Scrub typhus: Clinical spectrum and outcome

Background:

Scrub typhus is one of the differential diagnoses for fever with thrombocytopenia. ARDS associated with Scrub typhus has high morbidity and mortality.

Aims:

To evaluate clinical features, lab values, and outcome in patients with scrub typhus and comparison in patients with or without ARDS.

Methods:

A prospective observational study was conducted on 109 patients with febrile illness and thrombocytopenia during a period of 12 months. All 109 patients were tested with both Immune-chromatography test and Weil felix test. Patients having either Immune-chromatography test/Weil felix test positive have been included and considered as scrub typhus positive whereas negative for both Immune-chromatography and Weil felix test were excluded. Clinical features, lab parameters, and outcome were evaluated in all patients with scrub typhus. Statistical analysis used in this study was T-test.

Results:

Among 58 patients who were included (After exclusion of 51 patients among total of 109 patients) 34 patients had no ARDS and 24 patients had ARDS. The clinical feature like dyspnoea, cough, low blood pressure (MAP<65 mmHg), IVC collapsibility (by ultrasound) and laboratory parameters like decreased Hemoglobin, Hematocrit, Serum albumin, and increased serum creatinine, serum total bilirubin, SGOT, SGPT, LDH, CPK, and serum lactate were statistically significant (P < 0.0001) in scrub typhus patients group with ARDS. The higher titers of Weil-felix can be correlated with more severe form of disease according to our observation. All 34 Scrub typhus patients without ARDS recovered completely. Among 24 Scrub typhus patients with ARDS, 22 patients recovered, and 2 patients died.

Conclusion:

Scrub typhus is an important differential diagnosis in a patients having fever with thrombocytopenia. Scrub typhus associated with ARDS has high morbidity and mortality. Early diagnosis and treatment with doxycycline can prevent the occurrence of ARDS     

First time and repeat cardioversion of atrial tachyarrhythmias – a comparison of outcomes

Introduction: Repeat cardioversion may be necessary in over 50% of patients with persistent atrial fibrillation (AF), but identifying responders remains challenging. This study evaluates the long‐term success of direct current cardioversion (DCCV) and the clinical and echocardiographical parameters that influence them, in over 1000 sedation‐cardioversion procedures undertaken at Eastbourne General Hospital between 1996 and 2006. Methods: A total of 770 patients of mean age (SD) 70.1(10.1) underwent 1013 DCCVs (first n = 665, repeat n = 348) for atrial tachyarrhythmias from 1996 to 2006. Time to persistent arrhythmia recurrence was compared between first and multiple DCCV, and the effect of age, gender, presence of heart disease, left atrial size, fractional shortening, arrhythmia duration, anti‐arrhythmic drug therapy (AAD) and other concomitant cardiac medication was evaluated using the Kaplan–Meier method and Cox’s Proportional‐hazards model. Results: In all, 33% of first and 29% of repeat DCCVs were in sinus rhythm (SR) at 12 months (m). There was no difference in median time to arrhythmia recurrence (SE) between first and multiple procedures: 1.5 ± 0.1 m (1.3–1.7) and 1.5 ± 0.0 m (1.4–1.6) respectively, p = 0.45. AAD use was significantly higher, arrhythmia duration shorter and more diabetic patients underwent repeat procedures. Amiodarone, OR 0.56, p = 0.04, sotalol, OR 0.61, p = 0.02 and arrhythmia duration, < 6 m, OR 0.72, p = 0.03 were independent predictors of improved outcome in first procedures only. In patients undergoing first procedures on amiodarone or sotalol, median time to arrhythmia recurrence was longer and 12 m SR rates higher, 6.0 ± 2.4 m (42%) than those who had a repeat procedure on the same medication, 1.5 ± 0.1 m (33%), p = 0.06. Conclusions: The efficacy of first and subsequent DCCV procedures is similar, achieving a similar proportion of SR maintenance at 1 year. However, the benefits of AAD therapy are the greatest following first time procedures. Concomitant AAD therapy should be considered for all first time procedures for persistent AF.     

Comparison of bivalirudin with heparin versus abciximab with heparin for primary percutaneous coronary intervention in “Real World” practice

ObjectiveWe aimed to carry out a “real world” comparison of bivalirudin plus unfractionated heparin (UFH) versus abciximab plus UFH in patients undergoing primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI).MethodsWe included patients who had abciximab or bivalirudin during their PPCI in our unit between Sept 2009 and Nov 2011.ResultsThe study included 516 and 484 patients in the bivalirudin and abciximab group respectively. There were more women in the bivalirudin group (29% vs 20%, p 0.001), while cardiogenic shock (6.4% vs 10.1%, p 0.04) and thrombectomy device use (76.6% vs 82%, p 0.04) were lower in the bivalirudin group.The primary composite end point of 30-day mortality, 30-day definite stent thrombosis or non-CABG major bleeding was similar between the bivalirudin and abciximab groups (7.8% vs 9.5%, OR 0.8, 95% CI 0.5 to 1.2, p 0.4). There was also no difference in in-hospital mortality (4.1% vs 4.3%, p 0.9), 30-day mortality (5.2% vs 6.4%, p 0.5), 1-year mortality (9.1% vs 9.9%, p 0.7), 30-day stent thrombosis (1% vs 0.4%, p 0.5) and non-CABG bleeding (2.7 vs 3.7%, p 0.4) between the bivalirudin and abciximab group respectively. On Cox proportional hazard analysis after adjusting for all the co-variates, the use of bivalirudin was not a predictor of 30-day mortality (HR 1.13, 95% CI 0.7–1.9, p 0.7).ConclusionIn this “real-world” observational study, there was no significant difference in the clinical outcome of PPCI for patients who had abciximab or bivalirudin after initial pre-treatment with UFH.     

Validating optimal function of the closed loop stimulation sensor with high right septal ventricular electrode placement in ‘ablate and pace’ patients

Purpose  

The study aim was to validate the closed loop stimulation (CLS) vs. accelerometer (ACC) rate-responsive sensors with electrodes placed in the right ventricular high septal (RVHS) or right ventricular apical (RVA) lead positions in patients following ‘ablate and pace’ therapy for persistent atrial fibrillation.     

A randomised controlled trial comparing StarClose and AngioSeal vascular closure devices in a district general hospital--the SCOAST study

Aims: AngioSeal and StarClose are vascular closure devices (VCDs) that can be used following cardiac catheterisation via the femoral artery to achieve haemostasis. Both devices have been demonstrated to be superior to conventional manual pressure, which reduce time to haemostasis and time to patient ambulation. We sought to compare these devices in a prospective, randomised trial. Methods: Patients undergoing elective coronary angiography were randomised to receive either AngioSeal VIP or StarClose VCD with immediate postprocedure mobilisation. Bruising was recorded at 30 min, 60 min and at 1 week postprocedure. Patient satisfaction surveys were taken at 1 h and 1 week postprocedure. Complications for both groups were compared. Results: Four hundred and one patients were included. Arteriotomy closure was achieved in 144 of 208 (69.2%) patients randomised to AngioSeal and 134 of 193 (69.3%) patients randomised to StarClose (p = ns). There was no significant bruising in either group at either 30 or 60 min postprocedure. However, at 1 week, there was significantly more bruising in the AngioSeal group than the StarClose group (63.1 vs. 38.5cm², p = 0.02). Patient satisfaction and pain perception with the procedure at closure were not significantly different between the groups. Deployment success and instant mobilisation rates were significantly lower for junior, as compared with senior, operators. Conclusion: Achievement of haemostasis is similar with both AngioSeal and StarClose. The StarClose vascular closure device results in significantly less bruising at 1 week postprocedure as compared with AngioSeal, with no significant differences in complication rates. Patients’ pain perception and satisfaction are similar with both VCDs.