Can retinal changes predict coronary artery disease in elderly hypertensive patients presenting with angina?

BACKGROUND: The prevalence of coronary artery disease (CAD) has been increasing in India, and so is the population of elderly patients with hypertension. In the predominantly resource-poor setting prevailing in India, this study is an effort to analyze the accuracy of retinal changes in predicting CAD among a cohort of elderly patients with hypertension presenting to the emergency department with angina. METHODS: A total of 72 elderly patients with hypertension older than 65 years presenting to the emergency department with acute angina were studied. Optic fundi were assessed for retinopathy after pupillary dilatation, which were photographed. All patients underwent coronary angiogram, and the presence or absence of CAD was determined. RESULTS: Mean +/- SD age of the participants was 72.95 +/- 6.51 years, and there were 39 men (54.2%) and 33 women (45.8%). Prevalence of CAD and retinopathy was 40.8% and 30.6%, respectively. Coronary artery disease showed a strong association with retinopathy (P < .0001). Male sex (P = .035), microalbuminuria (P = .025), and increased high-sensitivity C-reactive protein (P = .001) were identified as risk factors for CAD. Tests of accuracy for retinopathy as a predictor of CAD showed a likelihood ratio of a positive test and likelihood ratio of a negative test of 3.92 and 0.52, respectively. Area under the receiver operating characteristics curve was 70.6%. CONCLUSION: Prevalence of CAD (40.8%) and retinopathy (30.6%) was quite high in our cohort of elderly patients with hypertension. Retinal changes of any grade have a moderate accuracy in predicting CAD and, hence, may be used as an early screening tool in a resource poor setting.

Role of gender in the associations of microalbuminuria with inflammatory markers in hypertensive subjects: a cross-sectional study.

BACKGROUND: Though the association between microalbuminuria (MA) and inflammatory markers has been studied, the possible gender differences in these associations have not yet been analyzed. Our study aims to analyze the role of gender in the associations of MA and inflammatory markers. METHODS: 1,060 hypertensive patients were assessed for MA (albumin-creatinine ratio), plasma levels of HsCRP (high-sensitivity C-reactive protein), IL-18, and sCD40L (soluble CD40 ligand). Patients with diabetes mellitus, metabolic syndrome and overt nephropathy were excluded. RESULTS: Mean age was 46 +/- 9.6 years, with 560 males and 500 females. The prevalence of MA was 35.6% (n = 378). MA was associated with HsCRP (OR: 2.13, CI: 1.155-3.168, p = 0.001) and sCD40L (OR: 2.35, CI: 1.014-3.912, p = 0.013) in the premenopausal females, whereas in males (OR: 1.83, CI: 1.037-3.920, p = 0.023) and postmenopausal females (OR: 2.31, CI: 1.688-3.274, p = 0.031) MA was associated only with HsCRP and not with sCD40L or IL-18. CONCLUSIONS: Association between MA and HsCRP is consistent in all hypertensive patients. However, MA is associated with sCD40L only in premenopausal females and not in males and postmenopausal females.

Sex-Specific Associations of Oral Anticoagulant Use and Cardiovascular Outcomes in Patients With Atrial Fibrillation.

BACKGROUND: Sex-specific effectiveness of rivaroxaban (RIVA), dabigatran (DABI), and warfarin in reducing myocardial infarction (MI), heart failure (HF), and all-cause mortality among patients with atrial fibrillation are not known. We assessed sex-specific associations of RIVA, DABI, or warfarin use with the risk of MI, HF, and all-cause mortality among patients with atrial fibrillation. METHODS AND RESULTS: Medicare beneficiaries (men: 65 734 [44.8%], women: 81 135 [55.2%]) with atrial fibrillation who initiated oral anticoagulants formed the study cohort. Inpatient admissions for MI, HF, and all-cause mortality were compared between the 3 drugs separately for men and women using 3-way propensity-matched samples. In men, RIVA use was associated with a reduced risk of MI admissions compared with warfarin use (hazard ratio [95% confidence interval (CI): 0.59 [0.38-0.91]), with a trend towards reduced risk compared with DABI use (0.67 [0.44-1.01]). In women, there were no significant differences in the risk of MI admissions across all 3 anticoagulants. In both sexes, RIVA use and DABI use were associated with reduced risk of HF admissions (men: RIVA; 0.75 [0.63-0.89], DABI; 0.81 [0.69-0.96]) (women: RIVA; 0.64 [0.56-0.74], DABI; 0.73 [0.63-0.83]) and all-cause mortality (men: RIVA; 0.66 [0.53-0.81], DABI; 0.75 [0.61-0.93]) (women: RIVA; 0.76 [0.63-0.91], DABI; 0.77 [0.64-0.93]) compared with warfarin use. CONCLUSIONS: RIVA use and DABI use when compared with warfarin use was associated with a reduced risk of HF admissions and all-cause mortality in both sexes. However, reduced risk of MI admissions noted with RIVA use appears to be limited to men.

Are elderly end-stage renal disease patients more susceptible for drug resistant organisms in their sputum?

End stage renal disease (ESRD) patients are at risk for pneumonia in view of their impaired immune status. Similar empiric antibiotic regimens are used in elderly as well as young ESRD patients with respiratory tract infections. We conducted an observational, cross sectional study between June 2007 and June 2008 in 100 ESRD patients half being > 65 yrs. All patients had positive sputum culture and chest X-ray findings of pneumonia Streptococcus pneumoniae was the commonest in younger while Klebsiella pneumoniae in > 65 yrs old patients. Elderly patients had significant resistance to common antibiotics. Ceftrioxone was the most suitable antibiotic in the younger patients while a combination of piperacillin with gentamycin was the best choice in the geriatric age group. In conclusion, organisms cultured from sputum in ESRD patients with pneumonia were different in the ESRD patients of more than and less than 65 years of age as well as the drug susceptibility. We should probably redefine the management of pneumonia according to the sensitivities in our local populations to better treat these patients.

Progressive hemi facial atrophy - Parry Romberg syndrome presenting as severe facial pain in a young man: a case report.

We present a 30-year-old South Indian man who presented with complaints of left sided headache and facial pain for past 3 months, severe for past 10 days. On physical examination, right side of the face appeared normal. Left side of the face showed signs of hemi atrophy with minimal drooping of left eyelid. All Systems were found to be normal. Routine blood and urine investigations results were within normal limits. X-ray chest revealed no abnormalities and x-ray skull showed both sides equal. Computerized tomogram of the brain showed left minimal sub dural hygroma with no midline shift, and no evidence of cerebral edema or cerebral atrophy. Nerve conduction study showed features suggestive of trigeminal neuralgia. MRI of the skull base was also normal and showed no evidence of trigeminal nerve compression. Interestingly, he had minimal response to analgesics, steroids, and propranolol, but showed immediate response to carbamazepine. Hence this patient indeed had Parry Romberg syndrome: Hemi facial atrophy with trigeminal neuralgia.

Rhabdomyolysis in community acquired bacterial sepsis--a retrospective cohort study.

BACKGROUND AND OBJECTIVES: Rhabdomyolysis is often associated with sepsis and gram positive bacterial pathogens are reported to be the most frequent cause of sepsis induced rhabdomyolysis. We report the pattern of infecting bacterial pathogens and associated causal factors in a South-Indian cohort. DESIGN, SETTING, PARTICIPANTS #ENTITYSTARTX00026; MEASUREMENTS: Retrospective cohort study of adult patients with community acquired bacterial sepsis complicated by rhabdomyolysis from March 2003--August 2008. Rhabdomyolysis was defined as serum creatine kinase >2000 IU/L. The study population was divided into group-I (sepsis with gram positive pathogens), group-II (sepsis with gram negative pathogens) and group-III (culture negative sepsis). RESULTS: 103 patients (group I -15, group II- 34 and group III- 54) formed the study cohort. Mean age was 55 years and two-third had diabetes. Mean creatine kinase was 7114 IU/L and mean serum creatinine on admission was 2.4 mg/dl. Causative pathogen of sepsis was identified in 47.5%. Gram negative pathogens were more frequently (33%) associated with rhabdomyolysis than gram positive pathogens (14.5%). Lung was the commonest foci of sepsis (38.8%). 78.6% of the study population had one or more additional causal factor for rhabdomyolysis like statin intake, chronic alcoholism, hypokalemia, hypernatremia and hypophosphatemia. Mortality was 59%. CONCLUSIONS: Gram negative bacterial pathogens were more frequently associated with rhabdomyolysis than gram positive pathogens. Rhabdomyolysis in patients with sepsis is multifactorial and is associated with high mortality.

Paraneoplastic (non-metastatic) adrenal insufficiency preceded the onset of primary lung cancer by 12 weeks.

Clinically evident adrenal insufficiency associated with lung cancer is a rare entity. Among reported cases, adrenal insufficiency has occurred with or succeeded the primary lung cancer. Adrenal insufficiency has also been secondary to metastasis to the adrenal gland. The present report concerns a 61-year-old man, a chronic smoker, who presented to us with symptomatic adrenal insufficiency. He had no evidence of lung cancer during this visit. The primary lung cancer was only identified 12 weeks later. Additionally, his adrenals showed no evidence of metastasis. Hence his adrenal insufficiency had been a paraneoplastic manifestation of the lung cancer, and it had also preceded the primary by 12 weeks.

Virilizing ovarian steroid cell tumor in a 40 year old South Indian female: a case report.

Virilism is the masculinization and enhancement of male secondary sexual characteristics in females. The etiology is usually of adrenal or ovarian origin. Here we report a case of virilizing Leydig cell type, steroid cell tumor of the left ovary, in a 40 year old female who presented with clinical signs and symptoms of virilization: deepening of voice, hirsutism (Ferriman-Gallwey score 26), clitoromegaly, and androgenic alopecia. On further evaluation, laboratory investigations revealed hyperandrogenism in the male range. Basal testosterone values were elevated. Folicle Stimulating Hormone and Luteinising Hormone levels were within normal limits. Dexamethasone suppression test did not alter cortisol or testosterone levels. An ovarian mass was confirmed radiologically. Following a total abdominal hysterectomy with bilateral salpingoophorectomy, histopathological studies confirmed a left sided steroid-cell ovarian tumor, Leydig cell type (stage T(1)N(0)M(0)), which proved to the etiology of virilization in this patient. Post-operatively her serum testosterone levels declined with near-complete reversal of symptoms over time.

Association between primary hypothyroidism and metabolic syndrome and the role of C reactive protein: a cross-sectional study from South India.

BACKGROUND: Hypothyroidism (sub-clinical and overt) and metabolic syndrome are recognized risk factors for atherosclerotic cardiovascular disease. This study is an effort to identify the proposed association between these two disease entities and the risk factors involved in this association. METHODS: A cross - sectional study from a tertiary care teaching hospital in Chennai city, South India. 420 patients with metabolic syndrome (NCEP - ATP III criteria) were included in the study group. 406 appropriately age and sex matched controls having no features of metabolic syndrome (0 out of the 5 criteria) were compared with the study group. The study extended over a 5 year period. TSH, FT4 were measured for both the groups using electrochemiluminescence immuno assay. HsCRP was measured for all the patients in the study group. The baseline characteristics between the groups were compared with Student's't' test. Chi-square test was used to analyze the association between metabolic syndrome and hypothyroidism (overt and sub-clinical). Logistic regression analysis was applied to identify the association between hypothyroidism and the patient characteristics in the study group. RESULTS: Of the 420 patients in the study group, 240 were females (57.1%), 180 were males (42.9%) with mean age 51 +/- 9.4 years. Of the 406 patients in the control group, 216 were females (53.2%), 190 males (46.8%) with mean age 49 +/- 11.2 years. In the study group, 92 had sub-clinical hypothyroidism (SCH) (21.9%), 31 were overtly hypothyroid (7.4%) and 297 were euthyroid (70.7%). In the control group 27 patients had sub-clinical hypothyroidism (6.6%), 9 patients had overt hypothyroidism (2.2%) and 370 patients were euthyroid (91.2%). On comparison SCH (P < 0.001) and overt hypothyroidism (P < 0.001) were significantly associated with the study group as compared to the control group. Logistic regression analysis recognized the association between female gender (P = 0.021) and HsCRP (P = 0.014) with sub-clinical hypothyroidism and female gender (P = 0.01) with overt hypothyroidism in the study group. CONCLUSION: Hypothyroidism is associated with metabolic syndrome and females are more at risk. Metabolic syndrome patients with a raised HsCRP are at significant risk of having sub-clinical hypothyroidism.

Accuracy of retinal changes in predicting microalbuminuria among elderly hypertensive patients: a cross-sectional study from a teaching hospital in South India.

OBJECTIVE: Microalbuminuria is an important marker of end organ damage in hypertensive patients, but is often not tested for, especially in a resource-poor setting. We studied the accuracy of retinal changes in predicting microalbuminuria among a cohort of geriatric hypertensive patients. METHODS: One hundred and eighty elderly hypertensive patients aged more than 65 years were assessed for their demographic characteristics, smoking status, duration of hypertension, current severity of hypertension, body mass index, left ventricular hypertrophy by electrocardiogram (ECG), and high sensitivity C-reactive protein (HsCRP). Optic fundi were assessed for retinopathy after pupillary dilatation, and were photographed. Microalbuminuria (albumin-creatinine ratio) was measured as an average of two nonconsecutive overnight spot urine samples. Patients with pre-diabetes, diabetes, metabolic syndrome, treatment with angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers, overt nephropathy or proteinuria, and active infection were excluded. RESULTS: Mean age was 74 +/- 6.56 years. One-third were obese and 18.9% had left ventricular hypertrophy. Prevalence of microalbuminuria was 39.4% and prevalence of retinopathy was 40%. Microalbuminuria showed a strong association with retinopathy (P < 0.0001). Logistic regression identified association of microalbuminuria with duration of hypertension (P = 0.001) and elevated high sensitivity C-reactive protein (P = 0.021). Retinopathy was associated with duration of hypertension (P = 0.001) and smoking (P < 0.0001). Tests of accuracy for retinopathy as a predictor of microalbuminuria showed a sensitivity of 72% and specificity of 81%. CONCLUSION: Prevalence of microalbuminuria and retinopathy were quite high in our cohort of elderly hypertensive patients. Retinal changes of any grade probably have moderate accuracy in predicting microalbuminuria and hence we can initiate work-up for target organ damage, especially in a resource-poor setting.

Acute myocardial infarction in an 18 year old South Indian girl with familial hypercholesterolemia: a case report.

Familial hypercholesterolemia is a single gene disorder with an autosomal dominant pattern of inheritance. Here we report an 18 year old South Indian girl who presented with myocardial infarction. She had xanthomas and an elevated serum low density lipoprotein cholesterol (LDL-C). Her mother and maternal uncle had died at a young age due to myocardial infarction. Her only sibling, 15 year old younger sister also had xanthomas and an elevated LDL-C. This report is to emphasise the need to clinically recognize xanthomas and its association with elevated LDL-C, premature atherosclerosis and familial inheritance. Early diagnosis and early initiation of treatment will save the affected individual and the other family members.

Unilateral hemothorax in a 46 year old South Indian male due to a giant arteriovenous hemodialysis fistula: a case report.

In a patient undergoing regular hemodialysis through an arteriovenous fistula access, pleural effusion is a known long term complication. However, a unilateral hemothorax is relatively uncommon. Here we report a 46 year old male, end-stage renal disease patient, on maintenance hemodialysis, who presented with a giant brachiocephalic AV fistula in his left arm and progressive breathlessness. Radiological imaging revealed a left sided pleural effusion. Ultrasound guided aspiration revealed a hemorrhagic pleural fluid. A Doppler study of the fistula revealed a high velocity blood flow through the fistula, thereby establishing the cause of the unilateral hemothorax. Ligation of the fistula resulted in complete resolution of the hemothorax. The other possible causes for hemothorax in a dialysis patient are also discussed in this case report.

Multidrug resistant tuberculosis co-existing with aspergilloma and invasive aspergillosis in a 50 year old diabetic woman: a case report.

Aspergilloma and invasive aspergillosis coexisting with multidrug resistant Mycobacterium tuberculosis (MDR-TB) in the same patient is a rare entity. We report a 50 year old South Indian woman, a diabetic, who presented to us with complaints of productive cough and hemoptysis for the past 2 months. She was diagnosed to have pulmonary tuberculosis 2 years ago for which she took irregular treatment. Lung imaging showed features of a thick walled cavity in the right upper lobe with an indwelling aspergilloma. She underwent a right lung upper lobe resection. Biopsy and culture of the resected specimen showed the coexistence of Aspergillus fumigatus and multi-drug resistant Mycobacterium tuberculosis. 2 blood cultures grew Aspergillus fumigatus. She was successfully treated with Voriconazole and anti tuberculous therapy against MDR-TB.