Central Auditory Processing Skills in Individuals with Takayasu Syndrome.

The current study was done to assess the central auditory processing in individuals with Takayasu's Syndrome. The Takayasu Syndrome is a rare disease, hence a case series was conducted with consecutive sampling. In this study, five patients diagnosed with Takayasu's syndrome were evaluated on the central auditory processing tests. The tests were administered using standard operating protocols. It was observed that the score on the dichotic digit test was drastically reduced suggesting difficulty in auditory integration skills in all the participants. There was an observed difficulty in speech perception in noise for all the participants indicating abnormal auditory closure ability. It was concluded that the reduced blood supply to the cortex would have caused a reduction in auditory skills. The current attempts to document the central processing disorder in a rare syndrome. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03733-1.

A comparative study of modulatory interaction between cytokines and apoptotic proteins among Scleroderma patients with and without pulmonary involvement.

BACKGROUND: Interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) are the most eminent forms of pulmonary involvement in Scleroderma. In this study we investigate the interaction between cytokines and apoptotic proteins in treatment naive Scleroderma (SSc) patients with and without pulmonary involvement. METHODS: Newly diagnosed treatment naïve Scleroderma (SSc) patients (n = 100) and healthy controls (n = 100) were enrolled. Patients were classified as ILD-SSc, PAH-SSc and non-pulmonary SSc (np-SSc). Study variables like mRSS score, autoantibody profile, serum cytokines, serum TGF-ß (1,2,3) and apoptotic proteins were assessed for these patients. RESULTS: Scleroderma patients showed elevated levels of serum cytokines, but significantly lower IL-22 and TGF- ß1 when compared to healthy controls (p < 0.05). Apoptotic proteins were significantly elevated among Scleroderma patients, but the patient groups also showed significant lower caspase 1/3/9 levels when compared to healthy controls (p < 0.05). ILD-SSc patients reported higher mRSS score (p = 0.0436) when compared with PAH-SSc and np-SSc. In ILD-SSc patients, finger tightening (p = 0.0481) and calcinosis/lesions (p = 0.0481) were significant clinical presentations whereas, digital ulcers were significantly prominent in np-SSc patients (p = 0.0132). Elevated TGF-ß3 levels (p = 0.02) in SSC-ILD and reduced IL-4 levels (p = 0.02) in SSC-PAH were significant cytokines as compared to np-SSc. Significant correlations were obtained among serum cytokines and apoptotic proteins in Scleroderma patients with and without pulmonary involvement. (p < 0.05) CONCLUSION: Our study highlights the correlation between mRSS score, cytokines and apoptotic proteins in SSc patients with pulmonary involvement. A longitudinal follow up in these patients with assessment of these immunological parameters may be helpful in monitoring the disease.

Clinico-immunological Profile of Systemic Lupus Erythematosus: An Observational Study.

BACKGROUND: SLE is a common connective tissue disease in Indians (mostly women) which is frequently underdiagnosed due to limited awareness and knowledge regarding the disease. METHODS: This is a retrospective observational study conducted in a tertiary care hospital in Western India among patients of SLE attending outpatient Rheumatology Clinic and inpatient admissions of Topiwala Medical College and BYL Nair Charitable Hospital, Mumbai. Sixty patients were recruited based on inclusion and exclusion criteria. RESULTS: In clinical profile, arthralgia was the most common manifestation seen in 53 patients (88.3%) followed by alopecia in 46 patients (76.7%). In systemic involvement, CNS lupus was the most common manifestation seen in 27 patients (45%) followed by renal involvement in 13 cases (21%). Pulmonary hypertension (PH) was another noticeable finding seen in 24 cases (40%) of which 18 (75%) had mild PH, 6 (25%) patients had severe PH. The mean SLEDAI score was 11.85 at baseline which reduced to 2.65 at 6 months and remained 3.65 at the end of 3 years of the study. In immunological profile, ANA was positive in all patients. Speckled pattern of ANA was the most common pattern seen in 34 patients (56.7%). A titre of above 1:100 was noted in 53 patients (88.3%). ds DNA was positive in 26 patients (43.3%). Anti Ro/La was positive in 3 patients (5%) and U1RNP in 2 patients (3.3%). Autoimmune hemolytic anemia (AIHA) was the most common autoimmune association seen in 25 patients (41.7%), antiphospholipid antibody(APLA) was seen in 15 patients (25%), 7 patients (11.6%) were anti TPO antibody positive, 3 patients (5%) were Ro/La positive while only 2 patients(3.3%) were U1RNP positive. CONCLUSION: Clinical profile and immunological patterns of SLE are diverse. A systematic work up is needed to identify the multisystem involvement and asking for specific antibody tests to identify common autoimmune associations is recommended.

Audio-Vestibular Findings in Individuals with Takayasu's Arteritis.

Takayasu's Arteritis is defined as inflammatory disease of the large blood vessels with unknown cause mostly affecting the aorta and its main branches. The patients diagnosed with Takayasu's arteritis are reported to have complaint of chronic dizziness. However, literature lacks detailed clinical evaluation of the auditory vestibular function in such patients. The current study documents the findings of auditory and vestibular evaluations in a rare syndrome. It was observed that patients with Takayasu's arteritis had abnormal auditory and vestibular evoked potentials.

Impact of Autoantibodies to Complement Components on the Disease Activity in SLE.

INTRODUCTION: Systemic Lupus Erythematosus (SLE) is a chronic multi-system autoimmune disease with varied clinical presentations. Complement components are the major players in disease pathogenesis. This retrospective cross-sectional study was aimed at assessing the role of autoantibodies to these complement components and their association disease activity in newly diagnosed SLE patients from India. METHOD: Clinically diagnosed SLE patients (n=57) classified as per 2015 ACR/SLICC revised criteria were enrolled between November 2016 to April 2017. Patients' sera were tested for C3 and C4 by nephelometry, while serum levels of factor H, factor P (properdin) as well as autoantibodies to C3, C4, factor H and factor P were detected by ELISA. GraphPad Prism Version 6.01 was used for statistical analysis. Mean, SD, SEM were calculated. Mann Whittney U-test, ANOVA, Chi-square test, Odd's Ratio were calculated. Pearson's correlation was used to study relativeness of the study parameters. RESULTS: Among the 57 SLE patients, low C3 were seen in 51% patients, low C4 in 49%, low factor H in 19% and low factor P in 49% patients. Positivity for autoantibodies against complement components, anti-C3 were seen in 42% patients, anti-C4 in 7%, anti-factor H in 19% and anti-factor P in 28% patients. Serum levels of C3 (p=0.0009), C4 (p=0.0031) and anti-C3 autoantibodies (p=0.0029) were significantly associated with ACR/SLICC 2015 scores. CONCLUSION: Hypocomplementemia was found to be associated with higher disease damage score in newly diagnosed SLE patients. This study adds novel arguments for the importance of the anti-C3 autoantibodies as a marker of SLE.

Use of Disease Activity Score (DAS28) and Routine Assessment of Patient Index Data 3 (RAPID3) for Assessment of Rheumatoid Arthritis Disease Activity, in the Indian Setting.

INTRODUCTION: Patient outcomes in rheumatoid arthritis (RA) have significantly improved with the advent of disease modifying anti rheumatic drugs and the newer biological agents. Various scoring systems available for monitoring disease activity in RA have not yet been put into full use in patient management in India. We aim to study the disease activity score 28 (DAS28) and Routine assessment of patient index 3 (RAPID3), their correlation and patient outcomes in RA. MATERIALS AND METHODS: The study was conducted between March 2011-May 2011. A total of 81 patients were included. Patient's history was noted. Clinical examination for tender and swollen joint counts was performed. DAS28 was calculated. MDHAQ was administered to each patient in a language they understood and responses noted. Correlation between DAS28 and RAPID3 was studied using Pearson's correlation coefficient. RESULTS: RAPID3 and DAS28 showed Pearson's correlation coefficient of 0.8699 (p<0.001). Of the 53 patients who met with DAS28 severity criteria of >5.1, 82.7% showed similar results with RAPID3 suggesting severe disease activity. (X2 = 33.512 and p<0.001). A greater proportion of those whose DMARD initiation was 2 years after disease onset, had higher disease activity as compared to those with earlier initiation.

Outcome in Survivors of Middle Cerebral Artery Territory Ischemic Stroke: Can it be predicted?

BACKGROUND: Stroke is the fourth leading cause of disability worldwide. The present study was designed to assess functional disability in middle cerebral artery (MCA) territory ischemic stroke patients by applying standard scales for stroke severity, cognitive impairment, disability, dependency and depression. We also wanted to study whether baseline assessment predicts outcome at 1 month. METHODOLOGY: After institutional ethics committee approval, patients were enrolled from the inpatients of the Department of Medicine at Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai from July 2014 to December 2015. Various clinical parameters were recorded on admission. On day 5(±1) the National Institutes of health Stroke Scale (NIHSS), Mini Mental state examination (MMSE) were administered. On 1 month follow up, these were repeated along with Modified Rankin scale, Barthel's index (BI) and Hospital Anxiety and Depression Scale (HADS). Presence of certain risk factors for stroke were reviewed at 1 month. RESULTS: 75 patients were enrolled. There was a delay in reaching the hospital and therefore imaging, in a greater majority. Only 4% could be imaged within the first 3 hours. Mean NIHSS score at day-5 was 9 and at day-30 was 6. Thus it had significantly reduced over 1 month. The MMSE remain unchanged at day 5 and at day 30. Lower baseline MMSE scores correlated with poorer outcomes on NIHSS, BI and mRS at 1 month. Both BI and mRS at 1 month indicated that about 60% of the cases had poor outcome. Amongst 48 of the non-aphasic MCA strokes, 11(22.92%) had depression. An NIHSS score of 6 or above on day 5, predicted poor outcome at 1 month. Presence of aphasia, dominant lobe affection and female sex were associated with a higher disability at 1 month. Around 30% cases had at least 1 risk factor uncontrolled at 1 month follow-up. CONCLUSIONS: Our findings show that disability assessment late in the first week after onset of stroke using NIHSS accurately forecast outcome at one month after onset of stroke. The MMSE too is not expected to change at 1 month. Those with aphasia are expected to have greater disability. Based on or study we recommend that stroke patients should be assessed with NIHSS and MMSE before discharge, to explain the prognosis of the patient. Also more intense counselling on controlling blood pressure and diabetes as well as abstinence from smoking should be undertaken routinely.

Adipokine interactions promote the pathogenesis of systemic lupus erythematosus.

BACKGROUND: Adipokines are chemical mediators released from adipose tissue involved in regulation of appetite, insulin sensitivity, immune system and inflammatory responses. Adipokines contributes to low grade inflammatory response in autoimmune disease like Systemic Lupus Erythematosus (SLE) but the pathophysiology is yet not clear. The aim of this study is to understand role of adipokine interactions in SLE disease pathogenesis. METHODS: Sixty newly diagnosed treatment naïve SLE patients fulfilling the ACR criteria and forty age-sex matched healthy subjects were enrolled in thiscase-control study. Disease activity in SLE patients was evaluated using SELENA-SLEDAI. Array of adipokines, C1q circulating immune complexes (C1q-CIC), anti-C1q, anti-ribososmal P0 (anti-RibP0) and anti-mitochondrial antibodies (AMA) levels were detected by ELISA. Antinuclear antibodies (ANA) and anti-dsDNA autoantibodieswere detected by Indirect Immunofluorescence (IIF), while antigen specificities were detected by Immunoassay blot. Serum levels of C3 and C4 complement factors were assessed by nephlometer. RESULTS: Statistically significant elevation in progranulin, adipsin and resistin levels was seen among SLE patients when compared to healthy controls (p < 0.0001). Leptin and omentin levels were significantly reduced in SLE patients (p < 0.0001). There was no statistically significant difference in serum adiponectin, chemerin and visfatin levels when these two groups were compared (p > 0.05). Adiponectin, adipsin and resistin levels were elevated in SLE patients with renal manifestations (p < 0.05). Reduced leptin levels were significantly associated with presence of renal manifestations (p < 0.05). Adiponectin levels positively correlated with disease activity (r = 0.294, p = 0.027) whereas negatively correlated with C3 levels (r = -0.439, p = 0.0007). A positive correlation was observed between hypocomplementemia and leptin levels (p < 0.05). Leptin levels were negatively correlated with disease activity, anti-dsDNA, C1q-CIC and anti-C1q levels (p < 0.05). A significant positive correlation was observed between progranulin levels and anti-ribosomal P0 antibodies (r = 0.499, p < 0.0001). CONCLUSION: Adipokines levels and associated clinical manifestations suggest involvement of adipokines in disease pathogenesis of SLE. SLE disease activity and complement components may suggest regulatory effect of adipokines (adiponectin and leptin) on disease pathogenesis. Further studies on adipokines in SLE patients with renal manifestations may propose them as prognostic markers in renal damage. TRIAL REGISTRATION: NA.

Osteoarthritis: Clinical and Radiological Correlation.

BACKGROUND: Osteoarthritis (OA) is a slowly progressive degenerative joint disease, characterized by pain and functional disability. Various outcome measures for radiographic and clinical OA are described in studies. A limitation of radiographic evaluation is that, except for the direct evaluation of bone, the tissues involved in the OA process are either evaluated indirectly (cartilage) or not at all (synovium). In evaluation of clinical OA, the scores for pain, stiffness and function are commonly used outcome measures. The objective of this study was to co-relate the clinical status with activity and radiological score in osteoarthritis of various joints. MATERIALS AND METHODS: A Cross-sectional study was conducted including 100 consecutive patients of osteoarthritis of various joints. A thorough clinical examination of affected joint was performed and relevant laboratory investigations and radiology of the affected joint was done in all patients. Grading of severity of osteoarthritis was assessed by following clinical indices: Knee/ Hip by Lequesne, Articular Index of Doyle for osteoarthritis and modified WOMAC index - KGMC index. Radiological indices used were: Kellgren and Lawrence global grading scheme for the severity of osteoarthritis of the knee, hip, lumbar disc degeneration and apophyseal joints of the cervical spine, Kallman grading scale for individual features of the hand and Individual radiographic features assessed in radiographs of the hip and lumbar spine. RESULTS: Knee joint was commonly involved (89%), followed by lumbar spine (49%). Knee joint tenderness was significantly co-relating with KGMC and radiological index. Lequesne and KGMC Indian index were co-relating positively with each other for knee joint. All clinical indices showed significant co-relation with radiological indices for knee joint. Clinical and radiological indices were also co-relating positively in cervical and lumbar spine. Visual analogue scale (VAS) co-related significantly with Lequesne and Indian KGMC index with respect to knee joint, but showed no co-relation with Doyle index. Also for hands, cervical and lumbar spine VAS and clinical indices did not co-relate. CONCLUSION: KGMC index is best applicable to assess the osteoarthritis knee joint. Radiological progression in OA co-relates well with all clinical indices including KGMC index. This study highlights the usefulness of visual analogue scale and various radiological and clinical indices to assess osteoarthritis especially for knee joint.

A Cross-sectional Study of Cardiovascular Involvement in Systemic Lupus Erythematosus in an Urban Indian Tertiary Care Centre with Emphasis on 2-D Echocardiography.

BACKGROUND: Cardiovascular manifestations are responsible for considerable morbidity and mortality in patients with SLE. A wide range of manifestations due to active lupus, like pericarditis, valvular affection, myocarditis, and less commonly pulmonary hypertension, are described. This study was undertaken to study cardiovascular manifestations in SLE, with a focus on echocardiography findings, in an urban Indian setting. METHODOLOGY: Fifty consecutive cases of SLE following up in the Rheumatology Clinic of TNMC and BYL Nair Charitable hospital, an Indian tertiary care hospital were studied. They were subjected to an echocardiographic examination if not already done. Detailed history, examination, study of past medical records and investigations were carried out, especially related to cardiovascular system. Treatment details, flares, other systemic involvement were noted. Serial echocardiography if done previously were noted down. The data was analysed using descriptive statistics. RESULTS: An echocardiographic abnormality was noted in 25 (50%) of the 50 subjects. Pulmonary hypertension in 21(42%); valvular abnormalities in 16 (32 %); pericardial effusion in 9 (18%) and diastolic dysfunction in 6(12%) were the echocardiography findings. Six out of the 7 cases with moderately to severe pulmonary hypertension seemed to be responding to immunosuppressive therapy clinically as well as on echocardiography; 1 did not respond. At least 1 traditional risk factor for atherosclerosis was present in 58% of cases. CONCLUSIONS: Screening echocardiography may be recommended, especially at presentation, during SLE flare, or in the presence of cardiac symptoms. Moderate to severe pulmonary hypertension can develop any time in the course of the disease. It may be responsive to immunosuppression. Further detailed studies including multiple echocardiographic parameters and right heart catheterisation need to be undertaken to study the responsiveness of pulmonary hypertension to immunosuppresssive therapy.

Dengue and Chikungunya Virus Co-infections: The Inside Story.

INTRODUCTION: There have been various studies from India describing the acute presentation and the long-term sequalae of Chikungunya (CHIKV) infection. However, there are very few studies discussing the Chikungunya-Dengue (DENV) co-infection from Western India. The present project was undertaken to study the clinical features of Dengue and Chikungunya co-infection and compare with Chikungunya mono-infection; correlate the clinical findings with seroprevalence and molecular identification of Dengue and Chikungunya using IgM ELISA and RTPCR. MATERIAL AND METHODS: Three hundred suspected cases of Dengue and/or Chikungunya patients from out patients department and indoor wards, more than 12 years of age suffering from acute febrile illness, joint pains and rash for less than 10 days were included from June 2010 to April 2015. Proven cases of malaria, enteric fever, leptospirosis were excluded from the study. Leptospira IgM, Dengue IgM and PCR, Chikungunya IgM and PCR was done on all 300 samples. RESULTS: Sero-surveillance of the patients revealed that 59% (177) patients were positive for Dengue IgM alone, while 2% (6) tested positive for Chikungunya IgM alone. 6.7% (20) patients tested positive for Dengue and Chikungunya both. Ninty seven (32.3%) patients were negative for Dengue and Chikungunya. Of the 300 samples, 7% (21) were positive for DENV, 35% (105) were positive for CHIKV, 10% (30) were both DENV and CHIKV positive and 48% (144) were negative for both through RT-PCR. DISCUSSION: In our study, the patients of CHIKV mono-infection and DENV + CHIK co-infection had high VAS score, morning stiffness, arthralgias, restriction of joint movements as compared to patients with DENV mono infection. Patients of dengue mono infection had bone pains and myalgias in addition to joint pains; however there was restriction of joint movements in only 13.2% as compared with 100% of mono CHIKV or dual infection. These clinical features can be helpful in distinguishing DENV mono infection as compared to co-infection. The study highlights the diagnostic importance of RT-PCR in CHIKV and DENV co-infection, as 10% cases were identified using RT-PCR as compared to 6.7% cases by IgM antibodies.

Pain quality of life as measured by utilities.

OBJECTIVE: Utilities are values of health-related quality of life (HRQoL) based on patient preference for a health status. The purpose of this study was to compare indirect measures to a directly elicited utility. DESIGN: Cross-sectional study. SETTING AND PATIENTS: Emory Spine Center and the Emory Center for Chronic Pain at Crawford Long Hospital. Patients at least 18 years of age with chronic pain, defined as pain that persists beyond the normal time of healing, usually beyond 6 months. MEASURES: Chronic pain subjects completed a paper-based, self-administered time trade-off (TTO) survey, EQ-5D survey, and a face-to-face (FTF) TTO interview. Current pain severity was graded using the Numeric Rating Scale-11, subsequently stratified into no (0), mild (1-3), moderate (4-6), and severe (7-10) pain. RESULTS: Paired t test comparing FTF TTO and proxy utility measures stratified by severity revealed FTF TTO utility values significantly higher than EQ-5D utility values for all pain severities (overall mean difference 0.18, standard deviation [SD] 0.30, P < 0.001; Pearson's correlation 0.34, P < 0.0001); FTF TTO utility values were lower than paper TTO utility values, reaching statistical significance for mild and moderate pain (overall mean difference 0.09, SD 0.29, P = 0.0006; Pearson's correlation 0.38, P < 0.0001). CONCLUSIONS: This study demonstrates that the EQ-5D overestimates, whereas the paper version of TTO underestimates, the impact of pain on HRQoL compared with the directly elicited FTF TTO utility. Our findings provide preliminary evidence that utilities vary by method, and directly elicited utility values differ from indirectly elicited measures.

Preference-based measures in dermatology: an overview of utilities and willingness to pay.

In this overview of preference-based measures, utilities and willingness to pay (WTP) are discussed as measures relevant to dermatology for capturing the burden of skin diseases. An overview is provided of the concepts of utilities and WTP and their importance in decision making. Specific examples of elicitation methods for capturing utility and WTP measures are provided. Prior studies exploring utilities and WTP in dermatology are reviewed. Each of these measures has limitations and likely varying relevance to specific dermatologic diseases and to specific individuals.

Overview of health status quality-of-life measures.

The concept of quality of life (QOL) is becoming increasingly important in medicine, particularly in dermatology where many cutaneous diseases have the potential to affect the quality rather than the length of life. There is increasing interest in devising methodology to accurately measure the impact of disease on QOL for use in clinical practice, research studies, and economic analyses. The question of which dermatologic QOL instruments to choose inevitably arises. The aim of this article is to familiarize readers with health status measures and to review their use in dermatology.

Melanoma reporting to central cancer registries by US dermatologists: an analysis of the persistent knowledge and practice gap.

BACKGROUND: Every state requires diagnosing physicians to report new cases of melanoma to its central cancer registry. Previous regional studies and anecdotal experience suggest that few dermatologists are cognizant of this obligation. This oversight could result in a large number of unreported melanomas annually and, in turn, US melanoma statistics that markedly underestimate the true incidence of the disease. OBJECTIVE: We sought to quantify the percentage of dermatologists who are unaware of melanoma reporting requirements (the knowledge gap) and who are not reporting melanoma diagnoses (the practice gap). We also sought to delineate factors predictive of reporting knowledge and behavior. METHODS: A survey was administered to attendees of the Cutaneous Oncology Symposium at the 2010 American Academy of Dermatology annual meeting. RESULTS: In all, 104 of 419 eligible attendees completed surveys (response rate 26%). Fifty percent of respondents do not believe they are required to report melanomas and 56% do not actively report their diagnoses to a registry. Practice duration of less than 10 years was significantly associated with both a knowledge gap (P = .047) and practice gap (P = .056). Similarly, dermatologists who diagnosed fewer than 10 melanomas per year were more likely to possess a knowledge gap (P = .096) and a practice gap (P = .087) than those who diagnosed more than 10. LIMITATIONS: Limitations include small sample size and low response rate. CONCLUSION: A majority of dermatologists are not reporting melanomas they diagnose to a cancer registry, and half of those surveyed were not aware that diagnosing physicians are required to report melanoma.

The impact of pruritus on quality of life: the skin equivalent of pain.

OBJECTIVE: To compare the impact of chronic pruritus and chronic pain on quality of life (QoL) using directly elicited health utility scores. DESIGN: Cross-sectional study. SETTING: Convenience sample of patients attending the Emory Dermatology Clinic, Emory Spine Center, and Emory Center for Pain Management, Atlanta, Georgia. PARTICIPANTS: Adult men and women (aged ≥ 18 years) experiencing chronic pain or pruritus for 6 weeks or more. MAIN OUTCOME MEASURES: The mean utility score of patients with chronic pruritus was compared with that of patients with chronic pain. A regression analysis was performed to determine the impact of the primary predictor variable-symptom type-on the primary outcome variable-mean utility score (a metric representing the impact on QoL). RESULTS: The study included 73 patients with chronic pruritus and 138 patients with chronic pain. The mean (SD) utility among patients with pruritus was 0.87 (0.27) compared with 0.77 (0.31) for patients with pain (P < .01). After symptom severity, duration, and demographic factors were controlled for, only symptom severity (0.03 [P < .05]) and single marital status (-0.12 [P = .02]), but not symptom type (P = .43), remained significant predictors of the mean symptom utility score. CONCLUSIONS: Chronic pruritus has a substantial impact on QoL, one that may be comparable to that of pain. The severity of symptoms and the use of support networks are the main factors that determine the degree to which patients are affected by their symptoms. Addressing support networks in addition to developing new therapies may improve the QoL of itchy patients.

Reflex sympathetic dystrophy following pacemaker insertion.

A 55 year old male presented with pain and swelling over dorsum of right hand and small joints, and loss of sweating over right hand since two months. He was a known case of mitral valve prolapse (MVP) with mitral regurgitation and complete heart block for which pacemaker was implanted 1 year back. Bilateral wrist X-ray was suggestive of pronounced demineralization (osteopenia) in the right hand. He was thus diagnosed to have reflex sympathetic dystrophy syndrome (RSDS) considered to be induced by pacemaker insertion. After treatment with amitryptiline and indomethacin his symptoms dramatically improved.