Effect of amitriptyline vs. physiotherapy in management of fibromyalgia syndrome: What predicts a clinical benefit?

CONTEXT: Fibromyalgia is a chronic disabling condition, and physicians treat it using a number of different treatment modalities. It is not known if one or more of such modalities are better than the others. We compared the efficacy of physiotherapy and amitriptyline in disability reduction in patients of fibromyalgia syndrome in a rural tertiary care hospital in Central India. DESIGN: Open-label alternate patient treatment allocation. MATERIALS AND METHODS: A six-month follow-up was done to assess the benefit of amitriptyline and physiotherapy for disability reduction in patients with fibromyalgia syndrome. Primary outcome measure was improvement in fibromyalgia impact questionnaire (FIQ) score. Statistical Analysis Used : Predictors of benefit were determined using multivariate logistic regression. RESULTS: A total of 175 outpatients were assigned to either amitriptyline (n=87) or structured physiotherapy (n=88) treatments. There was a significant but similar (P=0.82) improvement in disability in both groups. High FIQ score at baseline and low socioeconomic status scores were significant predictors of benefit. CONCLUSIONS: Therapy with amitriptyline or physiotherapy is equally effective in improving outcome in patients of fibromyalgia over a period of six months.

Portal hypertension associated with sickle cell disease.

We report a 12-year-old girl with sickle cell disease who presented with pain in abdomen, fever, joint pain and hematemesis. On examination she had mild jaundice and splenomegaly. Upper GI endoscopy showed esophageal varices. She was treated with variceal band ligation and is well on folic acid supplements and propranolol.

Evaluation of Parmotrema reticulatum Taylor for Antibacterial and Antiinflammatory Activities.

Lichens produce variety of secondary metabolites including depsides, depsidones and dibenzofurans having multifunctional activity in response to external environmental condition. Present study provides evidence for in vitro antibacterial and in vivo antiinflammatory activity of acetone and ethanol extracts of Parmotrema reticulatum. In vitro antibacterial activity was investigated against gram positive and gram negative bacteria. Cotton pellet-induced granuloma, xylene-induced ear swelling, carragennan-induced edema, histamine-induced and carboxymethylcellulose sodium-induced leukocyte emigration in mice models were used to quantify the antiinflammatory activity. Acetone and ethanol extracts were showed antibacterial activity against Bacillus subtilis (minimal inhibitory concentration: 100 and 150 µg/ml) and Staphylococcus aureus (minimal inhibitory concentration: 100 and 200 µg/ml), Escherichia coli (minimal inhibitory concentration: 200 and 250 µg/ml), and Pseudomonasa eruginosa (minimal inhibitory concentration: 200 and 300 µg/ml). Acetone extract was inhibited edema significantly at 200 mg/kg with xylene, cotton pellet, carragennan and histamine induced edema in vivo models. Ethanol extract was found effective at dose of 300 mg/kg with all in vivo antiinflammatory models. The results showed significant (P<0.01) antiinflammatory effects at 200 and 300 mg/kg dose of acetone and ethanol extracts, respectively, which can be concluded that significant activity may be due to presence of flavanoids in ethanol extract and usnic acid in acetone extract.

Pulmonary plasmacytoma with endobronchial extension: A rare presentation of solitary extramedullary plasmacytoma: A case report and brief review of literature.

Extramedullary plasmacytoma is the malignant proliferation of single clone of plasma cells arising outside the bone marrow. Solitary extramedullary plasmacytoma (SEP) are solitary lesion mostly located in upper respiratory tract and nasopharynx. Involvement of lower respiratory tract is rarely seen in case of SEP. Here, we report a rare case of pulmonary plasmacytoma in a 50-year-old male presenting as left lower lobe lung mass with endobronchial extension. Subsequent investigations, histological and immunohistochemical examination of tumor confirmed the diagnosis of plasmacytoma. Work-up for the multiple myeloma came out to be negative, thus confirming the diagnosis of SEP. Pulmonary plasmacytoma, a rare presentation of extramedullary plasmacytoma should be kept in mind by dealing with the patients of lung mass and endobronchial extension.

Omega-3 fatty acids and cardiovascular disease.

Cardioceuticals are nutritional supplements that contain all the essential nutrients including vitamins, minerals, omega-3-fatty acids and other antioxidants like a-lipoic acid and coenzyme Q10 in the right proportion that provide all round protection to the heart by reducing the most common risks associated with the cardiovascular disease including high low-density lipoprotein cholesterol and triglyceride levels and factors that contribute to coagulation of blood. Omega-3 fatty acids have been shown to significantly reduce the risk for sudden death caused by cardiac arrhythmias and all-cause mortality in patients with known coronary heart disease. Omega-3 fatty acids are also used to treat hyperlipidemia and hypertension. There are no significant drug interactions with omega-3 fatty acids. The American Heart Association recommends consumption of two servings of fish per week for persons with no history of coronary heart disease and at least one serving of fish daily for those with known coronary heart disease. Approximately 1 g/day of eicosapentaenoic acid plus docosahexaenoic acid is recommended for cardio protection. Higher dosages of omega-3 fatty acids are required to reduce elevated triglyceride levels (2-4 g/day). Modest decreases in blood pressure occur with significantly higher dosages of omega-3 fatty acids.

Bancroftian microfilariasis in association with pulmonary tuberculosis. Report of a case with diagnosis by fine needle aspiration.

A 25-year-old man presented with clinical and radiologic features suggestive of pulmonary tuberculosis. Since the examination of Ziehl-Neelsen-stained sputum smears for acid-fast bacilli was repeatedly negative, a transthoracic fine needle aspiration biopsy was performed. Papanicolaou-stained smears of the aspirate showed microfilariae of Wuchereria bancrofti and a tuberculous exudate but no acid-fast bacilli or classic granulomas. Subsequent sputum samples did show acid-fast bacilli, while a nocturnal peripheral blood sample showed microfilariae.

Left ventricular mass in normal Indian population.

A prospective study was conducted to ascertain the distribution of the left ventricular mass in normal adult Indian population and to establish the upper limit of the same. Four hundred and eighty normal subjects (men = 310; women = 170), in the age group of 18 to 60 years were screened echocardiographically, to estimate the left ventricular mass. The left ventricular mass in men was found to be 124 +/- 32 gm whereas in women it was 93 +/- 37 gm. The upper limit of the left ventricular mass (mean +/- 2 SD) was found to be 189 gm and 167 gm, for men and women respectively. The left ventricular mass in both men and women correlated with the body weight (r = 0.51, p less than 0.001; r = 0.22, p less than 0.001), height (r = 0.27, p less than 0.001; r = 0.22, p less than 0.01), and the body surface area (r = 0.49, p less than 0.001; r = 0.27, p less than 0.001), whereas it was found to be independent of age (r = 0.01, p = NS; r = 0.10, p = NS). In men alone the diastolic blood pressure influenced the left ventricular mass (r = 0.27, p less than 0.001), otherwise the left ventricular mass was independent of systemic blood pressure variations within the normal range. The left ventricular mass in the present study differs significantly from the Western population.

Adult tuberculous meningitis. An immunological study.

In adult tuberculous meningitis (10), delayed skin hypersensitivity to DNCB was significantly impaired, whereas to tuberculin not altered. Lymphocyte migration (LMI) index was lower in comparison with pulmonary tuberculosis (20) and healthy adults (20). Lower LMI index was statistically not significant than pulmonary tuberculosis. Serum IgG and IgM levels were higher than in healthy adults. In comparison with pulmonary tuberculosis, only IgM levels were raised. We conclude that in adult tuberculous meningitis, cell mediated immune response is impaired and non-specific antibody response is increased than pulmonary tuberculosis and healthy adults.

Haemorheological treatment of painful sickle cell crises. Use of pentoxifylline.

A variety of drugs have been tried, with little or no benefit, to prevent and treat painful crises in patients with sickle cell anaemia. The new drug pentoxifylline, which has the ability to alter red cell flexibility, was tried in nine patients with painful vaso-occlusive crises. Another nine matched patients served as control. While no patient in the control group improved, five patients in the pentoxifylline group responded favourably within 48 hours. We conclude that pentoxifylline may be useful in patients with acute painful vasoocclusive crises due to sickle cell anaemia.

Left ventricular muscle mass by echocardiography: methodology.

The limitations of electrocardiography for diagnosing left ventricular hypertrophy (LVH), due to unacceptable accuracy and lack of serial quantifications, are well known. The use of angiocardiography for LVH assessment is invasive, hazardous and costly. Echocardiography provides an excellent method of estimation of left ventricular muscle mass, which is simple, non-hazardous, accurate and reproducible.

False positive ECG and coronary heart disease.

In 1983, we carried out a cross-sectional, rural community based study and highlighted an abysmally low prevalence of probable coronary heart disease in resting electrocardiogram. A seven year follow-up (1983-1990) of 179 suspects showed no morbidity or mortality from coronary heart disease. Eighty one out of 98 suspects tested negative on a symptom limited maximal exercise test. Though seventeen suspects had an asymptomatic exercise-induced ST depression (> 1.0 mm) their haemodynamic response to exercise and effort tolerance was excellent. Of the twelve subjects who took a repeat exercise test six months later, eleven failed to show ST depression on exercise. We attribute the false positivity of exercise test and its poor reproducibility to labile electrocardiographic changes unmasked by exercise.

The prevalence of hypertension in rural population around Sevagram.

To detect the prevalence of hypertension in an asymptomatic rural community from Central India, we screened 4045 subjects (2247 men and 1798 women) aged 20 and beyond. The prevalence of hypertension was 34.12 per thousand population, being higher in women (40.60 per thousand) than in men (28.92 per thousand). Level of physical activity, economic status, smoking and body mass index showed real association with hypertension.

Evaluation of clinical variables as predicators of left ventricular function in acute myocardial infarction.

In 43 rural patients, all survivors of acute Myocardial infarction, left ventricular function was studied by 2-D echocardiography and evaluated in relation to 18 clinical predictors of left ventricular function. The mean left ventricular ejection fraction (LVEF) was 41.53 +/- 12.92% as compared to 70.02 +/- 7.02% in 506 healthy controls. LVEF was dichotomised at < 40% (n = 24) and > 40% (n = 19). Out of various clinical variables analysed following were found to be strong predictors of low LVEF. S3 gallop (p < 0.001) pulmonary rates (p < 0.001); Creatine phosphokinase > 200 I.U. (p < 0.001); Cardiomegaly on X-ray (p < 0.001); pulmonary congestion on chest X-ray (p < 0.001); and proportional pulse pressure (p < 0.001). There was a stepwise decline in the LVEF for each additional clinical variable. The over all predictive accuracy was 90%. It is concluded that readily obtainable clinical variables provide a useful bedside method of estimating LVEF after acute myocardial infarction.

Clinical profile of irritable bowel syndrome at a rural based teaching hospital in central India.

In a study of 52 patients with irritable bowel syndrome preponderance of males (4.2:1) and young adult age group (20-29 years) was observed. Distinct spastic colon and functional diarrhoea constituted 60%, whereas 40% had mixed presentation. Abdominal pain commonly in the umbilical and splenic flexure region, relieved after defaecation, and rectal dissatisfaction were the common symptoms. Upper gastrointestinal symptoms were present in 25% of patients.

Left ventricular mass by M-mode echocardiography.

A comparison of various M-mode echocardiographic methods for assessment of left ventricular mass (LVM) was done in 21 subjects. The anatomical LVM was taken as Standard; it varied from 64.55 to 341.82 g. Of the six different M-mode echo methods compared, the method of Devereux and Reichek (1977) was found to correlate best with anatomical LVM (r = 0.99; SD = 49.54). By this method LVM = 1.4 [(LVIDd + LVPWTd + IVSTd)3 - (LVIDd)3] - 14 g.

M-mode echocardiographic diagnosis of left ventricular hypertrophy.

To assess the utility of various primary and derived M-Mode Echocardiographic parameters for the purpose of defining left ventricular hypertrophy (LVH), 74 subjects with LVH were subjected to M-mode echocardiographic examination. It was concluded that except for cross sectional area, the other echocardiographic parameters performed too poorly to be of any clinical utility for defining LVH by echocardiography.

Left ventricular M-mode echocardiographic measurements of Indian population.

The left ventricular dimensions of 506 normal healthy subjects (men = 317, women = 189) in the age group of 17 to 80 years were measured echocardiographically. The measurements were found to differ significantly from the western data. A separate limit for left ventricular echocardiographic parameter for the normal Indian population was established.

Spontaneous bacterial peritonitis in liver cirrhosis with ascites.

OBJECTIVE: The study was designed to elucidate the correlation of spontaneous bacterial peritonitis (SBP) with aetiology of liver cirrhosis, overall mortality, ascitic fluid and systemic microbial infections. METHODS: Sixty three patients with cirrhosis of the liver were included in this study. These patients were diagnosed on the basis of clinical evaluation, biochemical investigation, ultrasonography, ascitic fluid examination for protein, cells, pH, and bacterial culture. RESULTS: SBP developed in 22 (34.92%) patients of cirrhosis. Culture positive SBP was present in 18 (81.81%) and culture negative neutrocytic ascitis (CNNA) in 4 (18.18%). In the culture positive group, 14 (77.7%) patients had monomicrobial bacterascites (MNB), the commonest organism being coagulase positive Staphylococcus aureus eight (44.44%) followed by E. coli (22.22%). Only 4 (22.22%) had infection by more than one organism. Direct bed side inoculation of ascitic fluid into blood culture bottle was a better method for bacterial yield than the conventional method of ascitic fluid culture (81.8% vs. 18.2%). Only 22.8% patients with SBP had ascitic fluid protein less than 1 gm%, ascitic fluid pH < 7.3 and polymorphonuclear cell count > 250/cmm. CONCLUSION: Spontaneous bacterial peritonitis is common complication in Child Pugh class C cirrhosis. Alcoholic cirrhosis with SBP carries high mortality than their non-alcoholic group. The most common organisms isolated were coagulase positive Staphylococcus aureus followed by E. coli.

Role of oxygen free radicals in causing endothelial damage in acute myocardial infarction.

OBJECTIVES: This work was done in order to study the oxidant and anti-oxidant status in a disease resulting from endothelial injury. The disease selected for study was acute myocardial infarction. METHODS: Sixty patients of acute myocardial infarction were selected after being diagnosed in accordance to the guidelines laid down by the WHO. Thirty subjects were included as controls. Plasma levels of certain markers of oxidative stress and anti oxidant activity were measured in all the subjects. Malonaldehyde (MDA) and nitrite (NO2) were measured as markers of free radical mediated endothelial injury, and superoxide dismutase (SOD) enzyme as an indicator of antioxidant activity. RESULTS: It was found that the plasma levels of MDA and nitrite were significantly elevated in the patients of acute myocardial infarction compared to the control group (7.29 +/- 3.28 v/s 4.57 +/- 0.63 nmol/ml and 12.85 +/- 8.71 v/s 0.97 +/- 0.25 microM respectively), thereby indicating that oxygen free radicals cause endothelial damage in them. The superoxide dismutase levels were also found to be elevated in these patients (5.57 +/- 1.47 v/s 3.91 +/- 0.66 U/ml). CONCLUSION: These results indicate that acute myocardial infarction is a state of enhanced free radical activity, which causes endothelial damage. The elevated SOD levels may imply that the body attempts to combat this oxidative stress by raising it's level of anti-oxidants.