Physical Frailty Phenotype and Depression are Associated with More Severe Disease in Older Subjects Presenting with Acute Coronary Syndrome.

OBJECTIVE: The primary objective was to determine the occurrence of frailty in elderly patients presenting with the acute coronary syndrome (ACS). The secondary objective was to study the association between the deficits in health with the severity of ACS at presentation among them. METHODS: A cross-sectional study conducted in the Departments of Medicine, Community Medicine and Biochemistry in a tertiary care teaching hospital, Delhi, India between November 2014 and April 2016. Patients (≥60 years age) presenting with any one of the spectra of ACS (STEMI, UA, NSTEMI) and giving informed written consent were assessed for frailty and health deficits using questionnaires. ACS assessed by ECG within 24 h and other relevant investigations. Appropriate statistical tests of significance like the Chi-square test were used and correlation coefficients were analyzed. A value of P < 0.05 was considered significant. RESULTS: Seven risk factors apart from old age were studied, in which smoking and dyslipidemia played a major role. 44% of the subjects were frail with the range of frailty scores between 3 and 5. Every one-unit increase in hemoglobin was associated with a reduction in the odds (OR 0.72) for being frail. No association was noted between the severity of ACS and established risk factors like smoking, hypertension, diabetes, family history of CAD, increased waist circumference, dyslipidemia, and male gender. On multivariable linear regression, presence of frailty and depression were associated with severe disease. CONCLUSIONS: Nearly one in two patients presenting with ACS were found frail. Depression and frailty were associated with poorer ejection fraction and severe disease. Correction of anemia and improvement of low-normal hemoglobin levels could reduce frailty and in-turn improve outcomes in ACS.

To study the prevalence and profile of metabolic syndrome, levels of hs-CRP, Lp(a) and serum ferritin in young Indian patients (< or = 45 years) with acute myocardial infarction.

OBJECTIVE: To study the prevalence and profile of metabolic syndrome, levels of hs-CRP, Lp(a) and serum ferritin in young Indian patients (< or = 45 years) with acute MI. METHODS: A total of 80 subjects in two groups (40 cases and 40 controls) of age < or = 45 years were studied. Diagnosis of MI was made using the American College of Cardiology and European Society of Cardiology guidelines for acute MI. Patients were assessed for presence of MetS, diagnosed as per modified ATP III criteria. The anthropometric measurements (including height, weight, waist circumference) and sample collection for lipid profile, fasting blood sugar, hs-CRP, Lp(a) and serum ferritin were done after seventy two hours of admission. RESULTS: The mean age for cases was 39.23 +/- 4.80 years and for controls it was 38.9 +/- 4.23 years. 19 (47.5%) patients out of 40 in group 1 fulfilled > or = 3/5 criteria for MetS while only 8 (20%) subjects in control group had MetS. Among five components of metabolic syndrome, increased waist circumference was most predominant factor followed by decreased HDL, increased TG, increased blood pressure and impaired fasting glucose. The mean value of serum ferritin was 279.33 +/- 46.69 mg in case group as compared to 245.15 +/- 56.94 in control group. hs-CRP (16.048 +/- 10.27 mg/l vs 1.8 +/- 1.6 mg/l) and Lp(a) (38.74 +/- 26.15 mg/dl vs 20.54 +/- 16.27 mg/dl) levels were significantly raised in cases as compared to control subjects. CONCLUSION: The present study revealed high prevalence of metabolic syndrome (47.5%) in young patients with acute MI. Serum hsCRP, a diagnostic and prognostic novel marker of inflammation was also significantly elevated in cases. Its relationship with metabolic syndrome is also well established. Lp(a) and serum ferritin were also raised in cases.

Disseminated tuberculosis: interesting hematological observations.

Disseminated tuberculosis can present in various ways including prolonged fever / pyrexia of unknown origin, hepatosplenomegaly, lymphadenopathy, meningitis and rarely extreme forms of hematological abnormalities such as pancytopenia and leukemoid reaction. We hereby report a case who presented with short history of fever, associated with vomiting and altered sensorium. He also had evidence of meningitis on neuroimaging with equivocal CSF finding. During his stay, he showed a spectrum of interesting hematological findings, including severe pancytopenia on peripheral smear, hemophagocytosis, epithelioid cell granuloma with Langhans' giant cells and focal necrosis consistent with tuberculosis on bone marrow examination. He showed an excellent clinical as well as hematological response to four drug antitubercular treatment (RHZE). The report highlights the significance of hematological picture in final confirmation of tuberculosis which may otherwise be passed off as nutritional or other unrelated causes.

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.

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.

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.

Correlation between dispersion of repolarization (QT dispersion) and ventricular ectopic beat frequency in patients with acute myocardial infarction: a marker for risk of arrhythmogenesis?

BACKGROUND: QT dispersion (QTd) has evoked a lot of interest in recent years as regards the basic concept of dispersion of repolarization, which it is supposed to reflect on a surface ECG, as being a marker or substrate for arrhythmogenesis. QTd has been shown to be high in patients with ventricular fibrillation and tachycardia. But there is still some debate about its possible role as a marker or substrate for arrhythmogenesis. We studied whether it has any correlation with simple benign ventricular ectopic beats (VEB) after acute myocardial infarction. STUDY: We studied four different dispersion parameters (QTd, QTcd, JTcd, AQTd) on 2 different days after AMI and also obtained a 24-h ambulatory ECG on the 2nd day after admission in 64 out of a total of 90 patients. Patients were divided into five groups based on VEB frequency/h on a 24-h ambulatory ECG. RESULTS: We found a gradual increase in dispersion parameters across the five groups with increasing frequency of VEB. A significant difference was noticed between group 1 (VEB 0.0-0.9/h) and group V (>30/h) on the day of admission: QTd 88.8+/-28.5 versus 123.3+/-23.4, P<0.02; QTcd 100.5+/-27.6 versus 160.3+/-30.7, P<0.01; JTcd 95.5+/-31.0 versus 160.4+/-30.9, P<0.01; AQTd 29.6+/-8.2 versus 48.6+/-13.7, P<0.01. We also noticed a significant positive correlation between VEB frequency and dispersion parameters on both days. CONCLUSION: We hypothesize that with increasing dispersion of repolarization the chances or the frequency of ventricular arrhythmias increase. Our findings also point to a definite role of QTd as an arrhythmogenic marker or substrate.

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.

Evaluation of oxidative stress in some cases of argimone oil poisoning during a recent outbreak of epidemic dropsy in India.

The study was designed to evaluate the oxidative stress and modulation of anti-oxidant enzymes in 10 accidental argimone oil poisoning cases admitted in a hospital in Delhi, India during a recent outbreak of epidemic dropsy in 1998. Serum malondialdehyde (MDA) level, oxygen free-radical scavenging enzymes such as superoxide dismutase (SOD) and catalase (CAT), and glutathione (GSH) and related enzymes, e.g. glutathione reductase (GR), glutathione peroxidase (GPx), gamma glutamyl transpeptidase (GGT) and glutathione-S-transferase (GST) in erythrocytes were assayed. The sanguinarine level in serum was measured by high-performance liquid chromatography. The serum MDA level was higher and the GSH level in erythrocytes was lower in argimone oil poisoning cases than those in controls. There was a significant decrease in SOD and GPx activities in erythrocytes of epidemic dropsy cases but no changes were observed in CAT, GR and GST assay. The depletion of GSH in erythrocytes, serum MDA level and clinical severity were dependent on serum sanguinarine level. The results indicate that sanguinarine (argimone oil) poisoning creates an oxidative stress in humans. The oxidative stress and differential modulation of anti-oxidant enzymes by sanguinarine might play a pathogenic role in epidemic dropsy, which suggests the incorporation of anti-oxidant drugs in the treatment protocol of the disease.

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.