Estimating the prevalence of elevated plasma neutrophil gelatinase associated lipocalin level in patients with acute coronary syndromes and its association with outcomes

Objectives The principal objective of this study was to estimate the plasma levels of neutrophil gelatinase associated lipocalin (NGAL) in a cohort of patients with acute coronary syndromes (ACS) across their entire spectrum, and to correlate them with outcomes. Methods 87 patients with acute coronary syndromes were included in the study. Apart from the routine work up and management, all patients underwent determination of plasma NGAL and serum high sensitivity C reactive protein (HSCRP) levels at admission. The patients were followed up through the hospital stay as well as for one month after discharge for clinical outcomes, and echocardiographic parameters of left ventricular function. Plasma NGAL was studied for its predictive power for various defined outcomes. Results Plasma NGAL levels were detectably elevated in 67% of patients with ACS without any significant proportion with renal dysfunction, sepsis or overt infection. Plasma NGAL was the strongest independent predictor of all cause hospital mortality in Cox regression multivariate analysis with an odds ratio of 8.353, p = 0.0237. Plasma NGAL did not correlate with HSCRP, or severity of coronary artery disease (CAD). Conclusion This is a small study that shows that plasma NGAL in patients admitted with ACS can predict hospital mortality and forms the basis for consideration of this molecule as a possible new risk marker in ACS meriting further and more extensive investigation.

Criss-cross heart: Transthoracic echocardiographic features

Objective To study the echocardiographic features of criss-cross heart (CCH), a congenital cardiac anomaly characterized by crossed ventricular inflow streams, in Indian patients. Methods In this retrospective observational study, all pediatric echocardiograms performed in a single tertiary care institution in South India over a three-year period were scrutinized for a diagnosis of CCH. Demographic, clinical and echocardiographic data were collected from patients’ medical records and echocardiographic database. Crossed ventricular inflow streams was identified when there was inability to visualize both atrio-ventricular valves in a single imaging plane in cardiac four chamber view. Results CCH was diagnosed in five patients from 10,500 pediatric echocardiographic studies. The age at diagnosis ranged from one month to 8 years. Cyanosis was present in all but one of the five cases. Crossed ventricular inflow streams was present by definition in all cases, whereas superior-inferior ventricular relationship was present in only three cases. All cases were associated with ventricular septal defects. Atrio-ventricular discordance was seen in three cases and concordance in two. Ventriculo-arterial discordance was seen in three cases, concordance in one and double outlet right ventricle in one. Three cases had pulmonary stenosis and the other two had pulmonary arterial hypertension. Straddling of AV valve was observed in four cases and hypoplastic aortic arch in one case. Conclusion CCH is an extremely rare congenital cardiac anomaly. Superior-inferior ventricular relationship often co-exists with CCH, but is not necessarily present in all cases. CCH requires early diagnosis because of its common association with diverse cardiac anomalies.

Efficacy of stem cell in improvement of left ventricular function in acute myocardial infarction - MI3 Trial.

Background & objectives: Acute myocardial infarction (AMI) is characterized by irreparable and irreversible loss of cardiac myocytes. Despite major advances in the management of AMI, a large number of patients are left with reduced left ventricular ejection fraction (LVEF), which is a major determinant of short and long term morbidity and mortality. A review of 33 randomized control trials has shown varying improvement in left ventricular (LV) function in patients receiving stem cells compared to standard medical therapy. Most trials had small sample size and were underpowered. This phase III prospective, open labelled, randomized multicenteric trial was undertaken to evaluate the efficacy in improving the LVEF over a period of six months, after injecting a predefined dose of 5-10 × 108 autologous mononuclear cells (MNC) by intra-coronary route, in patients, one to three weeks post ST elevation AMI, in addition to the standard medical therapy. Methods: In this phase III prospective, multicentric trial 250 patients with AMI were included and randomized into stem cell therapy (SCT) and non SCT groups. All patients were followed up for six months. Patients with AMI having left ventricular ejection fraction (LVEF) of 20-50 per cent were included and were randomized to receive intracoronary stem cell infusion after successfully completing percutaneous coronary intervention (PCI). Results: On intention-to-treat analysis the infusion of MNCs had no positive impact on LVEF improvement of ≥ 5 per cent. The improvement in LVEF after six months was 5.17 ± 8.90 per cent in non SCT group and 4.82 ± 10.32 per cent in SCT group. The adverse effects were comparable in both the groups. On post hoc analysis it was noted that the cell dose had a positive impact when infused in the dose of ≥ 5 X 108 (n=71). This benefit was noted upto three weeks post AMI. There were 38 trial deviates in the SCT group which was a limitation of the study. Interpretation & conclusions: Infusion of stem cells was found to have no benefit in ST elevation AMI. However, the procedure was safe. A possible benefit was seen when the predefined cell dose was administered which was noted upto three weeks post AMI, but this was not significant and needs confirmation by larger trials.

Gastrointestinal basidiobolomycosis first case report from Oman and literature review

Gastrointestinal basidiobolomycosis [GIB] is a rare fungal infection with few reported cases worldwide. We report here the first case diagnosed in Oman in a previously healthy 5-year-old Omani female child who had been thought initially to have an abdominal malignancy. The case was referred to the Royal Hospital, Muscat, Oman, in July 2012. She was treated successfully with surgical resection and prolonged antifungal therapy [voriconazole]. Physicians, including clinicians, radiologists and pathologists, should have a high index of suspicion for GIB when a patient presents with an abdominal mass and fever

Management of infants and children who are contacts of contagious tuberculous patients

Contact investigation and management form the key for tuberculosis [TB] control in countries with a low tuberculosis incidence. Oman, with a low TB incidence, has implemented contact investigation and management as one important strategy to control TB. However there is a lack of clear guidelines for the investigation and treatment of contacts, especially with regard to children who are contacts of TB cases. The failure to manage children in contact with infectious TB cases indicates a missed opportunity to prevent TB disease in a population which is prone to progress rapidly to severe and complicated illness. This article attempts to provide a concise and practical approach for managing infants and children who are in contact with TB patients. Essential steps in a variety of possible scenarios are briefly discussed

Mitral leaflet separation index-a simple novel index to assess the severity of mitral stenosis.

BACKGROUND: Mitral leaflet separation (MLS) index is a recently recognized method to assess the severity of mitral stenosis. The aim of this study is to assess the severity of mitral stenosis (MS) using the MLS index. METHODS AND RESULTS: One hundred and fifty consecutive patients with MS who underwent 2D echo were studied. In each patient the severity of MS was assessed using 2D mitral valve area, pressure half time and MLS index. The mitral leaflet separation was measured in diastole, as the maximal separation at the tips in long axis and apical 4 chamber views. There were 34 (22.7%) patients with mild MS, 52 (34.7%) patients with moderate MS and 64 (42.7%) patients with severe MS. One hundred and ten (73.3%) patients were in sinus rhythm and 40 (26.7%) patients were in atrial fibrillation. The MLS index correlated very well with MVA by planimetry (r = 0.87, P < 0.0001) and pressure half time (r = 0.86, P < 0.0001). Good correlation was found even in atrial fibrillation (r = 0.87 and r = 0.87, respectively). ROC curve demonstrates that MLS index of 0.80cm or less identified severe MS with 92% sensitivity and 92% specificity. MLS index of >1.11 cm identified mild MS with 97% sensitivity and 97% specificity. CONCLUSION: The MLS index can be used as a screening method to semi quantify patients with mitral stenosis. This should be added into yet another method to assess the severity. This index will complement the other methods in our practice.

Nonresponders to clopidogrel therapy among Indian patients undergoing elective/adhoc angioplasty.

BACKGROUND: Clopidogrel has become the standard antiplatelet drug along with aspirin in patients undergoing coronary angioplasty; however, data regarding the nonresponse rate to clopidogrel therapy in Indian patients are limited. METHODS AND RESULTS: Platelet aggregation was measured at baseline and 2 and 24 hours post administration of bolus dose of 300 mg clopidogrel, followed by 75 mg once daily in patients undergoing elective or adhoc coronary angioplasty. Baseline platelet aggregation with 2.5 and 10 micromol/L ADP was 27.91 +/- 20.9% and 53.45 +/- 22.44%. Platelet aggregation at 2 hours and 24 hours with 2.5 micromol/L of ADP was 19.65 +/- 16.9% and 10.44 +/- 11.9%. The corresponding values with 10 micromol of ADP were 48.81 +/- 25.3% and 27.04 +/- 22.4%. Platelet aggregation was maximally inhibited at 24 hours with both 2.5 and 10 micromol/L of ADP. Marked interpatient variability in platelet aggregation in response to clopidogrel administration was observed and varied from -43 to 65%, -32 to 85% with 2.5 micromol/L at 2 hours and 24 hours and -65 to 53%, -35 to 97% with 10 micromol/L ADP at 2 hours and 24 hours. Nonresponse rate 2 hours after clopidogrel administration was 47.7%, and decreased to 29.2% at 24 hours post drug administration. CONCLUSION: Clopidogrel nonresponse is prevalent among Indian patients, and there is wide interpatient variability in platelet inhibition among individual patients. However, the clinical implications of these findings need to be substantiated in larger studies with clinical end points.

Audit of radiation dose to patients during coronary angiography.

BACKGROUND: There is widespread concern about radiation doses imparted to patients during cardiology procedures in the medical community. The current study intends to audit and optimize radiation dose to patients undergoing coronary angiography (CA) performed using two dedicated cardiovascular machines. MATERIALS AND METHODS: One hundred and forty nine patients who underwent CA are reported in this study. Dose auditing was done by implementing dose reduction strategies using spectral filters and by evaluating work practices of operators involved in performing CA. STATISTICAL ANALYSIS: A Student's 't' test was used to analyze the statistical significance. RESULTS AND CONCLUSION: The radiation dose imparted to patients was measured using dose area product (DAP) meter. The mean DAP values during CA before optimization was 55.86 Gy cm2 and after optimization was 27.71 Gy cm2. No ill-effects of radiation were reported for patients who underwent CA. Use of copper filtration may be recommended for procedures performed using cardiovascular machines.

Recanalization of a single functioning kidney.

For patients with renal artery stenosis, percutaneous transluminal angioplasty is generally the treatment of choice. This report describes the case of an elderly lady with type III aortoarteritis whose right renal artery was successfully recalized and stented. There was satisfactory improvement in renal function and blood pressure post-procedure, and at one-month follow-up.

Serum leptin levels in acute myocardial infarction.

BACKGROUND: Several studies have shown an association of serum leptin levels with cardiovascular diseases. The present study was undertaken to assess levels of serum leptin in patients presenting with acute ST segment elevation myocardial infarction. METHODS AND RESULTS: Ninety-four consecutive patients presenting with acute ST segment elevation myocardial infarction were studied and 46 controls were taken from patients who presented with chest pain but had no history of myocardial infarction in the past. There were 59 patients with anterior wall infarction and 31 had inferior wall infarction and in 4 it was a combination of anterior and inferior wall infarction. The serum leptin levels in patients with myocardial infarction was 6.51 +/- 6.76 ng/ml versus 2.86 +/- 2.22 ng/ml in controls. In the multivariate analysis the odds ratio for serum leptin with myocardial infarction was 1.45 with a 95% confidence interval of 1.2 to 1.8. CONCLUSIONS: Our results suggest that serum leptin level is elevated in patients with acute ST segment elevation myocardial infarction.

Torsade de pointes in a case of pheochromocytoma--an unusual presentation of an uncommon disease.

We report the case of a middle aged lady with dilated cardiomyopathy, presenting with recurrent syncope due to torsade de pointes. Further evaluation revealed that she had a pheochromocytoma which caused the arrhythmia.

Prevalence of coronary artery disease in patients with rheumatic heart disease in the current era.

BACKGROUND: This study was undertaken to determine the prevalence of coronary artery disease in patients with rheumatic heart disease undergoing valve surgery. METHODS AND RESULTS: Consecutive patients with rheumatic heart disease (n=376) who were above the age of 40 years, and scheduled for valve surgery underwent diagnostic coronary angiogram to delineate coronary arteries. The patients were divided into three groups based on valve involvement (mitral valve, aortic valve, and combined aortic and mitral valve). Significant coronary artery disease was considered to be present if one or more coronaries showed 50% or more luminal stenosis. There were 287 (76.3%) males and 89 (23.7%) females. The mean age of the study population was 51.2+/-8.2 years. Eighty-nine (23.8%) patients had typical chest pain, 116 (30.6%) patients had atypical chest pain and 171 (45.5%) patients had no chest pain. Hypertension was noted in 88 (23.4%) patients, 65 (17.3%) patients had diabetes, 98 (26.1%) patients were smoker, and 66 (17.6%) patients had dyslipidemia, and 15 (4.0%) patients gave past history of myocardial infarction. Of the total 376 patients, 46 (12.2%) patients were found to have significant coronary artery disease. In patients with mitral vale disease the prevalence was 13.5% (13/96), while it was 15.3% (19/124) in patients with aortic valve disease and 9% (14/156) in those with combined mitral and aortic valve disease. CONCLUSIONS: Our results suggest that the overall prevalence of coronary artery disease in a group of patients with rheumatic heart disease undergoing valve surgery in the current era is 12.2%. This prevalence is much lower than the figures reported earlier in the Western literature.

Dengue shock syndrome

A three-and-half-year old indian boy, who had returned from Madras, was admitted with fever of five days' duration, vomiting of two days and altered sensorium of three hours prior to hospitalisation. He was investigated and was .empirically commenced on therapy for possible enteric fever. Later a raised haematocrit, thrombocytopaenia. hypoalbuminaemia, bilateral pleural effusion and tender hepatomegaly, prompted us to revise the diagnosis to possible dengue haemorrhagic fever/dengue shock syndrome [DHF/DSS], and this was subsequently confirmed by high titres of dengue virus antibodies. The child was treated conservatively, became asymptomatic and was sent home after ten days of hospitalisation. DHF/DSS remains a valid differential diagnosis in any child who presents with fever and circulatory collapse especially if there has been a visit to an endemic area. From our database, this is the first confirmed case of DHF/DSS from the Sultanate of Oman