Thromboembolic Occlusion of Left Bracheal artery Protein-C and Protein-S Deficiency – A Case Report.

Protein-C and Protein-S deficiency states are responsible for 3-5% (Protein-C) and 2-3% (Protein-S) of patients with venous thrombosis. Some cases of arterial thrombosis have been reported. It occurs twice as often in female as in males. A 50 years old lady presented with acute severe pain in the left upper limb for 2 days. On investigation she was diagnosed as a case of bracheal artery thrombosis with Protein-C & Protein-S deficiency. Bracheal thromboembolectomy was done and discharge her with life long warfarin therapy. In one year follow up the patient had no untoward event and INR done every month and warfarin is adjusted.

An evaluation of door to needle time (DNT) of thrombolytic therapy following acute myocardial infarction in three large tertiary referral hospitals in Dhaka City.

This study was conducted in three tertiary hospitals in Dhaka city at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka Medical College Hospital (DMCH) and National Institute of Cardiovascular Disease (NICVD) as a part of Inter-Heart Study. Secondary data was obtained from the standard questionnaires to determine door to needle time (DNT) following thrombolytic therapy in patients with Acute Myocardial Infarction (AMI) in coronary care units at three large tertiary referral hospitals in Dhaka city. Of total 192 patients studied in three centres, 156 (81.2%) received thrombolytic therapy. In BSMMU, 33 out of 45 (73.33%) patients received thrombolysis. Mean DNT was 147 minutes. Eighteen (55%) patients received thrombolysis within 90 minutes and 9 patients (27%) received with in 91-180 minutes, 6 patients (18%) received thrombolysis after 180 minutes. In DMCH, 44 out of 57 patients (77.1%) received thrombolysis. Mean DNT was 210 minutes. Five patients (11%) received within 90 minutes, 19 (43%) received thrombolysis between 91 to 180 minutes and 20 patients (46%) received thrombolysis outside the range of 180 minutes. In the NICVD, 79 out of total 90 (87.7%) patients received thrombolysis. Mean DTN was 64 minutes. Sixty seven (82%) patients received therapy within 90 minutes, 6 patients (9%) received between thrombolysis 91-180 minutes and 6 (9%) patients received after 180 minutes of reaching hospital. Inspite of overall improvement in the management of patients with AMI in coronary care units of major teaching hospitals, there seem to remain certain difficulty in our system which causes delay in thrombolysing patients with AMI. In this study, the mean DNT for thrombolysis was quickest (64 minutes) at NICVD and slowest (210 minutes) at DMCH. Although the study was conducted almost four years ago, it gives some insight regarding strength and weaknesses in the infrastructure of public sector hospitals in our country.

Role of exercise tolerance test (ETT) and gated single photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) in predicting severity of ischemia in patients with chest pain.

This was an observational study carried out in the department of cardiology. Bangabandhu Shikh Mujib Medical University (BSMMU), Dhaka in collaboration with Institute of Nuclear Medicine (INM), Shabag, Dhaka during the period October 2002-March 2003. A total of 54 patients presenting with Canadian Cardiovascular Society (CCS) class I-II severity of chest pain with mean +/-SD age 49.88 +/- 8.44 yrs and having male to female ratio 5.75:1 were included in the study. The main objective of the study was to predict severity of myocardial ischemia by Exercise Tolerance Test (ETT) determined by Duke Treadmill Score (DTS) and by perfusion pattern observed following Single-Photon Emission Computed Tomography myocardial perfusion imaging (SPECT-MPI). All patients underwent ETT and then SPECT-MPI scan using Tc-99m-tetrofosmin in one-day stress and rest protocol. Coronary angiogram (CAG) was done with in six months of the perfusion study. After performing ETT, patients were categorized by DTS and myocardial perfusion studies were also stratified according to severity of perfusion defect. The formula used to calculate the score was: Exercise time- (5 x ST segment deviation)-(4 X Treadmill angina index). The angiographic findings (significant >50% stenosis) and perfusion defects in MPI were compared with the severity of DTS. There were 31 patients who had CAG proven (>50% luminal diameter narrowing) CAD and 23 patients free of CAD. After ETT patients were categorized by Duke Treadmill Score into high DTS 12 (22.22%) patients, intermediate DTS 20 (37.03%) patients low DTS 22 (40.74%) patients. In high DTS group 91.66% patients had perfusion defect, whereas in intermediate and low risk group it was 60% and 40.9% respectively. In high DTS group 91.66% of patients had angiographicaly proven CAD, 58.33% of them had triple vessel disease (TVD) while in intermediate and low risk groups angiographically proven CAD were 65% and 22.72% of whom TVD only in 15% & 0% respectively. The results of ETT using DTS score were satisfactorily correlated with SPECT-MPI scanning in high DTS subsets of patients only. It is therefore, suggested that patient of high risk DTS do not need for myocardial perfusion imaging study and should undergo CAG for further evaluation. But the intermediate and low risk groups were needed myocardial perfusion imaging study to guide for further evaluation.

Improvement in pulsed wave Doppler echocardiographic assessment of pulmonary artery pressure.

Non invasive estimation of pulmonary artery pressure (PAP) is of paramount importance in various form of cardiac, respiratory and intensive care medicine practice. Using pressure gradient between different chambers enables a reliable estimation of PAP and are being largely practiced. In absence of these pressure gradient, various time interval or the ratios of pulmonary blood flow velocity curve (PBFVC) in pulsed wave doppler echocardiography (PWDE) can predict the PAP. But there is lack of general agreement as which parameter should be used. We hypothesized that using separate time interval or their ratios of PBFVC for different group of patient may improve the PWDE prediction of PAP. Forty-six consecutive patients with different cardiac diseases and 20 consecutive control persons underwent PWD echocardiographic examination. Pulmonary blood flow velocity curve derived time intervals--the time intervals--time to peak velocity (TPV), Pre-ejection period (PEP) and right ventricular ejection time (RVET) and their ratios were measured. The Doppler derived measurements were compared with cardiac catheterization (CC) measured PAP in 46 patients in whom CC were done. PBFVC derived time interval TPV and the ratio PEP/TPV correlated well with CC measured systolic PAP (r=-0.78 and r=0.77 respectively). For congenital left to right shunt disease the ratio PEP/TPV improved the prediction (r=-0.87) while the same measure showed weak correlation in patients with left sided heart disease. Only TPV could predict mean PAP in patients with left sided heart disease (r=-0.60). We concluded that the use of separate PBFVC derived time interval or their ratio from PWDE may improve the prediction of PAP with different pathological group of disease.

Streptococcal antibodies among rural school children in Bangladesh.

The upper limit of normal values of group A streptococcal antibodies should be known for a population concerned because it is influenced by many local conditions. As yet the reference value of the these antibodies has not been determined by using a quantitative method among Bangladeshi children. We determined the reference value of anti-streptolysin O and anti-deoxyribonuclease B among 361 apparently healthy rural Bangladeshi primary school children (aged 5 to 14 years, mean 9.2 years). Anti-streptolysin O was measured by an auto-analyzer and antideoxyribonuclease B was measured by microtitre method. The geometric mean titres for the entire group was 241 IU/ml and 222 IU/ml for anti-streptolysin O and anti-deoxyribonuclease B respectively. The upper limit of normal values (80th percentile) was 390 and 340 for anti-streptolysin O and anti-deoxyribonuclease B, respectively. These limits should be of value to physicians, epidemiologists and clinical laboratory personnel as well.

An unusual case of ABO-haemolytic disease of the newborn.

Haemolytic disease of the newborn (HDN) is a clinical condition in which foetal red blood cells are destroyed by maternal alloantibodies directed against red cells antigens acquired from the father. These antibodies usually belong to the Rhesus (Rh) or ABO blood group systems. ABO-HDN is usually a sub-clinical condition and less severe than Rh-HDN. The placenta is relatively impermeable to naturally occurring IgM anti-A/anti-B antibodies. However, immune anti-A and anti-B of the IgG type will cross the placenta and may thus cause ABO-HDN. ABO-HDN is the commonest in Group O mothers having A infants. Occasionally it is seen in Group O or A (A2) mothers of Group B infants. The most severe disease is seen in immune anti-B rather than anti-A antibodies. There are at present no satisfactory methods to predict ABO-HDN in the antepartum period. We report here a case of ABO-HDN where mother who was B, Rh-positive; delivered a baby girl of A1B, Rh-positive who developed severe haemolytic disease. The baby was the third child. To our knowledge this is the first of this kind of severe ABO-HDN in Bangladesh and one of the rarest ABO-HDN cases in the world.

Humoral immune response in a sample of Bangladeshi children with rheumatic fever.

Several researchers have investigated cellular response, and antibody response to different antigens of group A beta-haemolytic streptococci, cardiac tissues and B cell alloantigen in rheumatic fever (RF). However, immunoglobulins (Ig) which may indicate general immune status did not receive attention. This study was done in the outpatient clinic of the National Center for Control of Rheumatic Fever and Heart Diseases, Dhaka, to compare Ig levels in subjects with and without RF who have had recent group A beta-haemolytic streptococcal infections. We have recruited 44 RF cases aged 5 to 20 years, and 44 subjects without RF were randomly matched for age and sex as controls. Convalescent blood samples were used to measure antistreptolysin O and IgG, IgM, and IgA levels. The cases, as compared with the controls, had significantly higher levels of antistreptolysin O (mean 399 versus 321 IU/ml), IgG (mean 2386 versus 1885 mg/dl), IgM (mean 286 versus 222 mg/dl) and IgA (mean 258 versus 184 mg/dl). It is not clearly known why the immune response is higher in the RF cases. We have to elucidate factors responsible for higher immune response in children with RF.

Frequencies of cytotoxic T lymphocyte precursor estimate in three different populations.

There is speculation that high cytotoxic T lymphocyte precursor frequencies (CTLpf) correlate with poor clinical outcome of bone marrow/organ transplantation. It is also believed that human umbilical cord blood is immunologically naive, and, therefore cord blood T cells may be less able to mediate graft versus host disease than marrow-derived T cells. CTLpf were determined in peripheral blood mononuclear cells collected from healthy adults, human umbilical cord blood and renal dialysis patients who were randomly selected and entered into this study. A highly sensitive non-radioactive Europium release cytotoxicity assay was optimized and modified to carry out the CTLpf estimation by using the principle of limiting dilution analysis. The results of CTLpf in healthy adults ranged from 1/694 to 1/66,666, median 1/7,339 (n=10); cord blood ranged from 1/1,562 to 1/35,714, median 1/10,162 (n=6) and dialysis patients ranged from 1/1,054 to 1/17,857 median 1/5,208 (n=9). The results demonstrated that there is little difference of CTLpf median values between the groups, but there is a wide variation of CTLpf between individuals within a population. It suggests that this variation should be taken into account when considering CTLpf assay as pre-transplantation cross-match procedure.

Association of angiotensin converting enzyme (ACE) gene polymorphism with hypertension in a Bangladeshi population.

The association of angiotensin converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism with hypertension has not been confirmed. Inconsistencies may be due to the differences of background population characteristics. Till date, there has been no report in Bangladeshi population. This study was to examine the association of ACE (I/D) polymorphism with hypertension. Fifty-one primary hypertensives and fifty-two normotensives were recruited from a hospital in Dhaka city. Height, weight and blood pressure were measured. ACE (I/D) genotypes was established using polymerase chain reaction protocol. The genotype and allele frequencies did not differ significantly (P > 0.05) between the groups. In logistic regression analysis, adjusted for age, sex and body mass index, the genotypes were not associated with hypertension (DD vs II: Adds ratio = 2.6, P = 0.34; ID vs II: 0.4, 0.23; ID + DD vs II: 0.8, 0.69). In this hospital-based sample of Bangladeshi people, significant association of ACE I/D genotype with hypertension was not observed.

Prevalence of streptococcal sorethroat in the school children of Dhaka.

Beta Haemolytic Streptococcal (BHS) infections and their sequelae Rheumatic Fever (RF) and Glomerulonephritis (GN) have a world wide distribution and so pose an important health problem. Reports show that there is considerable variation in the number of isolations from different groups. Present study intended to find out the health status of the school children in relation to streptococcal throat infection, in Dhaka Cantonment. It was a cross sectional, observational study. During one year period total six hundred and one (601) children were examined from one school of Dhaka Cantonment. Prevalence of streptococcus was found to be 22% among the study population with highest rate (67%) for group-G among BHS positive cases. True streptococcal infection was found in 8.7% cases & 2.2% cases were true GABHS positive cases. GABHS was significantly higher in large size families. Females and children from lower socioeconomic group were at higher risk. Females and children of large families may require special attention regarding prevention of streptococcal infection and RF/RHD prevention programme.