Multi-factorial risk stratification in Acute Coronary Syndrome

Background: ST elevated myocardial infarction (STEMI), non-ST elevated myocardial infarction (NSTEMI) and unstable anginas (UA) are continual spectrum of coronary artery disease (CAD).These are terminal events arising as a result of coronary artery atherosclerosis and superimposed thrombosis.Materials and methods: A prospective study in which a total of 91 patients of either sex aged 20 to 60 years were recruited, of which 30 were STEMI, 31 were NSTEMI/ unstable angina and 30 were age and sex matched healthy controls. Patients with following complaints of maximum 24 hours duration were registered in the emergency department and were included in the study (ACC/AHA Guidelines, 2002).Results: In the present study, 91 subjects were recruited from medical emergency department. All of the subjects were meeting the inclusion criteria. Of the total 91 subjects 30 were of STEMI (Group 1),15 were of NSTEMI (Group 2), 16 were of unstable angina (Group 3) and 30 were controls (Group4).Conclusion: In patients of ACS, MPO is raised as compared to controls. Also in complicated ACS,irrespective of other risk factors, MPO was significantly raised as compared to controls and can beused to predict immediate clinical complication. There is no significant association between MPO, hs Chowdhury P, Pandey V, Avasthi R, Kandukuri MK, Giri S, Sharma S. Multi-factorial risk stratification in Acute Coronary Syndrome. IAIM, 2016; 3(1): 36-45.Page 37 CRP and CK-MB when taken together to predict complications. TIMI risk score is a simple prognostication scheme that categorizes a patient's risk of death and ischemic events and provides a basis for therapy.

Do joint national committee VII criteria also need to take non pharmacological measures into consideration? – Empirical evidence from slum resettlement colony from Delhi.

Background: Currently Joint National Committee (JNC) VII criteria are used worldwide to diagnose hypertension but it does not take non pharmacological measures into consideration. Also, it does not consider Indian system of medicine. Objectives: To assess whether JNC VII in its present form is valid to diagnose hypertension correctly or revision is required especially for Indian communities where such practices are prevalent. Material and methods: The present community based cross-sectional study was carried out in nand nagri, a slum resettlement of East Delhi which comes under field practice area of the Department of Community Medicine, UCMS, Delhi from August 2010 to February 2012. Total 310 subjects aged 20- 59 years were selected through multistage systematic random sample. Though the blood pressure cut-offs considered in our criteria was similar to the JNC VII cut-offs (SBP ³140 mmHg and or DBP ³90 mmHg), the difference was in the last part of JNC VII definition of hypertension i.e. treatment by anti hypertensive medicines; our criteria comprised of this statement as “any anti hypertensive measure”. Chi-square (χ²) test was applied for analysis. Results: Overall 54 were found to have hypertension by JNC VII criteria whereas 61 by our criteria. Seven patients who were not hypertensive by JNC VII but hypertensive by our criteria and the difference was found to be statistically highly significant (p<0.001). Exercise was the most common non pharmacological measure adopted by male gender where as in females, salt restriction was the most common measure adopted Conclusion: Our study emphasized inclusion of non-drug therapy measures into consideration while making diagnosis of hypertension in our setup.

Disseminated tuberculosis manifesting as chronic pancreatitis.

Pancreatic involvement in tuberculosis is known but uncommon. The clinical manifestation may vary from painless obstructive jaundice due to pancreatic mass (cyst or abscess) to fever of unknown origin. Here we report a case who initially presented as acute pancreatitis relapsing into chronic pancreatitis as an initial manifestation of disseminated tuberculosis.

Severe primary antiphospholipid syndrome.

Antiphospholipid syndrome (APS) is characterised by recurrent venous or arterial thrombosis and/or fetal losses. In APS, the homeostatic regulation of blood coagulation is altered, however, the mechanism of thrombosis is not yet defined and it has varied manifestations. Deep vein thrombosis with or without pulmonary embolism is the most common manifestation followed by arterial occlusion of cerebral, coronary and other arteries including subclavian, retinal, renal and pedal arteries. We report a case of a 42 years old female, with severe primary APS, who presented with symmetrical peripheral gangrene, an uncommon presentation and was treated successfully.

Testicular mixed germ cell tumor metastasizing to heart.

A 21 years old male presented with low grade fever, hemoptysis and progressively increasing dyspnoea of four month duration followed by acutely developing dizziness, hypotension, convulsion and altered sensorium. He had been operated (left inguinal orchidectomy) for left testicular swelling two years back with high alpha-fetoprotein and normal beta-human chorionic gonadotropin (beta-hCG). In view of this a possibility of metastasis secondary to a malignant testicular tumor was considered. Echocardiography demonstrated a large intracardiac mass, chest computed tomography (CT) revealed intracardiac mass, mediastinal masses and left sided pleural effusion. The histopathology revealed testicular mixed germ cell tumor (MGCT). This case is presented to demonstrate uncommon cardiac manifestations of secondary spread of testicular malignancy.

A clinical trial of the efficacy and safety of montelukast as monotherapy in patients with chronic stable bronchial asthma.

This study is aimed to evaluate the efficacy and safety of montelukast, as monotherapy, in the treatment of chronic stable bronchial asthma in adults. This was a multicentre, open label, non-comparative, prospective, 4-week study. Eligible patients discontinued all anti-inflammatory medication (steroids, chromoglycate sodium) 2 weeks prior to starting therapy with montelukast (10 mg daily). The primary efficacy criteria were improvements in forced expiratory volume in one second (FEV1), peak exploratory flow rate (PEFR) after 4 weeks of therapy. Secondary efficacy criteria were improvement in the patients' symptoms (assessed on an ordinal scale), decrease in discomfort levels (scored on a scale of 0-100), change in peripheral eosinophil counts, decrease in total daily dose of inhaled beta2 agonist (salbutamol). A total of 148 patients, mean age (+/- SD) 40.21 +/- 13.70 years, were enrolled into the study. At the end of the study there were significant improvements in FEV1 and PEFR (29% and 28% increase respectively from baseline values, p<0.000001). The mean total daily dose of inhaled salbutamol decreased significantly from prestudy values of 461 +/- 332 microg/day to 161 +/- 207 microg/day (p<0.000001). The mean eosinophil counts fell from 5.80 +/- 4.90% (+/- SD) to 4.84 +/- 4.42% (+/- SD) (p=0.02). Symptom scores improved significantly as did subjective assessment of discomfort. A total of 29 (19.6%) adverse events were reported, all of which were of mild to moderate intensity. Monotherapy with montelukast significantly improved parameters of asthma control. It was well tolerated with no reports of serious or severe adverse events.

Metrondazole-induced neurotoxicity.

A 50 year old male with history of prolonged intake of metronidazole for treatment of liver abscess developed acute ataxia, disorientation, distal symmetrical sensory and proximal motor neuropathy. Patients being treated with metronidazole particularly those on high doses for prolonged period should be monitored for neurotoxicity.

Behavioural parameters in hypertensives on atenolol therapy.

Behavioural responses which included psychological tests and cold pressor test as a stress test were studied in 20 mild to moderate hypertensives of both sexes, excluding smokers, alcoholics, secondary hypertensives and patients of chronic obstructive pulmonary diseases. Subjects were put on 2 weeks of placebo washout period followed by 6 weeks of treatment with atenolol. Following treatment with atenolol they showed no significant alteration in the scores of psychological tests which included Weschler adult intelligence scale for orientation, while showing significant depression in the rise of heart rate, systolic blood pressure and diastolic blood pressure following cold pressor test. On further analysis, the results showed that hypertensives on placebo had lower scores of memory and attention test as compared to normotensive controls. Besides this, hypertensives on placebo had higher rise of heart rate and systolic blood pressure as compared to normotensive controls after cold pressor test.

Leukemoid reaction in amoebic liver abscess.

A case of amoebic liver abscess with leukemoid reaction is described. This patient also had jaundice as the presenting feature. Therapy with metronidazole resulted in improved general condition and both blood picture and liver function tests also became normal.

Fat and oil inhibit phosphine release from aluminium phosphide--its clinical implication.

Poisoning by suicidal or accidental ingestion of aluminium phosphide (AlP) is a frequent medical emergency seen all over the world. AlP, a grain fumigant and rodenticide, on exposure to moisture, liberates highly toxic gas, phosphine. The rapidly inhibits mitochondrial respiration and has cytotoxic action. No specific antidote is known against it till date and prognosis depends much on dose and time lag between AlP ingestion and the stomach wash in the hospital (critical period). Physicochemical properties of AlP and nonmiscibility of fat and water promoted us to study the effect of different fats and oils as possible antidotes to inhibit phosphine liberation. In vitro experiments revealed that vegetable oils and liquid paraffin were much more effective than butter and ghee in inhibiting release of phosphine from AlP. These findings may have significant clinical implication.