Impact of COVID-19 Pandemic on acute cardiac emergencies: ST- Elevation Myocardial Infarction, Acute Aortic Dissection and Ventricular Septal Rupture

Aim: To evaluate the influence of the Covid? 19 pandemic on Acute Cardiac Emergencies, namely, ST-Elevation Myocardial Infarction (STEMI), Acute Aortic dissection (AAD) and Ventricular Septal Rupture (VSR) at a tertiary care hospital in India. Methods: A total of 880 acute cardiac emergencies patients presenting at the emergency department at a tertiary cardiac care centre, diagnosed with STEMI, VSR and AAD were included in the study. Results: A notable reduction in the number of STEMI, VSR and AAD patients presenting to the emergency department was observed coinciding with the COVID-19 pandemic. In STEMI patients the average time from onset of signs and symptoms to first medical contact changed from a central tendency of 5.5 hours pre Covid-19 to 6 hours post Covid-19 ; door to balloon time changed from a central tendency of 90 minutes pre Covid-19 to 82.5 minutes post Covid-19 ; a reduced ejection fraction of less than or equal to 40% was seen in 37.22% of patients pre Covid-19 to 50.7% of patients post Covid-19 ; Percentage of patients in Killip class-1 and Killip class-3 decreased from 84.09% to 69.85% and 1.13% to 0.73% respectively post pandemic. And the percentage of patients in Killip class-2 and Killip class-4 increased from 4.82% to 13.23%, and 9.94% to 16.17% respectively post-pandemic. We observed a sharp fall in acute cardiac emergency patients post Janta Curfew declared on March 22 nd , 2020. There was also a rise in STEMI and VSR patients seen post Unlock 4 declared on September 1 st , 2020. Conclusion: The COVID-19 pandemic has significantly decreased the presentations of acute cardiac emergencies at our tertiary care hospital. There was also a significant delay in time from onset of signs and symptoms to first medical contact. There was no impact on the quality of care given to patients, in fact a decrease in door to balloon time was seen post pandemic at our centre. However, patients presented with a lower ejection fraction and higher Killip’s classification post pandemic. This indicates the possibility of increased mortality and morbidity of such patients, which is a matter of public health concern globally. It is important that we address this by increasing access to immediate healthcare facilities via tele-consultation.

Sclerosing mesenteritis - rare cause of abdominal pain and intra-abdominal mass: a case report.

Sclerosing mesenteritis is a rare, benign, and chronic fibrosing inflammatory disease with unknown etiology that affects the mesentery of small bowel and colon. The disease has two well-established histological types: the acute or subacute form known as mesenteric panniculitis and the chronic form known as retractile or sclerosing mesenteritis. Because sclerosing mesenteritis lacks special clinical manifestations and typical signs, the patients are very easily misdiagnosed. The correct diagnosis of sclerosing mesenteritis depends on pathological examination after laparotomy. We report a case of sclerosing mesenteritis in a 55-year-old male who presented with chronic abdominal pain and intra-abdominal mass. He was misdiagnosed as lymphoma by Computed Tomography and then underwent exploratory laparotomy. Histopathological examination revealed it to be sclerosing mesenteritis. This patient went well and lives without recrudescence till date.

Amoxycillin Clavulanic Acid Induced Hepatotoxicity.

Drug-related hepatotoxicity is a serious health problem, with broad implications for patients, healthcare providers, the pharmaceutical industry and governmental regulatory agencies. Herein we report a rare case of amoxycillinclavulanic acid combination induced liver injury of cholestatic pattern in 40 years old, well educated male patient. Patient gave history that though other drugs were given to him by his physician for fever with chills & rigors, malaise, bodyache, except amoxycillin-clavulanic acid combination all other drugs were well tolerated previously by the patient, without appearance of jaundice. So jaundice in this patient was most probably due to amoxycillinclavulanic acid combination. Though severe liver injury is rare, proper history should be taken while prescribing amoxycillin-clavulanic acid combination. Attention must be paid to potential side-effects of the drugs and close follow-up with patients is a medical necessity to evaluate adverse reactions, especially in case of amoxycillinclavulanic acid combination.

High risk factors for elevated excretion of albumin in diabetic subjects.

Background: Microalbuminuria refers to the excretion of albumin in the urine at a rate that exceeds normal limits but is less than the detection level for traditional dipstick methods and is considered as a marker of diabetic nephropathy. Aims: To establish the prevalence of elevated urinary albumin levels (microalbuminuria) in a sequential sample of diabetic patients and to determine its relationship with known and putative risk factors, to ascertain relationship of serum angiotensin converting enzyme (ACE) activity with diabetic incipient nephropathy. Study design: This cross-sectional analytical study included 100 control and 325 diabetic patients (180 type 2 and 145 type 1 diabetic patients) subjects attending outpatient department of the hospital. Patients having clinical albuminuria and with other causes of proteinuria were excluded. Result: Microalbuminuria was observed in 34.48% in patients with type 1 and 28.33% in patients with type 2 diabetes mellitus respectively. Having the condition was significantly associated with advanced age, poor glycaemic control, dyslipidemia (with respect to total cholesterol, triglycerides and LDL-C), smoking, body mass index and coexisting hypertension. The duration of diabetes was a significant correlate in type 1 DM subjects only. No significant association with gender, HDL-C levels, age at onset of DM, mode of treatment, socio-economic status and other lifestyle variations was found. All clinical and biochemical parameters in patient with microalbuminuria was more adversely affected than patients with normoalbuminuria. Serum angiotensin converting enzyme (ACE) levels were significantly elevated (P<0.001) in both of the diabetic groups, moreover, its levels were higher in subjects with microalbuminuria than in those without this complication (P<0.05). Conclusions: Microalbuminuria in diabetes, which represents an earlier phase in the development of clinical nephropathy, is associated with many potentially modifiable risk factors. In estimating diabetic nephropathy risk, AER is most important and should be done frequently but there are gains to be made in predictive precision by considering family history, smoking habits, glycemia, B.P.,BMI lipid levels and ACE activity. Early screening for incipient diabetic nephropathy and aggressive management of these risk factors is important in optimising the renal outcome of patients with diabetes mellitus.

Hypersensitivity Reaction to Ofloxacin.

The quinolones are generally well tolerated. The adverse reactions of quinolones include gastrointestinal symptoms, which are the most frequent, neuropsychiatric symptoms, hematologic abnormalities and less frequently, hypersensitivity skin reactions. Herein we report a case of 13 years old boy, who was suffering from upper respiratory tract infection and was treated with ofloxacin by a private practitioner and developed hypersensitivity reaction, one hour after taking ofloxacin tablet. Hospitalization and treatment of patient was carried out. Since hypersensitivity reaction to ofloxacin is rare, proper history of drug reactions should be taken while prescribing ofloxacin. Attention must be paid to potential side-effects of the drug while prescribing any medication, and close follow-up with patients is a medical necessity to evaluate for these adverse reactions, especially with quinolones.

Glucose tolerance & insulin response in patients with hypertension.

Background: Insulin resistance leads to impaired glucose tolerance, dyslipidemia, and other adverse cardiovascular effects. Euglycemic insulin clamp have shown that essential hypertension per se is a state of insulin resistance and has been associated with an increased incidence of diabetes Aims: To ascertain the prevalence of several degrees of glucose abnormalities in patients with hypertension and to examine the insulin secretory response to oral glucose load. Study design, Material and Method: This cross-sectional analytical study included 325 hypertensive patients (with or without diabetes)and 100 control subjects. An oral glucose tolerance test (OGTT) following WHO guidelines was performed in all subjects, with measurement of insulin at baseline and every 30 minutes after the glucose load. Results: Abnormal glucose metabolism was observed in 70.77% of patients (95% confidence interval [CI], 65.87% - 74.21%). Of the 325 patients, 29.23% patients showed normal glucose metabolism. Impaired glucose tolerance (IGT) and Impaired fasting glycemia (IFG) were diagnosed in 30.46% and 16.61% patients respectively .Total diabetic population in the hypertensive patients were 23.69% (silent previously undiagnosed diabetes mellitus was diagnosed in 9.53% of patients while 14.15%reported a previous diagnosis of diabetes mellitus).Decreasing glucose tolerance was associated with insulin resistance. From normal glucose tolerance condition through IGT, IFG to diabetic, the HOMA IR progressively increased. Results of standard OGTT and corresponding insulin response after 0, 30, 60 and 120 minutes were significantly higher in patients compared with control subjects. LVMI and severity of glucose intolerance were significantly related. Male gender, higher levels of insulin (fasting insulin/HOMA IR) and greater adiposity (BMI) were all strongly associated with the severity of glucose abnormalities. Prevalence of metabolic syndrome increased progressively with severity of glucose abnormality. Conclusions: More than two-third of the hypertensive patients exhibited different glucose abnormalities and exaggerated insulin response to glucose load (hyperinsulinemia) along with cluster of other cardiovascular risk factors, whose prevalence increases with severity of glucose intolerance.

Ploidy status correlates with outcome in stage B prostate adenocarcinoma

1. While there are extensive data showing that aneuploidy is associated with adverse outcome in stage D prostate cancer, the utility of ploidy analysis in stage B disease in unclear. We determined ploidy in radical prostatectomy specimens from 28 patients with clinical stage B prostate cancer, and with a mean follow-up of 4.1 years (2-10 years). Patients who had no recurrences had a minimum 5 years of follow-up. Patients who had only 2 years of follow-up were included if they had developed bone metastases during this period. 2. Ploidy determinations were done on Feugen-stained 5-µm paraffin-embedded sections using a CAS 200 image analyzer. At least 400 tumor cells were counted in every case. Tumors with at least 70 percent diploid cells were classified as diploid, while those with less than 70 percent diploid cells were classified as aneuploid. The mean percentage of diploid cells in tumors classified as diploid was 90.6 ñ 7.4, while the mean percentage of diploid cells in tumors classified as aneuploid was 36 ñ 21.9. 3. Ploidy status correlated with disease progression: seven of the 10 patients (70 percent) with disease recurrence had aneuploid tumors, while 13 of 18 patients (72 percent) who remained disease-free had diploid tumors (P= 0.03, Chi-square test). 4. These data show that patients with stage B disease with aneuploid tumors at the time of prostatectomy are more likely to have recurrent disease within a mean of 3 years (2-6 years) compared to patients with diploid tumors. Ploidy determination done at the time of surgery may offer useful prognostic information