Felty syndrome (FS) is a late manifestation of severe active rheumatoid arthritis (RA). A high index of suspicion or FS is needed in patients who present with neutropaenia and splenomegaly with no initial or obvious identifiable cause. We present the case of a 52-year-old who presented with a one-week history of haemoptysis, fever, and night sweats. The patient was hypotensive, tachycardia, and febrile (38 °C). On examination, bilateral crackles and reduced air entry were identified on the right basal and middle zones. The patient was diagnosed with RA two years prior to this presentation and was not on a disease-modifying antirheumatic drug (DMARD). Haematology showed high inflammatory markers and pancytopenia. Chest X-ray showed a right upper lobe abscess. CT-thorax, abdomen, and pelvis confirmed lung abscesses and hepatosplenomegaly. Candida albicans was detected on the broncho-alveolar lavage. He responded well to antifungal medication and corticosteroids with normalisation of the pancytopenia and inflammatory markers and reduction of the spleen size. This case report details the unusual and early presentation of FS in a patient newly diagnosed with RA and who had no active arthritis. We wish to emphasize the importance of a high index of suspicion in patients with RA regardless of the length of their illness.

Reverse left ventricular (LV) remodeling and recovery of LV function are associated with improved clinical outcomes in patients with heart failure with reduced ejection fraction. A growing body of evidence suggests that even among patients who experience a complete normalization of LV ejection fraction, a significant proportion will develop recurrent LV dysfunction accompanied by recurrent heart failure events. This has led to intense interest in understanding how to manage patients with heart failure with recovered ejection fraction (HFrecEF). Because of the lack of a standard definition for HFrecEF, and the paucity of clinical data with respect to the natural history of HFrecEF patients, there are no current guidelines on how these patients should be followed up and managed. Accordingly, this JACC Scientific Expert Panel reviews the biology of reverse LV remodeling and the clinical course of patients with HFrecEF, as well as provides guidelines for defining, diagnosing, and managing patients with HFrecEF. (C) 2020 by the American College of Cardiology Foundation.

Reverse left ventricular (LV) remodeling and recovery of LV function are associated with improved clinical outcomes in patients with heart failure with reduced ejection fraction. A growing body of evidence suggests that even among patients who experience a complete normalization of LV ejection fraction, a significant proportion will develop recurrent LV dysfunction accompanied by recurrent heart failure events. This has led to intense interest in understanding how to manage patients with heart failure with recovered ejection fraction (HFrecEF). Because of the lack of a standard definition for HFrecEF, and the paucity of clinical data with respect to the natural history of HFrecEF patients, there are no current guidelines on how these patients should be followed up and managed. Accordingly, this JACC Scientific Expert Panel reviews the biology of reverse LV remodeling and the clinical course of patients with HFrecEF, as well as provides guidelines for defining, diagnosing, and managing patients with HFrecEF. • This consensus document was created because there are no guidelines for the management of patients with HFrecEF. • A working definition of HFrecEF that is consistent with the majority of studies in the literature includes the following: 1) documentation of a decreased LVEF <40% at baseline; 2) ≥10% absolute improvement in LVEF; and 3) a second measurement of LVEF >40%. • Guideline-directed medical and device therapy for patients with HFrecEF should be continued indefinitely until the biology and clinical epidemiology of HFrecEF is better understood. • HFrecEF patients should have close clinical follow-up due to the high risk of heart failure relapse.

Most cardiac tumors are benign and localized to the left atrium. Right atrial myxomas are rare and mostly discovered during symptomatic workup or as an incidental finding. Usually, right atrial myxomas are comparatively asymptomatic compared to their left atrial counterparts and do not embolize to systemic circulation unless associated with other anatomical defects. We report a rare case presenting with a history of fever and diagnosed by transthoracic echocardiography. The myxoma was successfully removed surgically, and the patient has significantly improved clinically since then.

Most nations face a range of medical workforce challenges with questions over not only how to overcome public demand for healthcare and maintain a sufficient number of general practitioners but also how to fill shortages in particular hospital specialties and ensure an even distribution of doctors across the population. For both the Gulf Cooperation Council (GCC) and United Kingdom (UK), considering the growth in healthcare expenditure, growing hospital beds, and increasing population burdened by the aging population, the craving for more healthcare professionals can only worsen in the coming future. There is a lack of scientific data comparing the economic aspects of shortage of healthcare professionals in the GCC and UK. These geographically apart regions share a common problem, due to similar etiologies behind them, and both countries are coming closer together on various academic and nonacademic platforms to combat this situation together. We aim to identify various practice methods, decipher the complexities of the healthcare industry of respective local regions in relation to the availability of professionals in their respective economies. There are several recommendations and solutions to bring together the best global practices in each other's jurisdictions to solve the shortage of healthcare professionals.

Objective: Controversy exists on whether hypertension has a cardioprotective effect in patients with acute myocardial infarction (MI). We sought to assess the influence of hypertension on cardioprotective effects, measured as myocardial salvage index (MSI) by using cardiac magnetic resonance (CMR), in patients with reperfused acute MI. Design and Method: A total of 31 patients with acutely reperfused first ST-segment elevation MI caused by proximal coronary culprit lesions and pre-procedual Thrombolysis in Myocardial Infarction (TIMI) flow 0/1 underwent CMR within 2 weeks. Area at risk (AAR), MI size and MSI were determined by T2-weighted and late gadolinium enhanced CMR. Results: AAR, MI size normalized by LV mass was 36 ± 14% and 27 ± 15%, respectively (P < 0.05), yielding a mean MSI of 28 ± 20% (range 0–69%). Seventeen patients (55%) had hypertension. Hypertensive patients had significantly lower MSI than non-hypertensive patients (20 ± 16% vs 38 ± 20%, p < 0.05). However, there was no significant differences in AAR and MI size between both groups (37 ± 15% vs 35 ± 15%, p = 0.7, 30 ± 15% vs 23 ± 14%, p = 0.2). Univariate analysis demonstrated that MSI was associated with MI size, TIMI flow, LV mass index (LVMI) and peak CPK level (r = −0.38, 0.62, −0.40, −0.46, respectively, all p < 0.05). The presence of hypertension was a significant predictor of lower MSI (B coefficient = −0.34, p < 0.05). Conclusions: The current results demonstrated that myocardial salvage was attenuated in hypertensive patients with acute MI and inversely related with LVMI. Thus, cardioprotective effects may be impaired in patients with hypertension through increased LV mass.

Objective: Gestational hypertension or pregnancy-induced hypertension (PIH) is the development of new hypertension in a pregnant woman after 20 weeks gestation without the presence of protein in the urine or other signs of pre-eclampsia. The aim of this study is to analyze the impact of gestational hypertension on the quality of life of these patients. Design and Method: Questionnaire based cross sectional study was done on 256 patients admitted with gestational hypertension (established according to the clinical and laboratory methods) in the Department of Gynaecology and Obstetrics in the University Hospital between 1st January 2014 and 30th June 2015. EuroQol - 5D-5L questionnaire was administered in these patients during the third trimester visit to the gynaecology department. EuroQol 5D-5L comprises of 5 dimensions: mobility, self care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problem, slight problems, moderate problems, severe problems and extreme problems. Results: The study revealed that among patients with gestational hypertension, according to EuroQol 5D, in case of mobility 8% were with moderate problems, 3% with severe problems and 1% with extreme problems. 5% of the patients had moderate problems, 2% had severe problems and 0.5% were with extreme problems on self care dimension. When considering the dimension pain/discomfort, 18% had moderate problems, 8% had severe problems and 2% had extreme problems. In case of anxiety/depression, 34% had moderate problems, 12% had severe problems and 6% were with extreme problems. With usual activities, 12% had moderate problems, 4% had severe problems and 1% had extreme problems. Conclusions: The study revealed that the incidence of anxiety/depression are at a high rate in patients with gestational hypertension. Hence proper psychological rehabilitation is to be implemented in patients with gestational hypertension in-order to improve their quality of life during the course of pregnancy.

This paper examines the effect of audit quality on accounting restatements in China. Evidence on the determinants and consequences of accounting restatements in emerging markets is scant, although these countries are more vulnerable to financial report manipulation and subsequent restatements. For accounting restatement analysis we regress non-cash flow restatement observations and cash flow restatement observations on audit quality and restatement–audit quality interaction variables. Earnings manipulation increases the likelihood of non-cash flow restatement observations, but high quality audit constrains this effect. However, no such evidence is found for cash flow restatements.

Objective : The objective of this study was to analyses the major risk factors for coronary artery disease (CAD) for patients with ischemic heart disease in Kerala. Design : A cross-sectional study among patients with established CAD admitted in the Department of Cardiology during the month of June-Dec 2012. Setting : Study was carried out in a tertiary cardiac center in Kerala. Participants: A total of 496 patients who were admitted in the Cardiology department between June 2012 and December 2012 with acute coronary syndrome or coronary angiographic or Electrocardiography evidence of ischemic heart disease. Risk factors studied were the conventional risk factors for coronary artery disease - hypertension, diabetes mellitus, dyslipidemia, body mass index (BMI), smoking, and family history of coronary artery disease. Data are collected from the patients, old medical records, Clinical Examination and Laboratory results of the patients were analyzed for the study. Results: From the study, it was seen that in Keralites-irrespective of gender, diabetes or impaired glucose tolerance (79%) and dyslipidemia (71%) are the major risk factor for Coronary artery disease. Hypertension (39%) and cigarette smoking (24%) were not seen to be a major risk factors for coronary artery disease as only a minority of the study population had hypertension or gives a history of cigarette smoking. 57% of the study population had a family history of coronary artery disease. Among the studied population, 55% of females are with increased BMI, whereas only 16% of males with CAD were with BMI above 30. Conclusion: Among South Indian population irrespective of gender, diabetes mellitus and dyslipidemia are the major Risk factor for Coronary artery disease. So early detection of diabetes mellitus and dyslipidemia and proper treatment of both, before developing the end organ damage, play a vital role for the prevention of coronary artery disease.

Objective: The objective of this study is to analyse the effect and side-effects of combination therapy of Olmesartan/Amlodipine in the treatment of Resistant Hypertension. Design and method: Querstionaire based cross sectional study among patients with Resistant Hypertension according to the 2013 ESC Guideline for management of Hypertension. Study was carried out in 64 patients admitted with history and holter blood pressure monitor evidence of Resistant Hypertension in the Cardiology Department between 1 st of July 2013 and 31 st of July 2014. Patients who fulfilled the inclusion criteria by the initial holter blood pressure moniter were started on combination therapy with Olmesartan/Amlodipine along with diuretic and Beta-blocker. Patients were analysed with control questionaire and holter blood pressure monitor after 3 months for the effect and side-effects and the circadian rythm of blood pressure control. Results: From the study it was seen that 45 (70.31%) of the patients included in the study had reached optimal control of blood pressure. 10 patients (15.64%) had non optimal control of blood pressure, 3 patients (4.68%) stopped the treatment due to pedal oedema. 6 patients (9.37%) patients continued to be with resistant hypertension inspite of our maximal therapy. From the initial holter blood pressure monitering it was observed that 19 patients (30%) included in the study were non- dippers and after the therapy with Olmesartan/Amlodipine combination it was found that only 7 patients (10.93%) were non- dippers. Conclusions: From our study we observed that the combination therapy with Olmesartan/Amlodipine in patients with Resistant Hypertension has high efficacy and minimal side-effects with good circadian control of Hypertension.

Objective: To analyse the effect of fixed dose combination therapy with Olmesartan/Amlodipine in the treatment of Resistant Hypertension. Design: Questionnaire based cross sectional study. Method: The study was carried out among 364 patients admitted with history and 24 hour holter blood pressure monitor evidence for Resistant Hypertension in the Department of Cardiology between 1 st January 2012 and 31 st January 2015. Patients with history of Resistant Hypertension were screened with 24 hour holter blood pressure monitoring and those who fullfilled the criteria for Resistant Hypertension according to the ESC guideline for Management of Arterial Hypertension based on the treatment history and 24 hour holter blood pressure monitoring were included in the study after obtaining informed consent. Patients included in the study were started on therapy with Olmesartan/Amlodipine at fixed dose combination along with diuretic and Beta-Blocker. Patients were continued on this fixed dose combination therapy for 3 months. After the 3 month period patients were reassessed with control holter blood pressure monitoring to access the efficacy of the treatment and the circadian control of arterial blood pressure. Result: From the study it was observed that 68.68% patients (250 of 364) had reached optimal control of arterial blood pressure by the fixed dose combination therapy with Olmesartan/Amlodipine. 17.04% patients (62 of 364) had non optimal control of arterial blood pressure and 8.79% patients (32 of 364) continued to be with resistant hypertension in-spite of the maximal dosage of the fixed dose combination therapy with Olmesartan/ Amlodipine. 5.49%- patients (20 of 364) discontinued the treatment due to pedal edema. We observed from the screening holter blood pressure monitoring that 29.94% - patients (109 of 364) with resistant hypertension were non-dippers and after the fixed dose combination therapy with Olmesartan/Amlodipine only 10.44% patients (38 of 364) were non-dippers. Conclusion: The study revealed that fixed dose combination therapy with Olmesartan/Amlodipine in patients with Resistant Hypertension has high efficacy and minimal side effects with good circadian control of arterial blood pressure.

In order to improve the photocatalytic activity and reduce the cost of graphene oxide/Bi2WO6 (GO/BWO) nanohybrids for practical application, silicon-modified graphene oxide/Bi2WO6 (Si-GO/BWO) nanoplates were successfully prepared by a facile one-pot hydrothermal method. X-ray diffraction and BET study of the products reveal that the incorporation of Si atoms can greatly alter the microstructure of GO/BWO composite with enlarged specific surface area. The UV–vis diffuse reflectance spectra indicate that the obtained Si-GO/BWO nanoplates have enhanced absorption in both UV and visible light regions. The Si–GO/BWO nanocomposite shows increased photocatalytic activity on the degradation of high concentration RhB solution under visible light irradiation and simultaneously keeps a very high stability, due to the good textural properties. In addition, the incorporation of Si with a load of 19.3 wt% could greatly reduce the cost of BWO based photocatalyst.

Objective: The epidemic of obesity and obesity related morbidities is an important public health challenge, and is paralleled by growing incidence of metabolic syndrome which acts as a strong and significant risk factor for Ischemic heart disease and other atherosclerotic vascular events. The psychological impact of these chronic conditions can be very disturbing. In practical terms the functional effect of an illness and its therapy upon a patient, as perceived by the patient - could be estimated by introducing the quantitative approach of - Health Related Quality of Life (HRQoL). Aim: The aim of this study is to evaluate the impact of obesity on quality of life of patients with ischemic heart disease. Design and method: Questionnaire based cross sectional study was conducted among patients with established Coronary Artery Disease admitted in the Department of Cardiology in the University Hospital. 520 patients who were admitted in the Cardiology Department between 1st of January 2012 and 30th June 2014 with acute coronary syndrome or coronary angiographic or Electrocardiography evidence of ischemic heart disease were included in the study, stratified by age, sex and BMI ( normal weight 18.5 - 24.9, overweight 25 - 29.9, obese 30 and above). EuroQol - 5D (EQ-5D) was administered in the patients during their hospital stay. EQ-5D comprises 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems and extreme problems. The height, weight and basic laboratory parameters were recorded. Results: Mean age of the participants was 65.1± 10.6 years. Male female ratio was 0.76. The distribution of patients in BMI groups was 36.8%/ 24.4%/ 38.8%. Statistically significant differences between BMI groups were seen in Usual activity (p=0.005) and self-care (p=0.044) dimensions of EQ-5D-5L with poorest outcome in the obese. We have found significantly positive correlation between BMI and usual activities (R=0.234, p=0.001) and between age and anxiety (R= 0.366 p=0.045). Mean BMI of patients with extreme problems with extreme problems with usual activities is significantly greater than those with lower intensity of problems. Patients with extreme anxiety tend to have higher mean age. Conclusion: Our study revealed that Ischemic heart disease patients with obesity had impaired QoL in terms of health, mobility, usual activity, discomfort and anxiety. Hence non-obese ischemic heart disease patients had a better sense of overall wellbeing.

Objective: Obesity is currently a leading epidemic and an important public health challenge. The psychological impact of obesity in the patients with Coronary artery disease can be very disturbing. In practical terms the functional effect of an illness and its therapy upon a patient, as perceived by the patient – could be estimated by introducing the quantitative approach of – Health Related Quality of Life (HRQoL). The aim of this study is to evaluate the impact of obesity on quality of life of patients with ischemic heart disease. Design and method: Questionnaire based cross sectional study was conducted among 520 patients who were admitted in the Cardiology Department between 1st of January 2012 and 30th June 2014 with acute coronary syndrome or coronary angiographic or Electrocardiography evidence of ischemic heart disease were included in the study, stratified by age, sex and BMI (normal weight 18.5 – 24.9, overweight 25 – 29.9, obese 30 and above). EuroQol – 5D (EQ-5D) was administered in the patients during their hospital stay. EQ-5D comprises 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems and extreme problems. The height, weight and basic laboratory parameters were recorded. Results: Mean age of the participants was 65.1 ± 10.6 years. The distribution of patients in BMI groups was 36.8%/ 24.4%/ 38.8%. Statistically significant differences between BMI groups were seen in Usual activity (p = 0.005) and self-care (p = 0.044) dimensions of EQ-5D-5L with poorest outcome in the obese. We have found significantly positive correlation between BMI and usual activities (R = 0.234, p = 0.001) and between age and anxiety (R = 0.366 p = 0.045). Mean BMI of patients with extreme problems with extreme problems with usual activities is significantly greater than those with lower intensity of problems. Patients with extreme anxiety tend to have higher mean age. Conclusions: Our study revealed that Ischemic heart disease patients with obesity had impaired QoL in terms of health, mobility, usual activity, discomfort and anxiety. Hence non-obese ischemic heart disease patients had a better sense of overall well-being.

Objective: The objective of this study is to analyse the effect and side-effects of combination therapy of Olmesartan/Amlodipine in the treatment of Resistant Hypertension. Design and method: Querstionaire based cross sectional study among patients with Resistant Hypertension according to the 2013 ESC Guideline for management of Hypertension. Study was carried out in 64 patients admitted with history and holter blood pressure monitor evidence of Resistant Hypertension in the Cardiology Department between 1 st of July 2013 and 31 st of July 2014. Patients who fulfilled the inclusion criteria by the initial holter blood pressure moniter were started on combination therapy with Olmesartan/Amlodipine along with diuretic and Beta-blocker. Patients were analysed with control questionaire and holter blood pressure monitor after 3 months for the effect and side-effects and the circadian rythm of blood pressure control. Results: From the study it was seen that 45 (70.31%) of the patients included in the study had reached optimal control of blood pressure. 10 patients (15.64%) had non optimal control of blood pressure, 3 patients (4.68%) stopped the treatment due to pedal oedema. 6 patients (9.37%) patients continued to be with resistant hypertension inspite of our maximal therapy. From the initial holter blood pressure monitering it was observed that 19 patients (30%) included in the study were non- dippers and after the therapy with Olmesartan/Amlodipine combination it was found that only 7 patients (10.93%) were non- dippers. Conclusions: From our study we observed that the combination therapy with Olmesartan/Amlodipine in patients with Resistant Hypertension has high efficacy and minimal side-effects with good circadian control of Hypertension.

Objective: The objective of this study was to analyses the major risk factors for coronary artery disease (CAD) among patients with ischemic heart disease in the state of Kerala in South India. Design and method: Study was done among randomly selected 496 patients who were admitted in the Department of Cardiology – in a tertiary Cardiac hospital in the state of Kerala in South India during the month of June –December 2012. Patients included for the study were those with Coronary artery disease, either with Acute Coronary Syndrome or with angiographic, ECG or stress test evidence for Ischemic heart disease. Risk factors studied were the conventional risk factors for Coronary artery disease- Hypertension, Diabetes Mellitus, Dyslipidemia, Body Mass index, Smoking and Family History of Coronary artery disease. Data collected from the patients, old medical records, Clinical Examination and Laboratory results of the patients were analyzed for the study. Results: From the study, it was seen that in Keralites-irrespective of gender, diabetes or impaired glucose tolerance (79%) and dyslipidemia (71%) are the major risk factor for Coronary artery disease. Hypertension (39%) and cigarette smoking (24%) were not seen to be a major risk factors for coronary artery disease as only a minority of the study population had hypertension or gives a history of cigarette smoking. 57% of the study population had a family history of coronary artery disease. Among the studied population, 55% of females are with increased BMI, whereas only 16% of males with CAD were with BMI above 30. Conclusions: Among South Indian population in the state of Kerala irrespective of gender, diabetes mellitus and dyslipidemia are the major Risk factor for Coronary artery disease. So early detection of diabetes mellitus and dyslipidemia and proper treatment of both, before developing the end organ damage, play a vital role for the prevention of coronary artery disease.

Neurohormonal antagonism remains the corner- stone of therapy in the management of congestive heart failure. Numerous clinical trials have demonstrated that blockade of the renin-angiotensin and adrenergic axes improves symptoms, decreases hospitalizations, and lowers mortality. Angiotensin receptor blockers (ARBs) are a newly-released class of agents that block the effects of angiotensin II at the level of the angiotensin type 1 receptor rather than inhibiting angiotensin II production. Although better tolerated in ELITE-II, the ARB losartan was not found to be more effective than the tried and proven ACE inhibitor cap- topril in improving clinical outcomes in heart failure. Yet the question remains, c ould more complete angiotensin II inhibition at the receptor level comple- ment the well-established benefits of ACE inhibitors when used in combination? Small clinical studies had shown that when added to an ACE inhibitor, ARBs can improve exercise tolerance, reduce ventricular remod- eling, a nd decrease neurohormonal activation. However, as recently demonstrated by ELITE-I and II, such observations cannot be readily translated into clinical endpoints such as mortality and hospitaliza- tions. The Valsartan in Heart Failure Trial (Val-HeFT) is the first large-scale clinical trial to specifically address this "add-on" use of an ARB (valsartan). Results from this study were presented at the AHA