Facile Magnetite Coating for Stable High-Voltage Cycling of Nickel-Rich Cathodes in Conventional Liquid and All-Solid-State Lithium-Ion Batteries.

The instability of Nickel (Ni)-rich cathodes at high voltage is a critical bottleneck toward developing superior lithium-ion batteries. This instability is driven by cathode-electrolyte side reactions, causing rapid degradation, and compromising the overall cycle life. In this study, a protective coating using dispersed "magnetite (FeO.Fe2O3)" nanoparticles is used to uniformly decorate the surface of LiNi0.8Co0.1Mn0.1O2 (NMC 811) microparticles. The modified cathode delivers significant improvement in electrochemical performance at high voltage (≈4.6 V) by suppressing deleterious electrode-electrolyte interactions. A notably higher cycle stability, rate performance, and overall energy density is realized for the coated cathode in a conventional liquid electrolyte battery. When deployed in pellet-stacked solid-state cells with Li6PS5Cl as the electrolyte, the magnetite-coated NMC 811 showed strikingly superior cycling stability than its uncoated counterpart, proving the versatility of the chemistry. The facile surfactant-assisted coating process developed in this work, in conjunction with the affordability, abundance, and nontoxic nature of magnetite makes this a promising approach to realize commercially viable high voltage Ni-rich cathodes that exhibit stable performance in liquid as well as solid-state lithium-ion batteries.

Clinical Profile, Intensive Care Needs and Outcome of Children with Dilated Cardiomyopathy Associated with Vitamin D Deficiency: A 5-year PICU Experience.

Aim: To describe the clinical profile, treatment details, intensive care needs, and long-term outcome of children with dilated cardiomyopathy (DCM) associated with Vitamin D deficiency (VDD). Materials and methods: Case records of 14 children with DCM associated with VDD [25(OH)D3 levels <20 ng/mL] admitted to the pediatric intensive care unit (PICU) of a tertiary care teaching hospital between January 2017 and December 2021 were retrospectively analyzed for clinical features, echocardiographic findings, treatment details, intensive care needs, and outcomes. Results: The median (IQR) age was 6 (2-9) months and 71% (n=10) were males. The common modes of presentation included respiratory distress or failure (78.6%), congestive cardiac failure (71.4%), cardiogenic shock (37.5%), and seizures and encephalopathy (14.3% each). The median (IQR) serum calcium was 8.7 (7-9.5) mg%, ionized calcium 0.7 (0.7-1.1) mmol/L, alkaline phosphatase 343 (316-415) IU/L, phosphate 3.5 (2.6-4.5) mg%, PTH 115 (66-228) pg/mL, and 25(OH)D3 5 (3-7) ng/mL. The median (IQR) left ventricular ejection fraction (LVEF) at admission was 22 (17-25)%. The treatment included intravenous calcium infusion (35.7%), vitamin D supplementation in all (57.1% parenteral and 42.9% oral), mechanical ventilation (35.7%), and vasoactive drugs (57.1%). There was no mortality. The median (IQR) duration of PICU and hospital stay was 76 (31-98) hours and 6 (4.7-10) days, respectively. Out of 14 children, 10 (71.4%) were followed-up till median (IQR) of 10 (7-58) months. All were asymptomatic and had normal LEVF (except one had residual moderate mitral regurgitation). Conclusion: Vitamin D deficiency is a potentially treatable and reversible cause of DCM in children. How to cite this article: Kumar S, Randhawa MS, Angurana SK, Nallasamy K, Bansal A, Kumar MR, et al. Clinical Profile, Intensive Care Needs and Outcome of Children with Dilated Cardiomyopathy Associated with Vitamin D Deficiency: A 5-year PICU Experience. Indian J Crit Care Med 2023;27(7):510-514.

Clinico-Laboratory Profile, Intensive Care Needs and Short-Term Outcome of Multisystem Inflammatory Syndrome in Children (MIS-C): Experience during First and Second Waves from North India.

OBJECTIVES: To describe the clinico-laboratory profile, intensive care needs and outcome of multisystem inflammatory syndrome in children (MIS-C) during the first and second waves. METHODOLOGY: This retrospective study was conducted in the paediatric emergency and paediatric intensive care unit (PICU) of a tertiary care teaching hospital in North India involving 122 children with MIS-C admitted during the first wave (September 2020-January 2021, n = 40) and second wave (February 2021-September 2021, n = 82) of coronavirus disease 2019 (COVID-19). RESULTS: The median (interquartile range) age was 7 (4-10) years and 67% were boys. Common manifestations included fever (99%), abdominal symptoms (81%), rash (66%) and conjunctival injection (65%). Elevated C-reactive protein (97%), D-dimer (89%), procalcitonin (80%), IL-6 (78%), ferritin (56%), N-terminal pro B-type natriuretic peptide (84%) and positive severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) antibody (81%) were common laboratory abnormalities. Cardiovascular manifestations included myocardial dysfunction (55%), shock (48%) and coronary artery changes (10%). The treatment included intensive care support (57%), non-invasive (33%) and invasive (18%) ventilation, vasoactive drugs (47%), intravenous immunoglobulin (IVIG) (83%), steroids (85%) and aspirin (87%). The mortality was 5% (n = 6). During the second wave, a significantly higher proportion had positive SARS-CoV-2 antibody, contact with COVID-19 and oral mucosal changes; lower markers of inflammation; lower proportion had lymphopenia, elevated IL-6 and ferritin; lower rates of shock, myocardial dysfunction and coronary artery changes; lesser need of PICU admission, fluid boluses, vasoactive drugs and IVIG; and shorter hospital stay. CONCLUSION: MIS-C is a febrile multisystemic disease characterized by hyperinflammation, cardiovascular involvement, temporal relationship to SARS-CoV-2 and good outcome with immunomodulation and intensive care. During the second wave, the severity of illness, degree of inflammation, intensive care needs, and requirement of immunomodulation were less as compared to the first wave.

Multisystem Inflammatory Syndrome in Children: Follow-Up of a Cohort from North India.

Multisystem inflammatory syndrome in children (MIC-S) is a hyperinflammatory manifestation of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Information on the long-term outcome of MIS-C is limited. This study was conducted to describe the long-term outcome of MIS-C from a tertiary care center in North India. Children admitted with MIS-C from September 2020 to January 2021 were followed up after discharge until June 2021. The details during the acute phase (clinical features, investigations, treatment, and outcome) and follow-up (symptoms, echocardiographic findings, ongoing treatment, and outcome) were collected retrospectively. During the acute phase, 40 children presented at median (interquartile range [IQR]) age of 7 (5-10) years with fever, mucocutaneous, gastrointestinal, and respiratory symptoms. The majority (66.7%) of the children had positive SARS-CoV-2 serology and elevated inflammatory markers (C-reactive protein, procalcitonin, ferritin, D-dimer, and fibrinogen), lymphopenia, and thrombocytopenia. Eighty percent had shock, 72.5% had myocardial dysfunction (left ventricular ejection fraction <55%), and 22.5% had coronary artery dilatation or aneurysm. Treatment included pediatric intensive care unit admission (85%), intravenous immunoglobulin (100%), steroids (85%), aspirin (80%), vasoactive drugs (72.5%), and invasive mechanical ventilation (22.5%). Two (5%) children died because of refractory shock. Thirty-four children were followed up with until a median (IQR) of 5 (3-6) months. During the follow-up, a majority were asymptomatic, myocardial function returned to normal in all, and only one had coronary artery aneurysm. Prednisolone and aspirin were given for a median (IQR) of 3 (2-4) weeks and 4 (4-6) weeks after discharge, respectively. There was one readmission and no death during the follow-up. To conclude, the long-term outcome of MIS-C is generally favorable with resolution of cardiovascular manifestations (myocardial dysfunction and coronary artery changes) in the majority of children during follow-up.

Evaluation of coronary arteries in congenital heart disease in children: diagnostic comparison of electrocardiogram-gated and non-electro-cardiogram-gated computed tomography cardiac angiography.

Purpose: To compare the visualization and anatomy of coronary arteries in children (≤ 2 years) with congenital heart disease (CHD) on non-electrocardiogram (ECG)-gated and ECG-gated computed tomography angiography (CTA). Material and methods: In this retrospective study, approved by the Ethics Committee of our institute, evaluation of coronary arteries in CHD was performed in 40 children on non-ECG-gated CTA and in 42 children on ECG-gated CTA. The origin and course of the right coronary artery (RCA), left main coronary artery (LMCA), left anterior descending (LAD) artery, and left circumflex (LCX) artery were evaluated by 2 paediatric radiologists independently. Results: ECG-gated CT scans yielded increased (additional) visualization of all the coronary arteries, when compared to non-ECG-gated CT scans. The RCA, LMCA, LAD artery, and LCX artery were visualized in 47.5%, 62.5%, 55%, and 32.5% of children, respectively, on non-ECG-gated studies, while they were visualized in 64.3%, 92.8%, 80.9%, and 62% children, respectively, on ECG-gated studies. The coronary artery anatomical variations were also supplementarily detected more in the ECG-gated group (23.8%) than in the non-ECG gated group (2.5%). Conclusions: ECG-gated CT cardiac angiography studies yield enhanced diagnostic outcomes for the evaluation of the coronary arteries in comparison to non-ECG-gated studies.

Fetal cardiac intervention and fetal cardiac surgery: where are we in 21st century?

Fetal cardiac intervention is an in-utero cardiac procedure done in fetuses with heart diseases like severe aortic stenosis with evolving hypoplastic left heart syndrome, hypoplastic left heart syndrome with an intact or restricted atrial septum, pulmonary atresia with an intact ventricular septum, fetal heart block obstructed total anomalous pulmonary venous return, pericardial collection. The successful biventricular repair can be done in postnatal life after aortic or pulmonary valvuloplasty. Fetal bypass is very challenging because of different physiology. Low prime volume with the high flow can be used to prevent an inflammatory response.

Intensive Care Needs and Short-Term Outcome of Multisystem Inflammatory Syndrome in Children (MIS-C): Experience from North India.

OBJECTIVES: To describe the intensive care needs and outcome of multisystem inflammatory syndrome in children (MIS-C). METHODOLOGY: This retrospective study was conducted in the pediatric emergency, pediatric intensive care unit (PICUs) and the coronavirus disease 2019 (COVID 19) hospital of a tertiary teaching and referral hospital in North India over a period of 5 months (September 2020 to January 2021). Clinical details, laboratory investigations, intensive care needs, treatment and short-term outcome were recorded. RESULTS: Forty children with median interquartile range age of 7 (5-10) years were enrolled. The common clinical features were fever (97.5%), mucocutaneous involvement (80%), abdominal (72.5%) and respiratory (50%) symptoms. Shock was noted in 80% children. Most cases (85%) required PICU admission where they received nasal prong oxygen (40%), non-invasive (22.5%) and invasive (22.5%) ventilation and vasoactive drug support (72.5%). The confirmation of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) exposure was in the form of positive serology (66.7%), reverse transcriptase polymerase chain reaction (10%), and contact with SARS-CoV-2 positive case (12.5%). The common echocardiographic findings included myocardial dysfunction (ejection fraction <55%; 72.5%), and coronary artery dilatation or aneurysm (22.5%). The immunomodulatory treatment included intravenous immunoglobulin (2 g/kg) (100%) and steroids (methylprednisolone 10-30 mg/kg/day for 3-5 days) (85%). Aspirin was used in 80% and heparin (low molecular weight) in 7.5% cases. Two children died (5%) and median duration of PICU and hospital stay in survivors were 5 (2-8) and 7 (4-9) days, respectively. Children with shock showed higher total leucocyte count and higher rates of myocardial dysfunction. CONCLUSION: Cardiovascular involvement and shock are predominant features in severe disease. Early diagnosis can be challenging given the overlapping features with other diagnoses. A high index of suspicion is warranted in children with constellation of fever, mucocutaneous, gastrointestinal and cardiovascular involvement alongwith evidence of systemic inflammation and recent or concurrent SARS-CoV-2 infection. The short-term outcome is good with appropriate organ support therapies and immunomodulation.

Infective endocarditis caused by Abiotrophia defectiva presenting as anterior mitral leaflet perforation mimicking cleft anterior mitral leaflet.

Infective endocarditis (IE) is primarily a bacterial infection of the heart valves. The most common organisms implicated include Staphylococcus and Streptococcus species. However, with the advent of MALDI-TOF and molecular techniques, the reports of IE being caused by rare organisms are on a rise. Here we describe a case of IE due to Abiotrophia defectiva. This is the first report of simultaneous infection of both mitral and aortic valves by Abiotrophia defectiva from India. IE caused by Abiotrophia defectiva has been seen to be more severe, associated with higher failure rates and relapse. This emphasizes the accurate identification of nutritionally variant Streptococcus (NVS) species as the management of choice varies between Abiotrophia and Granulicatella.

Fusobacterial brain abscess caused by paradoxical embolization associated with Ebstein's anomaly in an adult patient: A case report.

Brain abscess remains a life-threatening condition. Here, we are reporting a case of brain abscess due to Fusobacterium nucleatum in a previously known case of Ebstein anomaly. A 44-year-old male presented with the complaints of headache, and fever. Cerebral imaging revealed parieto-occipital (PO) abscess. The abscess was drained and culture showed growth of Fusobacterium nucleatum. This report illustrates the importance of considering anaerobes as the cause of brain abscess, underscores the usefulness of MALDI, which facilitated the selection of appropriate and prompt adjuvant antibiotic therapy and a favourable outcome.

Neuroimaging Abnormalities in Patients With Nontransfusion-dependent Thalassemia.

Independence from regular transfusions is the hallmark of nontransfusion-dependent thalassemia (NTDT). However, the associated complications need anticipation and screening. One such complication is a hypercoagulable state predisposing to development of thrombosis. We evaluated children with NTDT >10 years of age for prevalence of neuroimaging abnormalities (NIA) and identified associated risk factors. In total, 29 patients were evaluated. Blood counts, serum ferritin, protein C, protein S, antithrombin III, brain magnetic resonance imaging, and angiography was done in all patients. Possible risk factors for thrombosis or cerebrovascular disease were analyzed for association with NIA. The median age was 14 (12 to 15) years. Fifty percent were splenctomized and 31.5% were transfusion naïve. Eleven patients (37.9%) had NIA: 6 with silent cerebral infarction (SCI); 2 with cerebral arteriopathy (CA) and 3 having both CA and SCI. Higher white blood cell (WBC) count was associated with NIA (P=0.034) [silent cerebral infarction (P=0.047) and cerebral arteriopathy (P=0.067)]. Presence of 7 or more risk factors had 4.5 times greater risk of a NIA, especially silent cerebral infarction (SCI) (P=0.03). We conclude that cerebral infarction and arteriopathy seem to start in late childhood. There is a need to develop strategies for preventing neurologic complications in NTDT similar to sickle cell disease.

Type II aortopulmonary window with tetralogy of Fallot: successful repair.

Aortopulmonary window associated with tetralogy of Fallot is a rare cardiac anomaly. An 8-month-old boy presented with failure to thrive and recurrent chest infections. Echocardiography and imaging studies revealed a type II aortopulmonary window with tetralogy of Fallot. Corrective surgery in the form of patch closure of the aortopulmonary window and intracardiac repair of tetralogy of Fallot was carried out successfully.

Patent ductus arteriosus aneurysm: a rare cause of dyspnea in an adolescent boy.

We report a rare cause of dyspnea in an adolescent boy who presented with complaints of dyspnea on exertion since childhood without any cyanosis. Computed tomography angiography showed a large patent ductus arteriosus aneurysm that was seen compressing on the trachea and a left main bronchus with associated decreased left lung volume.

Estimation of pulmonary vascular resistance: correlation between echocardiography and catheterization data in patients with congenital heart disease.

BACKGROUND: The ratio of peak tricuspid regurgitation velocity (TRV) and right ventricular outflow time-velocity integral (TVI RVOT) has been described as a good correlate of pulmonary vascular resistance (PVR). However, this method has not been well studied in congenital heart disease. METHOD: Twenty patients with post-tricuspid shunt lesions who were planned to undergo cardiac catheterization were enrolled for the study. The ratio of TRV/TVI(RVOT) was measured via transthoracic echocardiography and correlated with invasively derived PVR (PVR(CATH)). PVR(CATH) was measured by cardiac catheterization. Fick's principle was used to calculate the pulmonary blood flow and oxygen consumption was assumed. Linear regression analysis was done to find the correlation between TRV/TVI(RVOT) and PVR(CATH). RESULTS: There was a significant correlation between the two variables, r = 0.635(P = 0.003). Subgroup analysis revealed that this correlation was better at lower values of PVR(CATH) (r = 0.817 for PVR < 6 Wood units (WU)) than higher values (r = 0.659 for PVR > 6 WU). TRV/TVI(RVOT) ratio of greater than 0.145 predicted with 80% sensitivity and specificity a PVR > 6 WU. CONCLUSIONS: There is modest correlation between TRV/TVI(RVOT) ratio and invasively derived PVR in congenital shunt lesions, especially in PVR < 6 WU. TRV/TVI(RVOT) ratio could be useful in identifying patients with congenital shunts whose PVR is likely to be <6 WU, and hence, do not need cardiac catheterization.

Severe pulmonary artery hypertension following intracardiac repair of tetralogy of Fallot: An unusual finding.

Although mild increase in pulmonary vascular resistance following intracardiac repair of tetralogy of Fallot is often seen in the early postoperative period, it usually subsides without any sequel. Persistent severe pulmonary artery hypertension after total correction is rare. We report a child with tetralogy of Fallot and Down's syndrome, who developed severe pulmonary hypertension and low cardiac output syndrome following an intracardiac repair, which was resistant to specific pulmonary vasodilators and increasing ionotropes. The post correction echocardiogram suggested an intact ventricular septal defect patch, no residual gradient across the right ventricular outflow tract, with free pulmonary regurgitation. The child had a poor outcome. A postmortem biopsy revealed histopathological signs of pulmonary hypertension.

Chylopericardial tamponade secondary to superior vena cava thrombosis in a child with nephrotic syndrome.

We report on a 4-year-old girl with steroid-resistant nephrotic syndrome who presented with life-threatening chylopericardial tamponade with chylothorax secondary to superior vena cava thrombosis. This is the first case report of this complication in a child. We outline the treatment, which included emergency pericardiocentesis and thoracostomy, parentral anticoagulation and dietary modifications. This therapeutic regimen resulted in a good outcome.

Circulating proinflammatory cytokines and N-terminal pro-brain natriuretic peptide significantly decrease with recovery of left ventricular function in patients with dilated cardiomyopathy.

BACKGROUND: Increased levels of TNF-alpha, IL-6, their soluble receptors, and NT-proBNP have been observed in patients with dilated cardiomyopathy (DCM). In the present study, we assessed the possible involvement of proinflammatory cytokines and their soluble receptors with and without recovery of LV function in DCM patients. METHODS AND RESULTS: Forty patients with DCM were enrolled and divided into two groups: Group I consisted of DCM patients (n = 30) whose left ventricular ejection fraction (LVEF) had not recovered on follow up and Group II comprised DCM patients (n = 10) whose LVEF had recovered. Ten healthy subjects were included as controls (Group III). TNF-alpha, IL-6,TNFR1, TNFRII, gp130, and NT-proBNP levels were significantly increased in Group I and were significantly lower in patients with LVEF recovery as compared to those without recovery of LVEF (P < 0.05). CONCLUSION: Circulating TNF-alpha, IL-6, and NT-proBNP appear to correlate with the LV function recovery of patients with DCM and could be used as prognostic biomarkers.

Scimitar syndrome: an uncommon cause of wheezing.

Scimitar syndrome is a rare congenital anomaly characterized by total or partial anomalous venous drainage of the right lung to the inferior vena cava. The infantile form presents with congestive heart failure and respiratory distress in early months of life. We report here the case of a 6-month-old male child who presented with second episode of respiratory distress and wheeze. Poor response to bronchodilators led to fibreoptic bronchoscopy and computed tomographic scan that revealed bronchial anomalies with aberrant drainage of right lung into the inferior vena cava by scimitar vein. The case illustrates that one of the rare causes of wheezing in an infant could be scimitar syndrome.

Lung hypoplasia with dilated cardiomyopathy: coincidence or association?

Pulmonary hypoplasia or aplasia is part of the spectrum of malformations characterized by incomplete development of lung tissue. In more than 50% of these cases, coexisting cardiac, gastrointestinal, genitourinary, and skeletal malformations are present, as well as the variations in bronchopulmonary vasculature. In literature there is no reported case describing lung hypoplasia with dilated cardiomyopathy without structural heart disease. Here, it is presented a 6-month girl, referred to us for persistent homogenous opacity in left hemithorax detected on chest X-ray. Subsequently, she was found to have dilated cardiomyopathy without structural congenital heart disease and congenital hypoplasia of left lung.

Comparison of left ventricular functional parameters measured by gated single photon emission tomography and by two-dimensional echocardiography.

The aim of the present study was to evaluate the correlation amongst left ventricular (LV) functional parameters estimated by gated single photon emission tomography (GSPET) and two-dimensional (2D) M-mode, echocardiography (ECHOC). GSPET was performed in a single day stress/rest protocol by using either technetium-99m methoxy-isobutyl-isonitrile ((99m)Tc-MIBI) or technetium-99m tetrofosmin ((99m)Tc-myoview) in 36 consecutive patients, 21 males and 15 females; mean age 57.6+/-11.8 y, range 32-82 y. The various LV parameters studied were: ejection fraction (EF), end systolic volume (ESV), end diastolic volume (EDV), stroke volume (SV) and LV mass (LVM). The GSPET data were reconstructed using an automatic algorithm employing filtered back projection (FBP) and further analyzed by Emory cardiac (EC) toolbox versions EO-00369 and EO-00733 for the quantitative determinations of these parameters. All patients underwent ECHOC within 1-2 h of the post-stress data acquisition of GSPET. Our results showed that the LV volumes and the LVM showed good correlation (r=0.749 to 0.952, P=0.01). These values could thus be used interchangeably. The assessment of these parameters by GSPET therefore does not seem to be affected by the dose of the radioactivity administered as the dose of the (99m)Tc-labeled myocardial agents for acquiring rest study was approximately four times higher than that for the stress study. Our results also showed that the mean +/- SD values of the volumes and the EF of the LV evaluated by the two techniques, differed significantly except significant correlations for ESV, EDV and LVEF were observed between the two methods: r=0.574 to 0.954; 0.347 to 0.952 and 0.516 to 0.876 respectively. On the other hand, a wide disagreement was observed in estimating the LVM by the two techniques. The LVM measurements by 2D ECHOC were approximately double the values estimated by GSPET. Despite the large disagreement, a small correlation (r=0.33, P=0.05) was observed for LVM between the two techniques. In conclusion, although we observed a good correlation for LV volumes and LVM between the GSPET and the ECHOC techniques, yet these two techniques cannot be used interchangeably.

Utilization of Telefax System for Early Detection, Interpretation and Management of Acute ST-Elevation Myocardial Infarction: An Initial Experience from Rural Punjab Telecardiology Rapid Access Project.

OBJECTIVES: The aim of this study was to assess the feasibility, safety and efficacy of telecardiology-guided initiation of therapy and management of acute coronary syndrome at primary care hospitals before the transfer of the patient to a tertiary care center. METHODS: This study covered 25 of 41 patients diagnosed with acute coronary syndrome at the Kharar Civil Hospital over a period of 15 months. These 25 patients (group A) had ST-elevation myocardial infarction. The remaining 16, with non- ST-elevation acute coronary syndrome, were excluded from the study. The group A patients were thrombolyzed at the Kharar Civil Hospital under telecardiology guidance (transmission of the electrocardiograms by fax to the coronary care unit of the PGIMER, where they were analyzed by a cardiologist). The patients were later sent to the PGIMER for further treatment. The group A patients were compared with two control groups (B and C) of 25 patients each with similar problems. The group B patients were referred for thrombolysis to the emergency ward of the PGIMER from local hospitals (situated at a distance of about 15 km), after acute myocardial infarction had been confirmed by electrocardiograms. The group C patients had come directly to the PGIMER emergency ward for thrombolysis. The patients in all groups were evaluated in terms of door-to-needle time saved, improvement in left ventricular systolic function and adverse events during hospitalization, as well as at three months' follow-up. RESULTS: For patients in group A, the mean door-to-needle time was 67.08 +/- 18.21 minutes. It was 121.8 +/- 48.71 minutes for those in group B and 22.68 +/- 9.24 minutes for those in group C. Thus, the differences among the groups were significant (p < 0.0001). Complications were rare and none occurred during transfer from the Kharar Civil Hospital to the PGIMER. The ejection fraction of all the patients showed an improvement between the time of admission and at three months' follow-up (p < 0.0001). CONCLUSIONS: Utilizing telecardiology advances, district hospital physicians, in collaboration with cardiologists at the tertiary center, can provide adequate standard diagnosis at the pre-coronary care unit level and also provide adequate therapy for acute myocardial infarction. Early administration of streptokinase in the civil hospital brought about a significant reduction in door-to-needle time and considerable improvement in left ventricular function.