Types of Rotavirus Causing Acute Diarrhea among Children in Western India, their Demographic Pattern and Disease Severity.

Background: Rotavirus infection is a major cause of severe acute gastroenteritis among infants and children all over the world1 with winter out-breaks of diarrhea in temperate and cooler parts almost round the year. However, this varies in different part of India.2-6 Diarrhea is a major cause of under-5 mortality, contributing to approximately over 1,50,000 infant deaths in our country per year.15,16 Different genotypes have been identified and many more are emerging by way of mutation, genetic shift and genetic drifts. Rotavirus are classified antigenically as A (Most common), B, C, D, E by ELISA and genotypically as G (1 through 12) and P (1 through 8) by Reverse Trans criptase PCR, in combinations. Materials and methods: Stool samples of 110 infants and children from 6 to 60 months of age, with suspected viral diarrhea over one year period were studied for serotypes and genotypes; and compared for their respective disease severity. Results: Thirty-four percent were found positive for Rotavirus-A by ELISA. Of the positive, 33.4% were found to be of G9 genotype, much higher than reported from other parts of the country. On the other hand, merely 13.6% of G1 and G4 each were detected, contrary to high prevalence elsewhere. On electro-pherotyping, the long-arm types were associated with more severe disease (64.6% showing moderate to severe dehydration) than their short-arm types (Only 16.6% showed moderate dehydration only) p < 0.009. No difference in incidence of severe dehydration between AD positive for Rotavirus (11.7%) and those found nega tive (11.8%), presumably due to other viruses, after excluding invasive diarrhea. Conclusion: Emergence of diverse strains, i.e. more of G9 and G12 genotypes than earlier reports of G1 and G2 types indicate considerable genetic shift in the region. Such trend could have significant implication on degree of seroconversion from currently used live vaccines, using G1 or bovine reassortant G1-3 strains only, seen in recent studies from Africa and Malayi.29 Contrary to claims that Rotavirus diarrhea usually threatened severe diarrhea, no significant difference in incidence of severe diarrhea was observed between Rotavirus positive and Rotavirus negative acute diarrhea.

Non-invasive assessment of arterial stiffness by pulse-wave velocity correlates with endothelial dysfunction.

BACKGROUND: Pulse-wave velocity is the speed of the blood pressure wave to travel a given distance between two sites of the arterial system and is determined by the elasticity, wall thickness and blood density. Pulse-wave velocity correlates well with arterial distensibility and stiffness and is a useful non-invasive index to assess arteriosclerosis. Arterial endothelial dysfunction is one of the key early events in atherogenesis, preceding structural atherosclerotic changes. This study sought to establish the correlation of non-invasive estimation of arterial wall stiffness by pulse-wave velocity and its association with endothelial dysfunction in subjects at higher risk for atherosclerosis. METHODS AND RESULTS: A total of 102 subjects (60 males and 42 females, mean age 51 years), including those with hypertension (n = 39), type 2 diabetes mellitus (n = 26), concomitant type 2 diabetes mellitus and hypertension (n = 29) and primary dyslipidemia without diabetes mellitus and hypertension (n = 8). Pulse-wave velocity was measured by the Vascular Profiler 1000 (VP-1000) waveform analysis and vascular evaluation system, an automated, non-invasive, screening device. Endothelial function was assessed by flow-mediated dilation of the brachial artery. The brachial-artery diameter was measured on B-mode ultrasound images, with the use of a 7.0 MHz linear-array transducer. Mean brachial artery pulse-wave velocity on the right extremity was 1699 cm/s and on the left 1694 cm/s. Mean flow-mediated dilation in the study subjects was 3.6 +/- 8.4%. Mean brachial artery pulse-wave velocity in the right and left extremities and the higher value of brachial artery pulse-wave velocity of the two extremities showed a negative and significant correlation with flow-mediated dilation of the brachial artery (correlation coefficient r = -0.32, p = 0.001; r = -0.40 p < 0.0001; r = -0.37, p = 0.001, respectively). Mean heart-brachial pulse-wave velocity also showed a negative and significant correlation with flow-mediated dilation of the brachial artery (r = -0.23, p = 0.022). Mean arterial stiffness was 36.2 +/- 22%. Arterial stiffness in the right extremity and the higher value of the two extremities showed a negative and significant correlation with flow-mediated dilation of the brachial artery (correlation coefficient r = -0.31, p = 0.002; r = -0.32, p = 0.001, respectively). CONCLUSIONS: Increased values of pulse-wave velocity reflecting upon arterial stiffness show an excellent correlation with reduced values of brachial artery flow-mediated dilation. We propose that the non-invasive modalities of estimation of the pulse-wave velocity and endothelial function estimation by flow-mediated dilation of brachial artery be used in clinical practice in assessment of pre-clinical atherosclerosis.

Thrombocytopenia in malaria--correlation with type and severity of malaria.

AIM OF THE STUDY: Malaria is a major health problem in the tropics with increased morbidity and mortality. Thrombocytopenia is a common finding in malaria. Although a reliable diagnostic marker, prognostic implications could vary in the two types of malaria. This study was undertaken to correlate the presence and severity of thrombocytopenia with the type of malaria. DESIGN: A total of 1565 subjects were included in the study and identified positive for malaria parasites on peripheral smear examination with conventional microscopy. Platelet count was done on a fully automated, quantitative, hematology Coulter analyser. RESULTS: Normal platelet count was noted in 21.6% cases. The mean platelet count in vivax malaria (n=973) was 1,15,390/microl (SD 64,580) with a range of 8000-5,73,000/microl, as against falciparum malaria (n=590) where the mean platelet count was 100,900/microl (SD 75,437) with a range of 2000-497,000/microl (Pearson coefficient 8.825, p < 0.0001). Platelet count < 20,000/microl was noted in only 1.5% cases in vivax malaria as against 8.5% cases of falciparum malaria, and none of the subjects with vivax malaria had a platelet count less than 5000/microl. CONCLUSION: Although absence of thrombocytopenia is uncommon in malaria, its presence is not a distinguishing feature between the two types. Thrombocytopenia less than 20,000/microl can occur in P. vivax malaria although statistically more common with P. falciparum malaria. The above findings can have therapeutic implications in context of avoiding unnecessary platelet infusions with the relatively more benign course in P. vivax malaria.

Apolipoproteins: correlation with carotid intimamedia thickness and coronary artery disease.

BACKGROUND: Lower levels of plasma apolipoprotein AI (Apo A-I) and higher levels of ApoB, and the ratio of ApoB to ApoA-I are considered to be independent risk factors for coronary heart disease, and may assume importance in the definite subset of Indian patients with normal levels of traditional lipid risk factors and an early-onset of coronary artery disease (CAD). Carotid intima-media thickness is considered as a marker of atherosclerosis and in prediction of clinical coronary events and coronary artery disease. With increasing interest in the role of non-traditional lipid risk factors in CAD and few studies reported in Indian subjects, we undertook this study to correlate the apolipoprotein levels with CAD and their impact on arterial thickening utilizing the carotid intima-media thickness as a surrogate marker. METHODS AND RESULTS: Traditional lipid profile, apolipoprotein A-I and B and carotid artery Intima-media thickness (IMT) with a B-mode scan were measured in 309 patients recruited for the study (age group 36-64 years), which included 193 males and 116 females. Mean of maximal IMT exceeding 0.8 mm at the far wall of common carotid artery, excluding plaques, was selected as the higher values for comparison. One hundred and twenty two subjects had evidence for CAD as diagnosed by documented hospitalization with myocardial infarction or acute coronary syndrome, coronary angiography when feasible or noninvasive cardiac evaluation. Prevalence of subjects with increased IMT was higher among subjects with an apolipoprotein B: apolipoprotein A-I ratio exceeding one compared to those with a ratio less than one (30.6% vs 16.5%, p = 0.005). Prevalence of CAD was significantly higher among subjects with apolipoprotein B: apolipoprotein A-I ratio exceeding one as compared to those with a ratio less than one (53.7% vs 30.3%, p = 0.0002). Subjects with apolipoprotein B: apolipoprotein A-I ratio exceeding one and carotid IMT more than 0.8 mm had a 2.7-fold prevalence for CAD as against those with a ratio less than one and IMT less than 0.8 mm. On multivariate logistic regression analysis, apolipoprotein B: apolipoprotein A-I ratio exceeding one was significantly associated with increased IMT (odds ratio 2.27) and CAD (odds ratio 2.50) even after inclusion of sex, smoking, body mass index, total cholesterol, LDL-cholesterol, HDL-cholesterol, total cholesterol:HDL-cholesterol ratio and serum triglycerides into the model. CONCLUSIONS: We conclude that apolipoprotein B to A-I ratio shows a strong association with carotid intimal medial thickening and coronary artery disease in this Western Indian population and may play an important role is assessment of coronary risk in addition to traditional coronary risk factors.

Noninvasive assessment of endothelial dysfunction by brachial artery flow-mediated dilatation in prediction of coronary artery disease in Indian subjects.

BACKGROUND: A noninvasive technique for testing endothelial function by ultrasound measurement of flow-mediated dilatation has recently generated considerable interest as a marker of atherosclerosis, and in the prediction of clinical coronary events and coronary artery disease. METHODS AND RESULTS: We measured the flow-mediated dilatation of the brachial artery (endothelium-dependent vasodilatation) in 136 subjects, with or without evidence of coronary artery disease. Endothelial dysfunction was diagnosed if flow-mediated dilatation was less than 4.5%. Of the 136 subjects (age group 40-70 years) recruited for the study, 94 were males and 42 females. Sixty-eight subjects had evidence of coronary artery disease as diagnosed by documented hospitalization due to myocardial infarction or acute coronary syndrome, proved by coronary angiography when feasible or noninvasive cardiac evaluation. Endothelial dysfunction was detected in 90 subjects (66.2%). Prevalence of coronary artery disease was higher among subjects with endothelial dysfunction compared to those without (57.5% v. 34.7%, p=0.013). Prevalence of endothelial dysfunction was significantly higher among subjects with coronary artery disease as compared to those without coronary artery disease (76.4% v. 55.8%, p=0.012). The present study showed a sensitivity of 76%, specificity of 44%, positive predictive value of 58% and negative predictive value of 65% for endothelial dysfunction in the prediction of coronary artery disease. Multiple regression analysis using coronary artery disease as a dependent variable revealed a statistically significant association with endothelial dysfunction (p=0.033) even after the inclusion of traditional risk factors into the model. CONCLUSIONS: We conclude that endothelial dysfunction shows a strong association with coronary artery disease and can be a useful noninvasive tool for the evaluation of coronary artery disease.

Association of microalbuminuria with carotid intima-media thickness and coronary artery disease--a cross-sectional study in Western India.

OBJECTIVE: Microalbuminuria, a slightly elevated albumin excretion in the urine, is considered a novel atherosclerotic risk factor, both in diabetics subjects and in general population. Carotid intima-media thickness assessed non-invasively by a B-mode ultrasound has been recently shown to be an early marker for atherosclerosis. This study aims at determining the role of microalbuminuria as an atherosclerotic risk factor and its association with coronary artery disease. METHODS: We measured the urine microalbumin excretion and carotid intima-media thickness (IMT) in 301 subjects, with or without evidence for coronary artery disease (CAD). Microalbuminuria was diagnosed if urinary excretion of albumin exceeded 20 microgm/ml. RESULTS: Of the 301 subjects (age group--30-80 years) recruited for the study, 194 were males, 107 females. One hundred amd eighteen subjects had evidence of CAD as diagnosed by documented hospitalization with myocardial infarction or acute coronary syndrome, coronary angiography when feasible or non-invasive cardiac evaluation. One hundred and sixty three subjects had diabetes mellitus. Microalbuminuria was detected in 74 subjects (24.6%). Prevalence of subjects with increased IMT was higher among subjects with microalbuminuria compared to normoalbuminuria (42% vs 21.4%, p < 0.003). Prevalence of CAD was significantly higher among diabetic subjects with microalbuminuria compared to those with normoalbuminuria (Diabetic subjects: 58% vs 31.9%, p = 0.002, Non-diabetic subjects: 41.7% vs 37.7%, p = 0.718). Multivariate logistic regression analysis using carotid intimal medial thickness as a dependent variable revealed a statistically significant association with microalbuminuria in diabetic subjects (p = 0.027). CONCLUSION: We conclude that microalbuminuria shows a strong association with increased carotid intimal medial thickening and coronary artery disease in diabetic subjects in this Western Indian population.

Carotid intima-media thickness as an independent predictor of coronary artery disease.

BACKGROUND: A noninvasive technique of measuring carotid artery intima-media thickness has recently generated considerable interest as a marker of atherosclerosis and in the prediction of clinical coronary events and coronary artery disease. The present study evaluated the association of carotid artery intima-media thickness in the prediction of coronary artery disease in a western Indian population. METHODS AND RESULTS: Carotid artery intima-media thickness was measured with a B-mode scan in an ongoing study of 266 patients, who were further subdivided into 4 subgroups: those with non-insulin dependent diabetes mellitus; hypertension; diabetes mellitus with hypertension; and those without diabetes or hypertension (labeled as controls). The maximal intima-media thickness greater than 0.8 mm at the far wall of the common carotid artery, excluding raised lesions and plaques, was selected as the highest value for comparison. The subgroups were further divided into those with and without apparent coronary artery disease. A statistically significant intima-media thickness greater than 0.8 mm was observed in 59.2% of the subjects with coronary artery disease as against 40.8% in those without the disease on univariate analysis. A higher incidence of intima-media thickness of more than 0.8 mm was observed in all subgroups with coronary artery disease as against those without the disease, which was most marked in the hypertensive group (22.2% v. 3.6%) and contributed to the increased arterial thickness in diabetics with concomitant hypertension. Multivariate regression analysis revealed carotid artery intima-media thickness to be associated with coronary artery disease with an odds ratio of 2.40. CONCLUSIONS: Carotid artery intima-media thickness is a simple, noninvasive and reproducible clinical tool to evaluate atherosclerosis and predict coronary artery disease in Indian subjects. Prospective studies in a larger number of subjects, particularly in those undergoing coronary angiography, will help in establishing the role of this technique.

Spontaneous expulsion of unusual tracheobronchial foreign body.

An extremely rare case of long, thin and sharp pin in a young boy which was inhaled initially and defied removal at branchoscopy was eventually recovered in stool after a long and variable course through alimentary tract has been reported.