Management protocols for chronic heart failure in India

Heart failure is a common clinical syndrome and a global health priority. The burden of heart failure is increasing at an alarming rate worldwide as well as in India. Heart failure not only increases the risk of mortality, morbidity and worsens the patient’s quality of life, but also puts a huge burden on the overall healthcare system. The management of heart failure has evolved over the years with the advent of new drugs and devices. This document has been developed with an objective to provide standard management guidance and simple heart failure algorithms to aid Indian clinicians in their daily practice. It would also inform the clinicians on the latest evidence in heart failure and provide guidance to recognize and diagnose chronic heart failure early and optimize management.

Leukocyte, Haemostatic and Inflammatory Biomarkers are Activated in Patients with Cardiovascular Disease (CVD): A Pilot Study.

Background: Cardiovascular disease (CVD) provides a huge economic strain worldwide and is responsible for over 4 million deaths in Europe annually. Atherosclerosis, a key component of CVD, is recognised as an inflammatory process. This clinical pilot-study aimed to compare a range of selective leukocyte, haemostatic and inflammatory biomarkers in patients with CVD to healthy volunteers. Original Research Article British Journal of Medicine & Medical Research, 4(26): 4392-4406, 2014 4393 Patients and Methods: Fifty participants were recruited, 21 patients with CVD (due to atherosclerosis) and 29 healthy volunteers (with no history of CVD or diabetes). All participants for the study provided a non-fasting venous blood sample prior to analysis (n=50). The biomarkers measured included the Cluster of Differentiation 11b (CD11b) cell surface expression in monocytes and neutrophils, neutrophil elastase, fibrinogen, von Willebrand Factor (vWF), protein C and C-Reactive Protein (CRP). Results: vWF levels were significantly raised in CVD patients (186.8±106.6 %vWF:Ag) compared to healthy volunteers (109.9±85.2 %vWF:Ag), (p<0.001). CRP was significantly raised (3mg/dL) in CVD patients compared to healthy volunteers (<3mg/dL), (p=0.036), with the CD11b cell surface expression in monocytes being higher (0.64±0.55 MFI) in CVD patients compared to healthy volunteers (0.37±0.44 MFI), (p<0.005). No differences were observed for protein C, fibrinogen, neutrophil elastase or neutrophil CD11b in CVD patients compared to healthy volunteers (p>0.05). Discussion and Conclusion: Patients with CVD have elevated levels of vWF, CRP and CD11b cell surface expression (monocytes) compared to healthy volunteers. The results of this study support the premise of leukocyte, haemostatic and inflammatory involvement during CVD, and that measuring biomarkers such as vWF and leukocyte CD11b cell surface expression, may aid in the diagnosis and monitoring of patients with CVD. However, further large-scale prospective studies are required to fully understand the relationship between these markers and CVD.

Variability in Linear Body Measurements and their Application in Predicting Body Weight of Afar Goats in Ethiopia.

Goats with their broad feeding habits, adaptation to unfavorable environment, low cost, suitability for small scale production and short reproduction put them at an advantage over cattle and sheep especially for resource poor livestock keepers. Body weight is mostly used to evaluate body development and carcass characteristics in animals. Meat animals visually assessed is a subjective method of judgment. In goats, objective evaluation of body weight and linear body measurements for describing and evaluating size and conformation characteristics can overcome problems associated with subjective evaluation. Hence, the objectives were: a) to evaluate variability in linear body measurements b) to determine best fitted regression model for predicting live weight under field conditions. The study conducted in two districts of Afar National Regional State of Ethiopia used 800 random samples. The effect of district was significant (p<0.05) on body length, chest girth, whither height, pelvic width, and rump height, while body weight, horn length and ear length were non-significant. Sex effect was significant on body weight and other linear body measurements except pelvic width, ear length and rump height. The estimated regression model using a SAS macro, for predicting body weight, included linear effects of horn length, body length, chest girth, whither height, rump height and quadratic effect of chest girth.

Validity of 20 meter multi stage shuttle run test for prediction of maximum oxygen uptake in Indian female university students.

BACKGROUND: The 20-meter multi stage shuttle run test (20-m MST) has not yet been used by Indian scientists and validity of the test has not been studied for use with any of the Indian population. AIMS: The purpose of this study was to validate the applicability of the 20-m MST in Indian adult female. MATERIALS AND METHODS: For application of direct method cross over design was followed. For validity of the results repeatability was used. Methods and Material: 32 female university students (age range 20.4 approximately 24.8 years) from three different universities of West Bengal, India were recruited for the study. Direct estimation of VO2 max comprised treadmill exercise followed by expired gas analysis by scholander micro-gas analyzer whereas VO2 max was indirectly predicted by the 20-m MST. STATISTICAL ANALYSIS: Paired t-test, Pearson's product moment correlation, linear regression statistics and Bland and Altman approach for limit of agreement were adopted for statistical analysis of the data. RESULTS: The difference between the mean (SD) VO2 max values of direct measurement (VO2 max = 32.84 +/- 2.92 ml/kg/min) and the 20-m MST (SPVO2 max = 32.60 +/- 3.40 ml/kg/min) was statistically insignificant (p>0.10). Limits of agreement analysis also suggest that the 20-m MST can be applied for use with the studied population. CONCLUSIONS: The results suggest that the application of the present form of the 20-m MST be justified in the studied population. For better prediction of VO2 max a new equation has been computed based on present data for use with Indian female university students.

Study of plasma lipid and lipoprotein profile in elite women boxers during a six weeks' training progamme.

The present study was undertaken with an objective to frame out the lipid profile of Indian Women Boxers. Women boxing is a newly recognized game and no work has been reported on elite female boxers in India till date. The study was based on a sample of 45 women boxers (age 17 ~ 24 years) attending Senior National Women Boxing Camp at Sports Authority of India. Each subject was evaluated for Lipid Profile variables at the beginning and end of the six weeks training camp. Fasting blood samples were taken from the antecubital vein by venipuncture. Before the samples drawn the subjects were asked to take rest for ten minutes. The blood sample was analyzed by HITACHI UV-2000 spectrophotometer (Japan). Standard techniques and procedures were followed for all the estimation. Volume and intensity of different components of training was measured by observational and physiological methods. Data were subjected to statistical treatment like mean and standard deviation. Test of significance't' - test (for paired sample) was applied to asses the difference in pre & post-test. Results reveal that mean (+/-SD) Cholesterol, Triglyceride, LDL, HDL - Cholesterol and Cholesterol / HDL Cholesterol ratio was 144.7 +/- 3.6 mg%, 59.7 +/- 17.5 mg% 81.4 +/- 21.1 mg% 51.3 +/- 8.2 mg% and 2.8 +/- 0.5 respectively as found in the pre-test. Significant difference (P < 0.01) was observed in Cholesterol, LDL-Cholesterol, HDL Cholesterol level in the post-test. The study concludes that women who practice sport of boxing on regular basis have a favorable lipid profile. A significant change in lipid profile of the boxers was observed after 6 weeks' training program.

Central neurocytoma: a clinico-pathological study of eight cases.

Central neurocytomas are benign neuronal tumours generally found in the lateral or third ventricles. They are rare, comprising < 1% of all brain tumours. It is frequently confused with other tumours of the central nervous system particularly oligodendroglioma. The present study was done to analyse the histopathological features including immunohistochemical profile of these rare tumours. Eight cases were taken up for the study. Seven of the cases had an intraventricular location and one was located outside the ventricles. Increased intracranial pressure was the most common presenting symptom. Microscopically all tumours were composed of small uniform cells with perinuclear halos and regular round nuclei. The tumour in extraventricular location showed atypical features. Immunohistochemistry showed positivity for neuronal markers. The present series highlights the characteristic clinical and pathological findings of this rare brain tumour. Immunostaining for neuronal markers are essential for distinguishing them from other small round cell tumours of the brain.

Energy expenditure in women boxing.

OBJECTIVES: Women boxing have got recognition recently and so far no work has been reported on energy expenditure of national women boxers in India. This study was aimed to estimate the energy expenditure in Indian female boxers during sparring. METHODS: A total of 20 female boxers were subjected. Energy expenditure was estimated using the same individual's HR-VO2 regression equation. Heart rate was recorded through radiotelemetry. RESULTS: Results reveal that average and maximum energy expenditure considering the total duration of boxing are 12.7 +/- 1.3 and 14.4 +/- 1.6 kcal/min. CONCLUSIONS: It is concluded that depending on the severity of energy expenditure female boxing comes under heavy category and as it is a pioneer attempt in India, further studies in this aspect are really required which will guide the coaches regarding the energy expenditure pattern in women boxing.

Demyelinating disease simulating brain tumours: a histopathologic assessment of seven cases.

BACKGROUND: Demyelinating diseases can present as space occupying lesions with in the brain. It is clinically and radiologically difficult to differentiate them from primary neoplasms. Histopathologically they mimic astrocytic neoplasms closely and identifying these lesions correctly has a profound impact in treatment and prognosis of these patients. AIMS AND OBJECTIVES: The objective was to determine the histopathologic features of such acute focal demyelinating disease that clinically presented as brain tumors. MATERIAL AND METHODS: Seven cases were included for the study. Detailed histopathological examination including stains for myelin and axon were performed. The histopathological keys in arriving at the right diagnoses included a well demarcated lesion that contains uniform distribution of foamy macrophages in the absence of any associated coagulative necrosis, sheets of gemistocytic astrocytes in the white matter that show well-formed processes, perivascular chronic inflammatory cell infiltration and total absence of myelin with relative preservation of axons within these areas. CONCLUSION: The degree of suspicion (clinical, radiological and histopathological) should be high to diagnose these group of lesions. The above-mentioned diagnostic keys should help in arriving at the correct histopathological diagnoses of such cases.

Subependymomas in children: a report of five cases including two with osseous metaplasia.

Subependymomas are highly differentiated slow growing gliomas. They are one of the few gliomas which are biologically benign. They are extremely rare in children. However, after going through the histopathology records of our department of fourteen years (1983-1997) we found that five (20%) cases of subependymomas have been diagnosed in children out of a total of twenty-six subependymomas. Two of our cases showed the presence of osseous metaplasia, a hitherto undescribed finding.

Histoplasmosis masquerading as tuberculosis: a case report.

Histoplasmosis is not reported very commonly from India. We report a patient in whom the presenting feature was persistent leucopenia and hepatosplenomegaly and was treated as a case of disseminated tuberculosis. At autopsy, this patient showed all features of progressive disseminated histoplasmosis.

Gastrointestinal stromal tumors the assessment of malignant potential.

GISTS are the largest category of non-epithelial neoplasms of stomach and small bowel. Numerous immunohistochemical, ultrastructural and flow cytometry studies have been carried out for evaluation of prognostic factors which could predict malignant behaviour of these neoplasms. Tumor size of 5 cm and mitosis of 2/10 hpf were suggested as two important parameters which could predict the chances of recurrence and clinically aggressive course. The aim of this study is to examine predictive value of these two important parameters in assigning the tumors as high, intermediate and low risk groups. Using these two parameters we categorized 30 cases of GIST over a period of 6 years (1990-95) into low, intermediate and high risk groups and examined other features of these cases. Based on these two parameters alone we found that 4 cases each in low and intermediate group could be assigned to a higher risk group clinically as there were presence of adjacent organ infiltration, lymphatic emboli, serosal nodules, lymph node metastasis and transmural infiltration. Hence, other features like hemorrhage, necrosis and anaplasia should also be included in risk assessment. Metaplastic tissues like bone, cartilage and adipose tissues were seen only in high-risk categories.

Cicatricial pemphigoid--a case report.

Cicatricial pemphigoid (CP) occurring in a 60-year-old male is described. He had involvement of conjunctival, nasal and oral mucosae, in addition to skin lesions. Diagnosis was confirmed by histopathology. He responded well to oral steroids and dapsone. However, vision in one eye was lost.

Flowcytometric and histopathological correlation of primary intracranial neoplasms.

DNA ploidy and synthetic phase fraction (SPF) of 52 cases of primary intracranial neoplasms have been determined from fresh tissues and the data was correlated with histopathological typing and grading. Fresh tumour tissues from 52 random surgical biopsies (28 malignant and 24 benign) were obtained from neurosurgical operations during the period 1994-1996. The cells were analysed in Becton Dickinson flowcytometer fitted with Consort 30 programme and 'Sober' software. Percentage of diploid cells, proliferative cells and DNA aneuploidy were evaluated. The tumours were classified and graded according to WHO classification (1993). On histology, there were 28 malignant (grade II to IV) and 24 benign cases (grade I). All the histologically benign tumours in this study showed diploid DNA content with the exception of a pituitary adenoma which had a heterogeneous population of cells. The S phase fraction in all the benign cases was less than 10% except in the case of choroid plexus papilloma (S-phase 54%) and an atypical meningioma (S-phase 14%). Out of the 28 malignant tumours, 12 cases were aneuploid (43%) and the rest were diploid (57%). Among the 16 diploid tumours, SPF was more than 10% in eight cases. DNA aneuploidy and high SPF are more common in histologically malignant tumours than benign tumours. SPF is a reflection of proliferation potential of a tumour and may have some role in prognostication of brain tumours.

Neuropathological complications of infective endocarditis : study of autopsy material.

78 autopsy proven cases of infective endocarditis (IE) seen during 1983 to 1995 were retrospectively reviewed. The brain was available for examination in 44 cases. In the remaining cases, brain was not examined because examination of it was not requested due to lack of neurological findings. Brain lesions were observed in 35 out of 44 cases of IE. Assuming remaining 34 cases to be without brain lesions, the brain involvement in IE would be 44.87% (35 out of 78 cases). Mean age of all cases of IE and those with brain lesions was similar i.e. 26.5+/-16.6 years and 26.6+/-13.06 years respectively. Largest number of cases with neuropathological lesions were associated with normal valve IE (48.57%). Mitral valve was most commonly involved in cases with CNS complications (57.14%) (p<0.05). The various types of brain lesions were infarction (68.57%), haemorrhage (57.14%), cerebral micro-abscess (31.42%) and focal meningitis (14.28%). More than one type of lesion was observed in 19 cases, indicating complicated nature of brain lesions in fatal cases of IE. Left sided middle cerebral artery (MCA) territory was the commonest site of infarction and haemorrhage. Staphylococcus aureus appeared to be the most common organism in fatal cases of IE. Normal valve IE with or without CNS complications constitutes a significant group in India and is different from the west as far as the predisposing conditions are concerned.

Cerebral abscess with astrocytoma.

A child with a right parieto-occipital astrocytoma, caped by a large acute pyogenic abscess with flimsy capsule, detected at emergency craniotomy, is presented. Patient succumbed to the disease three hours following surgery.

Clinically and biochemically silent thyrotroph adenoma with oncocytic change.

A case of clinically and biochemically silent pituitary tumour with ultrastructural and immunohistochemical evidence of thyroid stimulating hormone secretion is presented. Significance of recognition of such silent tumours is discussed.

Fatal complications of systemic lupus erythematosus--an autopsy study from north India.

Systemic lupus erythematosus (SLE) is a multisystem, autoimmune disease with varied clinical manifestations and outcome. It may prove fatal due to disease activity or intercurrent infections. In recent years, earlier diagnosis and better treatment modalities have resulted in a change in the pattern of organ involvement and mode of death in the west. This aspect of the disease is unknown in India. Hence, in this autopsy series of SLE, the organ involvement and cause of death have been studied. Twenty five cases of clinically diagnosed SLE have been analysed retrospectively. Renal involvement was invariably present (96%) with class IV being the commonest lesion in 60% cases. Disease activity was noted in 60% cases. Pleuro pulmonary lesions were seen in 92% cases with infection being the commonest. Pulmonary infections included bacterial pneumonias (13), disseminated tuberculosis (3), pulmonary mucormycosis (1) and aspergillosis (1). Massive pulmonary haemorrhage in 5 cases and acute lupus pneumonitis in one, contributed to the demise of the patient. Vasculitis was evident in single organ in 9 cases, in two or more organs in 3 cases with systemic vasculitis significantly attributing to morbidity in 1 case. Active disease was the cause of death in 60% cases and infection in 40%.