Peripartum cardiomyopathy presenting to cardiology department of Mayo Hospital, Lahore

Cardiac failure occurring in last trimester of pregnancy or within one to six months after delivery in a woman without a history of heart disease and with no cause for heart failure other than pregnancy is termed as peripartum cardiomyopathy. To determine fetomaternal morbidity and mortality in women presenting with peripartum cardiomyopathy, we did an open non-randomized observational descriptive study at Department of Cardiology Mayo Hospital, Lahore from January 2004 to Oct 2005. The women referred from Lady Willingdon and Lady Aitchison Hospitals to Cardiology Department of Mayo Hospital during last trimester and after delivery for work up of heart failure were included. Twenty five women presented with heart failure due to peripartum cardiomyopathy were included in this study, 40% in last trimester, 40% within one month and 20% within 4 month after delivery. The mean age was 35 + 5 years. Out of these 2 [8%] were primiparous, 13 [52%] were multiparous and 10 [40%] were grandmultipara. Ten [40%] were booked and 15 [60%] were nonbooked for antenatal care. Twenty [40%] patients were diagnosed for the first time and 5 [20%] had recurrence. Based on NYHA classification 20% were in class I, 40% class II, 20% class III and 20% in class IV. The patients were on standard medical treatment. All patients reviewed at follow up after 1, 6, and 12 months. No maternal mortality occurred. Antenatal ward admission was required for 32% women due to obstetric reasons and 8% due to cardiac cause. Five had spontaneous labor and 5 inductions were done for obstetric reasons: poor biophysical profile, previous caesarean section, uncontrolled diabetes, breech presentation and fetal distress. Three babies have intrauterine growth retardation. On echocardiography mean ejection fraction was 20-25% with global hypokinesia, 5 patients had clot in LV apex, 10 had whiff of mitral regurgitation and tricuspid regurgitation. We conclude that peripartum cardiomyopathy has high morbidity and mortality. Women are very much receptive about c ontraception in the immediate post partum period, therefore counseling of the patient and their family should be done to reduce maternal mortality

Prognostic value of initial Glasgow coma score in comatosed patients on medical floor

An open non-randomized prospective observational study of comatosed patients was conducted to correlate initial Glasgow Coma Score [GCS] with the outcome in patients having medical coma at Mayo Hospital, Lahore between January 2002 to September 2003. A total of 273 patients were followed throughout their hospital stay to determine the outcome after the current episode of coma. A thorough history and examination was obtained for each case. The 3 category Glasgow Coma Score was recorded as an indication of the degree of unconsciousness. One of three possible outcome categories was established, recovery [discharge], death, and referral or self discharge [by attendants] against medical advice. The outcome of 248 patients [90.84%] was established i.e. 152 [61.29%] were discharged after recovery and 96 [38.71%] died. The remaining 25 [09.16%] patients were lost to follow up. Four subcategories of the Glasgow Coma Score were made, at 3-point intervals. In the lowest score category [score 3-5] there was 59.67% mortality and only 30.66% patients were successfully treated and discharged. In the category of GCS 6-8, 30.91% died and 60% were discharged, while in the 9-11 category, 26.47% died and 66.18% were discharged. In the highest score category [12-15], 27.27% deaths occurred, probably related to the severity of main event, and 62.50% were discharged. The depth of coma as reflected by the initial GCS can reliably be used to predict the outcome in comatosed patients

Rosiglitazone and metformin in patients with type-2 diabetes mellitus who are inadequately controlled on metformin alone

Type 2 Diabetes Mellitus is almost reaching epidemic levels. With tight hyperglycemic control the risk reduction is 24% for any diabetes related end-point and 32% for death related to diabetes, against only 0.9% decrease in HbAlc level. Complementary mode of actions of Rosiglitazone and Metformin can be used to maximize the therapeutic effect and to decrease the side effects. We evaluated the efficacy, safety and tolerability of the combination of Rosiglitazone and Metformin on change in HbAlc levels from baseline over a period 24 weeks in patients with type 2 diabetes mellitus. Twenty eight type 2 diabetes mellitus patients were recruited randomly presenting to West Medical Ward, Mayo hospital Lahore, through OPD, Diabetic Clinic and Emergency, who were on Metformin alone and were poorly controlled from September 2003 to July 2004. They were given Rosiglitazone 4 mg/day or 8 mg/day with metformin for a period of 24 weeks. Only 2 patients were dropped and 26 patients completed the study [46% were males and 54% were females], and none of patient was dropped due to adverse effects. Their fasting blood sugar measured at baseline and at 4, 8, 16 and 24 week. HbAlc was measured at start and at 24 weeks. The fasting blood glucose responders were 84.6%, with mean fall of 46 mg/dl. HbAlc responders were 73% patients. Average weight gain was 1.125 kg over 24 weeks. Out of 26 patients, 89% showed a mild decrease in hemoglobin concentration but none reaching anemic levels. Only 10% patients had a rise in liver enzymes, which was less than 2 times the normal. Addition of rosiglitazone, in patients with type 2 diabetes mellitus, who are inadequately controlled on metformin alone, resulted in better glycemic control but a large scale study is required and other combinations with Rosiglitazone like sulphonylurea and insulin should be compared

Causes and outcome of suicidal cases presented to a medical ward

Suicide is one of the leading causes of death in world but its causes and methods may vary. We enrolled patients who presented to the emergency with attempted suicide. The end point was death, discharge or leaving the hospital against medical advice. The study was designed to know the modes of committing suicide and underlying causes. Of the total 107 patients, who presented to the emergency 59 [55%] were males and 48 [45%] were females. Most common poison ingested was wheat pill in 35 [33.3%] patients followed by bleach/bathroom cleaner in 27 [25.7%], benzodiazepines in 20 [19%] and a small proportion of patients had copper sulfate, organophosphorus compounds, rat pills, lice powder, dettol and varnish. Two patients presented after hanging. Twenty eight [26%] patients died, just after reaching hospital and 10 had permanent disability. For suicide the most common poisons used were those that were easily available and without any ban on their sale. So general awareness should be created among masses about them and legal restrictions should be imposed on their sale

audit of indoor morbidity and mortality in a medical ward at a tertiay care, hospital

There is a great geographical variation in disease burden around the world, which is due primarily to environmental, genetic, social and economic factors. Similar variations exist in worldwide mortality figures from a particular disease that can be attributed almost entirely to the access and efficacy of healthcare facilities. We did this audit to identify the major causes of morbidity and mortality in patients admitted in a medical unit of a tertiary care hospital and to highlight the importance of primary prevention. The audit was carried out in West Medical Ward Mayo Hospital Lahore, Pakistan from 1st January 2004 to 31st December 2004. All patients admitted with medical problems from the Outpatient and Emergency Departments were included. During the year 2004, a total of 2045 patients were admitted, out of which maximum number of patients admitted in the ward were suffering from chronic liver disease [17%] followed by ischemic heart disease [14.4%] cerebrovascular accidents [10.4%] and renal diseases. Total number of deaths were 321 with male mortality was 167 [14.40%] and female mortality 154 [17.40%]. Chronic liver disease also had the highest mortality [16.8%] followed by cerebrovascular accidents [14%], renal disease [11.5%] and ischemic heart disease [7.8%]. Even the mortality due to chronic liver disease was significantly higher [p <0.01] than ischernic heart disease. The number of patients having the four common diseases having age 45 years or more [770] was significantly greater [p <0.0001] then the number of patients [279] in the age range of 15 to 44 years. It was observed that significantly greater number of male patients [595] had morbidity than females [462], [p <0.0001], while mortality has no difference. Chronic liver disease, ischemic heart disease and cerebrovascular accidents are the diseases putting maximum burden on our health resources and disabling our productive population. This audit highlights the fact that all these three groups of diseases can be prevented and thus obviates the need of primary prevention of these major killers

there any relationship of age and sex to the etiology and outcome of medical coma?

As the diseases behave differently in males and females and even in different age groups, particular attention was made to classify and observe the distribution of various causes of coma according to age and sex of the patient in order to formulate our indigenous database for future reference. We studied the coma etiology with particular reference to the age and sex of the patient, and the outcome. All the 517 [312 male [60.35%] and 205 female [39.65%]] patients were divided into 7 groups according to decades from age 12 to 80 years. Patients older than 40 years predominated [318 [61.5%]]. Metabolic coma was predominant cause in almost all age groups. Structural coma was increasing progressively with the age. Poisonings were the common cause in patients under 30, representing 35.85% of all comas in the age group 12-20, and 33.70% in the group from 21-30 years. In the next two decades [31-50 years], hepatic and renal failure predominated making up more than half of all causes. Leading causes among males we re poisonings [69 cases], hemorrhagic CVA [48 cases], ischemic CVA [24 cases], renal failure [28 cases] and hepatic coma [35 cases]. Similarly among females causal distribution revealed renal failure [34 cases], followed by hepatic coma [29 cases], and hemorrhagic CVA [26 cases]. Out of the 476 [92%] patients whose outcome could be determined 297 [57.4%] were discharged after recovery and 179 [34.6%] died. Eighty out of 205 female patients died [39%], while 99 out of 312 males had a fatal outcome [31.7%]. We conclude that coma etiology has a significant effect on prognosis, while such significance could not be assigned to age or sex

Differences in clinical profile and echocardiographic findings in patients with valvular vs non-valvular origin of artial fibrillation

Atrial fibrillation [A Fib] is a common cardiac arrhythmia. Major causes include valvular and non-valvular. Prevalence of rheumatic/valvular origin is commonly observed but non-valvular diseases are also manifest in A Fib. The age, gender, left atrial size and presence or absence of thrombus in left atrium affects the outcome and associated morbidity and mortality. We evaluated 70 consecutive patients of A Fib to find out differences in clinical and Echocardiographic findings in valvular and non-valvular origin of A Fib. Seventy [31 males, 39 females] patients of A Fib were divided into valvular and non-valvular groups. There were 34 [48.16%] patients [22 females] in valvular group, out of which 27 [79.41%] had pure mitral stenosis [16 females] and 5 [14.70%] mixed mitral valve disease. In non-valvular group 36 [51.84%] patients [19 males] were observed, out of these 9 [15%] had hypertension, 12 [33.3%] coronary artery disease. Mean age in valvular group was 40.09 +/- 11.99 years and 61.42 +/- 13.23 years in non-valvular one. Ejection fraction was more [54.68 +/- 10.45%] in valvular group. Increased LA size of 52.44 +/- 8.96% noted in valvular group. A Fib is the commonest arrhythmia seen at relatively younger age, more common in females and with enlarged left atrium in valvular heart disease as compared to non-valvular group where it is seen at older age, in males and with relatively less enlarged left atrium. Early recognition and treatment of atrial fibrillation may help to reduce the occurrence of atrial fibrillation and its associated sequel