Background: Heart failure (HF) prevalence in India is about 1% which is about 8-10 million, and significant gender differences exist. Aims: This study was done to investigate the differences in modes ...of presentation, cardiac etiology, comorbidities, and inhospital outcomes between both genders and to identify predictors of prolonged hospital stay. Settings and Design: We conducted a cross-sectional descriptive study from November 2016 in the coronary care unit. Materials and Methods: Consenting adult patients admitted with the primary diagnosis of acute HF were included. Patients with reversible noncardiac circulatory failure and malignancies were excluded. Their clinical details and inhospital outcomes were recorded. Results: Out of 150 patients, 86 (57.33%) were males and 64 (42.6%) females. More women were admitted with Stage 4 New York Heart Association (59 92.2%, P = 0.002), cardiogenic shock (10 15.6%, P = 0.04), or with hypertensive emergency (23 35.9%, P = 0.027). The mean duration of stay in males was 6.17 ± 2.21 days and 7.23 ± 2.69 days in females (P = 0.009). Multivariate analysis showed that the adjusted risk of prolonged hospital stay (≥7 days) was 4.6 (95% confidence interval: 1.96, 10.82), with the risk being almost five times greater among patients with the presence of cardiorenal syndrome (CRS), compared to those who did not have it (P < 0.001). Statistical Analysis: Chi-square, Student's t-test, and logistic regression were used in the study. Conclusion: Our study highlighted that women were more vulnerable, and came in with advanced HF or hypertensive emergency and stayed in the hospital for a longer duration. CRS was the crucial predictor of prolonged hospital stay.
Background and aimsHypertensive emergencies are caused by acutely occurring massive elevations in blood pressure with features suggestive of acute end-organ damage and are a common complication of ...hypertension. About 1-2% of all patients with hypertension develop this complication in their lifetime. This study was undertaken to assess short-term outcomes associated with hypertensive emergencies in a tertiary care center.MethodsWe conducted a prospective cohort study and recruited 66 consenting adults with a hypertensive emergency. Sociodemographic details, clinical characteristics, blood pressure readings at different intervals, in-hospital course, and diagnosis of end-organ damage were recorded. The in-hospital outcome was noted as dead or alive. After four weeks, patients were followed up through telephonic interviews and the patient’s status was then reviewed and recorded. Multiple logistic regression determined the predictors of death. Data were analyzed in SPSS version 26.0 (IBM Corp., Armonk, NY, USA).ResultsA total of 66 patients were enrolled, with a mean age of 54.57 (±38.18) years and a male predominance of 44 (66.35%) patients. The majority of patients were known hypertensives (n=55, 83.35%). Of the known hypertensives, 41 (74.54%) patients had discontinued their anti-hypertensive medications prior to admission. The median duration of hospitalization was 10 (7-14) days. The most common presenting complaints were dyspnea (n=35, 53.03%), pedal edema (n=29, 43.94%) and headache (n=25, 37.87%). Forty-one (62.12%) patients required ICU care, and 39 (59.09%) required ventilator support. The most common end-organ damage was acute-on-chronic kidney disease (n=21, 31.81%). The short-term mortality documented at the end of one month was 24 (36.36%). Of these, seven (10.6%) patients died in the hospital, and 17 (25.75) patients died within one month of getting discharged from the hospital. The factors that were associated with high mortality were newly-diagnosed hypertension and in-hospital hypotension.ConclusionWe found high mortality associated with hypertensive emergencies. At one month follow-up, we found that more than one-third of the patients had died. Post-hospitalisation mortality was higher than in-hospital mortality. Most patients had discontinued their anti-hypertensive medication before admission. The most frequently encountered end-organ damage was acute-on-chronic kidney disease. The factors associated with high mortality were newly-diagnosed hypertension and in-hospital hypotension.
Background: Crisis resource management (CRM) skills are nontechnical skills that are often neglected during the training of residents in the management of clinical emergencies. This study was ...conducted to assess the utility of high-fidelity simulation to enhance the learning of CRM among internal medicine postgraduates (PGs). Materials and Methods: After obtaining IEC approval, a total of ten (five 1st year and five 3rd year) internal medicine PG students were included by convenience sampling. Each student participated in four simulated emergencies in the simulation laboratory of a tertiary care hospital, one before and three after CRM training. They participated in groups of 3–5 at intervals of 15–30 days. All the scenarios were video graphed and viewed by the investigators and each student was assessed in each session for CRM using Ottawa global rating score (GRS). The outcome variable was an overall score (OS-ordinal from 1to 7). After the last session, a questionnaire was administered to assess the perceptions of the participants about the course. After 1 year, the participants self-assessed their CRM in a real emergency using GRS and also identified barriers for the application of CRM in real life. The statistical tests used were paired t-test, Student's t-test, and repeated measures ANOVA. Results: The mean OS at baseline was 3.9 ± 1.5 and after training, it improved to 4.6 ± 1.26 (P = 0.024). In the three posttraining sessions, the OS did not decline and this indicated good retention of CRM (P = 0.056). PGs had a consistently favorable opinion of this course. The self-assessed OS in a real emergency was 5.7 ± 0.82. The barriers to CRM application in real emergencies were lack of practice and lack of team training. Conclusions: High fidelity simulation is an effective and acceptable method of teaching CRM to internal medicine PGs and should be incorporated into the PG curriculum.
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Context: Extrapulmonary tuberculosis (EPTB) presentation can be unusual, and the diagnosis may often be challenging when associated with HIV. Aims: This study was conducted to find out the pattern of ...newly diagnosed EPTB in hospitalized patients, the diagnostic modalities used to arrive at the diagnosis, frequency of HIV positivity among them, and its association with CD4 counts. Settings and Design: All patients newly diagnosed to have EPTB admitted in a tertiary care medical college hospital in various departments over 1 year were included. Methods and Materials: Clinical presentation, comorbidities, and investigations done to arrive at diagnosis of EPTB were recorded. They were classified based on the affected site. HIV was tested for all patients, and CD4 counts in positive patients. Results: A total of 230 patients were newly diagnosed to have EPTB. The median age was 35 years (IQR 29–45), and the proportion of males was 127 (55%). Imaging was used alone in 47 (20%) patients and in combination with cytology or biopsy in 133 (57.8%) patients to establish the diagnosis. Pleural effusion, 50 (21.7%) patients, peripheral lymph node TB (LNTB), 44 (19.1%) patients, and CNS TB, 37 (16.1%) patients, were the most common forms. HIV was associated in 61 (26.5%) patients and diabetes in 27 (11.5%) patients. Both diseases influenced the presentation of EPTB. There was an association between HIV positivity and type of EPTB with peripheral LNTB being the most common in HIV patients. High CD4 counts were associated with pleural effusion and low counts with disseminated forms. Statistical Analysis Used: chi-square, ANOVA, and Student t test. Conclusion: The pattern of EPTB changes with HIV and vigilance is required to detect severe and disseminated forms of EPTB with lower CD4 counts.
Background: Type 2 diabetes contributes to significant productivity losses in paid work and unpaid work. Patients with Type 2 diabetes also feel distressed due to the concerns about disease ...management, its emotional burden, physician-related issues, and regimen-related distress.
Objective: The objective of this study is to assess the productivity loss and diabetes distress among patients with Type 2 diabetes attending the outpatient department at a tertiary care setting and the association between productivity loss and diabetes distress in the study population.
Materials and Methods: A cross-sectional study was done among 121 outpatients with Type 2 diabetes at a tertiary care hospital. A semistructured interview schedule that included questions on sociodemographic profile, details about diabetes, the Institute for Medical Technology Assessment Productivity Cost Questionnaire, and Diabetes Distress Scale was administered.
Results: Around half of the study participants (47.1%) reported productivity losses either in paid and/or unpaid work. The total cost of productivity loss among 121 patients over 4 weeks was calculated to be Indian National Rupees 2,526,880. Individuals with diabetes distress levels worthy of clinical attention (moderate and high levels of distress) were found to be 20.6%. Significant emotional burden was seen among 40.5% of the study participants. Of the population who had distress due to diabetes, 60% had productivity loss.
Conclusion: Patients with type 2 diabetes have high productivity losses and distress due to diabetes. Patients with productivity losses have significantly higher levels of diabetic distress.
Describe the use of tofacitinib in severe and critical coronavirus disease-2019 (COVID-19), and explore the association of drug initiation time with survival. A retrospective study of inpatients with ...severe or critical COVID-19 at a tertiary care hospital, who were prescribed generic tofacitinib for at least 48 hours, was conducted. Baseline demographics, comorbidities, illness severity, treatment, adverse effects and outcomes were analyzed. Patients were grouped based on median duration of symptomatic illness prior to tofacitinib administration, as early or late initiation groups. Forty-one patients (85.4% males, mean age 52.9 ± 12.5 years), were studied. 65.9% (n = 27) had severe COVID-19, while 34.1% (n = 14) were critically ill. Death occurred in 36.6% patients (n = 15). The median time to prescription of tofacitinib was 13 (9.50, 16.0) days of symptom onset. Tofacitinib was initiated early (8-13 days) in 56.1% of patients (n = 23), while the remaining received it beyond day 14 of symptom onset (late initiation group). Multivariate logistic regression adjusted for age, presence of diabetes mellitus and illness duration prior to hospitalization demonstrated higher odds of survival (adjusted odds ratio 19.3, 95% confidence interval 2.57, 145.2) in the early initiation group, compared to the late initiation group. Early initiation of tofacitinib in severe and critical COVID-19 has potential to improve survival odds.
Abstract Human retro-viral disease and the myriad opportunistic infections associated with it continue to pose a diagnostic challenge to clinicians. Disseminated Kaposi sarcoma (KS) and KS-associated ...immune reconstitution inflammatory syndrome (IRIS) are entities that can be associated with adverse clinical outcomes unless recognized early by the treating physician. We present the case of a 36-year-old homosexual HIV-positive male who presented with unusual symptoms of KS and KS IRIS with lower gastrointestinal bleeding and respiratory distress devoid of any cutaneous manifestations.
Abstract
Introduction:
Team-based learning (TBL) is a student-centric teaching–learning (TL) method and fosters active learning. TBL has an advantage over other small group TL methods for balancing ...teaching time and resources.
Aim:
The study aimed to determine the effectiveness of TBL methodology in improving learning outcomes among 2
nd
-year undergraduate medical students in pathology.
Settings and Design:
This was a quantitative interventional study involving 100 2
nd
-year MBBS students in pathology at AIMS, BG Nagara.
Methodology:
Two groups of 50 students were exposed to three TBL and case-based learning (CBL) sessions on similar topics. For the TBL session, individual readiness assurance test scores and team readiness assurance test scores were obtained.
Statistical Analysis Used:
For both the TBL and CBL sessions, retention test scores were obtained after 2 weeks and the effectiveness of two methods of learning was determined by comparing the retention test scores by independent Student’s
t
-test. Feedback on students’ perception of TBL was obtained using a five-point Likert scale.
Results:
The mean test score of the TBL session was significantly higher than that of CBL sessions (19.80 vs. 15.86,
P
< 0.0001). Similarly, it was also observed that the retention scores were higher among average performers after the TBL session (19.71 vs. 12.50,
P
< 0.0002).
Conclusion:
TBL is more effective than CBL in fostering learning and it selectively benefits average performers more than higher performers, evidenced in this study by better retention of knowledge.
Background & objectives: Prediabetes is associated with increased prevalence of cardiovascular disease (CVD). In participants with prediabetes, the effects of exercise and metformin were evaluated on ...high-sensitivity C-reactive protein (hsCRP) and carotid intima-media thickness (CIMT), surrogate markers of atherosclerosis and CVD compared with standard care.
Methods: In a pilot randomized control trial, the participants were randomized in to three arms: standard care (STD), intensive lifestyle modification (ILSM) or ILSM and metformin (ILSM+Met) and followed up for six months. Monitoring of ILSM was done by a trained healthcare facilitator. hsCRP, CIMT and other relevant parameters were measured before and after intervention.
Results: A total of 103 participants were randomized into three arms and followed up for six months. At six months, there was a reduction from baseline in weight and fasting blood sugar (FBS) (P <0.01) in all three arms and a reduction in haemoglobin A1c (P =0.03) only in the ILSM+Met arm. The differences in hsCRP over six months within the STD, ILSM and ILSM+Met arms were −0.12 (95% confidence interval, −1.81, 2.08), −0.58 (−2.64, 0.43) and −0.11 (−1.84, 1.56), respectively. There was no difference in hsCRP, CIMT (right) or CIMT (left) between the three arms at six months.
Interpretation & conclusions: There was a reduction in weight and FBS from baseline in all three arms. There was, however, no difference seen in hsCRP and CIMT in the two intervention arms compared to standard care. Larger studies with long-term follow up need to be done to detect differences in risk markers for CVD in prediabetes.
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