A View on Combination Antiplatelet Agents in Ischemic Stroke.

The evaluation of antiplatelet agents for prevention of ischemic stroke is being focused as a strategy for stroke reduction. The aim of this analysis was to focus specifically on the necessity of combination antiplatelet agents for secondary prevention of ischemic strokes. Aspirin, clopidogrel, ticlopidine and the combination of aspirin plus extended-release dipyridamole are all effective in reducing the risk of recurrent ischemic strokes and transient ischemic attack. Furthermore, the combinations of all above drugs show some merits and demerits in one or more condition. National guideline endorses any of these antiplatelet agents as appropriate treatment options but more research into this strategy is needed. Choosing a single antiplatelet agent or the combination must be tailored according to patient characteristics, cost, disease condition and tolerability. Other classes of antiplatelet drugs should undergo clinical trials to optimize antiplatelet therapy.

A profile of skin disorders in children in Saurashtra.

Four hundred children, up to the age of 12 years, attending dermatological outpatients' department (OPD) in Irwin group of hospitals, Jamnagar were studied in detail. Desired investigations were done in addition to routine blood, urine, and stool examinations. Maximum number of cases (43.50%) were found in school going children. Highest number of cases were of skin infections (83.25%) followed by allergic (8.5%) and miscellaneous disorders (8.25%). Out of 333 cases of skin infections, 137 (41.14%) were of pyoderma, 113 (33.93%) of parasitic infections, 45 (13.51%) of fungal infections and 35 (10.51%) of viral infections. Amongst allergic disorders, atopic dermatitis was commonest followed by papular urticaria, unclassified eczema and contact dermatitis. Thirteen types of miscellaneous disorders (33 cases) were noted. Commonest being vitiligo (8 cases) and epidermolysis bullosa and ichthyosis, 6 cases each. Unhygienic living conditions seem to be an important factor responsible for higher incidence of skin infections in developing countries.

CSF/blood glucose ratio and other prognostic indices in pyogenic meningitis.

Fifty cases of pyogenic meningitis were examined for various prognostic indices, especially cerebrospinal fluid (CSF)/blood glucose ratio. Overall mortality was 40%. Age below one year and depressed level of consciousness were associated with high mortality. Illness of more than 7 days, presence of associated illness and absence of neck rigidity were not found to be statistically significant factors associated with higher mortality. CSF leucocyte count of more than 1000 cells/cmm and CSF protein more than 500 mg/dl were statistically significant factors associated with higher mortality. In cases of CSF glucose level below 20 mg/dl and CSF/blood glucose ratio below 0.2, the increase in mortality was highly significant. CSF/blood glucose ratio in cases who recovered was much higher than those who died. CSF/blood glucose ratio increased to normal in cases who recovered but remained low in cases who expired.

Lectin mediated binding of Streptococcus pyogenes to human oropharyngeal mucosal epithelial cells.

The study was carried out to determine the role of lectins and sugars in the adhesion of S. pyogenes to human pharyngeal and buccal epithelial cells. In vitro adhesion assay has shown that Con A and Dolicos biflorus lectins inhibited the attachment of S. pyogenes to the oropharyngeal mucosal cells. Among different sugars used, N-acetyl-D-galactosamine and D-galactose have significantly blocked the binding of streptococci to PEC and BEC. These findings indicate that lectins and sugar molecules mediate the adhesion of S. pyogenes to the pharyngeal epithelial cells which may be important in the cellular pathogenesis of streptococcal infections which originate at the human oropharyngeal mucosa.

Epidemiology of coronary heart disease in a rural Punjab population--prevalence and correlation with various risk factors.

An epidemiological study to find out the prevalence of coronary heart disease (CHD) and the influence of risk factors on the prevalence of CHD in a total rural community of Punjab was conducted in Pohir, situated near Ludhiana. A total of 1100 individuals (623 males and 477 females) out of a possible 1617 individuals (> 30 yrs) living in 3 villages were studied. In each case a detailed history, physical examination and a 12 lead electrocardiogram (ECG) were recorded. Samples for blood sugar and serum cholesterol were taken. By Epstein's criteria of ECG (using the Minnesota coding), the prevalence of CHD was 30.8/1000, being higher in women (37.7/1000) than in men (25.6/1000). By a clinical judgement method considering history, ECG and treadmill testing (TMT) collectively, prevalence was 31.8/1000, being still higher in women (33.5/1000) than in men (30.5/1000). The prevalence of various risk factors like hypertension, smoking, hypercholesterolemia and diabetes was found to be 14.5%, 8.9%, 7.0% and 4.6% respectively. Of the various risk factors tested, hypertension, hypercholesterolemia and a positive family history showed an association with CHD. Only 38% of patients with CHD, 37% of the hypertensives and 52% of the diabetics were aware of its presence. The knowledge in the general population about risk factors causing CHD is poor.

Can common exercise indices determine peak exercise oxygen consumption and anaerobic threshold during stress testing in patients with chronic congestive heart failure?

Maximal oxygen consumption (VO2 max) is one of the most important predictors of prognosis in chronic heart failure and is now used to define degree of heart failure. While most centres can routinely do treadmill exercise testing (TMT), VO2 max measurements are not widely available. We, therefore, analysed the ability to predict VO2 max from common TMT variables: Peak exercise heart rate, exercise time, and METS achieved in 26 patients with chronic congestive heart failure (NYHA II-III, ejection fraction 43 +/- 2%) in whom exercise VO2 studies were simultaneously done by breath to breath expiratory gas analysis using a metabolic cart. METS achieved during exercise and exercise time correlated reasonably well although not perfectly (r = 0.78 & 0.73 respectively, tail critical value +/-0.41). Resting ejection fraction did not correlate at all (r = 0.0004). The regression equation (2.7) (METS) + 5.8 defined VO2 max with SE of 0.47. Although in unvariate analysis, exercise time, METS achieved & peak heart rate predicted VO2 max, only METS achieved was predictive in step wise regression. None of the parameters predicted the anaerobic threshold accurately although there was a modest relation between AT and peak exercise VO2. We conclude that most exercise variables do not accurately predict VO2 max in patients with chronic congestive heart failure. METS achieved is the best predictor and the VO2 max can be predicted using a regression equation. Anaerobic threshold cannot be predicted without tests involving expiratory gas analysis.

Study of acute mountain sickness during "rapid ascent" trekking to extreme altitude.

Acute mountain sickness (AMS) is an important cause of morbidity and mortality following acute exposure to high altitude. Several clinical variables were evaluated during the 1990 Trans-Kalindi Exploration to extreme altitude (5949 m) in 10 healthy adult lowlanders (age 31.7 +/- 6.4 yrs) who undertook a relatively rapid ascent from sea level to 5949 m with short periods of acclimatisation at 4393 m, 4898 m and 5700 m. 40% of the subjects had definite AMS. Only one subject had features of early cerebral oedema at 4393 m and had to be brought down temporarily to 3878 m. All subjects completed the trek without needing medication. Proper acclimatisation was characterised by absence of significant symptoms of AMS above 4500 m, absence of sustained tachycardia, fall in daily positive fluid balance from 1.7 +/- 0.9 (sea level) liters to 0.7 +/- 0.3 litres (at 5700 m) (p < 0.05), increase in 24 hours urinary sodium excretion from 174 +/- 78 mmol to 344 +/- 145 mmol (p < 0.01) and an increase in the ratio of urinary excretion of sodium and potassium from 3.1 (sea level) to 3.6 (5700 m). We conclude that the incidence of AMS at extreme altitude is similar to that at lower altitude. Reasonable acclimatisation is possible during the climb to extreme altitude.

Relation between major indices of prognosis in patients with chronic congestive heart failure: studies of maximal exercise oxygen consumption, neurohormones and ventricular function.

Peak exercise capacity (Peak VO2), neurohormonal changes, ventricular enlargement and ejection fraction are among the most important determinants of prognosis in congestive heart failure. However, the inter-relation between these parameters is unknown. We, therefore, correlated these indices in patients with hemodynamically severe congestive heart failure (NYHA class II, pulmonary artery wedge pressure 25 +/- 2 mm Hg, cardiac index 2.5 +/- 0.2 l/min/m2, ejection fraction 43 +/- 2% and fractional shortening 19 +/- 1%). Peak VO2 measured directly during exercise by breath to breath expiratory gas analysis using a metabolic cart was 23 ml/min/kg. Plasma epinephrine (E) and norepinephrine (NE) were measured by high performance liquid chromatography (HPLC) and plasma renin activity (PRA), aldosterone (Aldo), cortisol, prolactin, growth hormone, anti-diuretic hormone (ADH) and antinatriuretic peptide (ANP) by radioimmunoassay. Ejection fraction was measured by echocardiography. There was no relation between peak VO2 and any of the neurohormones E: r = -0.43, NE: r = -0.43, ANP: r = -0.49, Cortisol: r = -0.37, ADH: r = -0.07, Aldo: r = -0.45, 2 tail critical value 0.55. PRA showed a modest correlation (r = -0.61). Similarly, there was no relation between ejection fraction or degree of ventricular enlargement and any of the other indices (r = -0.05). We conclude that although peak VO2, neurohormonal profile and ventricular function are important individual prognostic determinants, there seems to be no direct relation between them.

Feasibility of thrombolytic therapy--a one year prospective study.

A one year prospective study was conducted on all the patients admitted with clinical diagnosis of acute myocardial infarction (AMI) to determine the proportion of patients who can be given thrombolytic therapy. Factors responsible for non-administration were analysed. 213 patients with AMI entered the study. Standard inclusion criteria for thrombolytic therapy were used. 101 (47%) patients failed to meet the inclusion criteria. This included 7 (3.3%) who failed to satisfy the electrocardiographic (ECG) criteria. Nine patients with atypical symptoms were unable to reach within the stipulated 6 hours while the remaining 85 (40%) patients were delayed inspite of typical features due to inability of the patient to attribute the symptoms to the heart, lack of proper transport facility and self medication. 112 patients (53%) met the inclusion criteria but 7 patients were excluded because of age (> 70 years), and another 8 because of contraindications. Of the remaining 97 patients, 47 failed to receive thrombolytic therapy due to lack of awareness of the benefits of thrombolytic therapy by the first treating physician, misinterpretation of ECG, inability to afford and refusal to give consent. Only 50 patients (23%) received thrombolytic therapy. This low figure can be easily improved upon by the correction of a number of remediable factors.

Do hemodynamic indices correlate with maximum exercise capacity and oxygen consumption in chronic congestive heart failure?

The mechanism of exercise intolerance in chronic congestive heart failure remains unclear. We correlated resting haemodynamic variables with the peak exercise capacity and maximum oxygen consumption (VO2 max) in patients with congestive heart failure in 27 studies on treadmill exercise testing using the modified Bruce protocol. VO2 max was measured using breath by breath expiratory gas analysis. The patients were in severe congestive heart failure (NYHA class II and III, pulmonary artery wedge pressure 23 +/- 2 mmHg, cardiac index 2.4 +/- 0.21 l/min/m2). VO2 max was 23 +/- 2 ml/kg/min. Fatigue was the commonest symptom limiting the exercise. None of the hemodynamic variables correlated well with VO2 max. [right atrial pressure (r = 0.08), pulmonary artery pressure (r = 0.05), pulmonary artery wedge pressure (r = 0.08), aortic pressure (r = -0.3) & cardiac index (r = 0.29)]. Both uni- and multi-variate analysis failed to show any relation between VO2 max and resting hemodynamic variables. We conclude that unlike the acute heart failure syndromes, resting hemodynamic variables do not correlate with exercise capacity in patients with chronic congestive heart failure. The abnormal resting haemodynamics do not limit exercise in these patients. Peripheral mechanisms may thus be more important.

Aluminium phosphide poisoning: haemodynamic observations.

Haemodynamic measurements were made on 25 patients with aluminium phosphide poisoning. There was severe hypotension (mean arterial pressure 62.7 +/- 19.3 mmHg) and reduction in cardiac output (2.13 +/- 0.9 lit/min/m2). However, the systemic vascular resistance was only moderately elevated (2050 +/- 732 dynes/m2). The right atrial pressure was increased but the pulmonary artery and pulmonary capillary wedge pressures were normal, even in patients with pulmonary oedema. Thirteen patients (52%) who died had a lower cardiac output (p less than 0.05). Saline infusion significantly improved haemodynamics in some patients. Its judicious use early in the course of treatment may be beneficial.

Role of foetal echocardiography in predicting perinatal outcome.

To establish foetal cardiovascular parameters as predictors of perinatal outcome in pregnancy, M-Mode, 2-D echocardiography and pulse Doppler study was performed at 24-32 weeks of gestation in 65 pregnancies. These pregnancies were followed up for perinatal outcome. The studied population included 24 normal pregnancies, 21 pregnant women with heart disease (14 rheumatic and 7 congenital heart disease) and 20 high risk pregnancies (bad obstetric history in 7, suspected intrauterine growth retardation in 4, hypertensive disease of pregnancy in 6 and diabetes mellitus in 3). There was no perinatal mortality. Two foetuses were born with complete heart block and one with a small ventricular septal defect; 6 neonates had intrauterine growth retardation and two of these had neonatal asphyxia with APGAR score less than 6 at one minute. Anatomically normal heart was correctly diagnosed in all 64 foetuses and ventricular septal defect was detected antenatally in one. Antenatal diagnosis of complete heart block was correctly made in two foetuses. One new born with complete heart block required a permanent pacemaker, which was implanted. The ratio of peak velocity across mitral valve during atrial systole (A) to peak velocity during early diastolic ventricular filling (E) was chosen to correlate with perinatal outcome. The ratio was less than 1.0 in 6 foetuses, all of whom were subsequently confirmed to have intrauterine growth retardation. In normal pregnancies A/E ratio was more than 1.0. We conclude that foetal echocardiography is a useful tool for predicting perinatal outcome and may be helpful in screening patients who require specific perinatal management.

Evaluation of pulmonary hypertension in chronic rheumatic mitral regurgitation.

The incidence of pulmonary arterial hypertension (PAH) in 39 patients with angiographically proven chronic rheumatic mitral regurgitation (MR) is reported. The overall incidence of PAH were found to be 76.9%. There were 51.3% patients with mild, 15.4% with moderate and 10.2% with severe PAH. Pulmonary arterial hypertension was present in 93% of patients below 20 years of age. Clinical and radiological assessment of PAH did not show any correlation with the haemodynamic data. Electrocardiographic right ventricular hypertrophy was seen in 4, and biventricular hypertrophy in 5 patients. All of them had moderate to severe PAH. Echocardiographic left atrial (LA) size showed an inverse correlation with mean pulmonary artery pressure (PAP) (p less than 0.001), r = 0.63). Presence of mid-systolic notch in pulmonary valve echoes indicated mean PAP more than 37mmHg (mean 54.1 +/- 19.1). Fifty-six percent patients with mid-systolic notch had moderate to severe PAH. Sixteen (94%) out of 17 patients with raised left ventricular end diastolic pressure had elevated mean PAP, and 30% of them had moderate to severe PAH. This data shows that pulmonary hypertension is relatively common in our patients with chronic rheumatic MR, and that the severity of PAH correlates well.