for maintaining sinus rhythm was 29 of 42 (69.1%) versus 16 of 44 (36.4%) ( P = .008). A larger number of electrical cardioversions were required in the placebo group (2.1 vs. 1.4, P = .011).

Conclusions: Maintenance of sinus rhythm is superior to ventricular rate control in patients with rheumatic atrial fibrillation with respect to effects on exercise capacity, quality of life, morbidity, and possibly mortality. Sinus rhythm could be restored in most patients, and amiodarone was superior to placebo in the restoration and maintenance of sinus rhythm.

Underutilization of Timely Kidney Transplants in Those With Living Donors

Preemptive kidney transplant (PKTx) and kidney transplant (KTx) within 1 year of dialysis initiation have been associated with superior outcomes. Wait times should be minimal for transplants with living donors; however, there is lack of literature studying utilization of timely KTx in this population. We designed this retrospective study using data from United Network for Organ Sharing Standard Transplant Analysis and Research files from 2000 to 2012 to assess the trends in utilization of PKTx and Early KTx (combination of PKTx or transplant within 1 year of dialysis initiation) in recipients of living donor KTx. Only 32.6% transplants were PKTx, and 61.9% were Early KTx. A significant improvement in proportion of PKTx was seen from 27.5% in 2000 to 35.4% in 2006, with no change since. Similarly, the proportion of Early KTx increased from 61.4% in 2000 to 63.6% in 2006, with no increase since. Similar results were seen after adjusted analysis and were independent of living donor type. Although there was some improvement in utilization of timely transplants in the early part of the last decade, there has been no improvement since. Considering the benefits of timely kidney transplant, it is important to understand the reasons behind the same and to improve utilization.

Quality-of-life outcomes with coronary artery bypass graft surgery in ischemic left ventricular dysfunction: a randomized trial

BACKGROUND

The STICH (Surgical Treatment for Ischemic Heart Failure) trial compared a strategy of routine coronary artery bypass grafting (CABG) with guideline-based medical therapy for patients with ischemic left ventricular dysfunction.

OBJECTIVE

To describe treatment-related quality-of-life (QOL) outcomes, a major prespecified secondary end point in the STICH trial.

DESIGN

Randomized trial. (ClinicalTrials.gov: NCT00023595).

SETTING

99 clinical sites in 22 countries.

PATIENTS

1212 patients with a left ventricular ejection fraction of 0.35 or less and coronary artery disease.

INTERVENTION

Random assignment to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients).

MEASUREMENTS

A battery of QOL instruments at baseline (98.9% complete) and 4, 12, 24, and 36 months after randomization (collection rates were 80% to 89% of those eligible). The principal prespecified QOL measure was the Kansas City Cardiomyopathy Questionnaire, which assesses the effect of heart failure on patients' symptoms, physical function, social limitations, and QOL.

RESULTS

The Kansas City Cardiomyopathy Questionnaire overall summary score was consistently higher (more favorable) in the CABG group than in the medical therapy group by 4.4 points (95% CI, 1.8 to 7.0 points) at 4 months, 5.8 points (CI, 3.1 to 8.6 points) at 12 months, 4.1 points (CI, 1.2 to 7.1 points) at 24 months, and 3.2 points (CI, 0.2 to 6.3 points) at 36 months. Sensitivity analyses to account for the effect of mortality on follow-up QOL measurement were consistent with the primary findings.

LIMITATION

Therapy was not masked.

CONCLUSION

In this cohort of symptomatic high-risk patients with ischemic left ventricular dysfunction and multivessel coronary artery disease, CABG plus medical therapy produced clinically important improvements in quality of life compared with medical therapy alone over 36 months.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute.

Regional variations in baseline characteristics of cardiac rhythm device recipients: The PANORAMA observational cohort study

Background

The PANORAMA study was designed to collect concurrent data on subjects from different worldwide regions implanted with CRM devices.

Methods

In this prospective, multi-center study, we analyzed baseline data on 8586 subjects implanted with CRM devices with no additional selection criteria (66% pacemaker (IPG), 16% implantable cardiac defibrillators (ICD), 17% cardiac resynchronization therapy (CRT) and < 1% Internal Loop Recorder) from 156 hospitals across 6 geographical regions between 2005 and 2011.

Results

Regardless of the device implanted, subjects from the Middle East and India often had more diabetes than other regions. Eastern and Western Europe had higher rates of atrial fibrillation reported, and men were more likely to smoke than women (46% vs 11%, p < 0.001). Within the CRT cohort there was significant variation in the proportion of males receiving a device, ranging from 55% in India to 83% in Eastern Europe.

Conclusions

We provide comprehensive descriptive data on patients receiving CRM devices from a range of geographies that are not typically reported in literature. We found significant variations in clinical characteristics and implant practices. Long term follow-up data will help evaluate if these variations require adjustments to outcome expectations.

When the living and the deceased cannot agree on organ donation: a survey of US organ procurement organizations (OPOs)

The legal concept of first person authorization (FPA) is based on the principle that a decision by a person with decision-making capacity should be respected even after he or she dies. Although the transplant community largely supports this concept, its implementation has not been universal. We conducted a web-based survey of all 58 Organ Procurement Organization (OPO)executive directors in the United States to assess OPOs' procurement policies and practices in the context of family objections. All 58 respondents(100%) responded to our survey. All OPOs except one have an online donor registration website. Most OPOs(89%) (51 of 57 respondents) estimated that the frequency of family objecting to organ donation in cases of registered donors was <10%. No OPOs reported the frequency to be higher than 25%. Only 50% (27 of 54) of the OPOs have a written policy on handling family objections. Approximately 80% of the OPOs reported honoring FPA. However, in the past 5 years, 20 OPOs (35%) have not yet participated in organ procurement from a registered deceased donor over family objection. Further research to identify the barriers and possible solutions to implementing FPA is warranted.