Organophosphate induced delayed neuropathy after an acute cholinergic crisis in self-poisoning.

INTRODUCTION: Despite organophosphate pesticide is the most prevalent cause of acute poisoning in low- and middle-income countries, data on organophosphate induced delayed neuropathy (OPIDN) are limited. We aimed to characterize organophosphates' long-term effects on the peripheral nervous system after an acute cholinergic crisis in adults. METHODS: We performed a prospective observational study in an academic hospital of north India in patients aged 13-40 years with acute organophosphate ingestion. After resolving the cholinergic crisis, the patients were followed for six months with neurologic assessments, including history, neurologic examination, and nerve conduction study (NCS). RESULTS: Twenty-three patients were recruited to the study. All but one had normal neurological examination and NCS at discharge from hospital a median duration of six days (interquartile range, 3-10) after self-poisoning. Eight (34.8%) developed OPIDN during the six-month follow-up. Three patients had symptomatic neuropathy, and NCS detected subclinical peripheral nerve involvement in five. All cases were associated with chlorpyrifos ingestion (8/17 total chlorpyrifos cases). Two OPIDN cases had foot drop and gait ataxia at three-month which persist at six-month. One patient had distal paresthesia at three months, which improved at a six-month follow-up. NCS in OPIDN cases invariably revealed axonal degeneration, injury to motor fibers more than sensory fibers, and frequent peroneal nerve involvement. None of the baseline characteristics, including the ingested amount, predicted clinical or subclinical OPIDN in chlorpyrifos self-poisoned patients on a univariant analysis. CONCLUSION: Peripheral nerve involvement is not uncommon after recovery from a cholinergic crisis in chlorpyrifos self-poisoning and debilitating in some patients. Detection of subclinical injury on NCS may provide an early window to prevent severe symptomatic neuropathy.

Task shifting of cardiovascular risk assessment and communication by nurses for primary and secondary prevention of cardiovascular diseases in a tertiary health care setting of Northern India.

BACKGROUND: Cardiovascular diseases (CVDs) are the leading cause of morbidity and mortality in India. CVDs are to a large extent preventable with the availability of wide range of interventions focusing on primary and secondary prevention. However human resource deficit is the biggest challenge for implementing these prevention programs. Task shifting of the cardiovascular risk assessment and communication to nurses can be one of the most viable and sustainable option to run prevention programs. METHODS: The study was quasi experimental in nature with 1 year follow up to determine the effect of CVD risk assessment and communication by nurses with the help of risk communication package on primary and secondary prevention of CVDs. The study was done in the outpatient departments of a tertiary health care center of Northern India. All the nurses (n = 16) working in selected OPDs were trained in CVD risk assessment and communication of risk to the patients. A total of 402 patients aged 40 years and above with hypertension (HTN) were recruited for primary prevention of CVDs from medicine and allied OPDs, whereas 500 patients who had undergone CABG/PTCA were recruited from cardiology OPDs for secondary prevention of CVDs and were randomized to intervention (n = 250) and comparison group (n = 250) by using block randomization. CVD risk modification and medication adherence were the outcomes of interest for primary and secondary prevention of CVDs respectively. RESULTS: The results revealed high level of agreement (k = 0.84) between the risk scores generated by nurses with that of investigator. In the primary prevention group, there were significantly higher proportion of participants in the low risk category (70%) as compared to baseline assessment (60.6%) at 1 year follow up. Whereas in secondary prevention group the mean medication adherence score among intervention group participants (7.60) was significantly higher than that of the comparison group (5.96) with a large effect size of 1.1.(p < 0.01). CONCLUSION: Nurse led intervention was effective in risk modification and improving medication adherence among subjects for primary and secondary prevention of CVDs respectively. TRIAL REGISTRATION: Trial registration no CTRI/2018/01/011372 [Registered on: 16/01/2018] Trial Registered Retrospectively.

Genetic susceptibility of glutathione S-transferase genes (GSTM1/T1 and P1) to coronary artery disease in Asian Indians.

Genetic polymorphisms in glutathione S-transferase (GST) genes may modulate the risk of cardiovascular diseases. The objective of present study was to investigate the potential association between the polymorphisms of GSTM1/T1 and P1 genes and their influence on diverse clinical parameters and oxidative stress biomarkers in coronary artery disease (CAD) patients in Asian Indians. The present study includes 562 angiographically confirmed CAD patients and 564 healthy control subjects from the north Indian population. Anthropometric and clinical measurements were performed for all the participants. The oxidative stress biomarkers including malondialdehyde and total antioxidant capacity were also measured. The genotyping of the GSTM1/T1 and P1 genes was performed using the multiplex-PCR and PCR-RFLP methods. The CAD patients exhibit significantly high values of waist circumference, waist-to-hip ratio, body fat (%), glucose, triglycerides, and very low-density lipoprotein, and reduced high-density lipoprotein levels compared to control subjects (P < 0.001). Malondialdehyde levels were significantly enhanced, and the total antioxidant capacity was reduced in CAD patients compared to controls (P < 0.001). However, no significant difference in body mass index and total cholesterol levels were observed in CAD patients and control subjects. The frequencies of the GSTM1 and GSTM1/T1 null genotypes in the CAD patients were significantly higher than the control subjects. In contrast, the GSTT1(-) genotype frequencies were significantly lower in CAD patients than the controls. Logistic regression analysis of the data revealed the null genotype of GSTM1 and the GG genotype of the GSTP1 (313A/G) gene were associated with an approximately twofold enhanced risk of developing CAD, whereas GSTT1(-) plays a defensive role against CAD development in north Indians. Upon stratification of data according to the genotypes of the GSTM1/T1 and P1 genes, we did not find significant a difference among the various metabolic traits in CAD patients and controls. Our results suggest that oxidative damage induced by lipid peroxidation with reduced antioxidant capacity and genetic variants in GST genes (GSTM1/T1 and P1) may modify the risk of CAD development in Asian Indian population.

Implications of ACE (I/D) Gene Variants to the Genetic Susceptibility of Coronary Artery Disease in Asian Indians.

Angiotensin-1-converting enzyme (ACE) gene has established substantial attention in the recent years as a candidate gene for hypertension, cardiovascular diseases and type 2 diabetes. The aim of the present study was to investigate the association of ACE (I/D) polymorphism with coronary artery disease (CAD) in a north Indian population. A total of 662 subjects (330 CAD patients and 332 healthy controls) were examined for association of ACE gene (I/D) polymorphism and environmental risk factors. The mean age of the CAD patients and control subjects was 60.53 ± 8.6 years and 56.55 ± 7.7 years, respectively (p = 0.000). Anthropometric and demographic data showed BMI values significantly higher among CAD patients and control subjects (26.98 ± 4.9 vs 24.04 ± 4.7, p = 0.000). We observed pronounced central obesity in both CAD patients and controls, even at the lowest BMI values (<23 kg/m2). Dyslipidemia was highly prevalent in CAD patients compared to control subjects. Genotypic data showed significantly higher frequency of DD genotype in CAD patients than that of control subjects (40 vs 28.3 %). No significant difference was observed in the distribution of ID genotypes between CAD patients and control subjects. Logistic regression analysis of data demonstrate that DD genotype was associated with 1.8 fold increased risk of development of CAD in Asian Indians (OR 1.8; 95 % CI 1.22-2.66; p = 0.003). The frequency of D allele was significantly higher in CAD patients (p = 0.001). No significant difference was observed in the clinical and biochemical characteristics of CAD patients and controls when the data was stratified according to the genotypes of ACE gene. In conclusion, DD genotype of ACE gene may be associated with increased risk of CAD in Asian Indian population.

High traffic congestion in right atrium.

A 62-year lady presented with limb swelling and heart failure due to leads induced venous fibrosis and severe tricuspid stenosis, 33 years after pacemaker implantation. After undergoing surgical removal of all leads and tricuspid valve replacement under cardiopulmonary bypass, she regained a normal functional status and tricuspid and right ventricular functions.

Azygos continuation of interrupted inferior vena cava in association with sick sinus syndrome.

Various diagnostic and therapeutic procedures of the right side of the heart and the systemic venous system have increased the need for ready access to the inferior vena cava (IVC) through the transfemoral route. Anatomical variations or obstruction of the IVC can make these procedures difficult. The case of 47 year old woman with an interrupted infrahepatic IVC with azygos continuation accompanied by sick sinus syndrome and a structurally normal heart is reported. Negotiating a temporary pacing lead from the IVC to the right atrium was difficult. Ultimately, the lead took the course from the IVC to azygos vein to superior vena cava to right atrium to right ventricular apex. Permanent VVI pacing through the right subclavian route was uneventful, as the superior vena cava and its tributaries had a normal course. An awareness of the existence of these anomalies before pacing can lead to the use of an alternative route for pacing, which may avoid undue delay of an otherwise urgently needed procedure.

Primary aortoesophageal fistula: presenting as massive upper gastrointestinal hemorrhage.

Primary aortoesophageal fistula is a rare cause of upper gastrointestinal bleeding. A six-year-old boy presented with massive upper gastrointestinal hemorrhage. Endoscopy revealed a submucosal bulge in the esophagus with an ulcer and clot at the top. Lateral skiagram of the chest showed a posterior mediastinal mass. CT scan of the chest revealed a ruptured aortic aneurysm into the oesophagus, confirmed the diagnosis. The patient succumbed to the illness before he could be subjected to definitive treatment.

Unusual foreign bodies of upper gastrointestinal tract.

We report management of unusual foreign bodies of upper gastrointestinal tract, namely beer bottle cap, raisins and pistachu, mango peel, betelnut and plum seed at a university hospital in Northern India.