1. Percutaneous Intervention in Budd Chiari Syndrome – A Case Series

J Paul, K Varghese, H Devarbhavi, MS Sandeep, SS Iyengar
Department of Medicine, St. John's Medical College, Bangalore.

Objectives : Budd-Chiari syndrome is an uncommon condition induced by thrombotic or non thrombotic obstruction to hepatic venous outflow (either large or small caliber veins), leading to congestive hepatomegaly, hepatocellular injury from microvascular ischemia, portal hypertension and liver insufficiency. The early mortality rate in untreated patients with the classic form of this syndrome is very high. Medical therapy alone is also associated with a high 2-year mortality rate (80- 85%). Innovative and sophisticated therapies have played a role in reducing morbidity and mortality rates. This case series reviews the outcome of percutaneous intervention in such patients.

Materials and Methods : We report a series of patients diagnosed as Budd Chiari syndrome who, having showed no improvement with medical therapy, successfully underwent angioplasty and stenting of the hepatic vein (HV) (one patient) and the inferior vena cava (IVC) (five patients). ALL PATIENTS HAD Doppler/antiogram proven obstruction of the HV/IVC. They underwent angiogram and placement of metallic stents across the level of obstruction including transhepatic hepatic vein stenting.

Results : The immediate assessment showed a good result in all patients. Immediately following the stenting all patients had significant symptomatic relief and adequate weight loss. On 6 months to one year follow up they remained asymptomatic.

Conclusion : Angiography and stenting should be considered as a therapeutic option in patients with symptomatic Budd Chiari syndrome. Long term effect on prognosis of patients undergoing this procedure needs to be studied.

2. Value of Initial Electro Cardiogram in Predicting Multivessel Coronary Artery Disease in Patients with Inferior Wall Myocardial Infarction

D Mukherjee, J Lawrance
Institute of Post Graduate Medical Education and Research, Kolkata.

Background : Patients with inferior wall acute myocardial infarction (AMI) who have ST segment depression in the left pericardial leads (LSTD+) on initial electrocardiogram (ECG) were reported to have more severe coronary Artery Disease (CAD) than those without this finding (LSTD).

Objective : To compare the coronary angiography findings and treatment strategies for patients with inferior wall AMI according to the LSTD Pattern.

Methods : The study included 200 patients of inferior wall myocardial infarction admitted in our hospital between May 2006 and May 2007. The patients were divided into two groups according to the patterns of precordial ST segment depression : (LSTD+) ST depression in Leads V4-V6 and (LSTD-) absence of this findings. All patients were treated according to the Current practice guidelines.

Result : Of the study population of 200 patients. Seventy nine were (LSTD+) and 131 were (LSTD-). All underwent coronary angiography within 30 days of infarction. Compared with (LSTD+) patients, (LSTD-). Patients tended to be older (Mean age 63.7 ± 11.7 versus 58.3 ± 9.6 yrs). Three vessel CAD was more common and single vessel CAD much less common in (LSTD+) than (LSTD-) group (66.0 versus 10.0 and 20 versus 50%). Thus (LSTD-) pattern predicted single vessel disease where as (LSTD+) patients of multivesel CAD.

Conclusions : Among the patient with inferior wall AMI, left pericardial ST segment depression predicts very high prevalence of multivessel CAD and use of extensive revascularization interventions. The absence of this finding predicts, non diffuse CAD and lack of need for extensive revascularization.

3. Case Report – Rare Cause of Secondary Hypertension

A Totagi, SM Shetty, VH Naik, J Inbnathan, B Dinesha, Vamdev, KJ Pradeep
Mysore Medical College and Research Institute, Mysore, Karnataka – 570 021.

Hypertension is one of the leading risk factor of cardiovascular disease and common cause for cardiovascular morbidity and mortality. Hypertension in young raises suspicion of secondary cause. Here is one case report.

A 28 year old female came with paroxysm of headache, palpitation, sweating and generalized weakness.

On general physical examination pulse was 104/min, normal volume, regular and BP was 220/140 mmHg. Face was flushed. JVP was normal. On cardiovascular examination apex was in normal position with heaving type. On auscultation S1 loud, A2 loud, A2 loud, P2 normal. Perabdomen, respiratory system, central nervous system examination was normal.

Routine examination showed Hb 11 gm%, normocytic normochromic picture. Routine urine was normal. Chest X was normal. Serum electrolytes were normal. Thyroid profile was normal. Calcium level was normal. Echocardiography showed concentric hypertrophy of left ventricle. Ultrasound abdomen revealed superior mesenteric lymph adenopathy and para aorric lymph adenopathy. CT abdomen revealed normal adrenals with superior mesenteric lymphadenopathy and para aoric lymphadenopathy. Vanillyl mandelic acid, metanephrines increased in urine. Excision biopsy of superior mesenteric lymph nodes and para aortic lymph nodes done and they found that they were enlarged ganglia and microscopy confirmed them as extraadrenal pheochromocytoma.

Common causes of secondary hypertension are renal parenchycal, renal vascular diseases, coarctation of aorta,
endocrinal causes like primary hyperaldosteronism, cushings syndrome and pheochromocytoma. Pheochromocytoma accounts for 0.1% of these cases. Extraadrenal pheochromocytoma accounts for 10% of pheochromocytoma.

4. Electrocardiographic Localization of the Occlusion Site in Left Anterior Descending Coronary Artery in Acute Anterior Myocardial Infarction.

NK Thota, VR Rao, S Reddy, Ramulu, R Rao
Gandhi Medical College, Secunderabad, Andhra Pradesh – 500 020.

Background : Among patients presenting with ACS, Acute Anterior Myocardial Infarction forebodes worse prognosis due to the extent of myocardial involvement. The prognostic information of AMI is often evaluated by ECHO and invasive investigations. Bed side ECG has good correlation in the localizing the lesion in LAD coronary artery in relation to SEPTAL and DIAGONAL branches. The present study is performed to localize the site of lesion in LAD in relation with CORONARY ANGIOGRAPHIC evaluation.

Materials and Methods : In the present study we have evaluated 30 consecutive patients who were admitted with AMI and subsequently underwent CAG. They had ECG findings of ST elevation in lead aVR, V1 > 2.5 mm, q RBBB, ST depression in lead V5 which were strongly predictive of LAD occlusion proximal to First Septal, whereas Q wave in V4-6 was associated with occlusion Distal to First Septal. Abnormal q waves in lead aVL was associated with occlusion proximal to D1, were as ST depression in lead aVL was suggestive of occlusion distal to D1 branch, for both Septal and Diagnoal branches ST segment depression > 1 mm in inferior leads strongly predictive of proximal LAD occlusion where as absence of ST depression in inferior leads predictive of occlusion distal to Septal and Diagonal. All the patients were followed during their in hospital stay (Median of 7 days) during which 7 patients with Proximal to S1 and D1 and 1 patients with distal to S1 and D1 died.

Conclusion : In Acute Myocardial Infarction ECG is very useful to localize the lesion and in prognostication of patients.

5. A Study of Prevalence of Microalbuminuria in Essential Hypertension and Its Correlation with Duration and Severity of Hypertension

VK Sharma, TN Dubey, RK Jain, M Gupta, N Rao, S Chittawar, R Nayak
Gandhi Medical College, Bhopal.

Objective : To study Prevalence of microalbuminuria in essential hypertension and its correlation with duration and severity of hypertension.

Methods : Fifty patients of essential hypertension, known or newly detected, were included. Patients less than 18 years of age, having macroalbuminuria, diabetes mellitus, urinary tract infection evidence of impaired renal function, congestive heart failure (NYHA class II and higher) and acute febrile illness were excluded. Every patient underwent urinary albumin concentration and albumin to creatinine ratio on first morning spot midstream urine sample by immunoturbidimetric assay.

Results : Out of the 50 essential hypertension patients 12 had microalbuminuria. Among eight newly detected hypertensive patients, only one had microalbuminuria (12.5%), 25% had microalbuminuria with upto 10 years duration of disease and 50% with greater than 10 years duration of disease and 50% with greater than 10 years duration of hypertension. Twelve percent patients with stage I and 47% patients with stage II hypertension had microalbuminuria.

Conclusion : Prevalence of microalbuminuria in essential hypertension was 24% and strong correlation with severity and duration of hypertension.

6. Study of Correlation of Serum Magnesium Level with Cardiac Arrythmias Following Acute Myocardial Infarction.

GC Behera, Arun Mohan, Gagnika Tripathy, PK Padhi
VSS Medical College, Burla, Orissa – 768 017.

Ninety three patients with 88 males and five females electrocardiographically proven acute myocardial infarction
developed within 24 hours in the age group of 20-80 years with 40 age sex matched controls were included in this study. CRF, pain more than 24 hours and patients with thrombolytic therapy were excluded from the study. Serum magnesium was estimated from each case following acute MI.

Smokers were found 66.7%, diabetes mellitus 26%, systemic hypertension 28.1% and dyslipidemia 65.9%. Anterior myocardial infarction was 41%, inferior myocardial infarction was 12.9% and rest was in combination. Cardiac arrhythmias were found RBBB 4.3%, VT 4.3%, VF 2.2%, CHB 2.2% and mobiz type – 1 1.1%. Majority of patients with acute myocardial infarction were in the 50-60 years age group. Major risk factors of acute MI were smoking and dyslipidemia. Men were affected more than women. Anterior wall myocardial infarction was the major type of myocardial infarction. The incidence of mypomagnesemia in acute MI was 20% and it was concluded that there is significant correlation between ventricular arrythemia and hypomagnesemia. There is no significant correlation between serum magnesium level and mortality following acute myocardial infarction.

7. Giant ‘T’ Wave Inversion

TK Biswas
MGM Medical College and Hospitals, Kamothe, Navi Mumbai – 410 210.

Mrs. V Devi 59 years old lady, a case of long standing hypertension presented with history of recurrent syncopal attacks since three months. ECG (12 leads) taken in MOPD is shown in Fig. 1. She was admitted to hospital two weeks later soon after one such syncopal attack. ECG (12 leads) taken immediately on hospitalization is shown in Fig. 2.

Interpretations : The ECG (Fig. 1) shows complete A-V block. The atrial rhythm is regular at rate of 107 per minute. The ventricular rhythm is regular at rate of 45 pear minute but is completely independent of the atrial rhythm.

The ECG (Fig. 2) taken immediately after syncopal attack shows complete A-V block with multifocal QRS complexes in lead I and aVL and “Giant T wave inversion” best seen in chest leads (V2-V5) and the Q-Tc (0.69 sec) is prolonged (the normal Q-Tc should not exceed 0.42 sec in male and 0.43 sec in female).

Discussion : The ventricular rhythm in cases of complete A-V block is at times associated with very large broad, bizarre and inverted waves. This phenomenon is usually best seen in leads V2-V4 and has been termed “Giant T wave inversion” (Jacobson and Schrire 1965 and 1966) and “Massive T wave inversion” (Ipollite (1954). The manifestation is partly an expression of marked prolongation of the Q-T interval; the Q-Tc may be increased to as much as 0.75 sec.

Fig. 01

Fig. 02

The most likely genesis of these “Giant” inverted T waves and the associated prolonged Q-Tc is intense sympathetic stimulation resulting from the anoxia of syncopal attack. The appearance of these T waves in cases of complete A-V block therefore, indicates that the patient has had a recent syncopal or Stokes-Adams attack due to either ventricular standstill or a complicating ventricular flutter particularly multiform ventricular flutter-the torsade de pointes. In other words “Giant T wave inversion” does not occur in cases of complete A-V block which are not complicated by syncopal attacks. The “Giant” T waves with prolonged A-Tc are virtually pathognomic of preceding episodes of unconsciousness (Stokes-Adams attack).

8. Efficacy of Torsemide in the Treatment of Congestive Heart Failure

SK Kamra, HK Madaan, SK Sachdeva, S Bansal, S Utreja
Government Medical College, Patiala, Punjab

Background : Diuretics are the first drug to be given in CHF to treat it because they can relieve symptoms very quickly. Torsemide, a new loop diuretic due to predictable pharmacokinetics induces greater improvement in functional and social limitation in CHF.

Aim : To determine the efficacy and safety of torsemide 20 mg in the treatment of patients of CHF caused by CAD and/or HT and its effect on serum electrolytes (Na+, K+).

Material and Methods : Thirty patients of CHF (NYHA II-IV) caused by CAD and/or HT were selected for the study. They were given 20 mg of torsemide once daily orally. Patients were followed up every 2 weeks for clinical evaluation and serum electrolytes estimation for a period of six weeks. Results : Significant improvement in mean severity score of dyspnea, edema, nocturia, orthopnea and pulmonary rales occurred. 50% of patients showed improvement by atleast one NYHA class. Mean bodyweight, mean SBP and DBP decreased significantly. No significant effect on serum Na+ and K+ was seen. Conclusion : Torsemide 20 mg is safe, well tolerated and very efficacious in treating CHF (NYHA class II-IV) with no significant effect on serum electrolytes.

9. A Rare Congenital Coronary Anamoly Presenting in Adulthood

YC Lakshmana, N Praveen Kumar, S Shuba, V Karthik, WT Azhar
Sri Devaraj URS Academy of Higher Education and Research, Tamaka, Kolar, Karnataka – 563 101.

A 35 year old female patient presented with sudden onset of retrosternal chest pain and palpitations of 1 day duration. Past history of similar complaints was present since 2 years. On examination, patient had pallor and collapsing pulse. Cardiovascular examination revealed a systolic thrill and continuous murmur in the left second and third intercostals spaces. Electrocardiogram showed QS pattern in V1-V3 and T wave inversions in I, aVL, V4-V6. echocardiographic diagnosis of anamolous origin of left coronary artery from Pulmonary artery (ALCAPA) was made. Angiogram confirmed ALCAPA and also showed narrowing of origin of LCA from PA which might have
reduced coronary steal resulting in long survival.

ALCAPA is a very rare congenital malformation with incidence of 1 in 300,000 live births. 80-90% of patients die during first year of birth and about 10-15% reach adulthood. The diagnosis is suspected in adults, when a patient with angina has a continuous murmur in pulmonary area or mitral regurgitation. This paper is being presented due to the rarity of presentation of this syndrome is adulthood.

10. Seasonal Variation in Incidence of Complete Heart Block

B Majumdar, D Kumar, A Kumar, V Kumar, P Rajan, Saroj Mondal
IPGME and R, SSKM Hospital, Kolkata.

Introduction : Seasonal variation in the incidence of cardiovascular events such as acute myocardial infarction, sudden death, stroke and atrial fibrillation is well recognized but there is lack of literature regarding the seasonal variation of complete heart block.

Methods : We conducted a retrospective study of the patient who underwent permanent pacemaker implant during period of 1996-2006 at our institution. The age, sex and geographical profile of patients were reviewed as well as seasonal preponderance of CHB was studied.

Result : There was total 6367 permanent pacemaker implant during above mentioned period, out of which 4696 (73.75%) were implanted to patient having diagnosis of complete heart block. The male to female ratio was 1.6:1 and commonest age group was 45-55 years. There was significant seasonality in the incidence of complete heart block. It was more in summer season then winter (p < 0.0001). Highest number of implants for CHB was done in April-June quartile in most of the years and least during Oct.-Dec. quartile.

Conclusion : There is substantial seasonal variation in incidence of complete heart block more in summer than winter unlike all other cardiovascular events.

11. Stress Cardiomyopathy in Attempted Suicide by Hanging

DBD Sathiakumar, Gnanavelu
Sugam Hospital, Chennai – 19.

Acute and rapidly reversible left ventricular dysfunction may be triggered by various emotional and physical stress. Emotional stress like anger, loss of Loved ones, Extreme grief and physical stress like Trauma and sepsis are known to cause LV dysfunction.

Hanging Cases has not been reported to so far to have caused Cardiac failure.

From Sugam Hospital we report cardiac failure occurring in attempted suicidal hangings for the first time in India. Sugam Hospital treated a total of 32 cases of attempted suicidal hangings from January 2005 to October 2007. Of the 32 cases we observed three people presenting to us with severe shock (Hypotension). All three survived with appropriate Anti-failure measures.

I am giving the clinical profile of one of the cases.

Twenty one years old educated unmarried girl was seen in the emergency room with history of attempted suicide by hanging using her sari from a ceiling fan. On examination, her Glasgow Coma Scale was 3 and she was gasping for breath. She was very restless and her SpO2 was 65% with systolic blood pressure of 80 mmHg and pulse rate of 134 bpm. There was no significant injury to head and cervical spine. She was ventilated. ECG revealed sinus tachycardia with diffuse T wave inversion. Chest X-ray showed features of pulmonary edema. Her arterial blood gas analysis showed Respiratory acidosis. Transthracic 2 dimensional and M-mode Echocardiography revealed global hypokinesia of left ventricle and moderate left ventricular dysfunction with an
ejection fraction of 39%. Qualitative Tropanin T was negative. Her hemodynamics improved with Dopamine and Dobutamine. Steriods and Mannitol were given to decrease cerebral edema. She was extubated on the second day. Her hemodynamics remained stable and she had no residual neurologic deficit. But she was intensely depressed. ECG on day 4 was within normal limits and transthoracic echo revealed normal left ventricular contraction and function with an ejection fraction of 64%. She was discharged on day 7 without neurologic and cardiac sequelae.

Recently it has been established that either Emotional stress or physical stress can cause increased secretion of hormones like Adrenaline and Cortisone through Hypothalamo pituitary adrenal axis and Hypothalamo Sympathetic nerve pathway which are responsible for the Cardio Vascular effect. In Suicidal attempts the person goes through severe emotional stress before the attempt and super added physical stress of hanging could have further caused the damage. Severe Hypoxemia also could have caused the LV dysfunction. Many lives could be saved when this complication is recognized and promptly treated.

12. Course Changes in Brain Natriuretic Peptide in Severe Mitral Regurgitation

R Prakaschandra, DP Naidoo
Department of Cardiology, University of KwaZulu Natal, Inkosi Albert Luthuli Central Hospital, Durban.

Aim : Brain natriuretic peptide (BNP) rises in response to ventricular muscle stretch and levels have been used to detect early heart failure. We hypothesized that BNP would be activated in patients with regurgitant valvular heart disease with concomitant ventricular dilatation. We therefore studied the pattern of changes in BNP in patients with chronic severe rheumatic mitral regurgitation who were undergoing mitral valve replacement.

Method : Twenty seven consecutive patients undergoing surgery in the last eight months were prospectively evaluated. Simultaneous quantification of the severity of mitral regurgitation (MR), left ventricular (LV) end systolic volume (ESV), left atrial (LA) volume and Doppler filling ratios (mitral (E)/annulus (Ea)) were performed preoperatively, at 1-week and at the six-week follow-up visit. Twenty-eight controls subjects with severe MR were selected from the hospital clinic where they were being follow up.

Results : There were seven males and 20 females with a mean age of 20 years. BNP levels were markedly elevated preoperatively (262 pmol/l) in all patients selected for surgery compared to patients with similar degrees of MR (57 pmol/l) who were being followed up at the clinic (p=0.001). EchoDoppler parameters were similar in all patients preoperatively except LA size (76 vs. 66 mm p < 0.01) and volume (309 vs. 173 ml p < 0.004) which were elevated in the surgical group. BNP levels increased further immediately (at one week) post surgery (497 pmol/l) and subsided at the six week follow-up visit (71 pmol/l). These changes were accompanied by significant reduction in LA (205 to 175 ml p=0.042) and LV chamber dimensions (ESV 83 to 64 ml p=0.003) with an increase in the ejection fraction from 42% at one week to 52% at six weeks. Myocardial tissue Doppler showed an increase in the systolic wave (0.06 to 0.07 p=0.019). Four patients had abnormally elevated BNP levels (> 31 pmol/l) at the 6-week follow-up visit. These were accompanied by increased E/Ea ratio (>10) on tissue Doppler and impaired LV contractility (ejection fraction < 40%). One patient demised postoperatively at 1 week follow-up. The BNP level recorded was 2065 pmol/l.

Conclusion : Elevated BNP correctly identified patients selected for surgery. BNP levels subsided at the six weeks follow-up visit after surgery, but remained elevated in those with persistent LV dysfunction. Estimation of BNP could assist in the timing of surgery in patients with regurgitant valvular heart disease prior to the onset of irreversible LV dysfunction.

13. A Study of the Clinical Profile of Secondary Hypertension

SS Dhage, Geetha Francis, Reshma Singh, KP Gireeshkumar, MGK Pillai, VP Gopinathan
Amrita Institute of Medical Sciences and Research Centre, Ernakulam, Kerala – 682 026.

Secondary Hypertension is the one which results from underlying, identifiable and often correctable causes.

We hereby present a prospective study of 100 patients with secondary hypertension in a Tertiary Care centre of South India, from February, 2005 to April 2006. Relevant review of literature will be discussed.

14. Combination of Olmesartan and Hydrochlorthiazide in Stage II Hypertension

SP Jindal, SK Sachdeva, HK Madaan
Ashish Medical Centre, Mansa, Punjab – 151 505.

Background : Effective control of hypertension is mandatory to avoid morbidity and mortality associated with it. JNC VII recommends the use of two antihypertensive drugs for stage II hypertension.

Objective : To study the efficacy and safety of one daily combination of olmesartan medoxomil (20 mg) and hydrochlorthiazide (12.5 mg) in stage II hypertension.

Methodology : Fifty patients of stage II hypertension aged between (18-75 years) were included in study. After clinical evaluation and baseline investigations including ECG, they were administered the combination drug once daily for eight weeks. Patients were classified as responders, if the (i) sitting DBP was < 90 mm of Hg after treatment (ii) DBP decrease from baseline by > or = 10 mm of Hg after treatment. Patients were followed up at 2, 4 and 8 weeks for clinical evaluation, compliance and side effects.

Results : Olmesartan medoxomil 20 mg and HCTZ 12.5 mg significantly reduced both mean SBP and DBP at end of 2nd and 8th week (16.2 and 12.2 mm, 22.4 and 17.2 mm of Hg respectively). No significant adverse events were seen.

Conclusion : Once daily combination of olmesartan 20 mg + hydrochlorthiazide (12.5 mg) is effective and safe in stage II hypertension.

15. Significance of Microalbuminuria in Essential Hypertension

VA Kothiwale, M Jagadeesh, R Solabannavar, Preethy Vergheese
KLE Society’s Hospital and Medical Research Centre, Belgaum – 590 010.

Hundred cases of Essential Hypertension of varying duration studies for 1 year. Microalbuminuria was estimated by 24 hours urine collection by Immunoturbidimetric assay.

In the present study, prevalence of Microalbuminuria was 48% in Essential Hypertension cases. Microalbuminuria has significant correlation with duration of hypertension and severity of hypertension. Cases having less than 10 years duration of hypertension only 32% cases had Microalbuminuria. Whereas cases having more than 10 years duration of hypertension almost all i.e. 100% cases had Microalbuminuria. This indicates that longer the duration of hypertension more number of cases will be Microalbuminuric and which is statistically significant (P 0.000). Likewise, severity of hypertension also had significant correlation i.e. among 48 cases who had Microalbuminuria in present study, 29.62% cases presented with stage 1 hypertension who had mean range of Microalbuminuria of 72.19 + 36.48 MG/Day and 69.56% cases who had stage II Hypertension, had mean range of Microalbuminuria of 132.1 + 92.6 MG/Day. This shows that as the stage of hypertension increases the quantity of Microalbuminuria also increases (P 0.000).

In present study, Microalbuminuria also showed positive correlation with hypertensive associated complications like Retinopathy 9100%, Left Ventricular Hypertrophy (85%), Ischaemic Heart Disease (65%), Stroke (85%).

16. Efficacy and Safety of Amlodipine and Atorvastatin in Hypertensives with Dyslipidaemia

Mukta N Chowta, Prabha M Adhikari, SK Shenoy
Kasturba Medical College, Mangalore, Karnataka – 575 001.

Objective : To evaluate the efficacy and safety of fixed dose combination of amlodipine and atorvastatin in hypertensives associated with dyslipidaemia.

Methods : The study was designed as a prospective, open labeled, noncomparative trial in 35 adult patients of mild to moderate essential hypertension with dyslipidaemia. Blood pressure criteria for patients of mild to moderate essential hypertension with dyslipidaemia. Blood pressure criteria for inclusion was > 140/90 mmHg and less than 180/110 mmHg. Dyslipidaemia criteria was LDL cholesterol > 130 mg/dl and triglycerides more than 150 mg/dl. Patients were screened at baseline visit and evaluated on day 4, week 1, week 2, week 4, week 6 and week 8. Active medication stared at week 2.

Results : Total of 35 patients was included in the study, out of which 27 were males and eight were females. Average decrease of supine systolic and diastolic blood pressure from baseline recording was 10.3 ± 3.62 mmHg and 9.51 ± 2.13 mmHg respectively at the end of treatment. Statistically significant decrease in the levels of total cholesterol and LDL cholesterol were observed with the treatment.

Conclusion : Combination of amlodipine and atorvastatin is well tolerated and effective in reducing both blood pressure and lipid levels.

17. Study of Plasma Fibrinogen Level in Cases of Stroke

A Ligeesh, PR Raika, GC Behera, PK Padhi, BK Barik
VSS Medical College, Burla.

Aims and Objective : To study the clinical profile and altered plasma fibrinogen levels in stroke patients and to assess the role of fibrinogen level as a risk factor in pathogenesis, type of CVA and ultimate prognosis.

Materials and Methods : The study carried out in this Institute from June 2005 to 2006, included 42 cases who were diagnosed clinically and supported by CT scan findings. Cases where plasma fibrinogen level likely to be altered were excluded from study. All the patients were subjected to routine investigation along with measurement of plasma fibrinogen level (Immunological assay method) after 2 weeks to 4 weeks to minimize influence of acute phase response on coagulation and fibrinolytic factors. An equal no of control group was included in this study.

Observation : In this study 27 (64%) were infarct and 15 (36%) were cerebral haemorrhage cases. The plasma fibrinogen level was higher in cases (mean 585.88 ± 158.06 mg/dl) than control (mean 354.5 ± 44.12 mg/dl). The plasma fibrinogen in cerebral infract (mean 606.92 ±171.71 mg/dl) was higher than cerebral haemorrhage (mean 567 ± 128.37 mg/dl). The stroke patients who died had higher level of plasma fibrinogen than who survived. Smokers had increased level of fibrinogen. There was no significant difference of level between hypertensive and non-hypertensive stroke patients.

Conclusion : Plasma fibrinogen is an important marker of stroke its higher level indicates type of CVA and poor prognostic value. Smoking and hypertension are additional risk factors where the value is elevated.

18. Pregabalin (150 mg) in Painful Diabetic Peripheral Neuropathy

SK Sachdeva, HK Madaan, NS Chaudhry
Government Medical College, Patiala, Punjab – 147 003.

Pregabalin binds with high affinity to alpha 2 delta ligand of voltage gated calcium channels and has analgesic, antiepileptic and anxiolytic activity. It is indicated for management of neuropathic pain associated with diabetic peripheral neuropathy.

Aims : To study the efficacy, safety and tolerability of 150 mg of pregabalin in painful diabetic peripheral neuropathy.

Methodology : Fifty patients of T2DM with painful diabetic peripheral neuropathy of 1-5 years duration were administered Pregabalin 75 mg BD for 8 weeks. Only patients with pain score e” 40 mm on SF-MPQ-VAS (Short Form – McGill Pain Questionnaire – Visual analogue scale, were 0 mm = no pain and 100 mm = worst possible pain) were included. Primary efficacy measures included end point mean pain score. Secondary efficacy measures included improvement in SF-MPQ-VAS, mean weekly sleep interference score, Patient and Clinical Global impression of change. Patients were followed at 1, 4 and 8 week for clinical evaluation.

Results : Pregabalin 150 mg significantly (> 50% reduction in pain score) reduced end point mean pain score in 34% of patients. Significant improvements were also seen in mean weekly sleep interference score, SF-MPQ-VAS and in patient and clinical global impression of change. Pregabalin effects were seen as early as week one and were sustained throughout study period. Most common adverse events were dizziness and somnolence. Pregabalin was well tolerated.

Conclusion : Pregabalin 150 mg is safe, well tolerated safe and efficacious in painful diabetic peripheral neuropathy.

19. Poems in Neuropathy

Tashi Luke, V Kamath, T Mathew, GSK Sarma, AK Roy
St. John’s Medical College, Bangalore.

Fourty three year old male agriculturist from Tamil Nadu presented with a history of chronic pain and burning sensation, with progressive weakness of early distal and subsequent proximal weakness, of bilateral lower limbs.
Examination revealed clubbing with diffuse hyperpigmentation with sclerodermoid features. On systemic examination hepatomegaly and features of peripheral neuropathy was noted.

ENMG was suggestive of axonal and demyelinating neuropathy. Hypotheyroidism was detected. Serum electrophoresis revealed M-Spike. Radiography showed an obsteolytic lesion in the left pelvis, which was histopathologically consistent with plasmacytoma. Patient was thus steroid therapy and local irradiation for the plasmacytoma.

Poems syndrome should always be considered in any case of peripheral neuropathy, as it is a treatable condition.

20. Analysis of Risk Factors in Relation to Large Vs. Small Vessel Ischaemic Stroke in 100 Patients Treated at a Tertiary Referral Centre

RP Rajesh, R Pazhani, A Kalanidhi, GB Vidhyashankari, NTR Balasubramanian
Southern Railway, HQ Hospital, Chennai.

Aim of the Study : To find out the role of individual versus multiple common stroke risk factors in the incidence of small vessel versus large vessel ischaemic stroke.

Materials and Methods : In this retrospective and prospective study, 100 patients presenting with stroke, admitted in Southern Railway Head Quarters Hospital, Perambur, Chennai over the period from January 2005 to December 2007 are included. These patients are classified into small vessel disease (lacunar and small infarcts), and large vessel disease (major arterial stroke – ACA/ MCA/PCA territory). We have excluded cardio embolic stroke. The major stroke risk factors – hyperlipidaemia, hypertension, diabetes, smoking are analyzed in both the group patients. We have done carotid Doppler in all patients in addition to Neuroimaging.

Results and Conclusion : The analyzed data with statistics will be published in the meeting. The results will give information about the common risk factors and their role in small vessel versus large vessel ischaemic stroke.

21. An Interesting Case of Lower Cranial Nerve Palsies

S Shuba, N Nagaraj, YC Lakshmana, M Azeem, C Udayashankar
Sri Devaraj URS Academy of Higher Education and Research, Tamaka, Kolar, Karnataka – 563 101.

A 59 year old male presented with h/o pain and swelling on the right side of the neck since 20 days. H/o acute onset dysphagia for solids with nasal regurgitation and hoarseness of voice since 15 days. Patient was a diabetic on treatment. O/E, he had a tender swelling on the right side of the neck with involvement of right IXth, Xth, XIth and XIIth cranial nerves. Rest of the examination was normal. A clinical diagnosis of Collect Sicard syndrome was made. MRI of the neck and base of skull revealed extensive inflammation involving the right parapharyngeal and carotid spaces. Aspiration/I and D was not possible since it was a diffuse inflammation encasing the carotid artery. After 4 weeks of antibiotics, MRI revealed significant resolution of inflammation. The patient recovered almost completely, except for residual vocal cord palsy.

Collect sicard syndrome is a rare syndrome involving the last 4 cranial nerves after they exit the jugular foramen and hypoglossal canal. The most common causes are schwannomas, base of skull tumours, carcinomatous or lymphomatous lymphadenopathy and metastasis. Less common causes are trauma and granulomatous basal meningitis. Ours is a rare case of non granulomatous infection, where the patient recovered with antibiotics alone.

22. To Study Lipoprotein (a) Serum Concentration in Patients of Ischemic Cerebrovascular Disease

M Beg, M Jasim, A Gupta, N Akthar, A Aziz
JN Medical College Hospital, Aligarh.

Background and Aim : Strokes are one of the most common causes of mortality and long term severe disability. There is evidence that lipoprotein (a) (Lp(a)) is a predictor of many forms of vascular disease, including premature coronary artery disease. Several studies have also evaluated the association between Lp (a) and ischaemic stroke with conflicting results. The aim was to study the levels of Lp(a) serum levels and other lipid parameters in patients of ischemic CVD.

Methods : Lp(a) concentration, apolipoprotein(a) phenotype, triglyceride, low-density lipoprotein, high-density lipoprotein, and total cholesterol levels of blind-coded specimens were assessed in a consecutive series of patients with ischemic cerebrovascular. We evaluated 100 (male (65) and female (35)) patients (mean age, 60 ± 7 years).

Results : Lp(a), total, and low-density lipoprotein cholesterol were statistically significantly elevated in all patients compared with control subjects. Lp(a) correlated with the severity of symptomatic cerebrovascular disease. Lp(a) correlated with the severity of symptomatic cerebrovascular disease. With a cutoff of 20 mg/dL of Lp (a), the odds ratio for a subject to have had ischemic stroke with elevated Lp (a) was 30.

Conclusions : This case-control study shows that an elevated Lp (a) level is primary factor associated with the presence and severity of ischemic cerebrovascular disease.

23. Tumefactive Demyelination Mimicking Tuberculoma

S Ray, JN Panicker, S Gopinath, S Kumar, K Vinayan, A Kumar
Amrita Institute of Medical Sciences and Research Centre, Ernakulam, Kerala – 682 026.

Tuberculosis can have varying presentations, and neurological involvement is characterized by the ring-enhancing lesion on neuroimaging. We describe two cases with clinical profile and neuroimaging closely mimicking Koch’s disease, which on further work up, however, turned out to be tumefactive demyelination. The existence of this entity must be kept in mind as it closely mimicks Neurotuberculosis and has very good response to immunosuppressive therapy as proven in our cases.

24. Vertebral Artery Dissection – A Rare Cause

N Jayalakshmi, E Ravi, V Umadevi, N Balamurugan
Department of Neurology and Radiology, Sri Gokulam Hospital, Salem.

Dissection of vertebral or basilar artery has been increasingly recognized in recent years following clinical and angiographic description of internal carotid artery dissections. We report a rare cause of vertebral artery dissection.

Report : A 45 year old man presented with acute onset of vertigo, ataxia and dysarthria. On examination he had right side Horner’s, 9th, 10th and 12th cranial nerve palsy. He had incoordination on right and extensor plantar on left side. His biochemistry and cardiac work up were normal. He had no clinical or serological evidence for vasculitis or immuno deficiency state. His MRI Brain was normal. As no cause could be identified, further questioning the patient revealed that he had habit of self neck manipulation. On the day of ictus, following self chiropraxy, he had neck pain and then vertigo. CT angio showed vertebral artery dissection on right side. He was treated with anticoagulants. On the day of discharge he had no neurological deficit but for mild 12th nerve palsy.

Discussion : Extra cranial VAD is a common cause of cervicocerebral arterial dissection. Trauma is a common cause of VAD. Incidence of vertebral artery dissection following chiropractic manipulation is not known. Chiropractic manipulation is a common form of alternative medicine worldwide and more so in South India. Most of our patients do not reveal history of chiropractic manipulation unless specifically asked as happened in our case givnette. Seventy percentages of these patients present with an infarct and out patient had no infarct in MRI. Anticoagulants are the main stay of therapy. Most of these patients show complete clinical recovery on follow up as happened in our case.

Conclusion : We report a case of vertebral artery dissection following chiropractic manipulation, a rare and preventable cause.

25. Cerebral Venous Thrombosis in Chronic Headache

MB Mahadik, EJ David, PM Kulkarni
Wanless Hospital, Miraj, Maharashtra – 416 410.

Object : A study conducted for evaluation of CVT in patients with chronic headache.

Methodology : Total 48 patients with chronic headache with no neurodeficit were examined. Common other causes like migraine refractory errors and others were ruled out. These patients were subjected for MRI/CT venoram for CVT as cause.

Summary : Out of 48 patients 17 were found to have CVT. Of these 5 patients had protein C or S deficiency and 12 had idiopathic CVT. All 17 patients received anticoagulation. Thirteen patients responded to anticoagulation with radiological disappearance and resolution of headache. Remaining four patients continued to have headache but with decreased intensity of headache.

Conclusion : 1) Incidence of CVT is as high as 35% in selected chronic headache. 2) CVT should be considered as one of the causes of chronic headache.

26. Lipid Profile in Primary Intracerebral Hemorrhage

PK Routray, BL Parija, BN Mohapatra, G Ray, P Patra
SCB Medical College, Cuttack.

During the study period of two years (September 2004 – September 2006) a total of 300 cases of primary intracerebral hemorrhage admitted to medicine ward of SCB Medical College were selected randomly. Hemorrhagic infarction and tumour hemorrhage were excluded. All previous cases of hypertension were excluded from the study group. Serum total cholesterol less than 200 mg/dl was found in 77% of cases with median value of 174 mg/dl, 25th quartile was 156 mg/dl and 75th quartile was 208 mg/dl. Serum LDL cholesterol less than 130 mg/dl was found in 79% cases with median value of 116 mg/dl and 25th quartile was 98 mg/dl, 75th quartile was 127 mg/dl. Triglyceride level less than 160 mg/dl was found in 79.6% of cases. It is concluded that hypocholesterolemia can be considered as a potent risk factor of primary intracerebral hemorrhage.

27. Prognostic Significance of CRP in Acute Ischaemic Stroke

SK Giri, G Ray, BL Parija, PR Murmu, S Singh
SCB Medical College and Hospital, Cuttack, Orissa – 753 007.

Materials : Sixty two cases of acute ischaemic stroke were included in the study, diagnosis of ischaemic stroke was established by clinical examination, investigation and CT scan.

Methods : Routine hematological and biochemical investigations, CRP at admission and discharge, ECG, CT scan.

Follow up : Patient were followed 1st, 3rd and 6th month after discharge.

Observation : The patients were divided into 3 groups, according to CRP value, < 5, 6-33, > 33 mg/L. Out of 62 patients 9 had fatal events and 14 had non fatal events (unstable angine, AMI, Restroke). 66% of the fatal events occured in patients having high CRP value at admission and 80% of the fatal events occurred in patients having high CRP value at discharge. Patients having high CRP value at discharge also had maximum disability after 6 months follow up.

Conclusion : It was concluded that CRP level in ischaemic stroke is a prognostic indicator and higher value at discharge is associated with increased mortality, morbidity and disability in the subsequent period.

Prevalence of Heart disease in Patients with COPD

Nibedita Mishra, BS Rao, AC Jha
Tata Main Hospital, Jamshedpur, Jharkhand – 831 001.

Object of the Study : To find out the prevalence of cardiac disease in patents diagnosed and being treated as COPD or Br. Asthma.

Methodology : Prospective study. Period April 2006 to March 2007. Setting – Large industrial tertiary care hospital inclusion criteria – Cases diagnosed and being treated as COPD or Bronchial Asthma. Exclusion criteria – Pre-existing heart disease. ECG and X-ray were done in all cases. Pulmonary function tests and 2D ECHO done in selected cases.

Summary of Result : Out of 65 cases, 40 (61.5%) were uncomplicated COPD or bronchial asthma. 13 (20%) had features of cardiac complications of COPD. 12 (18.5%) were diagnosed to have primary cardiac conditions.

Conclusion : Before labeling a patient as having COPD or bronchial asthma it is essential to exclude pre-existing heart disease. In managing COPD cases the cardiac complications should be monitored.

Ventilator Associated Pneumonia

AP Joshi, EJ David, PM Kulkarni
Wanless Hospital, Miraj Medical Centre, Miraj, Maharashtra – 416 410.

Object of Study : To study incidence, risk factors, common organism, antibiotic sensitivity pattern and outcome of patients with ventilator associated pneumonia.

Methodology : Patients were selected according to inclusion criteria in CDC guidelines. All patients who were ventilated for > 48 hrs. were observed for signs of VAP.

Summary and Conclusion : VAP had an incidence of 52% in our ICU. Prolonged ventilation, reintubation, multiorgan failure are all risk factors for VAP. MDR gm –ve aerobic bacteria was the common group, amongst Klebsiella pneumoniae was the most common organism. Imepenem was most common antibiotic which was sensitive.

Pulmonary Alveolar Microlithiasis – A Rare Cause of Breathlessness

S Abkari, M Talluri, VR Srinivasan, B Ayapti, S Uppin
Nizam’s Institue of Medical Sciences, Hyderabad.

Pulmonary alveolar microlithiasis (PAM) is an uncommon chronic disease characterized by calcifications within the alveoli and a paucity of symptoms in contrast to the imaging findings.

We present a 32 year old lady with a 2 year history of shortness of breath on exertion. Lung auscultation revealed bilateral basal end inspiratory creptations. Pulmonary function tests showed a severe restrictive pattern. Chest radiograph revealed bilateral diffuse confluencing micronodular calcification with a sandstorm appearance and the typical black pleura sign. High-resolution CT revealed bilateral diffuse micronodular densities, interlobular septal thickening, and linear calcifications along the pleura. Serum calcium was normal. 2D echocardiography was normal. The patient underwent a transbronchial lung biopsy that revealed round, concentrically laminated, microliths (calcispherites) in the alveoli that were diagnostic of PAM.

This case illustrates a rare cause of breathlessness with bilateral pulmonary infiltrates PAM should always be considered in the differential diagnosis of calcific micronodular pulmonary lesions.

To Test the Hypothesis that Hypoxemic Episodes in Obstructive Sleep Apnea Cause Myocyte Necrosis by Estimating Cardiac Troponin T

NS Choudhary, HS Hira, MK Daga, S Garg, T Sethi,
Naresh Maulana Azad Medical College, Delhi – 110 002.

Introduction : Patients of obstructive sleep apnea syndrome (OSAS) have predisposition to myocardial infarction by multiple known mechanisms. ST segment depression episodes suggestive of ischemia occur during sleep in patients of OSAS with or without coronary artery disease. It is hypothesized in various studies that hypoxemic episodes may cause cardiac myocyte necrosis. In this study an attempt was made to find out myocyte necrosis in non coronary artery disease patients by troponin T estimation.

Methods : Thirty five individuals having snoring and excess daytime sleepiness were divided in case group (n=25, having moderate or severe OSAS) and control group (n=10, having mild or no OSAS). Patients having hypothyroidism or coronary artery disease were not included in study. Troponin T estimated with qualitative method (sensitive up to .08 ng/ml), before sleep and after 4 hours of sleep in both groups.

Results : Troponin T estimation was found to be negative in both of the groups. Positive correlations were found between apnea hypopnea index and body mass index, bradycardia/ tachycardia index. Epworth sleepiness score and desaturation index were not found to be correlated with either of these.

Conclusion : Patients having moderate or severe OSAS did not reveal any episode of night time cardiac myocyte injury as detectable by troponin T estimation method. However, more studies including larger number of patients or more sensitive methods of troponin T estimation are needed in this regard. Further implications are to be discussed.

Clinical Profile and Outcome of ARDS

GSN Chandra, BA Shastry, Kavita Saravu, S Raghu
KMC Manipal, Karnata – 576 104.

ARDS is a clinical syndrome characterized by severe dyspnea of rapid onset, hypoxemia, and diffuse pulmonary infiltrates leading to respiratory failure with high mortality.

Aim of the Study : To study the clinical profile, risk factors, outcome and mortality occurring in patients with ARDS.

Material and Methods : This is a one year prospective study carried out on patients who are diagnosed of ARDS in Kasturba Hospital, Manipal a tertiary care referral centre between January 2007 to December 2007. The expected study group will consist of 30 patients.

The criteria used for diagnosis of ARDS was based upon American/European consensus. The patient demographic data will be taken. The presence of sepsis will be assessed by ACCP/ SCCM consensus definition.

Severity of illness will be measured by the acute physiology and chronic health evaluation II (APACHE II) on the day of onset of ARDS for all patients. The patients will be followed up in the stay of hospital and treatment regimens were followed up including the use mechanical, ventilation, antibiotics, use of steroid, duration of stay in the hospital. The outcome of the study will be assessed.

In the pilot study till now 10 cases have been studied with mean APACHE II score on the day of development of ARDS was 27. Sepsis was most important risk factor observed in 7 of the cases (70%) and mortality of 60% was noted.