Prehospital delay and time to reperfusion therapy in ST elevation myocardial infarction.

BACKGROUND: Despite efforts aimed at reducing the prehospital delay and treatment delay, a considerable proportion of patients with ST elevation myocardial infarction (STEMI) present late and receive the reperfusion therapy after unacceptably long time periods. This study aimed at finding out the patients' decision delay, prehospital delay, door-to-electrocardiography (ECG), door-to-needle, and door-to-primary percutaneous coronary intervention (PCI) times and their determinants among STEMI patients. MATERIALS AND METHODS: A cross-sectional study conducted among 96 patients with STEMI admitted in a tertiary care center in South India. The data were collected using interview of the patients and review of records. The distribution of the data was assessed using Kolmogorov-Smirnov test, and the comparisons of the patients' decision delay, prehospital delay, and time to start reperfusion therapy with the different variables were done using Mann-Whitney U-test or Kruskal-Wallis test based on the number of groups. RESULTS: The mean (standard deviation) and median (range) age of the participants were 55 (11) years and 57 (51) years, respectively. The median patients' decision delay, prehospital delay, door-to-ECG, door-to-needle, and door-to-primary PCI times were 75, 290, 12, 75, 110 min, respectively. Significant factors associated (P < 0.05) with patients' decision delay were alcoholism, symptom progression, and attempt at symptom relief measures at home. Prehospital delay was significantly associated (P < 0.05) with domicile, difficulty in arranging money, prior consultation at study center, place of symptom onset, symptom interpretation, and mode of transportation. CONCLUSIONS: The prehospital delay time among the South Indian population is still unacceptably high. Public education, improving the systems of prehospital care, and measures to improve the patient flow and management in the emergency department are essentially required. The time taken to take ECG and to initiate reperfusion therapy in this study points to scope for improvement to meet the American Heart Association recommended timings.

A retrospective study on epidemiology of hypoglycemia in Emergency Department.

BACKGROUND: Hypoglycemia is one among the leading causes for Emergency Department (ED) visits and is the most common and easily preventable endocrine emergency. This study is aimed at assessing the incidence and elucidating the underlying causes of hypoglycemia. MATERIALS AND METHODS: A retrospective, observational study which included patients registering in ED with a finger prick blood glucose ≤60 mg/dl at the time of arrival. All patients aged above 15 years with the above inclusion criteria during the period of August 2010 to July 2013 were selected. The study group was categorized based on diabetic status into diabetic and nondiabetic groups. RESULTS: A total of 1196 hypoglycemic episodes encountered at the ED during the study period were included, and of which 772 with complete data were analyzed. Underlying causes for hypoglycemia in the diabetic group (535) mainly included medication related 320 (59.81%), infections 108 (20.19%), and chronic kidney disease 61 (11.40%). Common underlying causes of hypoglycemia in nondiabetic group (237, 30.69%) included infections 107 (45.15%), acute/chronic liver disease 42 (17.72%), and malignancies 22 (9.28%). Among diabetic subjects on antidiabetic medications (n = 320), distribution over 24 h duration clearly reported two peaks at 8th and 21st h. The incidence of hypoglycemia and death per 1000 ED visits were 16.41 and 0.73 in 2011, 16.19 and 0.78 in 2012, 17.20 and 1.22 in 2013 with an average of 16.51 and 0.91, respectively. CONCLUSION: Bimodal distribution with peaks in incidences of hypoglycemic attacks at 8th and 21st h based on hourly distribution in a day can be correlated with the times just before next meal. None of the patients should leave ED without proper evaluation of the etiology of hypoglycemia and the problem should be addressed at each individual level. Increasing incidence of death over the years is alarming, and further studies are needed to conclude the root cause.

Trend and manifestations of falciparum malaria in a tertiary care hospital of India.

BACKGROUND: The recent focus is on the increase in the burden of falciparum cases with a varied spectrum of presentation and outcome, especially in developing countries like India. This study was undertaken to analyze the trend and manifestations of falciparum malaria in a tertiary care hospital. MATERIALS AND METHODS: This descriptive study was carried out at the Gauhati Government Medical College and Hospital from June 2006 to May 2007. The data were collected on demographic and time characteristics, clinical and laboratory findings, the outcome of disease and expressed in proportion or percentages. RESULTS: Out of the 100 cases, around 2(nd)/3(rd) (63%) of cases were in the age group of 15-30 years and the mean age was found to be 29.51 years. About 66% of them were males. Clinical presentations included pain abdomen (42, 42%), nausea and vomiting (35, 35%), jaundice (34, 34%), oliguria (24, 24%), altered sensorium (24, 24%), breathing difficulty (10, 10%), and seizures (5, 5%). Number of cases and mortality were more with a peak in the month of May and September. Manifestations of severe falciparum malaria included hepatopathy (38%), renal failure (28%), shock (9%), acute respiratory distress syndrome (7%), hypoglycemia (3%), and severe anemia (1%). Eighty-two cases (82%) recovered and 18 cases (18%) expired. CONCLUSION: Falciparum malaria is more among younger adult age group and males. Complications and mortality are also more due to falciparum malaria.

A Study on the Role of Heart Type Fatty Acid Binding Protein in the Diagnosis of Acute Myocardial Infarction.

INTRODUCTION: Heart type Fatty Acid Binding Protein (H-FABP) has been proposed as an early cardiac biomarker for the diagnosis of acute myocardial Infarction (AMI) using animal models and clinical samples. AIM: The study aimed to evaluate the role of H-FABP in early detection of AMI by comparing its sensitivity, specificity and predictive value with Creatinine Kinase-MB (CK-MB) and Cardiac Troponin I (cTnI). MATERIALS AND METHODS: This is a cross-sectional descriptive study of 50 patients admitted with the diagnosis of AMI at a tertiary care hospital in South India. The study group was categorised in to those coming to the hospital within four hours of symptom onset and those coming in between 4 to 12 hours. H-FABP was compared with those of troponin T and myoglobin tests. RESULTS: Among patients presenting within four hours of symptom onset, the sensitivity of H-FABP was 60% and was significantly higher than that of cardiac Troponin I (cTnI, 18.8%) and Creatinine Kinase (CK)-MB (12.5%). But specificity was only 23.53% and was less than that of cTnI (66.67%) and CK-MB (100%). In patients presenting during 4 to 12 hours of symptom onset, the sensitivity of H-FABP was 86.96% which was comparable to that of cTnI (90.9%) and CK-MB (77.3%). The specificity was 60% in the 4-12 hours group which was comparable to that of cTnI (50%) and CK-MB (50%). CONCLUSION: The H-FABP is a sensitive biomarker for the diagnosis of AMI in the initial hours after symptom onset when the standard biomarkers may not be elevated, but it is less specific. During 4-12 hours of symptom onset it is as sensitive and specific as standard cardiac biomarkers troponin and CK-MB. Due to these factors H-FABP can be considered as a promising cardiac biomarker which can be used along with troponins and CK-MB at present.

Femoral and Tibial Tunnel Widening following Anterior Cruciate Ligament Reconstruction using Various Modalities of Fixation: A Prospective Observational Study.

INTRODUCTION: Bone tunnel enlargement after Anterior Cruciate Ligament Reconstruction (ACL-R) is a well-accepted phenomenon but there are very few published data comparing the extent of tunnel widening by various methods of fixation after ACL-R. AIM: To compare the femoral and tibial tunnel widening following ACL-R with different methods of fixation using CT scan. MATERIALS AND METHODS: This one year prospective study included all patients with chronic Anterior Cruciate Ligament (ACL) injury who underwent primary arthroscopic ACL-R using tripled hamstring tendon autograft. The graft was fixed to the tibial tunnel by Interference Screw (IFS) or Suture Disc (SD) and to the femoral tunnel by IFS, SD, Cross-Pin (CP) or Endo-button CL (Smith & Nephew). The widening of the tibial and femoral tunnels in different methods of fixation was assessed by Computed Tomography (CT) at 12 months follow-up; and was compared using paired sample test. RESULTS: A total of 63 patients were included in the study of which 58 (92%) were males and 5 (8%) were females, with a mean age of 29.1 ± 5.9 years. The tibial tunnel widening at one year follow-up was 1.680 ± 1.08794 (19.37%) and 1.517 ± 0.94834 mm (17.39%) by IFS and SD methods respectively. Femoral tunnel widening at one year follow-up was 1.294 ± 0.231, 1.809 ± 0.912, 1.320 ± 0.238, 1.779 ± 0.889 mm by IFS, SD, EB, and CP methods respectively. Femoral tunnel widening following suture disc method of fixation was very highly significant (p<0.001) in comparison with other methods. CONCLUSION: Femoral tunnel and tibial tunnel widening varies with different methods of fixation and was maximum with suture disc method compared to others at one year follow-up after ACL-R.

Early Diagnosis of Penetrating Cardiac and Pleural Injury by Extended Focused Assessment with Sonography for Trauma.

In India, stab injury is not uncommon, but identifying potential life threatening conditions in the emergency room (ER) and initiating prompt treatment are challenging. This is a case report of a young patient who presented to the ER with assault injury to the chest and shock; timely extended focused assessment with sonography for trauma helped to fast-track the patient to the operating room. A brief review of diagnosis and management of penetrating cardiac injury is presented herewith.

Assessment of Serum VASPIN Levels among Type 2 Diabetes Mellitus Patients with or without Acute Coronary Syndrome.

INTRODUCTION: Type 2 Diabetes Mellitus (DM) is on the verge of becoming a pandemic in India. Type 2 DM patient have two to four times increased risk of carotid artery disease. Adipokines have been regarded recently as direct link between diabetes and atherosclerosis. Visceral Adipose Tissue Derived Serine Protease Inhibitor (VASPIN); one of the most recently discovered adipokine, inhibits the proteases responsible for insulin resistance, carotid plaque development and rupture. In literature, few studies have addressed the role of VASPIN in pathogenesis of Acute Coronary Syndrome (ACS) in patients with type 2 DM. AIM: To find association between serum VASPIN with lipid profile, creatine kinase-total, creatine kinase-MB, troponin-I, age, height, weight, blood pressure, smoking, family history of ACS and to prove the hypothesis of low serum VASPIN level as predictor of ACS in patients with type 2 DM. MATERIALS AND METHODS: Forty-one type 2 DM patients (controls) and 41 type 2 DM patients with ACS (cases) were enrolled in the study. Anthropometric measurements were performed and fasting serum biochemical parameters and VASPIN were measured. The results of cases and controls were compared by student t-test or Mann-Whitney test. All the parameters were correlated with serum VASPIN by Pearson's or Spearman's correlation. RESULTS: Fasting serum VASPIN concentration was significantly (p< 0.0001) lower in the cases (0.43±0.22 pg/ml) than in the controls (0.83±0.29 pg/ml). Correlation analysis undertaken on all type 2 DM showed that serum VASPIN concentration was negatively correlated with age, waist circumference, hip circumference, systolic and diastolic blood pressure, duration of diabetes, serum Creative Kinase-Total, CK-MB and urea (p< 0.05). Utilizing Receiver Operating Characteristic (ROC) curve, the serum VASPIN level of less than 0.594pg/ml showed greatest risk of ACS among type 2 DM patients (p< 0.0001). CONCLUSION: Type 2 DM patients with low serum vaspin concentration were at risk of ACS independent of other cardiovascular risk factors.

Perceptions and practices of self-medication in healthcare and nonhealthcare university students in South India.

BACKGROUND: The aim was to study and compare knowledge, attitude and practices regarding self-medication in healthcare and nonhealthcare university students. METHODS: Suitably constructed, structured and pretested questionnaires were distributed to 350 students in each group; data were documented in SPSS software version 20.0 and analyzed using χ2-test and multivariate logistic regression analysis. RESULTS: Completed questionnaires only were analyzed, which were 314 and 310 in healthcare and nonhealthcare groups, respectively. The majority of students practiced self-medication (84.4% vs. 68.1%; p<0.001) with the most common indications being fever (46.4% vs. 37.9%; p<0.001) and cough and common cold (30.9% vs. 37%; p=0.004). Most commonly self-medicated drugs were antipyretics (67.9% vs. 52.6%; p=0.03) and multivitamins (28.7% vs. 16.8%; p<0.001). A few of them experienced adverse drug reactions due to self-medication (6.8% vs. 1.9%; p<0.001). Independent risk factors for self-medication were younger age group (OR=2.93, CI 95% 1.09-7.85), storage of medicines at home (OR=2.49, CI 95% 1.21-5.12), healthcare students (OR=2.54, CI 95% 1.72-3.74), higher knowledge scores (OR=1.65, CI 95% 1.08-2.52), those consuming homeopathic preparations (OR=9.19, CI 95% 1.24-68.11), multivitamins (OR=6.7, CI 95% 2.88-15.6) or health supplements (OR=6, CI 95% 2.15-16.74), participants who strongly agreed that self-medication is a part of self-care (OR=3.97, CI 95% 1.56-10.09), and those self-medicating with an old prescription for same illness (OR=0.04, CI 95% 0.01-0.15) or over advice from home (OR=0.11, CI 95% 0.04-0.3). CONCLUSIONS: Though self-medication is common in university students, there is a dearth in their knowledge regarding the same. This highlights the need for increasing awareness among students regarding hazards of self-medication.

Clinical Manifestations and Predictors of Thrombocytopenia in Hospitalized Adults with Dengue Fever.

BACKGROUND: India is one of the seven identified Southeast Asian countries reporting frequent outbreaks of dengue fever (DF). AIMS: This study was to analyze clinical and laboratory profile and predictive markers of thrombocytopenia and length of hospital stay in DF. MATERIALS AND METHODS: This record-based retrospective study conducted in a coastal district of Karnataka, South India, included all dengue cases in adults aged >18 years, admitted during period of January 2011 to December 2014. Multivariate logistic regression analysis was carried out to compute odds ratio (OR) and 95% confidence interval (CI) to assess independent associations of variables with low platelet count and longer duration of hospital stay. RESULTS: Among 207 dengue immunoglobulin M (IgM) antibody confirmed cases (mean age of 36.94 ± 14.61 years), 143 (69.1%) were males and 64 were females. The mean duration of illness and hospital stay were 4.94 ± 3.58 days and 5.98 ± 2.58 days, respectively. Abdominal symptoms included nausea and vomiting (53.6%), abdominal pain (25.1%), and diarrhea (13.5%). Bleeding manifestations were seen in 24 (11.6%) cases and fluid accumulation was revealed in 18 (8.7%) cases. The mean platelet count was 110,159.42 ± 68,397.32 (cells/mm(3)). Low platelet count on admission was associated with the presence of rash (OR = 0.43, 95% CI 0.23-0.81), high aspartate aminotransferase (AST) levels (OR = 3.14, 95% CI 1.58-6.23), high alanine aminotransferase (ALT) levels (OR = 2.91, 95% CI 1.55-5.47), and low albumin levels (OR = 4.48, 95% CI 1.02-19.75). The duration of hospital stay was associated with diarrhea (OR = 0.4, 95% CI 0.18-0.9), abdominal pain (OR = 0.52, 95% CI 0.27-1.00), ascites (OR = 0.26, 95% CI 0.09-0.69), and low hemoglobin (OR = 0.46, 95% CI 0.25-0.86) level on admission. CONCLUSIONS: Though thrombocytopenia on admission was associated with the presence of rash, high AST and ALT levels, and low albumin levels, it was not predictive of length of hospitalization. Duration of hospital stay was longer with the presence of diarrhea, abdominal pain, ascites, and low hemoglobin level on admission.

Malarial hepatopathy and its outcome in India.

BACKGROUND: Jaundice in Plasmodium falciparum malaria is multifactorial and its incidence varies in different regions. It is important to assess the incidence and factors associated with malarial hepatopathy as well as its complications to understand the pattern of disease presentation in order to undertake appropriate interventional measures. There is a paucity of data with regard to malarial hepatopathy and its outcome at the global level. AIM: The study was conducted to assess the pattern, spectrum of biochemical parameters and complications of hepatopathy related to P. falciparum malaria. MATERIALS AND METHODS: A descriptive study was conducted in a tertiary care hospital attached to a government medical institution in Assam, India. Demographic details of the hundred patients with P. falciparum malaria, their clinical and biochemical parameters, complications and outcome were collected using a prestructured proforma. Data was compared using proportion and Chi Square test. RESULTS: The proportion of those with malarial hepatopathy was 38% and the incidence was more in males and younger age group. The degree of hyperbilirubinemia, complications that include renal failure, shock, acute respiratory distress syndrome, hypoglycemia and mortality were significantly more among patients with hepatopathy (P<0.05). CONCLUSION: Malarial hepatopathy is associated with a higher incidence of complications like renal failure, shock, acute respiratory distress syndrome and hypoglycemia. Further studies are required to elucidate the factors associated with malarial hepatopathy and to prevent the complications and mortality.