Congenital giant right atrium in an elderly woman.

Enlargement of right atrium is usually secondary to pulmonary hypertension due to valvular heart diseases or obstructive pulmonary disorders, atrial septal defect, tricuspid atresia or stenosis, pulmonary stenosis, primary pulmonary hypertension, Ebstein's anomaly. Congenital enlargement of right atrium is rare and it commonly presents in children. Our patient presented with congenital giant right atrium at 65 years of age, other cardiac diseases being excluded. Patient developed tricuspid regurgitation, but pulmonary hypertension was absent till the date. Congenital giant right atrium has rarely been reported from India.

Haemorrhagic pericardial effusion in type I Gaucher's disease.

Gaucher's disease is a rare lysosomal storage disorder. Excess accumulation of glucosylceramide predominantly occurs in abdominal viscera. Cardiac involvement is rare, though they generally represent as restrictive cardiomyopathy and pericarditis. Our case, a 19-year old boy initially presented with hepatosplenomegaly but later diagnosed with haemorrhagic pericardial effusion. Enzyme supplementation gives successful outcome but our case was managed symptomatically with pericardiocentesis.

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE); a rare association with phyllodes tumour of breast.

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is a rare entity mainly found in elderly males. It is characterized by pitting edema mainly of dorsum of both hands giving a "boxing glove hand" appearance; rarely involving feet also, acute in onset, negative rheumatoid factor and a good response to low dose corticosteroid therapy. Clinically it almost resembles a case of polymyalgia rheumatica, late onset rheumatoid arthritis or other seronegative spondyloarthropathy.Though there are multiple underlying factors causing this rare entity but it has very close associations with many malignancies.So far its association with solid tumours and hematological malignancies has been reported. Phyllodes tumour of breast shows wide spectrum of activity from a benign condition to a locally aggressive and sometimes metastatic tumour.One fourth of the cases recur after definitive treatment.Our case represent an unusual association with recurrent phyllodes tumour of breast with RS3PE.

Leptospirosis: an institutional experience.

Leptospirosis, a common zoonotic disease, may present with variable clinical manifestations in between two extremes. Possibility must be excluded in any febrile patient with hepatorenal derangement. There are different reports regarding prevalence pattern, presentations and case fatality rate from different parts of the country. The purpose of this study was to find out the mode of presentation, biochemical profile and complications of leptospirosis cases in an apical level and make a comparison of same with other parts of India. Fifty-one consecutive cases of leptospirosis were selected for this study. Thorough clinical examination was done. ELISA test was done in the second week of illness. Haemogram, liver and renal function tests, coagulation profile, creatine phosphokinase (CPK), chest xray, ECG were done in all patients. Presenting features were fever (100%), myalgia (78.4%), headache (41.2%), jaundice (17.6%), oliguria (29.4%), respiratory distress (25.5%), bleeding manifestations (9.8%), altered sensorium (21.6%). Icterus was found in 74.5% of patients, hepatosplenomegaly in 72.5%, tachypnoea in 52.9%, bleeding manifestations in 35.3%, encephalopathy in 21.6%, hypotension in 15.7% and meningeal signs in 5.9% cases. Case fatality rate was 7.8%. From the study, it becomes evident that though severe leptospirosis has declined, mild leptospirosis has Increased. The reasons for decline of severe leptospirosis may be greater awareness, availability of better diagnostic tool along with widespread use of antibiotics. So, high index of suspicion may eventually reduce complications. It would be wise to start appropriate antibiotics empirically in suspected cases of leptospirosis.

Assessment of the efficacy of pamidronate in ankylosing spondylitis: an open prospective trial.

INTRODUCTION: Bisphosphonates have anti-inflammatory properties in arthritic conditions. This study was conducted to assess the therapeutic potential of intravenous pamidronate in nonsteroidal anti-inflammatory drug (NSAID) refractory/intolerant cases of ankylosing spondylitis (AS). METHODS: A total of 35 NSAID refractory/intolerant AS patients with Bath AS Disease Activity Index (BASDAI) score 4 or above were recruited for the study. Monthly pamidronate infusions (60 mg) were administered to the patients for six months. Treatment outcomes were assessed by comparing baseline values with the values after six infusions using BASDAI, Bath AS Functional Index (BASFI), Metrology Index (BASMI) and Global Score (BAS-G), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). An improvement was defined according to the Assessments in Ankylosing Spondylitis (ASAS)-20 and BASDAI-50. RESULTS: 26 patients received all the six infusions. Of these, 22 (85 percent) achieved ASAS-20 and 20 (77 percent) achieved BASDAI-50 responses. Decrements were noted in the mean BASDAI (56.4 percent), BASFI (52.66 percent), BASMI (55.72 percent), BAS-G (66.71 percent), ESR (52.12 percent) and CRP (72.84 percent) after six months. The tender and swollen joint counts of 14 (54 percent) patients with peripheral arthritis were respectively reduced to a mean value of 0.85 and nil, from the baseline of 2.57 and 1.2. Early feel good response was noted in 16 (62 percent) patients within 48 hours of the first infusion. Fever, arthralgia and myalgia were observed in six cases after the first infusion, and in one case, after the second infusion. These symptoms resolved spontaneously within 24 hours. CONCLUSION: Intravenous pamidronate has good efficacy for the treatment of AS.

Randomised controlled trial evaluating the role of tirofiban in high-risk non-ST elevation acute coronary syndromes: an East Indian perspective.

INTRODUCTION: Glycoprotein IIb/IIIa inhibitors such as tirofiban inhibit platelet aggregation. We evaluated the immediate and early outcomes in patients with high-risk non-ST elevation acute coronary syndrome (NSTE ACS) who received tirofiban with conventional therapy compared to patients who received only conventional therapy (a combination of aspirin, clopidogrel, low-molecular-weight heparin with or without beta-blockers and angiotensin-converting enzyme inhibitors). METHODS: A total of 165 patients received conventional therapy with a placebo, and 136 patients received conventional therapy with tirofiban after randomisation. The outcomes were measured on Day 7, Day 14, one month and three months after the administration of therapy. RESULTS: A significant reduction was noted in the occurrence of primary endpoints in patients receiving tirofiban, compared to those who received a placebo at seven days (14 versus 32; p-value is 0.036), 14 days (14 versus 28; p-value is 0.043), one month (19 versus 34; p-value is 0.01) and three months (30 versus 44; p-value is less than 0.001) after administration. There was a significant reduction in the occurrence of fatal myocardial infarction (MI) (1 versus 8; p-value is 0.044) and non-fatal MI at Day 7 (1 versus 8; p-value is 0.044), and refractory ischaemia at the end of one month (14 versus 24; p-value is 0.04) and three months (25 versus 36; p-value is less than 0.01) in patients receiving tirofiban as compared to those receiving a placebo. CONCLUSION: It may be concluded that tirofiban has a definite role in improving the outcome of patients with high-risk NSTE ACS.

Determination of risk factors of neonatal pneumonia.

Pneumonia is an important cause of neonatal infection and accounts for significant morbidity and mortality in the neonatal period. The best way to reduce the high prevalence of pneumonia at this age group is through identification and elimination of its risk factors. This case-control study was conducted in the department of Pediatrics, Dhaka Medical College & Hospital during Nov 2007 to Nov 2008 with an aim to identify the risk factors of pneumonia. Data were collected from 100 neonates, 50 cases and 50 controls who met the predefined inclusion criteria. Results shows mean birth weight (p<0.05), inadequate antenatal care (p<0.001), normal vaginal delivery (p<0.05), home delivery (p<0.001), delivery by untrained personnel (p<0.001), neonatal resuscitation (p<0.001), intrapartum fever (p<0.01), obstetric problem of mother (p<0.001), foul smelling liquor (p<0.01), prolonged rupture of membrane (p<0.001), prolonged labour (p<0.05) were significantly associated with pneumonia. Multivariate analysis showed inadequate antenatal care (OR 168.9), home delivery (OR 13.8), intrapartum fever (OR 225.9), obstetric problem of mother (OR 33.4), requirement of resuscitation (OR 12.5), prolonged labour (OR 15.2) as significant risk factors of neonatal pneumonia.

Haematological presentation of systemic lupus erythematosus.

Haematological manifestations are quite common in systemic lupus erythematosus (SLE) but bone marrow aplasia and secondary myelofibrosis are rare manifestations. We report a case of 45 years old male patient who presented with fever, malaena and anaemia without any clinical features of SLE. He had patches of vitiligo for 25 years for which he was applying psoralen with sunlight exposure. This probably precipitated SLE in this patient. The patient presented with pancytopenia which was due to a combination of Comb's positive haemolytic anaemia and myelofibrosis.

Rheumatological manifestations of leprosy.

Rheumatological manifestations are common in leprosy. A study was conducted among 30 patients to observe the prevalence and spectrum of rheumatological manifestations in leprosy. Seventeen patients were referred from leprosy clinic from 287 consecutive leprosy cases and 13 patients presented de novo at the rheumatology clinic and later diagnosed to have leprosy. In the first group, the most common manifestation was small and large joints polyarthritis resembling rheumatoid arthritis found in 64.7% cases and in the second group tenosynovitis (38.5%) was the commonest. Rheumatoid factor was positive in 60% cases.

Rheumatological manifestations in diabetes mellitus.

A study was undertaken in the department of medicine from November 2003 to July 2005 with a view to find out the prevalence of different rheumatological problem in Indian diabetic population. Although several such studies have been conducted in western population very limited data are available from our country. A total of 80 patients were studied out of which 43 had some form of rheumatological manifestations. Dupuytren's contracture was found in highest number of cases (n = 23) followed by limited joint mobility in 16 patients; adhesive capsulitis in 19 patients; trigger finger in 4 patients; aglodystrophy, carpal tunnel syndrome and hyperostosis were found in 2, 3 and 2 cases respectively. Symptomatic osteo-arthritis was found in 19 cases.

A study of bone mineral density in diabetes mellitus in eastern India.

To measure bone mineral density in diabetic patients at the time of clinical diagnosis of diabetes mellitus and to find out correlation, if any, with microvascular complication of diabetes mellitus and glycosylated haemoglobin, a study was conducted at Medical College and Hospital, Kolkata among 138 cases of diabetes and 212 controls. All patients were screened for ophthalmoscopy, routine blood and urine examinations. Bone ultrasound attenuation study of the calcaneus was performed in all cases. The bone ultrasound attenuation result was compared to a mean normal population result and expressed as Z score and T score. The age of diabetic patients varied from 11 years to 70 years. Of 138 diabetics, 32 (23.18%) had type 1 diabetes and rest type 2 diabetes. Forty-two diabetic patients had retinopathy, 42 nephropathy and 48 had neuropathy. Glycosylated haemoglobin was above 7% in 124 patients. The broadband ultrasound attenuation of type 1 diabetics ranged from 38 to 95 dB/MHz and in type 2 it was 35 to 104 dB/MHz. There was no statistically significant correlation between neuropathy, nephropathy, retinopathy and bone mineral density status. It was also found no correlation between glycosylated haemoglobin values and ultrasound attenuation.

Comparative evaluation of diabetic and non-diabetic stroke--effect of glycaemia on outcome.

Though there are extensive data on diabetic retinopathy, neuropathy and peripheral vascular disease, there are not enough data on diabetic stroke. Present study was carried out to evaluate distinctive feature of diabetic and non-diabetic stroke and to compare early mortality between two groups. Four hundred and fifty consecutive stroke cases categorised into group I of 171 known diabetic and 279 non-diabetics. Reactive hyperglycaemia seen in cases with HbA1c below 7.0% were put into group II. Patients were evaluated clinically. Evidence of peripheral vascular disease, retinopathy and other target organ damage were assessed. Glycaemic parameters monitored include fasting plasma glucose (FPG), random plasma glucose (RPG) and HbA1c. Total serum cholesterol was taken as the main risk factor in both groups though lipid profile was done in all cases. CT scan was done in all cases and a repeat one when needed. Out of 450 cases 171 were diabetic and 279 cases were non-diabetic. There was female preponderance in diabetic. Average age of diabetic stroke was lower than non-diabetic, 51.2 years as against 67 years. History of previous stroke was higher in diabetic (15.8%) than non-diabetic (5.7%). There was higher incidence of transient ischaemic attack in diabetic (22.8%) than non-diabetic (7.5%), which was highly significant (p<0.001). Hypertension and hypercholesterolaemia (> 175 mg/dl) were two important risk factors in 70.9% and 30.9% respectively in group I compared to 47.6% and 21.1 % respectively in group II, both of which are significant (p<0.001). Ischaemic stroke were higher in group I(69%) as compared to group II (45.8%) which was significant (p<0.001). Lacunar infarct were more in group I (73.7%) than group II (61.7%). Haemorrhagic stroke was higher in group II (52.7%) than in group I (30.4%). Apart from recent event CT scan showed evidence of old lacunar infarct in 36.8% cases of group I compared to 21.1% of group II. During follow-up mortality within 4 weeks was higher in haemorrhagic stroke of group I (55.8%) compared to 49.6% in group II which is significant (p<0.05). For ischaemic stroke mortality in group I was 26.3% compared to 14.8% in group II which is very significant (p<0.001). Out of total mortality in group I, 35.08% had high HbA1c. Increased risk of stroke in diabetic is probably related to hypertension and lipid abnormalities. Increased mortality from abnormal glycaemic control needs to be evaluated further.

Effect of calorie restriction on the development of virus induced leukaemia in mice.

The present study reports for the first time the influence of dietary restriction to mother of suckling animals in reducing incidence of virally induced leukaemia. A delay in the carcinogenic process was also noted in the offsprings maintained on dietary restriction during suckling.