Isolated Protein S Deficiency –Cause of Recurrent Stent Thrombosis-A Case Report.

Stent thrombosis (ST) is one of the major complications that occur in percutaneous coronary interventions (PCIs) with stents. Various factors have been attributed to the development of ST, and several strategies have been recommended for its management. Protein C or protein S deficiencies may uncommonly be responsible for coronary arterial thrombosis. We report a young woman with recurrent stent thrombosis due to the deficiency of protein S. After coronary stenting, stent thrombosis occurred two times despite aggressive medical therapy. This report suggests that the deficiency of protein C or S should be born in mind in a young patient with recurrent thrombotic events, and that anticoagulants in addition to antiplatelet agents considered in the presence of their deficiency.

Drug-Eluting Stent (DES) Induced Coronary Artery Aneurysm - A Case Report.

Drug-eluting stents (DES), which locally elute antiproliferative drugs, can dramatically inhibit neointimal growth. However, several pathological studies have indicated that DES may delay healing after vascular injury, and DES implantation may be theoretically associated with a risk of coronary artery aneurysm formation. Coronary aneurysms have been reported from 3 days to up to 4 years after DES implantation procedures, with varying clinical presentations. Mr. X, 60 years old diabetic, hypertensive got admitted in NICVD and was diagnosed as a case of Chronic Stable Angina. His ETT was strongly positive, CAG showed significant long lesion in LAD. Direct stenting with DES to LAD done and whole procedure was uneventful. After 10 days of PCI patient got readmitted in hospital with complaints of chest discomfort with high grade fever for 2 days. ECG showed AMI (Extensive Anterior) indicating involvement of LAD territory with strong suspicion of Sub Acute Stent Thrombosis (SAST). Streptokinase could not be given due to delayed arrival. Patient was treated conservatively with Low Molecular Weight Heparin. Check CAG was done 7 days after readmission showing Patent stent in LAD with aneurysmal dilatation at the distal end of stent in LAD. The objective of this case report is to focus on the rare but not uncommon incidence of stent implantation.

Impact of Blood Glucose Levels on Contrast Induced Nephropathy after Percutaneous Coronary Intervention in Patients not known to be Diabetic with Acute Coronary Syndrome.

Background: Contrast-Induced Nephropathy (CIN) is an iatrogenic disorder, resulting from exposure to contrast media. The association between pre-procedural blood glucose levels and CI-AKI risk (regardless of pre-existing diabetes) is unknown. The present study was conducted to evaluate the incidence of CI-AKI in patients with admission hyperglycemia in non-diabetic ACS patients. Methods: This is Prospective, observational study done in the department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka. Considering inclusion and exclusion criteria, 50 patients were non diabetic with ACS with normal blood glucose (d”7.8 mmol/l or d”140 mg/dl) in (Group I) and 50 patients were non diabetic with ACS with high blood glucose (>7.8 mmol/l or >140 mg/dl) undergoing percutaneous coronary intervention in (Group II). On admission random blood glucose was measured. Non- ionic low osmolar contrast agents (lopamidol) was used in all patients. Serum creatinine, serum electrolytes was measured and creatinine clearance rate was determined within 24 hours before PCI and day 1 and 2 after PCI. Results: The incidence of CIN was 24% in high blood glucose group and 4% in normal blood glucose group (p=0.004). It was also observed that gradual incremental increase in risk of CIN associated with higher admission blood glucose level. There was positive correlation between s. creatinine and admission blood glucose but it showed negative correlation between CCr and admission blood glucose after PCI in ACS patients not known to be diabetic. Conclusion: The present study reveals that index admission high blood glucose in acute coronary syndrome patients not known to be diabetic is associated with increased incidence of contrast induced nephropathy after percutaneous coronary intervention.

Prolonged QTc Dispersion Correlates with Coronary Artery Disease in Acute ST Elevated Myocardial Infarction (STEMI).

Background: It has been found that there is strong association of QT dispersion and QT dispersion ratio with extent and severity of coronary artery disease. Qualitative importance of QTc dispersion on the base line ECG in patients with MI is recognized clinically but quantification of this phenomenon is less commonly used in clinical practice, which might be a better independent risk predictor of this group of patients. Methods: A total of 100 patients were selected, Study populations sub-divided into two groups on the basis of QTc dispersion. In group I (comparison group): QTc dispersion is <60 milliseconds (msec) in group II (study group) : QTc dispersion e”60milliseconds(msec). 50 patients in each group. QT dispersion was calculated on standard resting 12 lead ECGs. QT interval was measured from the beginning of the inscription of the QRS complex to the point at which the T wave returned to the isoelectric line. Angiographic severity of coronary artery disease was assessed by- Vessel score, Friesinger score and Leaman score. Interpretation of coronary angiogram was reviewed by at least two cardiologists. . Results: The mean vessel score for group I patients was 1.16±0.68 and that of group II patients was 2.30±0.64 and the mean difference was statistically significant (p<0.05). Patients those had single vessel involvement had mean QTc dispersion 57.05, patients those had double vessel disease mean QTc dispersion was 102.00 and patients those had triple vessel involvement had mean QTc dispersion 177.60. There was a strong positive correlation with the QTc dispersion and increasing number of vessel involvement (Pearson’s correlation coefficient). The mean Friesinger score for group I patients was 4.84±2.56 and that of group II patients was 9.80±2.60. The mean difference was significantly (p<0.05) higher in group II patients. There was a strong positive correlation between the QTc dispersion and Leaman score (Pearson’s correlation coefficient). In group I patients 56% had insignificant coronary artery disease and 44% had significant coronary artery disease defined by Friesinger index (n=100). In group II patients 6% had Insignificant coronary artery disease & had 94% significant coronary artery disease. Conclusion: QTc dispersion>60 ms had independent predictive value for the severity of coronary artery disease. The greater the QTc dispersion the higher the number of coronary artery involvement. We observed that there is a positive correlation between prolonged QT dispersion and coronary artery disease severity in terms of Vessel score, Friesinger score, Leaman score.

Evaluation of Efficacy and Tolerability of Perindopril 8 mg in Bangladeshi Hypertensive Patients: Results from an Open-label, Observational, Multi-center Study (CONTROL).

Background: The CONTROL (COversyl in Newly diagnosed stage-II & unconTROlled hypertensive patients triaL) was performed with an objective to evaluate the blood pressure (BP) lowering efficacy and tolerability of Perindopril 8mg in newly diagnosed stage II patients and uncontrolled hypertensive patients among Bangladeshi population. Methods: This was an open-label, observational, multi-center study conducted in consultation centers for out-patients located in different cities of Bangladesh. Adults, aged above 18 years with newly diagnosed stage-II hypertension or uncontrolled hypertension, were recruited. Patients were treated with Perindopril 4mg daily for first 1 week, afterwards uptitrated to Perindopril 8 mg daily and continued treatment for 12 weeks. Patients were followed-up at week-1, week-4, week-8 and week-12. Results: In total, 245 patients were enrolled. Among them, 88 were newly diagnosed stage-II (Group- I) and 157 were uncontrolled (Group-II) hypertensive patients. Male and female distribution was 57% and 43% respectively. Mean age of patients was 54.5 ±11.7 years. After 12 weeks treatment, there was a significant reduction in BP from baseline (p<0.001) in overall population as well as in Group I and in Group II. In overall population, the mean BP reduction was -31/-15 mmHg (from 163.7/96.8 mmHg to 132.4/81.7 mmHg. In Group I, the reduction was -33/-16 mmHg (from 166.5/98.2 mmHg to 133.4/82.0 mmHg) and in Group II, -30/-14 mmHg (from 159.3/ 95.6 mmHg to 129.1/81.6 mmHg). 10 patients (4.1%) had to discontinue the treatment due to adverse effects. Dry cough (2%) and hypotension (1.2%) were the main cause of discontinuation. Perindopril 8mg was well tolerated as indicated by the high proportion of physicians (81%) reporting ‘good’ to ‘excellent’ tolerability at week 12. Conclusion: This study suggests that Perindopril 8mg is effective and safe in the treatment of hypertension in Bangladeshi patients.

Impact of Low Hemoglobin on Contrast-Induced Nephropathy After Percutaneous Coronary Intervention.

Background: Contrast-Induced Nephropathy (CIN) is an iatrogenic disorder, resulting from exposure to contrast media. The aim of this study was to assess whether anaemia is a predictor of contrast induced nephropathy after Percutaneous Coronary Intervention (PCI). Methods: This was a prospective observational study. A total of one hundred patients fulfilling the inclusion and exclusion criteria who underwent (PCI) Percutaneous Transluminal Coronary Angioplasty with stenting, were studied during the study period of two years from January 2008 to December 2009. Patients were divided into two groups : Group-I (n=50), patients with low hemoglobin (male <13-10gm/dl, female < 12-10 gm/dl) and Group-II (n=50), patients with normal hemoglobin (male >13gm/dl, female >12gm/dl). Non-ionic low-osmolar contrast agents was used in all patients.Volume of contrast medium (ml) was recorded. Adequate hydration given intravenously (ml). Prior to procedure serum creatinine, serum electrolytes and Creatinine clearance rate were measured within 24 hrs before PCI and on days 1,2,3 after PCI. If there is renal impairment (CIN) serum creatinine, serum electrolytes and Creatinine clearance rate were measured daily from the 4th day onward after PCI until recovery. Results: The mean serum creatinine level of low hemoglobin group and normal hemoglobin group were 0.9mg/dl and 1mg/dl respectively at base line. The low hemoglobin group experienced a considerable increase in serum creatinine up to 1.5mg/dl at day 3 compared to 1.3 mg/dl in normal hemoglobin group. When the most common definition of contrast induced nephropathy (as an increase in the serum creatinine concentration >0.5 mg/dl from baseline) was used the incidence of CIN was 26% in low hemoglobin group and 8% in the normal hemoglobin group. Conclusion: preprocedural low hemoglobin is an independent determinant of increased incidence of contrast induced nephropathy after percutaneous coronary intervention.

Radiofrequency Catheter Ablation of Left Free Wall Accessory Pathways: Comparison Between Retrograde and Transeptal Approach.

Background : This study was conducted to compare the conventional retrograde arterial approach (RAA) with the transeptal approach (TSA) for radiofrequency catheter ablation (RFA) of left accessory pathways (AP). Materials and Methods: Sixty consecutive patients (44 male; mean age of 35.60 ± 11.63 years) with 60 left APs (39 overt and 21 concealed) underwent catheter ablation using the TS method (30 patients) and the RA method (30 patients) in an alternate fashion. The analysis was performed according to the intention-to-treat principle. Results : The transeptal puncture was successfully performed in 29 patients (96%). This access allowed primary success in the ablation in all the patients without any complication. When we compared this approach with the RAA there was no difference as regards the primary success (p = 0.103), fluoroscopy time (p = 0.565) and total time (p = 0.1917). Three patient in the RAA group presented a vascular complication. The TSA allowed shorter ablation times (p=0.006) and smaller number of radiofrequency applications (p = 0.042) as compared to the conventional RAA. The patients who had unsuccessful ablation in the first session in each approach underwent with the opposite technique (cross-over), with a final ablation success rate of 100%. Conclusion : The TS and RA approaches showed similar efficacy and safety for the ablation of left accessory pathways. The TSA allowed shorter ablation times and smaller number of radiofrequency applications. When the techniques were used in a complementary fashion, they increased the final efficacy of the ablation.

Echocardiographic Evaluation of Left Ventricular Diastolic Function after Percutaneous Coronary Intervention in Patients with Coronary Artery Disease.

Background: Although percutaneous coronary intervention (PCI) is an excellent therapy for coronary artery disease, there is a paucity of information on the efficacy of PCI in improving diastolic function, especially in Bangladesh. Because of the high prevalence of left ventricular diastolic dysfunction in coronary artery disease patients and its probable progression to heart failure, an evaluation of the role of PCI in improving diastolic function is required. Objective of the study was to evaluate the impact of percutaneous coronary intervention on left ventricular diastolic dysfunction by Doppler echocardiography in patients with coronary artery disease. Methods: One hundred patients scheduled for elective PCI were enrolled in this study whose left ventricular systolic ejection fraction was normal or only mildly abnormal. Before PCI and 48 hours after PCI, echocardiography was done to evaluate the indices of LV diastolic function in these patients.

Coronary Artery Dissection and Perforation Complicating Percutaneous Coronary Intervention – A Review.

After its introduction by Andrew R. Gruentzig in 1977 percutaneous coronary intervention (PCI) is widely utilized in the treatment of symptomatic coronary artery disease. Though it has numerous benefits, serious and potentially life-threatening complications of PCI can occur, including iatrogenic coronary artery dissection and perforation. The incidence of these complications has been augmented by the development of coronary interventional devices intended to remove or ablate tissue. Here we review the classification, incidence, pathogenesis, clinical sequelae and management of coronary artery dissection and perforation in the current era due to PCI. Specifically, the current angiographic classifications of coronary artery dissections and perforations are reviewed. The findings of several recent, registries of PCI-related coronary artery perforations and dissection are summarized. The management of coronary artery dissection and perforation is discussed in details, including the application of newer modalities such as covered stents

Association between Morphological Changes of Nail and Nail Arsenic Level in Patients with Arsenicosis.

This case-control type of analytical study was conducted in the Department of Dermatology and Venereology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh to find out the association between morphological changes of nail and nail arsenic level in arsenicosis patients. Majority of arsenicosis patients were male (56.67%). The mean age of the cases was 43.07+/-13.73 years. Nail changes were found in 26.67% of cases, most were nail dystrophy (23.33%) and rest were Mee's line (3.34%). There was significant difference between cases with or without nail changes and nail arsenic level. But cases with or with out nail changes had a significant difference between duration of intake of arsenic contaminated water. There was no correlation between nail changes and nail arsenic level for nail dystrophy and Mee's line. The study result failed to establish association between the morphological changes of nail and nail arsenic level.

Pacing in a Woman with Full Term Pregnancy: First Case Report in Bangladesh.

A 19-year-old primigravida was diagnosed to have complete heart block (CHB) during her antenatal checkup at 36 weeks. The patient had history of syncope a few years back. She was referred to the National Institute of Cardiovascular Diseases (NICVD). A temporary pacemaker was implanted at NICVD. She was then referred to Dhaka Medical College Hospital (DMCH), where a baby girl was delivered by cesarean section. A permanent pacemaker was implanted later at NICVD. To our knowledge this is the first case report of pace maker implantation in a pregnant woman from Bangladesh.

Serum zinc level in preterm low birth weight babies and its comparison between preterm AGA and preterm SGA babies.

Low birth weight (LBW) is a major child health problem in Bangladesh and continuing to great threat to child health and child survival in Bangladesh. LBW is a silent emergency but crisis is real and its persistence has profound and frightening impact on neonatal mortality. This observational study was conducted in Dhaka Shishu Hospital, Dhaka, Bangladesh during July 2004 to June 2005. Serum zinc levels were estimated between two groups: group-I preterm AGA (n=50), group II preterm SGA (n=50) babies. Blood samples were collected from the study population in neonatal unit and serum zinc levels were measured by flame atomic absorption spectrophotometry in Atomic Energy Center, Dhaka, Bangladesh. Observed data were made comparison among groups by Students 't' test. It was observed serum zinc level (60.2+/-15.2) in group I and (62.1+/-12.4) in group II. Serum zinc level was in lower limit of normal range in both groups with more lower level in preterm AGA babies but their difference was not statistically significant (p>0.05). So zinc supplementation may enhance the growth of preterm LBW babies in their early months of lives.

Short Term Outcome of Patients with Acute Myocardial Infarction Preceded by Angina.

Background: It has been reported that acute myocardial infarction preceded by angina has favorable short term outcome. To validate this in our setting, this study was undertaken in National Institute of Cardiovascular Diseases. Method: This is a prospective and observational study. 100 patients were evaluated for the short term outcomes of patients of AMI preceded by angina. Result : Observation showed that patients of AMI preceded by angina has less damage of the myocardium as evident by lower CK-MB values and better preservation of left ventricular function. It has also been shown that early complications like death, VT & VF, asystole, CHB, acute LVF, cardiogenic shock were significantly lower in patients of AMI preceded by angina than those without angina. Conclusion: It is observed that incidence of previous angina is an important independent predictor of outcome of the patients with myocardial infarction.

Comparison between Total Echo Score and Total Commissural Morphology Score for the Outcome and Complication of Balloon and Surgical Closed Mitral Commissurotomy.

Background: Now a days mitral balloon valvoplasty(PTMC) is an alternative to closed surgical mitral commissurotomy (CMC) for the treatment of selectcd patients with rheumatic mitral stenosis. To compare between the total echo score (Wilkin’s score) total echocardiographic commissural morphology score (TC) for outcome and as a predictors of complications of both procedures. Method: We carried out a prospective well matched comparative observational study on 123 patients of symptomatic mitral and three patients were rejected due to procedural complications and technical failure. Result: Age ranges were 12 55 years, mean (±SD) age was 28.83+9.33 years. Out of 120 patients, 41 (34.2%) were male and 79 (65.8%) were female. Before procedure, 29 (48.3 %) and 32 (53.3 %) patients were in NYHA class III.Total Wilkins score was in the range of 4 10. Mean (±SD) of total Wilkins score were 6.43+1.53 and 6.30+1.33. Good commissural morphology (score 0 1) were present in 38 (63.5%) and 36 (60%) and bad commissural morphology (score 2 3) were present in 22 (26.7 %) and. 24 (40 %) in both groups respectively. Mitral valve area increased from a mean (±SD) of 0.80±0.16 and 0.79±0.15 to 1.94 ±0.24 and 1.92 + 0.26cm2. in PTMC and CMC groups respectively. Transmitral mean and peak pressure gradient also decreased significantly in both the individual procedures but no statistically significant difference between the procedures. NYHA class improved by class 1 or more in most patients in both groups. There were 2 (3.33 %) cases of cardiac temponade due cardiac perforation in PTMC group, of which one need repair and CMC and another was managed conservatively. There were also 3 (5 %) patients in PTMC and I (1. 66 %) patient in CMC developed peripheral thromboembolism and one patient (1.66%) developed arteriovenous fistula in PTMC group. Mitral regurgitation grade III, developed in 3 (5%) patients and one patient (1.66%) in PTMC and CMC respectively having no statistical significance. Conclusion: Total Wilkin’s score and total commissural morphology score were found to be most important preprocedural variable associcated with the outcome and as a predictors of post procedural complications.

Diagnostic efficacy of Aldehyde test in late cases of Kala-azar.

This case control study was carried out in the Paediatric wards of Mymensingh Medical College Hospital for a period of one year from April 2002 to March 2003 to determine the sensitivity, specificity and predictive values of Aldehyde test in the diagnosis of Kala-azar. A total of seventy five febrile cases of Kala-azar from Paediatric wards were enrolled in the study and Seventy five controls having splenomegaly with or without fever were also included from the same source. Aldehyde test was done in both cases and controls. Diagnosis of Kala-azar was confirmed by demonstration of Leish-man-Don-o-van body (LD) in bone marrow or splenic aspirates. Out of 75 parasitologically proven cases of Kala-azar, AT was positive in 56 cases. The sensitivity irrespective of duration of illness was 74.6%. We found sensitivity of AT increases with the duration of illness where AT was sensitive in 34.7% cases having fever for less than 3 months, 90.90% with fever for 3 months to less than 6 months and 100% with fever for 6 months or more in duration. Specificity of AT was calculated as 96% with positive and negative predictive values of 94.9% and 79.1% respectively. So AT is a very sensitive and specific test with high positive and negative predictive values. Considering the cost, availability, simplicity, sensitivity, and specificity we would recommend the Aldehyde test as an important diagnostic tool for field diagnosis of Kala-azar especially after three months of febrile illness.

Head and neck squamous cell carcinoma (HNSCC) 5 year study at BSMMU.

Head and Neck Squamous Cell Carcinoma (HNSCC) are generally similar in their clinical features, epidemiology and etiology although their natural and clinical history and treatment differ. Despite lot of improvement in diagnostic and management technique, there is little improvement in survival rate over the last few decades. This study was carried-out in a multidisciplinary tertiary level hospital (BSMMU), with a country-wide catchment area to see the burden of HNSCC existing in our country and their clinical pattern. The overall incidence rate of HNSCC in this study was (0.15%) i.e. 150 person in 1,00,000 population. Male incidence (0.19%) was higher than female (0.12%). This study revealed that carcinoma of the larynx (25.22%) and pyriform fossae (20.57%) were the main culprit, whereas buccal carcinoma was the main component (37.70%) in the female series. Highest incidence was found in the 6th decade in both sexes. As the treatment of HNSCC may be time consuming, requires multidisciplinary approach, demands lot of clinical, social and financial consideration, therefore, the best treatment can be offered through a combined board consisting of Surgical, Radiation, Medical oncologists, Histopathologist and Speech therapist as required.

Cutaneous tuberculosis--a study of 400 cases.

A prospective study was conducted on 400 cases having clinical manifestation of cutaneous tuberculosis from 1992 to 2001 in the department of Dermatology and Venereology, Dhaka Medical College Hospital (DMCH) and Bangabandhu Sheikh Mujib Medical University (BSMMU), formerly Institute of Postgraduate Medicine and Research, Dhaka, Bangladesh. The clinical diagnosis was confirmed by histopathological examination. Among 400 cases, 260 (65%) were males and 140 (35%) were females with a male to female ratio 1.86:1. Age ranged from 10 to 70 years. Majority of the cases 200 (50%) were diagnosed as Tuberculosis verucosa cuties, 160 cases (40%) and 40 cases (10%) were diagnosed as Lupus vulgaris and Scrofuloderma respectively. All patients received combined antitubercular therapy.

Effectiveness of montelukast in the treatment of atopic dermatitis.

Leukotriene receptor antagonist ( montelukast) are recommended for the treatment of asthma, and have proved anecdotally successfully even in atopic dermatitis.In this open randomized clinical trial, the efficacy and safety of montelukast were assessed in the atopic dermatitis. Out of 31 enrolled patients all completed the study among which 16 in the montelukast group and 15 in the control group. No patient dropped from the study. Statistically significant SCORAD improvement (P = 0.003) was observed in montelukast group but in the control group SCORAD improvement was not statistically significant (P = 0.088).According to the patients impression pruritus was the most influenced SCORAD item by montelukast group immediately followed by sleep loss and inflammatory signs. On the contrary montelukast seemed to be completely devoid of activity on xerosis. No adverse effect of montelukast was observed in the present study.

Diphyllobothriasis: update on human cases, foci, patterns and sources of human infections and future considerations.

Diphylobothriasis is a well documented disease of humans. On a world scale new infections are reported regularly, especially from Russia and parts of Japan. Globally, new species have been discovered and the etiology of the disease may be changing. Human infections appear to be in decline but it is not clear if the sources of infection are also in decline or if public health awareness has improved. In North America there has been a decline in human cases while in South America an increase in reports from fish, especially salmonids suggests high levels in these fish species. The history of human infections of Diphyllobothrium latum is primarily associated with the consumption of the northern circumpolar distributed pike and percids and is often considered a parasite of humans only. Indeed some researchers believe that D. latum was introduced to North America by northern European immigrants. The more benign human infections of D. dendriticum appears to be primarily associated with salmonids and coregonid fishes and fish eating birds. Although the early cases of diphyllobothriasis in the 1930s in North America came from fish originating in Lake Winnipeg, Manitoba, there was general belief that it was declining in fish populations and therefore of little significance to humans in the area. However, high levels of a plerocercoid in the flesh of walleyes and pike led to rejection of commercially harvested walleye and pike in Manitoba and northern Ontario, Canada, and a financial loss to Aboriginal fishers. D. latum is widely distributed in fishes of Manitoba and is infective to humans where it is not pathogenic and has a life span up to 4.5 years. The distribution and potential infection routes has not changed in a century and is still well established in natural hosts in the boreal regions of North America. Evidence is building for an old pre-European presence in North America, involving the Beringian land bridge and later involvement of susceptible hosts (northern European immigrants).

Epidemiological studies of blood groups in the district of Bankura with special reference to tribals.

Distribution of ABO blood groups was studied in 4301 subjects, both tribals and non-tribals of the district of Bankura in West Bengal. It was observed that group 'O' blood was found in most cases and group 'AB' was seen in least number of cases. It was also found that there was no significant difference in distribution of blood groups between the tribals and non-tribals.