Clinical presentation, management, and outcomes in the Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF) registry.

AIM: A national atrial fibrillation (AF) registry was conducted under the aegis of the Indian Heart Rhythm Society (IHRS), to capture epidemiological data-type of AF, clinical presentation and comorbidities, current treatment practices, and 1-year follow-up outcomes. METHODS: A total of 1537 patients were enrolled from 24 sites in India in the IHRS-AF registry from July 2011 to August 2012. Their baseline characteristics and follow-up data were recorded in case report forms and subsequently analyzed. RESULTS: The average age of Indian AF patients was 54.7 years. There was a marginal female preponderance - 51.5% females and 48.5% males. At baseline, 20.4% had paroxysmal AF; 33% had persistent AF; 35.1% had permanent AF and 11% had first AF episode. At one-year follow-up, 45.6% patients had permanent AF. Rheumatic valvular heart disease (RHD) was present in 47.6% of patients. Hypertension, heart failure, coronary artery disease, and diabetes were seen in 31.4%, 18.7%, 16.2%, and 16.1%, respectively. Rate control was the strategy used in 75.2% patients, digoxin and beta-blockers being the most frequently prescribed rate-control drugs. Oral anticoagulation (OAC) drugs were used in 70% of patients. The annual mortality was 6.5%, hospitalization 8%, and incidence of stroke 1%. CONCLUSIONS: In India, AF patients are younger and RHD is still the most frequent etiology. Almost two-third of the patients have persistent/permanent AF. At one-year follow-up, there is a significant mortality and morbidity in AF patients in India.

Electrocardiographical case. J wave and presyncope in a middle-aged woman.

A 46-year-old woman presented with three episodes of presyncope in the previous two days. Electrocardiogram (ECG) showed sinus rhythm, relatively short QT interval (QTc of 340 msec) and prominent J-waves in the inferior leads. Biochemical evaluation revealed serum calcium of 17.4 mg/dL, phosphorus of 2.3 mg/dL and alkaline phosphatase of 533 IU/ml. She was managed with saline diuresis followed by elective parathyroidectomy. ECG became normal with the disappearance of J-waves after correction of hypercalcaemia. She was asymptomatic at six months of follow-up. The presence of J-waves (Osborne waves) in hypercalcaemia has rarely been reported.

Cardiac malformations are increased in infants of mothers with epilepsy.

We aimed to ascertain the prevalence of cardiac malformation (CM) and its association with antenatal exposure to an antiepileptic drug (AED) in infants of mothers with epilepsy (IMEs). Women with epilepsy (WWE) are enrolled in Kerala Registry of Epilepsy and Pregnancy (KREP) in the prepregnancy or early pregnancy period and are followed up with a standard protocol until the IMEs are 6 years old. At 3 months postpartum, a cardiologist, blinded to the AED exposure, carried out a clinical examination and echocardiography on all live-born babies. Patent foramen ovale (PFO) and interatrial septal defects of < 5 mm in size were excluded from CM. Details of maternal epilepsy, folate usage, AED exposure in the first trimester, and newborn characteristics were abstracted from the records of the KREP. We examined 462 babies. Maternal epilepsy was generalized in 201 (43.50%) or localization related in 241 (52.2%). The AED exposure was monotherapy in 262 (56.7%)--carbamazepine (112), valproate (71), phenobarbitone (43), phenytoin (31), and clonazepam (2)--and polytherapy in 126 (27.3%). Seventy-four infants (16.01%) had no AED exposure. There were 36 infants with CM (7.8%; 95% confidence interval: 5.5-10.6). CMs included atrial septal defect (26; 72.2%), tetrology of Fallot (3; 8.3%), patent ductus arteriosus and pulmonic stenosis (2 each; 5.6%), and ventricular septal defect, tricuspid regurgitation, transposition of great arteries (1 each; 2.8%). CMs were significantly more for IMEs with premature birth (p < .003). There was no association between CM and maternal age, epilepsy syndrome, seizure frequency during pregnancy, and folate use. CMs were more frequent with polytherapy (13; 10.3%) compared to monotherapy (17; 6.5%). Those with valproate exposure had a trend (not statistically significant) toward higher frequency of CM compared to IMEs on other AEDs as monotherapy.

Induction of atrioventricular nodal reentry tachycardia with intravenous adenosine.

Adenosine, used to terminate paroxysmal supraventricular tachycardia (SVT), is often useful in understanding the mechanism of tachycardia. This case report describes induction of SVT with adenosine in a 36-year-old man presenting with recurrent palpitations. After a short run of conduction via both slow and fast pathways, SVT was induced following a long PR interval. The long PR interval resulted by conduction via the slow pathway due to the preferential conduction block by adenosine over fast pathway. The notching at the terminal part of QRS during antegrade slow pathway conduction and during tachycardia indicated activation of the atrium via retrograde fast pathway. This electrocardiographical feature confirmed the mechanism of the tachycardia as atrioventricular nodal reentrant tachycardia.

Ebstein's anomaly, Wolff-Parkinson-White syndrome and rheumatic mitral stenosis: role for combined electrophysiological and surgical management.

The coexistence of rheumatic mitral stenosis, Ebstein's anomaly and Wolff-Parkinson-White syndrome is an uncommon entity. To our knowledge, the successful management of this combination of lesions has not been previously described. We report a 23-year-old woman with the combination of these abnormalities. She was managed with preoperative electrophysiological study, followed by mitral valve replacement and Danielson's repair of tricuspid valve. The management issues involved are discussed in detail.

Protection from the nephrotoxicity of contrast dye.

Previous studies have reported a 4%-50% incidence of acute renal failure (ARF) following the use of radiocontrast media in patients with preexisting chronic renal insufficiency. In these studies, ARF was defined as a rise of the serum creatinine of at least 1 mg/dl above baseline. Using the same criteria, we studied 214 patients undergoing various intravascular radiocontrast media procedures. Patients were infused with a specially prepared cocktail solution (NSMF) containing 1000 ml half-normal saline, 12.5 g of mannitol (M), I ampule NaHCO3, and 200 mg of furosemide (F) at 100 ml/h from one hour prior to two hours after the procedure. Urinary output was replaced with normal saline for at least 6 h after the procedure. Seven percent of the patients developed acute renal insufficiency. Only 3% of the patients had a rise in serum creatinine greater than 2 mg/dl. No patient required dialysis therapy after the procedure. There was one unrelated death caused by acute myocardial infarction postangioplasty. Risk factors for development of ARF despite cocktail administration included the presence of diabetes mellitus and angiotensin converting enzyme (ACE) inhibitor therapy. We concluded that the properly administered NSMF solution protects against radiocontrast dye induced renal failure. In select patients with chronic renal insufficiency, consideration should be given to withholding ACE inhibitor therapy for 24-48 h prior to administration of intravenous radiocontrast dye. A large controlled trial will be required to establish whether the NSMF solution offers benefit beyond that of saline hydration alone.

The use of fluconazole in the management of Candida peritonitis in patients on peritoneal dialysis.

In patients receiving peritoneal dialysis, fungal peritonitis is generally impossible to eradicate with previously available therapy in the absence of catheter removal. Corbella et al. described a patient with fungal peritonitis treated with fluconazole without catheter removal. We studied this drug's effectiveness in the treatment of 5 patients with peritonitis secondary to Candida species. Patients received a loading dose of 200-400 mg fluconazole, followed by 50-200 mg fluconazole daily. Patients improved initially after therapy with fluconazole. Abdominal pain and fever abated, dialysis returns cleared, cell counts decreased, and, in four cases, cultures were sterilized. Dialysate fluconazole levels were adequate. However, despite maintenance of fluconazole therapy, all patients had recurrent peritonitis within 1 month. Complete cure did not occur unless the Tenckhoff catheter was removed. When the catheter was removed, tip cultures grew pure Candida species, and microscopic examination of catheter sections revealed abundant yeast. Although there may be continued isolated reports of successful eradication of fungal peritonitis without catheter removal, we conclude that in the vast majority of cases catheter removal is required.

Increment-decrement tables for human reproduction.

PIP: An increment-decrement life table method has been applied to family building patterns among women. Age at the occurrence of a specified birth is considered the principal duration variable. The data base used to illustrate the table method was a sample of currently married women from the 1965 U.S. National Fertility Survey. It is possible to calculate the average number of births occurring to a woman of given parity during any specific age interval. The average number of births occurring before age 25 for women who are childless at age 20 can be obtained by completing the reproductive history for 100,000 childless 20 year old women through age 25. In a sample of 86,242 first births, 51,425 second births, 17,485 third births, and 4755 fourth births for an average of 1.6 children before age 25. Summary measures such as average parity attained within a given age interval and the conditional probability of transition from one parity to the next in a given age interval can be calculated from a table providing the age intervals do not involve fractions of the age groups used in constructing the abridged table.^ieng

Some observations on the economic framework for fertility analysis.

Abstract The economic framework for fertility analysis, first expounded in detail by Gary S. Becker(1), has attracted considerable attention among demographers. While some writers have enthusiastically endorsed the model, others have rejected it outright(3). A few attempts have also recently been made by some writers to modify or refine some of the concepts employed, and/or to change the modes of treatment of some of the factors in the original model. Unfortunately, several major objections levelled against the model still remain. It also remains to be examined whether the criticisms can be met without violating the principles and strategies espoused by economists. I believe (1) that most of the objections advanced against the model can be met by suitably modifying it, and (2) that the required modifications can be effected by employing strategies and conceptual schemes similar to those used in the demand analysis of consumer behaviour. The objective of this paper is to expound this belief. There is a strong possibility that after modification a healthy new theory will emerge which may prove useful in guiding research, as well as help to bring together different empirical findings in the literature, or to serve as a 'binder' for the theoretical speculations advanced by many research workers.

The integrative potential of a fertility model: An analytical test.

Abstract In an earlier paper a working model of marital fertility was presented.(1) That model grew out of a close study of Becker's economic model for fertility analysis.(2) Becker's model was modified in several respects in order to meet a number of major objections levelled against it by Judith Blake, Deborah Freedman, and others.(3) The purpose of the present paper is to examine how far the model presented earlier can serve as a 'binder' for the interpretative schemes now available in the literature on fertility differentials. More specifically, the objective is to identify the underlying explanatory factors of a number of analytical hypotheses concerning fertility differentials, and to examine whether the factors thus identified can be located in the fertility model presented in the earlier paper.(4) Little attention will be paid to the causal directions, if any, recognized in the hypotheses studied, nor will we attempt to provide a systematic review of empirical findings.

On the relation between economic status and family size preferences when status differentials in contraceptive instrumentalities are eliminated.

Abstract In this paper an attempt is made to formalize the essential elements of a theory of reproductive motivation outlined by Judith Blake in a recent article. On the basis of the results of that exercise, it is argued that the theory, as it stands now, is not specific enough to 'predict' whether the affluent would choose to have fewer children than the poor, if contraceptive instrumentalities were to be equalized among the economic strata. It is also argued that the negative (though weak) association between ideal family size and economic status and the non-negative association between desired number of children and economic status, observed in survey data, are both consistent with the basic premisses of the theory under reference.