Ophthalmology residency training in India: Comparing feedback about how the training equips ophthalmologists to combat retinal diseases. READS report #6

Purpose: To document whether the residency training in management of retinal diseases has improved in 2000s to meet the increasing demand of retina care in India. Methods: A survey, using a prevalidated questionnaire, was conducted by Academic and Research Committee (ARC) of the All India Ophthalmological Society (AIOS) in 2014–2016 among ophthalmologists to document teaching of retina-related clinical and surgical skills in the postgraduate residency program. Results: The 144-item questionnaire was mailed to 4512 practicing ophthalmologists with residency training in two different periods, between 1967 and 2000 (group 1; 20th-century trained) and between 2003 and 2012 (group 2; 21st-century trained). Response was received from 320 (19.1%) of group 1 ophthalmologists and 531 (18.7%) of group 2 ophthalmologists. The average age was 49.2 ± 8.7 and 32.6 ± 4 years, respectively. Group 2 residents had received superior training in indirect ophthalmoscopy, slit lamp biomicroscopy using + 78 and + 90D lens, optical coherence tomography, fundus photography, and fluorescein angiography (all P < 0.001), but there was large variation between the training institutions. The residents were not taught vitreous and retinal detachment surgeries in either period of training. Conclusion: Teaching of retina-related clinical skills have improved in Indian residency program, but there are variations across programs. This information might help redesign the ophthalmology residency programs to meet the demands of comprehensive eye care and universal health coverage of increasing retinal diseases in India.

Arcuate keratotomy infiltration following uneventful femtosecond laser assisted cataract surgery

An 84-year-old gentleman underwent uneventful femtolaser-assisted cataract surgery (FLACS) with an arcuate keratotomy (AK) in the left eye. On the 18th post-operative day, a corneal infiltrate developed involving the AK. Staphylococcus epidermidis was the organism isolated on culture. The infiltrate resolved with topical fortified vancomycin and amikacin eyedrops, and the patient regained a visual acuity of 6/6 after 12 weeks. This is the first case from south-east Asia reported in the literature of an infective infiltrate along a femtosecond laser AK. We propose strict peri-operative recommendations to be followed to prevent and treat such infections.

Effect of dietary incorporation of natural attractants on growth and survival during seed rearing of Indian butter catfish, Ompok bimaculatus

Aim: The objective of the study was to assess the effect of dietary incorporation of different feed attractants viz. tubifex, earthworm and fish meal on growth and survival of O. bimaculatus (pabda fish) fry. Methodology: Fifty numbers of fifteen days weaned fry (0.105±0.008g; 2.14±0.14cm) were stocked into each aerated aquariums (30.0 x 15.0 x 15.0 cm) following a completely randomized design (CRD) consisting of four treatments including the control with three replicates each. Four iso-nitrogenous purified diets were prepared including three treatment diets with attractants (5%) by replacing an appropriate amount of casein and cellulose and fed to the fishes twice daily. Results: Results from the study showed that growth of fry as measured by final weight, weight gain, mean daily weight gain and specific growth rate of fries were significantly (p<0.05) higher in tubifex supplemented group and lower in control group. Survival was significantly higher in tubifex supplemented group (42.66±1.3%) and lower in control group. Moreover, other yield parameters such as total biomass, condition factor and performance index also followed the same trend as survival. Further, higher protease activity was found in control group (2.233±0.038 units mg protein-1 min-1) followed by earthworm (0.354±0.031 mg protein-1 min-1) supplemented group (p<0.05). The lipase and amylase activity were higher (p<0.05) in tubifex and control groups, respectively. Interpretation: It could be concluded that the dietary supplementation of tubifex at 5% inclusion level could be a promising aquaculture feeding strategy for pabda fish due to its rich nutrient content, increased feeding stimulation and more palatability.

Septopremaxillary ligament traction system: a review

Over the years, several animal studies have been conducted concerning the role of cartilaginous nasal septum, septopremaxillary ligament in midfacial growth. Most of the studies utilized non primate animal models at first and then more recently in primates such as chimpanzee. Proper choice of animal model to extrapolate from is critical for successful experimental design. Although nonhuman primates are phylogenetically closer to humans than other mammalian groups for better extrapolation to human condition, not all the craniofacial experiments require primate models. Renewed interests in understanding the influence of septopremaxillary ligament resection on midfacial growth led to many in vitro experiments on animal models. Recently systematic review of relevant animal experiment is regarded as a prerequisite for the conduct of the new clinical trials. Despite this fact, the literature addressing this topic in humans and systematic review on the effect of the septopremaxillary ligament is scarce. The more recent studies show that the maxillary labial frenum encloses the septopremaxillary ligament and forms an important constituent of septopremaxillary traction system. The biomechanical force mediating through the septopremaxillary ligament, maxillary labial frenum and nasolabial muscles results in stimulating their effects on sagital growth of the maxilla. The main purpose of this review is to update and extend the knowledge of the role of septopremaxillary traction system on the midfacial growth by synthesizing the available literature involving the septopremaxillary ligament resection in experimental models. If this review could synthesize the results of relevant research, a change in the therapeutic notions can also be expected.

Pars plana vitrectomy and re-directing a dexamethasone implant into vitreous cavity following misdirected entry into the crystalline lens

A known diabetic patient presented with diabetic macular edema (DME) and nonproliferative diabetic retinopathy in both eyes with a vision of 6/18, N12in the right eye and 4/60, N36in the left eye (LE). The patient had undergone injection of dexamethasone implant in the LE which got misdirected into the crystalline lens. The patient was taken up for phacoemulsification with intraocular lens implantation along with vitrectomy and posterior vitreous detachment induction, and redirection of the dexamethasone implant into the vitreous cavity. The DME resolved over the next 3 months

Residency Evaluation and Adherence Design Study III: Ophthalmology residency training in India: Then and now朓mproving with time?

Purpose: To gauge the differences in ophthalmology residency training, academic, clinical and surgical, in the last three decades of the 20th century and the first decade of the 21st century. Methods: A survey was conducted by the Academic and Research Committee of the All India Ophthalmological Society, in 2014�16, using a prevalidated questionnaire, which was circulated to ophthalmologists to gauge the practicality of the teaching protocols of clinical and surgical skills during postgraduate residency program. Results: Of the 1005 respondents, 320 ophthalmologists who completed residency between 1967 and 2002 (20th century trained) and 531 who completed a residency in 2003�12 (21st century trained) fulfilled the inclusion criteria. The average age was 49.2 years (standard deviation [SD] 4) and 32.6 years (SD 4), respectively. Twenty-first century trained ophthalmologists rated their training significantly better than the 20th century trained ophthalmologists for slit lamp examination (P = 0.001), indirect ophthalmoscopy, gonioscopy, automated perimetry, optical coherence tomography, and fundus photography (all having P < 0.001), while the 20th century trained rated their teaching of refraction, synoptophore, diplopia charting better (all P < 0.001). The range of grading was 0� in all categories. The median number of surgeries performed independently by 20th century and 21st century trained (during their training period) were: intracapsular cataract extraction (ICCE) 10, 0; extracapsular cataract extraction (ECCE) 43, 18; small incision cataract surgery (SICS) 5, 55; phacoemulsification (Phaco) 0, 1; pterygium excision 20, 15; dacryocystectomy 11, 4; dacryocystorhinostomy 11, 2; chalazion 35, 30; trabeculectomies 5, 0; strabismus correction 0, 0; vitrectomy 0, 0; keratoplasty 0, 0; eyelid surgery 6, 2; and ocular emergencies 18, 20. Conclusion: Teaching of many clinical skills had improved over decades. Cataract surgery training has shifted from ICCE and ECCE to SICS and Phaco, but other surgeries were still taught sparingly. There was an enormous variation across the country in residency training which needs immediate attention.

Impaired Renal Function is Associated with Severe Coronary Artery Disease in Chronic Stable Angina Patients.

Background: Cardiovascular disease is the leading cause of morbidity and mortality in renal impaired patients. Many of the patients of chronic kidney disease die of cardiovascular disease before requiring dialysis. Cardiovascular disease in renal impaired patient is potentially preventable and treatable. The aim of this study was to evaluate the association between renal impairment and coronary artery disease severity in chronic stable angina patients. Methods: 110 patients with chronic stable angina who got admitted for coronary angiography were included in the study. They were divided into impaired renal function group (with estimated glomerular filtration rate [eGFR] <90 ml/min/1.73m2) and normal renal function group (eGFR e” 90 ml/min/1.73m2) on the basis of eGFR. The severity of the CAD was assessed by angiographic Vessel score and Gensini score. Results: Mean Gensini score was significantly high in impaired renal function group (42.30±24.9 vs 25.65±17.9, p <0.05). There was significant negative correlation between eGFR and vessel score (r=-0.30, p <0.05) and between eGFR and Gensini score (r =-0.65, P <0.05). In multivariate logistic regression analysis, after adjustment of factors eGFR remain independent predictors of severe CAD (P=0.002, OR -5.73). Conclusion: Impaired renal function, assessed by eGFR is associated with angiographic severe coronary artery disease in chronic stable angina patients and this association is independent of conventional cardiovascular risk factors.

Eye health and adolescence.

Complete development of eyes occurs between 8 and 11 years, though longitudinal growth of axial length may occur up to 13 years (approximately). Except a few, most of the eye diseases affecting adolescence age group are similar to adult type. Diseases like myopia, keratoconus, vernal keratoconjunctivitis, juvenile diabetic retinopathy and injuries to eye are exclusively diseases of adolescence that are commonly encountered. Psychologically, impact of eye disease on adolescent mind may be profound, thinking they might lose their eyesight. Early detection of diseases, prevention of injuries, health education and frequent eye check-up are essential.

Management of the Budd-Chiari syndrome by balloon cavoplasty.

BACKGROUND: Obstruction of the suprahepatic inferior vena cava (IVC) by a membrane or stricture is the commonest cause of Budd-Chiari syndrome in the eastern hemisphere. We present our experience with the outcome of balloon cavoplasty in such cases. METHODS: We followed up 40 consecutive cases of Budd-Chiari syndrome over seven years. Doppler study of hepatic venous outflow tract (in all cases), liver biopsy (30 cases) and necropsy (two cases) were performed. Balloon cavoplasty was done in selected cases. RESULTS: Of 40 patients with BCS (mean age 35.2 [SD 8.7] years; 26 men) 5, 5 and 30 had fulminant, acute and chronic presentation, respectively. Inferior vena cavography was performed in 32 cases, and showed membranous obstruction of the IVC in 12, segmental occlusion of the IVC in 11 cases, and block in both the IVC and the main hepatic veins in the rest. Successful balloon cavoplasty was done in 18 cases with obstruction of the IVC (membrane or stricture); 15 of them are well over a mean follow up of 56 (14.6) months. Three patients developed restenosis; two of them, treated with redilatation, are doing well, and one died of septicemia and hepatic failure following a surgical bypass. Pressure gradient between the IVC and right atrium decreased significantly after cavoplasty (15.4 [2.8] vs 6.6 [2.0] mmHg; p< 0.001). CONCLUSION: Balloon cavoplasty gave encouraging results in the management of Budd-Chiari syndrome due to membranous obstruction or stricture of the IVC.

Rural people and fine needle aspiration cytology (FNAC)--some findings in North Bengal Medical College, Darjeeling, West Bengal.

A hospital based interdepartmental collaborative study was carried out from 1st July to 30th September, 2000 on 269 rural people residing in six districts of the northern part of West Bengal and attending the Pathology Department in North Bengal Medical College for Fine Needle Aspiration Cytology (FNAC) after being referred from different clinical departments. The objectives of the study were to study some aspects of the outcomes of FNAC among rural people and to suggest for its wider application in rural community through Community Health Centre/Rural Hospital/Block Primary Health Centre. The results shows that Hindus (80.3%) are attending more in number than Muslims (14.13%), Christians (4.83%) and Buddhist (0.74%); 53.54% of the population are in 11-40 years age group. In benign conditions 76.95% are coming from up to 100 kms. of N.B.M.C; people in lower per capita income group of up to Rs.400/- per month are attending twice in number than those in the income groups of Rs.401/- and more per month. In malignancy however people do not think of distance or expenses due to seriousness of the diseases. In 14.5% cases FNAC remains inconclusive whereas in 85.5% cases it provides definite diagnoses.

Colonic mucosal changes in portal hypertension.

Forty one consecutive patients with portal hypertension (PHT) were evaluated by colonoscopy to study the prevalence, type, extent and predictors of haemorrhoids, colorectal varices, and portal hypertensive colopathy. Specific inquiry and regular follow-up assessed frequency of hematochezia. Twenty five patients with obscure gastrointestinal bleeding without PHT who underwent colonoscopy served as controls. Haemorrhoids were seen in nine of 41 (21.9%) patients with PHT and four of 25 (16%) controls (p = ns). Colorectal varices were seen in 13/41 (31.7%) patients with PHT and none of the controls (p = 0.005). Portal colopathy was present in 15/41 (36.6%) patients with PHT and none of the controls (p = 0.0005). None of the parameters (e.g. aetiology of PHT, Child's class, oesophageal variceal eradication by EST with or without EVL, history of variceal bleeding, grade of oesophageal varices, presence of portal hypertensive gastropathy or gastric varices) predicted the occurrence of colorectal varices and portal hypertensive colopathy. Detection of colorectal varices but not portal hypertensive colopathy was associated with occurrence of hematochezia.

Etiology based prevalence of Budd-Chiari syndrome in eastern India.

BACKGROUND: Diagnosis of Budd-Chiari syndrome (BCS) is often missed unless its possibility has been kept in mind. Obstruction of inferior vena cava (IVC) is reportedly the most frequent cause of BCS in Afro-Asian variety. AIM: An attempt was made to classify BCS (in an eastern Indian population) etiopathologically. PATIENTS AND METHODS: Thirty consecutive cases of BCS presenting over a period of five years were included. Following a thorough physical examination, necessary investigations (including coagulation profile, ultrasonography (with Doppler study) of hepatobiliary tract, hepatic vein and IVC angiography (n = 22) and liver biopsy (n = 26, including autopsy in two cases) were performed. RESULTS: Mean age at presentation was 32.7 +/- 10.36 years (range 12-60 years) with M:F = 21:9. Clinical presentations included, hepatomegaly in 28 (93.3%), ascites in 27 (90%), splenomegaly in 15 (50%), pain in abdomen in 26 (86.6%), jaundice in 10 (33.3%), back veins in 20 (66.6%) and gastrointestinal bleeding in three (10%) cases. Amongst the total of 30 patients, four, six and 20 cases presented as fulminant, acute and chronic BCS respectively. Twenty four cases of BCS could be diagnosed by ultrasonography alone, while the remainder required angiography for diagnosis. IVC and hepatic vein angiography revealed membranous obstruction in nine, partial stricture of IVC in six, and IVC and/or hepatic vein block in others. The etiopathological nature in 30 cases were as follows: idiopathic membranous obstruction in nine (30%), hepatocellular carcinoma in six (20%), idiopathic stricture in six (20%) cases and one case (3.3%) each of the following: cholangiocarcinoma, renal cell carcinoma, chronic pancreatitis, hydatid cyst in liver, protein S deficiency, oral contraceptive use, nephrotic syndrome (with antithrombin III deficiency), polycythemia rubra vera and chronic lymphatic leukemia. CONCLUSION: Idiopathic membranous obstruction and stricture of IVC are the commonest cause of BCS in the eastern part of India. Hepatocellular carcinoma is also a common cause, presenting in the fulminant form. Ultrasonography may be a helpful screening test for BCS, but IVC and hepatic vein catheterisation is essential for a complete work up of these patients.

Aetiological spectrum of chronic liver disease in eastern India.

AIM: To evaluate the aetiologic spectrum of chronic liver disease (CLD) in a tertiary referral center in Eastern India. METHODS: A total of 175 patients (cirrhosis 166, chronic hepatitis 9) diagnosed by clinical, biochemical, radiological and histopathological (42 cases) parameters were evaluated for aetiology. Investigations included: HBsAg and anti HCV (third generation) by ELISA. HBeAg and HBV DNA were tested in HBsAg positive patients. HCV RNA was tested in anti-HCV positive patients. Markers for autoimmune and Wilson's disease (anti-nuclear antibody, anti smooth muscle antibody, serum ceruloplasmin, urinary copper and slit lamp examination for KF ring) were done where clinically indicated. RESULTS: A total of 62 (35.4%) patients had HBV related CLD and 6 (9.7%) of them had pre-core mutant. HCV was present in 17/114 (14.9%) cases and none had infection with both viruses. Autoimmunity, Wilson's disease and alcohol were the aetiological factors in 5 (2.8%), 5 (2.8%) and 3 (1.7%) patients respectively. No aetilogy could be found in 18/114 (15.8%) patients. CONCLUSIONS: It is concluded that HBV is the commonest cause of CLD in Eastern India. Alcohol and HCV are uncommon in this part of the country.

Heart rate variability in dilated cardiomyopathy.

Chronic heart failure is associated with excessive neurohormonal activation. Analysis of heart rate variability is considered a valid technique for assessment of the autonomic balance of the heart. Twenty symptomatic patients of dilated cardiomyopathy in NYHA class II-IV symptomatic status and as many normal controls were subjected to 24 hours Holter monitoring to assess the heart rate variability with both time domain and frequency domain analysis. Age of the patients ranged from 12 to 67 years (mean +/- SD 38.6 +/- 7 years), the male-female ratio was 4:1. The left ventricular ejection fraction of the patients was between 18-42 percent (mean +/- SD 30.2 +/- 9%) and all received diuretics, digoxin and angiotensin-converting enzyme inhibitors. Heart rate variability parameters measured included mean heart rate with standard deviation, hourly heart rate with SD and the mean of all normal RR intervals from the 24-hour recording. Time domain measures calculated were SD of all normal RR intervals, SD of 5 minute mean RR intervals and root mean square of difference of successive RR intervals. Using spectral plots, frequency domain subsets of low frequency and high frequency were analysed and expressed in normalised units. Total power was also measured. In the dilated cardiomyopathy patients, mean 24-hour heart rate in beats per minute was significantly higher in comparison to controls (82 +/- 13 vs 72 +/- 8; p < 0.001) whereas mean hourly heart rate with standard deviation (msec) was significantly lower (97 +/- 41 vs 232 +/- 25; p < 0.001), SD of all normal RR intervals (msec) was 85.5 +/- 26.3 vs 139.4 +/- 16.9 in controls (p < 0.001), SD of 5 minute mean RR intervals (msec) was also significantly less in patients in comparison to controls (75.8 +/- 39.6 vs 130.8 +/- 20.3; p < 0.001). However, although root mean square of difference of successive RR intervals (msec) was reduced in patients (30.1 +/- 9.3 vs 37.3 +/- 11.7; p < 0.05), the difference was non-significant. Low frequency power (0.05-0.15 Hz) (normalised units) was reduced in the dilated cardiomyopathy group (0.0721 +/- 0.003 vs 0.136 +/- 0.047 in the control group; p < 0.001). High frequency power (0.35-0.50 Hz) (normalised units) (0.08 +/- 0.05 in patients vs 0.09 +/- 0.02 in controls; p > 0.1) and total power frequency (0.02-0.50 Hz) (normalised units) (0.34 +/- 0.05 in patients vs 0.35 +/- 0.12 in controls; p > 0.1) was non-significantly different in the two groups. Regression analysis showed a significant decrease in SD of all normal RR intervals, SD of 5 minute mean RR intervals, low frequency, high frequency, total power and a non-significant decrease in root mean square of difference of successive RR intervals with a decrease in ejection fraction percent whereas there was a significant decrease in SD of all normal RR intervals, SD of 5 minute mean RR intervals, low frequency and total power and a less significant decrease in root mean square of difference of successive RR intervals and high frequency power with an increase in NYHA class. At 6 months duration, 6 patients were lost to follow-up, 3 patients were readmitted (2 for congestive cardiac failure, one of paroxysmal supraventricular tachycardia). One patient who was NYHA class IV at baseline was readmitted for congestive cardiac failure and showed much lower heart rate variability parameters compared to the average of the patients. We conclude that in symptomatic dilated cardiomyopathy patients, heart rate variability parameters are significantly reduced in comparison to control subjects.

Primary pulmonary hypertension in cirrhosis of liver.

BACKGROUND: Primary pulmonary hypertension (PPH) is a grave association of portal hypertension, and is potentially fatal in liver transplant candidates. AIM: To investigate the prevalence of PPH among cirrhotics with portal hypertension. METHODS: 43 cirrhotics with portal hypertension (Child B 22, C 14), after screening for cardiopulmonary diseases, were evaluated by hemodynamic study. RESULTS: PPH was detected in 2 cases (4.7%), both in Child B, hepatitis B and C viruses being the etiologies. Neither had portal axis thrombosis. Two other cases also had pulmonary hypertension, but with high pulmonary capillary wedge pressure (PCWP). The 41 cases without and 2 cases with PPH had, respectively, mean pulmonary artery pressure (MPAP) 16.3 (5.9) mmHg, 26 mmHg and 33 mmHg; PCWP 11.5 (6.7) mmHg, 12 mmHg and 11 mmHg; transpulmonary pressure gradient 4.8 (2.6) mmHg (n = 27), 14 mmHg and 22 mmHg; and pulmonary vascular resistance 80.2 (55.8) dyne.sec.cm-5 (n = 27), 155.6 dyne.sec.cm-5 and 366.7 dyne.sec.cm-5. No correlation of MPAP was found with either Child-Pugh scoring (r2 = 0.0347) or with hepatic venous pressure gradient (r2 = 0.0021). CONCLUSION: PPH has a prevalence of 4.7% among cirrhotics with portal hypertension; it bears no relation with severity of liver disease.

Primary pulmonary hypertension in non-cirrhotic portal fibrosis.

BACKGROUND: Primary pulmonary hypertension (PPH) has been reported in association with cirrhosis and extrahepatic portal venous obstruction; reports of PPH in noncirrhotic portal fibrosis (NCPF) are few. AIM: To evaluate pulmonary arterial pressure in patients with NCPF. METHODS: Twenty two patients with NCPF underwent hemodynamic studies for pulmonary arterial pressure after excluding secondary causes of pulmonary hypertension. Hemodynamic studies were carried out through the femoral route using 7F Swan-Ganz catheter. Splenoportal venography was done by percutaneous splenic puncture. RESULTS: The mean pulmonary arterial pressure was 12.9 +/- 3.1 mmHg with pulmonary capillary wedge pressure of 8.3 +/- 2.1 mmHg in 20 of 22 cases; in the remaining two cases, the corresponding pressures were 30 mmHg and 28 mmHg and 13 mmHg and 12 mmHg, respectively. CONCLUSION: Two of 22 patients with NCPF had PPH. PPH can thus develop without hepatocellular failure or recurrent embolization from portal axis thrombosis as has been described in cirrhosis.

Follow-up results of balloon angioplasty for native coarctation of aorta.

Balloon angioplasty of native discrete (< 1 cm) coarctation of thoracic aorta was performed in 29 patients [aged 13 to 31 years (mean 21.5 +/- 5.8 years), 22 males and 7 females], from March 1993 to December 1995. The patients were followed up for two years. After angioplasty, peak systolic arterial pressure (PSAP) decreased from 173.5 +/- 18.1 mm Hg to 122.5 +/- 9.9 mm Hg (p < 0.001), peak systolic pressure gradient (PSG) decreased by 90.9 percent from 86.2 +/- 15.77 to 7.77 +/- 3.8 mm Hg (p < 0.001) and the coarcted segment diameter increased about three times from 3.7 +/- 1.6 to 10.9 +/- 3.3 mm (p < 0.001). PSG decreased to < 10 mm Hg in 27 patients (93%) whereas in the other two patients PSG was 17 and 13 mm Hg. Restenosis appeared in 2 patients (6.8%); aneurysm in one patient (3.4%) which remained static even after 1.3 years of follow-up; mild dissection in 3 patients (10.3%); temporary femoral artery occlusion in 2 (6.8%) patients who recovered with heparin injection. Though hypertension disappeared after balloon dilatation in all patients, it reappeared in 3 patients (10.3%) within 7 days and in 10 patients (34.5%) within 6 months. In conclusion, balloon angioplasty of CoA is a good alternative to surgical correction.

Low-dose amiodarone in severe chronic heart failure.

Sudden cardiac death is a common cause of mortality in patients with congestive heart failure. Asymptomatic ventricular arrhythmia has been attributed as the cause for increased overall mortality in such patients. We conducted a prospective randomised single-blind placebo-controlled trial with low-dose amiodarone to assess its efficacy in reducing mortality in severe congestive heart failure and its effect on exercise tolerance, left ventricular systolic function and ventricular ectopic activity. Patients were randomised to receive amiodarone (n = 36) 400 mg/day orally for one month followed by a maintenance dose of 200 mg/day, or to a standard treatment (n = 40) according to intention-to-treat principle. There were 10 cardiac deaths in the amiodarone-treated group and 16 in the control group. Significant improvement was noted in exercise time in the treadmill test (modified Bruce Protocol) among patients in the amiodarone-treated group while no such statistical difference was detectable in the placebo group. Side-effects in the amiodarone group included asymptomatic rise in hepatic enzymes (three-fold) in 6 percent and proarrhythmia in 3 percent of patients. Nausea was reported in one patient and rash in one. Though low-dose amiodarone proved to be an effective antiarrhythmic agent, it failed to live up to the expectation of improving sudden cardiac death in patients with severe chronic heart failure and asymptomatic ventricular ectopy.