Assessing lameness prevalence and associated risk factors in crossbred dairy cows across diverse management environments.

BACKGROUND: A thorough understanding of lameness prevalence is essential for evaluating the impact of this condition on the dairy industry and assessing the effectiveness of preventive strategies designed to minimize its occurrence. Therefore, this cross-sectional study aimed to ascertain the prevalence of lameness and identify potential risk factors associated with lameness in Holstein Friesian crossbred cows across both commercial and smallholder dairy production systems in Bengaluru Rural District of Karnataka, India. METHODS: The research encompassed six commercial dairy farms and 139 smallholder dairy farms, involving a total of 617 Holstein Friesian crossbred cattle. On-site surveys were conducted at the farms, employing a meticulously designed questionnaire. Lameness in dairy cattle was assessed subjectively using a locomotion scoring system. Both bivariate and binary logistic regression models were employed for risk assessment, while principal components analysis (PCA) was conducted to address the high dimensionality of the data and capture the underlying structure of the explanatory variables. RESULTS: The overall lameness prevalence of 21.9% in commercial dairy farms and 4.6% in smallholder dairy farms. Various factors such as age, body weight, parity, body condition score (BCS), floor type, hock and knee injuries, animal hygiene, provision of hoof trimming, and the presence of hoof lesions were found to be significantly associated with lameness. Binary logistic regression analysis indicated that the odds of lameness in crossbred cows increased with higher parity, decreased BCS, presence of hard flooring, poor animal hygiene, and the existence of hoof lesions. These factors were identified as potential risk factors for lameness in dairy cows. Principal component analysis unveiled five components explaining 71.32% of the total variance in commercial farms and 61.21% in smallholder dairy farms. The extracted components demonstrated higher loadings of housing and management factors (such as hoof trimming and provision of footbath) and animal-level factors (including parity, age, and BCS) in relation to lameness in dairy cows. CONCLUSIONS: The findings suggest that principal component analysis effectively reduces the dimensionality of risk factors. Addressing these identified risk factors for lameness is crucial for the strategic management of lameness in dairy cows. Future research in India should investigate the effectiveness of management interventions targeted at the identified risk factors in preventing lameness in dairy cattle across diverse environments.

Left cardiac sympathetic denervation in children with Jervell Lange-Nielsen syndrome and drug refractory torsades - A case series.

INTRODUCTION: Long QT syndrome is an inherited malignant channelopathy which leads to life-threatening arrhythmia, with multiple genotypes. Jervell and Lange-Nielsen syndrome (JLNS) is an autosomal recessive subtype of this disease, characterized by congenital sensorineural deafness and a high incidence of sudden cardiac death (SCD). METHODOLOGY: We prospectively followed up six children who underwent left cardiac sympathetic denervation (LCSD) for JLNS in view of high-risk features despite being on maximally tolerated doses of oral propranolol. RESULTS: Mean age at diagnosis was 2.75 ± 0.39 years, with a significant delay between onset of symptoms and diagnosis (mean 7.2 ± 3.5 months). All had sensorineural hearing loss, conforming to the JLNS phenotype. Mean QTc interval was 603 ± 93 ms, with T wave alternans (TWA) seen in all cases. All were started on propranolol and subsequently subjected to LCSD, and 3 underwent AAI permanent pacemaker implantation. Over a mean follow-up of 20 months, there was a significant reduction in QTc (603 ± 93 ms to 501 ± 33 ms, p = .04), which was persistent on follow-up (525 ± 41 ms) and only two out of six had persistent T wave alternans on ECG (p < .01). None of these children had presyncope, syncope, seizures, torsades de pointes, cardiac arrest or death on follow up following LCSD. CONCLUSION: Jervell Lange-Nielsen syndrome is a subtype of LQTS with high-risk features. LCSD, an effective therapeutic option for those having symptoms despite being on propranolol, results in significant reduction of QTc interval and amelioration of symptoms.

Outcome of percutaneous transhepatic biliary interventions in the management of biliary enteric anastomotic strictures with hepatolithiasis.

AIM: To evaluate percutaneous transhepatic biliary interventions (PTBI) using the ADDFREE (Access-Drain-Dilate-Flush-REpeat periodically-Evaluate and remove) technique and its outcomes in patients with biliary enteric anastomotic strictures (BEAS) and hepatolithiasis. MATERIAL AND METHODS: A retrospective review was undertaken of patients having hepatolithiasis with BEAS who underwent PTBI with a therapeutic intent (from January 2010 to January 2021) was performed. The technical and clinical successes of PTBI were analysed. Technical success was divided into duct access, crossing of BEAS, stricture resolution, and calculi clearance. Improvement of liver function tests, resolution of leucocytosis and presenting complaints were considered as clinical success. The patients were followed-up for a minimum duration of 6-months. RESULTS: Eighteen patients received PTBI in form of the ADDFREE technique. Hepatolithiasis was bilobar (44.4%), unilobar in multiple ducts (unilobar-m; 27.8%) and unilobar in a single duct (unilobar-s; 27.8%) along with anastomotic stricture. The average number of sessions of stone clearance for bilobar, unilobar-m, and unilobar-s was 4.4 (±1.6), 3.6 (±2.4), and 1.5 (±0.5), respectively. Clinical success was observed in 14 (77.8%), while one patient had recurrence of calculi and received repeat treatment. Bile culture was positive for bacterial organisms in 17 (94.4%) patients. No major complication were seen while minor complication were seen in five patients consisting of self-limiting haemobilia (n=1), per-catheter bile leak (n=2) and aggravation of cholangitis (n=2). CONCLUSION: PTBI, consisting of bile duct access, cholangioplasty, and calculi clearance, is a safe and effective technique for the treatment of patients having hepatolithiasis secondary to BEAS.

Electroconvulsive Therapy in Patients With Cardiac Implantable Electronic Devices: A Case Report and Systematic Review of Published Cases.

OBJECTIVE: The aims of the study were to report the case of a 54-year-old man with recurrent depressive disorder with multiple medical comorbidities having a dual-chamber pacemaker, treated successfully with 11 sessions of electroconvulsive therapy, and to conduct a systematic review of published cases documenting the use of electroconvulsive therapy (ECT) in patients with cardiac implantable electronic devices (CIEDs) for treating major psychiatric disorders. METHODS: We searched electronic databases (MEDLINE, PubMed, Google Scholar, Embase, Cochrane Library, PsycINFO, and Crossref) and included studies reporting on the use of electroconvulsive therapy in patients with CIEDs. RESULTS: Thirty-five publications across 53 years (1967-2021) reported on 76 patients (including current report) who received a pooled total of 979 modified ECT sessions. The most common adverse events were premature ventricular contraction and hypertension. There have been no reports of serious adverse effects that necessitated the cessation of ECT. CONCLUSIONS: Electroconvulsive therapy is a safe and efficacious treatment for major psychiatric disorders, and the presence of CIEDs should not delay or deter the use of ECT in these patients.

Response evaluation of locoregional therapies in combined hepatocellular-cholangiocarcinoma and intrahepatic cholangiocarcinoma versus hepatocellular carcinoma: a propensity score matched study.

AIM: To evaluate the response of locoregional therapy (LRT) on combined hepatocellular-cholangiocarcinoma (cHCC-CC) and intrahepatic cholangiocarcinoma (IHC) and compare their outcomes with propensity matched hepatocellular carcinoma (HCC) patients. MATERIALS AND METHODS: From January 2011 to July 2020, 13 patients with cHCC-CC (11 men, two women, median age 56 years) and 15 IHC patients (10 men, five women, median age 60 years) were compared with 101 HCC patients (79 men, 22 women, median age 60 years) after LRT. All tumours were proven histologically. Among the 13 cHCC-CC patients, 11 received transarterial chemoembolisation (TACE), one received microwave ablation (MWA) and one received TACE with radiofrequency ablation (RFA). Of 15 IHC patients, eight received TACE, five received RFA, and one received MWA, and one received TACE with RFA. Propensity score matching (PSM) was done with conditional logistic regression adjusted for age, type of LRT, tumour specific features and Child-Pugh score. RESULTS: After LRT, on univariate analysis an objective response was seen in 30% of cHCC-CC and 53% of IHC patients. PSM analysis demonstrated shorter progression-free survival (PFS; cHCC-CC versus HCC: 1.5 versus 7.5 months; IHC versus HCC: 6 versus 14 months, p<0.05), overall survival (OS; cHCC-CC versus HCC: 12 versus 28 months; IHC versus HCC: 18 versus 34 months, p<0.005), and poor objective response (cHCC-CC versus HCC: 25% versus 91%; IHC versus HCC: 58% versus 88%, p<0.05) in cHCC-CC and IHC patients versus HCC patients. Hypovascular tumour, macrovascular invasion, and infiltrative appearance were independent prognostic factors for OS in IHC patients. CONCLUSION: cHCC-CC and IHC are aggressive tumours with a poor objective response, greater distant progression of the disease and shorter PFS and OS post LRT as compared to HCC.

Anti-Müllerian hormone as an endocrine biomarker of reproductive longevity and assessment of single nucleotide polymorphisms in AMH gene of Bos indicus breeds of cattle.

Anti-Müllerian hormone (AMH) is a member of the TGF-ß superfamily produced by follicular granulosa cells in women and cattle and is considered an endocrine biomarker of ovarian follicular reserve. The study examined how age and parity influence serum AMH concentration and investigated the presence of single nucleotide polymorphisms in AMH gene in Bos indicus breeds viz Malnad Gidda Amritmahal and Hallikar. All five exons of AMH gene amplified by polymerase chain reaction were subjected to sanger sequencing and identified important SNP and its effects. We observed a highly significant relationship between parity and AMH concentration in Amritmahal cattle, whereas Malnad Gidda and Hallikar breeds did not show a significant difference. We identified one SNP located in exon 5 (rs21402788) with base change A>G, a non-synonymous mutation resulting in a change in amino acid Q>R and the protein product. It is concluded that AMH level could be considered as an indicator of the ovarian reserve and productive herd life (longevity) irrespective of age/parity, especially in B. indicus breeds of cattle.

Deep Proteome Profiling of Semen of Indian Indigenous Malnad Gidda (Bos indicus) Cattle.

Malnad Gidda is a dwarf indigenous cattle breed of India, which is known for its uniqueness of calving every year under a low input grazing system of rearing. Bulls of Malnad Gidda are known to be highly fertile even in stress conditions. However, the proteomic profiling of semen of this breed has not been investigated so far, which might provide a platform for a better understanding of its semen quality and male fertility. Therefore, we made an effort to characterize and quantify the proteome of seminal plasma and spermatozoa components of Malnad Gidda semen using a high-resolution mass spectrometry platform. We identified 2814 proteins from spermatozoa and 1974 proteins from the seminal plasma of this breed. Furthermore, >90% of proteins from each fraction were quantified using the intensity-based absolute quantification. We observed signal peptides in 33% of seminal plasma proteins, indicating their secretory nature. Gene Ontology analysis revealed their involvement in cytoskeletal assembly associated with sperm head, sperm motility, acrosome reaction, seminal plasma binding, and spermatogenesis-associated protein. An in-depth proteome profiling of semen of a unique indigenous cattle breed of India was carried out. Our findings could provide a reference for further studies on sperm functions, semen quality, and reproductive health of Bos indicus cattle. Mass spectrometry data generated in this study is deposited and publicly made available through ProteomeXchange Consortium via the PRIDE partner repository with the dataset identifier PXD014172.

What are the atrioventricular delays in right ventricular apical and septal pacing for optimal hemodynamics in patients with normal left ventricular function?

INTRODUCTION: There is a surge of interest in alternate site pacing to prevent pacing-induced left ventricular dysfunction. However, little is known regarding the appropriate atrioventricular (AV) delay between right ventricular (RV) septal and RV apical pacing for optimal hemodynamic benefit. OBJECTIVES: To determine the programmed values of atrial sensed and atrial paced AV delays in basal RV septal and apical RV pacing that results in the maximum delivered stroke volume (SV). METHODS: We calculated the Doppler-derived SV at various sensed and paced AV delays in 50 patients with complete AV block implanted with a dual-chamber pacemaker (group A: 25 RV apical pacing; group B: 25 RV septal pacing). The hemodynamic difference in terms of the SV between sensed and paced AV delay, corresponding to the site of RV pacing was then compared for statistical significance. RESULTS: In group A, maximal SV was derived at a sensed AV delay of 123.2 ± 11 ms and paced AV delay of 129.2 ± 10 ms, and in group B, at a sensed AV delay of 123.6 ± 8 ms and paced AV delay of and 132.8 ± 7 ms. At these intervals, there was no difference in the SV between septal and apical RV pacing (P = .28 and .22, respectively). CONCLUSION: The atrial sensed and atrial paced AV delays for septal and apical RV pacing for optimal hemodynamics are similar. For optimal hemodynamics, the atrial paced AV delay is longer than the atrial sensed AV delay.

Short-term response to phenytoin sodium in Andersen-Tawil syndrome-1 with a cardiac-dominant phenotype.

BACKGROUND: Andersen-Tawil syndrome (ATS) is a rare familial periodic paralysis that typically also affects the heart and skeletal system. Ventricular arrhythmias (VAs) are profound and difficult to control, but minimally symptomatic. In this report, we describe an atypical phenotype of ATS in two related families. We also report our experience with phenytoin sodium for the control of resistant VAs in these patients. METHODS AND RESULTS: Between 2014 and 2018, seven siblings were diagnosed with ATS on the basis of cardiac arrhythmias and genetic evaluation. Heterozygous mutation with c.431G > C (p.G144A) in exon 2 of KCNJ2 gene was observed in all patients. Characteristic cardiac manifestations were noted in all patients but periodic paralysis or objective neurological involvement was distinctly absent. Phenytoin was considered for control of symptomatic VA in three patients. Intake of oral phenytoin (5 mg/kg/day) for 1 month completely suppressed VA (<1% in 24-h Holter monitoring) in two patients, and significantly in the third (8% per 24 h) patient. Phenytoin was well-tolerated in all three patients. CONCLUSIONS: We describe a cardiac-predominant phenotype in ATS. ATS should be suspected in patients with typical cardiac manifestations even in the absence of periodic paralysis. Our initial experience with short-term use of phenytoin for control of resistant VAs is encouraging.

A novel prediction model for risk stratification in patients with a type 1 Brugada ECG pattern.

BACKGROUND: Risk stratification in Brugada syndrome remains a controversial and unresolved clinical problem, especially in asymptomatic patients with a type 1 ECG pattern. The purpose of this study is to derive and validate a prediction model based on clinical and ECG parameters to effectively identify patients with a type 1 ECG pattern who are at high risk of major arrhythmic events (MAE) during follow-up. METHODS: This study analysed data from 103 consecutive patients with Brugada Type 1 ECG pattern and no history of previous cardiac arrest. The prediction model was derived using logistic regression with MAE as the primary outcome, and patient demographic and electrocardiographic parameters as potential predictor variables. The model was externally validated in an independent cohort of 42 patients. RESULTS: The final model (Brugada Risk Stratification [BRS] score) consisted of 4 independent predictors (1 point each) of MAE during follow-up (median 85.3 months): spontaneous type 1 pattern, QRS fragments in inferior leads≥3,S wave upslope duration ratio ≥ 0.8, and T peak - T end ≥ 100 ms. The BRS score (AUC = 0.95,95% CI 0.0.92-0.98) stratifies patients with a type 1 ECG pattern into low (BRS score ≤ 2) and high (BRS score ≥ 3) risk classes, with a class specific risk of MAE of 0-1.1% and 92.3-100% across the derivation and validation cohorts, respectively. CONCLUSIONS: The BRS score is a simple bed-side tool with high predictive accuracy, for risk stratification of patients with a Brugada Type 1 ECG pattern. Prospective validation of the prediction model is necessary before this score can be implemented in clinical practice.

Fosphenytoin for control of electrical storm in acute myocardial infarction and Purkinje fiber-mediated arrhythmias.

BACKGROUND: Purkinje fiber-mediated arrhythmias in the setting of acute myocardial infarction are poorly responsive to conventional antiarrhythmic therapy, increases overall mortality and often requires radiofrequency ablation (RFA) for control. In this study, we report the use of intravenous Fosphenytoin for the control of arrhythmic storm in patients with acute myocardial infarction. METHODS AND RESULTS: Six patients with acute myocardial infarction (5 AW/1 LW) and Purkinje-triggered ventricular arrhythmias refractory to conventional antiarrhythmics were treated with intravenous Fosphenytoin before considering RFA. Arrhythmia control was obtained in all patients after the initial bolus dose. Breakthrough episodes were seen in 5/6 within 24-36 hours of the initial bolus, necessitating a second bolus. Complete arrhythmia control was obtained in all patients within 72 hours and 5/6 patients were successfully discharged from the hospital. One patient succumbed to sepsis in hospital while another patient succumbed to Sub Dural Hematoma after 3 months. CONCLUSIONS: Intravenous Fosphenytoin should be considered before RFA for control of Purkinje fiber-mediated refractory arrhythmias in acute myocardial infarction patients.

Bio-width index: a novel biomarker for prognostication of long term outcomes in patients with anaemia and heart failure.

BACKGROUND: The utility of biomarkers for prognostication of long term outcomes in patients with anaemia and heart failure(HF) is not well defined. The objective of this study was to assess the ability of a novel biomarker, bio-width index (BWI),to improve risk stratification in patients with anaemia and acutely decompensated heart failure(ADHF), in comparison to conventional markers, B-type natriuretic peptide(BNP) and red- cell distribution width(RDW). METHODS: Data from 1569 consecutive patients with ADHF treated at a multidisciplinary HF unit was analysed in this study. The bio-width index (BWI) was calculated by multiplying BNP to RDW and dividing the product by 10 (BWI = BNP x RDW/10). The primary outcome was one year all-cause mortality. RESULTS: During follow up (median 422 days), subjects with anaemia had significantly higher one year mortality (49.6 vs. 30.5%, p < .001). Cox regression analysis revealed that, BWI(HR 2.13, 95%CI 2.02-2.24, p = .018) as well as BNP(HR 1.86, 95%CI 1.78-1.94, p = .024), and RDW (HR 1.98, 95%CI 1.91-2.05, p = .033) were all independent predictors of one year mortality after adjusting for conventional risk factors. BWI had a higher discriminative ability compared to BNP(AUC 0.90 vs. 0.75, p < .001) and RDW(AUC 0.90 vs. 0.81, p = .012). The patients with higher BWI ( >1024.9) had a higher one year mortality(85.1 vs. 29.2%, p < .001). In addition, BWI significantly improved the net reclassification compared to both BNP(p = .002) and RDW(p = .018). CONCLUSIONS: In patients with anaemia and ADHF, bio-width index is superior to the established biomarkers such as BNP and RDW in prognostication of long term mortality.

Monitoring foot surface temperature using infrared thermal imaging for assessment of hoof health status in cattle: A review.

Detection of lameness early in cows is important from the animal welfare point of view and for reducing economic losses. Currently, many studies are being conducted for assessment of hoof health status by measuring the surface temperature of skin in cattle and other animal species in different parts of the world. Infrared Thermography (IRT) is able to detect lesions of hooves associated with lameness by measuring the changes in coronary band and hoof skin surface temperature. The surface temperature of a lame limb will be increased when the hoof has lesion(s). IRT has been used as a non-invasive diagnostic tool for early detection of hoof lesions based on the temperature difference between affected and non-affected hoof and maximum foot temperature on the regions of interest. In spite of having many potential applications in cattle production, factors affecting the temperature readings in thermograms must also are considered while taking images. Standard operating procedures must be established before taking thermographs under different circumstances, by considering all the factors that affect its normal function. IRT may help in minimising the cost of veterinary services, low yield, compromised fertility and culling expenses, where lameness cannot be resolved in early stages.

The Utility of Exercise Testing in Risk Stratification of Asymptomatic Patients With Type 1 Brugada Pattern.

INTRODUCTION: Risk stratification of asymptomatic patients with a Brugada type 1 ECG pattern remains an unresolved clinical conundrum. In contrast to provocative pharmacological testing in Brugada syndrome, there is limited data on the role of exercise stress testing as a risk stratification modality. The objective of this study was to evaluate the utility of exercise testing in asymptomatic patients with type 1 Brugada pattern to prognosticate major arrhythmic events (MAE) during follow-up. METHODS AND RESULTS: Treadmill exercise testing was conducted for 75 asymptomatic patients with type 1 Brugada pattern and for 88 healthy control subjects. The clinical end point of MAE was defined as the occurrence of sudden cardiac death (SCD) or resuscitated ventricular fibrillation (VF). During a follow-up of 77.9 ± 28.9 months, eight MAE occurred (five VF and three SCD). Multivariate Cox regression analysis showed that the following were independent predictors of MAE in asymptomatic patients with a type 1 Brugada pattern: increase in S wave upslope duration ratio >30% at peak exercise (HR 1.35, 95% CI 1.08-10.97, P = 0.023), augmentation of J point elevation in lead aVR >2 mm in late recovery (HR 1.88, 95% 1.21-15.67, P = 0.011), and delayed HR recovery (HR 1.14, 95% CI 1.06-18.22, P = 0.042). A high-risk cohort was identified by the final step-wise regression model with good accuracy (specificity = 98.4%, sensitivity = 62.5%) and discriminative power (AUC = 0.93, 95% CI 0.89-0.96, P = 0.002). Kaplan-Meier analysis revealed increasing MAE in subjects with one, two, or three predictors, respectively (log rank P < 0.001). CONCLUSIONS: Exercise testing in asymptomatic patients with type 1 Brugada pattern aids in identification of high-risk patients and provides a unique window of opportunity for early intervention.

Radiofrequency Ablation of Left Atrial Reentrant Tachycardias in Rheumatic Mitral Valve Disease: A Case Series.

BACKGROUND: Left atrial (LA) reentrant tachycardias are not uncommon in regions where rheumatic heart disease is prevalent. Some of these arrhythmias may be curable by radiofrequency ablation (RFA). However, there are limited data pertaining to this in existing literature. CASE REPORT: Three patients who had rheumatic mitral valve disease with past history of surgical-/catheter-based intervention and having no significant residual disease had symptomatic atrial flutter despite optimal medical management. An electrophysiological study confirmed an LA focal/micro-reentrant mechanism in all. There was patchy scarring of the LA, and successful RFA of these arrhythmias could be achieved. CONCLUSION: The focal nature of the scar in these patients may suggest that the rheumatic involvement of the atrium or the hemodynamic consequence of the vulvar lesion causes nonuniform insult to the atrial tissue and limited scar. At least in some patients with limited scarring, early RFA may help in the maintenance of sinus rhythm.

'Optimized' LV only pacing using a dual chamber pacemaker as a cost effective alternative to CRT.

BACKGROUND: Cardiac Resynchronization therapy (CRT) remains largely under-used in developing countries owing to the high cost of therapy. In this pilot study, we explore 'optimized' Left Ventricle Only Pacing (LVOP) as a cost effective alternative to cardiac resynchronization therapy in selected patients with heart failure. HYPOTHESIS: In economically poorer patients with heart failure, left bundle branch block (LBBB) and intact AV node conduction, synchronization can be obtained using a dual chamber pacemaker (leads in right atrium and Left ventricle) with the help of 2D strain imaging. METHODS AND RESULTS: 4 patients underwent LVOP for symptomatic heart failure. Post procedure 'optimization' was done using 12 lead electrocardiography and 2D- Strain imaging. Difference between Time to Peak longitudinal strain and Aortic valve Closure (Diff TPL-AC) was calculated for each segment at different AV delays and the AV delay with the smallest Diff TPL-AC was programmed. The mean AV delay that resulted in electrical and mechanical synchrony was 150 ms. After a mean follow up of 6 months, all patients had improved by at least 1 NYHA class. The mean reduction in QRS duration post procedure was -54.5 ± 22.82 ms and the mean improvement in EF was 7 ± 2.75%. CONCLUSION: Optimized LVOP using 2D strain and ECG can be a cost-effective alternative to CRT in patients with LBBB, heart failure and normal AV node conduction.

Familial atrioventricular nodal re-entrant tachycardia: A case seriers and a systematic review.

Multiple reports of familial clustering suggest that genetic factors may contribute in the pathogenesis of atrioventricular nodal re-entrant tachycardia (AVNRT). We report three cases of AVNRT in a father and his two sons along with a review of literature of other similar cases. Electrophysiological studies induced typical AVNRT, which was successfully eliminated by radiofrequency ablation in all of them. Of the 22 reported cases, 96% had typical (slow-fast) variant of AVNRT. The predominant pattern of inheritance appears to be autosomal dominant, though other patterns may exist. Further research is needed to understand the genetic influence of AVNRT and its pathophysiology.

Evaluation of baseline ECG in patients undergoing Oral Flecainide Challenge test for suspected Brugada Syndrome: An analysis of lead II.

BACKGROUND AND OBJECTIVES: We analyzed Lead II in patients undergoing an Oral Flecainide Challenge test (FCT), to identify any pointers that could predict a positive FCT and thereby help in recognition of latent BS. METHODS: The following parameters in lead II were retrospectively analyzed from the pre-test ECG in 62 patients undergoing FCT for suspected BS: The presence or absence of S waves, S wave amplitude, duration and upslope duration; J point parameters- Early repolarization, QRS notch, and QRS Slur; ST segment parameters-lack of isoelectric ST segment, ST duration and QT interval. RESULTS: 48 had positive FCT (Group-1) while 14 were negative for FCT(Group-2). Lack of an isoelectric ST segment (50% vs 14.29%, p = 0.018) and slurring of QRS (33.33% vs 0%, p = 0.014) was more common in Group-1 than Group-2. Group-1 had shorter ST segment duration (median 81.5 (IQR 64-103.5) vs 110 (IQR 90-132), p = 0.002) and shorter ST: QT ratio (median 0.28 (IQR 0.22-0.35) vs 0.23 (0.18-0.27), p = 0.007). QRS notch/depressed J point (87.5%), QRS slur (100%), and lack of isoelectric ST segment (92.31%) had high sensitivity for predicting an inducible Type 1 Brugada pattern. Combining two parameters- ST: QT ratio<0.24 and lack of isoelectric ST segment-considerably improved the specificity (73.3%), and the positive predictive value of the test to 76%. The results remained accurate when validated in a small prospective cohort. CONCLUSION: Shortened ST segment in Lead II, lack of isoelectric ST segment, slurred QRS and ST/QT ratio <0.24 are predictive of underlying Brugada pattern in baseline ECG.

Histopathological Study of Left and Right Atria in Isolated Rheumatic Mitral Stenosis With and Without Atrial Fibrillation.

BACKGROUND: Mitral stenosis (MS) has the highest incidence of atrial fibrillation (AF) in chronic rheumatic valvular disease. There are very few studies in isolated MS comparing histopathological changes in patients with sinus rhythm (SR) and AF. OBJECTIVES: To analyze the histological changes associated with isolated MS and compare between changes in AF and SR. METHODS: This was a prospective study in patients undergoing valve replacement surgery for symptomatic isolated MS who were divided into 2 groups, Group I AF (n = 13) and Group II SR (n = 10). Intra-operative biopsies performed from 5 different sites from both atria were analyzed for 10 histopathologic changes commonly associated with AF. RESULTS: On multivariate analysis, myocytolysis (odds ratio [OR]: 1.48, P = 0.05) was found to be associated with AF, whereas myocyte hypertrophy (OR: 0.21, P = 0.003), and glycogen deposition (OR: 0.43, P = 0.002) was associated with SR. Interstitial fibrosis the commonest change was uniformly distributed across both atria irrespective of the rhythm. CONCLUSION: In rheumatic MS, SR is associated with myocyte hypertrophy whereas AF is associated with myocytolysis. Endocardial inflammation is more common in left atrial appendage irrespective of rhythm. Interstitial fibrosis is seen in >90% of patients distributed in both the atria and is independent of the rhythm. Amyloid and Aschoff bodies are uncommon and the rest of the changes are uniformly distributed across both the atria.

Suicidal Zinc Phosphide Poisoning Unmasking Brugada Syndrome and Triggering Near Fatal Ventricular Arrhythmia.

Brugada syndrome (BrS) is an inherited channelopathy associated with increased incidence of ventricular arrhythmias and has many acquired triggers. Zinc phosphide (ZnP) is a rodenticide and is commonly implicated in suicidal poison ingestion. ZnP poisoning can cause myocardial toxicity and death. We report a case of ZnP poisoning that triggered a type I Brugada pattern and ventricular fibrillation in a 67-year-old male. He had no other features of toxicity and recovered later. As metal phosphide is the commonest toxin involved in suicidal poisoning in India and BrS being endemic here, this case highlights an important clinical problem.