Management protocols for chronic heart failure in India.

Heart failure is a common clinical syndrome and a global health priority. The burden of heart failure is increasing at an alarming rate worldwide as well as in India. Heart failure not only increases the risk of mortality, morbidity and worsens the patient's quality of life, but also puts a huge burden on the overall healthcare system. The management of heart failure has evolved over the years with the advent of new drugs and devices. This document has been developed with an objective to provide standard management guidance and simple heart failure algorithms to aid Indian clinicians in their daily practice. It would also inform the clinicians on the latest evidence in heart failure and provide guidance to recognize and diagnose chronic heart failure early and optimize management.

Intra-arterial methylene blue injection into ex vivo colorectal cancer specimens improves lymph node staging accuracy: a randomized controlled trial.

AIM: A randomized controlled trial was carried out to study the effect of a recently proposed technique of ex vivo intra-arterial methylene blue injection of the surgical specimen removed for colorectal cancer on lymph node harvest and staging. METHOD: Between May 2012 and February 2013, 100 consecutive colorectal cancer resection specimens in a single institution were randomly assigned to intervention (methylene blue injection) and control (standard manual palpation technique) groups before formalin fixation. The specimen was then examined by the histopathologist for lymph nodes. RESULTS: Both groups were similar for age, sex, site of tumour, operation and tumour stage. In the intervention group, a higher number of nodes was found [median 23 (5-92) vs. 15 (5-37), P < 0.001], with only one specimen not achieving the recommended minimum standard of 12 nodes [1/50 (2%) vs. 8/50 (16%), P = 0.014]. However, there was no upstaging effect in the intervention group [23/50 (46.0%) vs. 20/50 (40.0%); P = 0.686]. With a significantly lower number of nodes harvested in rectal cancer, the positive effect of the intervention was particularly observed in the patients who underwent preoperative neoadjuvant radiotherapy [median 30 nodes (12-57) vs. 11 (7-15); P = 0.011; proportion of cases with < 12 nodes 0/5 vs. 5/8 (62.5%), P = 0.024]. CONCLUSION: Ex vivo intra-arterial methylene blue injection increases lymph node yield and can help to reduce the number of cases with a lower-than-recommended number of nodes, particularly in patients with rectal cancer having neoadjuvant treatment. The technique is easy to perform, cheap and saves time.

High prevalence of subclinical hypothyroidism during first trimester of pregnancy in North India.

BACKGROUND: Thyroid dysfunction is a common occurrence in pregnancy and affects both maternal and fetal outcomes. There are limited data on prevalence of hypothyroidism during pregnancy from India. Therefore, this study was designed to evaluate the prevalence of thyroid dysfunction especially hypothyroidism during first trimester in a large public hospital in North India. MATERIALS AND METHODS: All the consecutive first trimester pregnant women attending Lok Nayak and Kasturba Hospitals were enrolled in the study after institutional ethics approval and consent from the study subjects. The pregnant women with diagnosed thyroid disease and on thyroid medications were excluded from the study. Morning samples of study participants were analyzed for thyroid hormone profile which included free T3, free T4, TSH, and TPO Ab. In addition, all study participants were tested for CBC, LFT, KFT, and lipid profile. RESULTS: A total of 1000 women were enrolled for this prospective observational study. The mean (SD) age of study subjects was 25.6 (11.1) years, and mean (SD) gestational age was 10.3 (3.4) weeks. One hundred and forty-three (14.3%) subjects had TSH values more than 4.5 mIU/L above the cutoff used for definition of hypothyroidism. Out of these, 135 had normal free T4 and therefore labeled as subclinical hypothyroidism and 7 had low free T4 suggestive of overt hypothyroidism. TPO Ab was positive in 68 (6.82%) of total, 25 (18.5%) of subclinical and 5 (71%) of overt hypothyroid patients. CONCLUSION: Hypothyroidism, especially subclinical, is common in North Indian women during first trimester. Further countrywide studies are needed to evaluate the prevalence and etiology of hypothyroidism to prevent maternal and fetal adverse effects of hypothyroidism in India.

The association between serum progesterone and outcome of medical management of early fetal demise: a pilot study.

The study objective was to determine the relationship between serum progesterone level and the outcome of mifepristone-misoprostol regimen for medical management of missed miscarriage up to 12 weeks. A blood sample was collected just before mifepristone administration for serum progesterone assay. After 48 h, misoprostol 800 µg was administered vaginally; further 400 µg was administered 4 h later if necessary. Treatment was classed as a success if retained tissues were expelled within 72 h (Group 1), and a failure if this did not occur (Group 2). Of 52 analysed cases, complete medical evacuation occurred within 72 h in 40 (76.9%) women (serum progesterone ranged 13-90 nmol/l). Serum progesterone between the two groups were statistically significant (p < 0.001), by Mann-Whitney test. Of the 12 patients who did not respond, nine (75%) women had serum progesterone < 10 nmol/l. We found mifepristone-misoprostol regimen is less effective in missed miscarriage when serum progesterone is < 10 nmol/l.

Targeting tuberculosis: a glimpse of promising drug targets.

Tuberculosis caused by Mycobacterium tuberculosis has emerged as the biggest curse of our time causing significant morbidity and mortality. Increasing resistance in mycobacterium to existing drugs calls for exploration of metabolic pathways for finding novel drug targets and also for prioritization of known drug targets. Recent advances in molecular biology, bioinformatics and structural biology coupled with availability of M. tuberculosis genome sequence have provided much needed boost to drug discovery process. This review provides a glimpse of attractive drug targets for development of anti-mycobacterial drug development.

New targets, new hope: novel drug targets for curbing malaria.

Malaria continues to plague the tropical and subtropical regions causing high morbidity and mortality. Every year, millions die due to lack of affordable and effective anti-malarial drugs. Malaria poses significant threat to half of the world's population and our arsenal to combat this disease is nearly empty. Pharmaceutical companies shy away from investing in research and development for anti-malarial drugs and have shunned it as non-profitable venture. In wake of emergence and spread of drug resistant malaria to newer territories, there is imperative need to develop new drugs for curbing malaria. This underscores the need of exploring new drug targets and reevaluation of existing drug targets. Availability of genome sequence of both parasite and human host has greatly facilitated the search for novel drug targets. This endeavor is complemented well by advances in functional genomics, structure - based drug design and high throughput screening methods and raises much optimism about winning this battle against malaria. This review discusses potential drug targets in the malarial parasite for designing intervention strategies and suitable chemotherapeutic agents.

Targeting strategies for Human immunodeficiency virus: a combinatorial approach.

The battle between human and the Human immunodeficiency virus (HIV) is on, with both of them rapidly improving their attacking and defense strategies. Many therapeutic agents for HIV infection have been designed and developed, However there are various aspects, like novel targets against HIV, which are yet to be unfolded with a goal of designing and developing novel drug molecules against HIV. This article reviews the current status and innovative new options for antiretroviral therapy for HIV and also discusses the various mechanisms of action for each class of drugs, and the problems yet to be solved with respect to HIV as a target for improvised treatment against AIDS.

Limbic encephalitis secondary to HIV seroconversion.

We present a case of acute limbic encephalitis secondary to HIV seroconversion. The patient made a gradual neurological recovery following treatment with antiretroviral therapy, steroids and intravenous immunoglobulin.

Parasitic infections of the lung: a guide for the respiratory physician.

Parasitic infections of the lung occur worldwide among both immunocompetent and immunocompromised patients and may affect the respiratory system in a variety of ways. This review provides an update on the presenting symptoms, signs, investigation and management of diseases affecting the lung caused by protozoa, nematodes and trematodes. The clinical presentations and radiographic findings of several of these diseases may mimic tuberculosis and malignancy. It is important to consider parasitic infections in the differential diagnosis of such lung diseases. If identified early, most parasitic diseases that affect the lung are curable with medical or surgical treatments.

Chest radiography findings in adults with pandemic H1N1 2009 influenza.

The current pandemic of a novel influenza A (H1N1) virus, commonly referred to as "swine flu", began in Mexico in March 2009 and reached the UK in April 2009. By 21 July 2009, more than 850 suspected cases of influenza had been seen at Birmingham Heartlands Hospital (BHH), including 52 adults with laboratory-confirmed pandemic H1N1 influenza who were admitted. Of seven patients (13%) requiring intensive care, six needed mechanical ventilation, two needed extra-corporeal membrane oxygenation (ECMO) and one died. Of the 52 admitted adults, 42 (81%) had respiratory symptoms or signs and positive PCR tests for novel Influenza A (H1N1) virus. These patients also had chest radiographs (CXR) taken, which were abnormal for 12 patients (29%). Of these, six patients had bilateral consolidation, which was bibasal in three and widespread in three; all six had pleural effusions. A further six patients had unilateral consolidation with predominantly basal changes; one of these patients had a pleural effusion. The odds ratio for requiring intubation and ventilation with H1N1 influenza and an abnormal CXR was 29.0 (95% confidence interval 2.93-287.0). CXR changes were not common in swine flu, but a significant minority of those requiring admission had consolidation on their CXR. Those who required admission and had CXR changes are more likely to require intubation and ventilation than those without abnormalities on CXR.

Dyselectrolytemia in chronic obstructive pulmonary diseases with acute exacerbation.

Chronic Obstructive Pulmonary Disease (COPD) is one of the leading causes of mortality and morbidity world wide. Due to lack of awareness about the precipitating factors and predictors of prognosis, cases of acute exacerbation of COPD often suffer the fatal outcomes. In our study we assessed the levels of serum sodium and potassium in subjects with acute episodes of COPD and their healthy controls. We found a significantly low level of serum sodium (133± 6.86 meq/lit) and potassium (3.39 ± 0.96 meq/L)) in subjects with acute exacerbation of COPD than their healthy counterparts [sodium-142 ± 2.28 meq/L and potassium- 4.52 ± 0.02 meq/L (p <0.05)]. Therefore, our study findings suggest that, serum sodium and potassium levels may get deranged in subjects with acute exacerbations of COPD which should be routinely checked for to avoid fatal outcomes.

Validity of 20 meter multi stage shuttle run test for prediction of maximum oxygen uptake in Indian female university students.

BACKGROUND: The 20-meter multi stage shuttle run test (20-m MST) has not yet been used by Indian scientists and validity of the test has not been studied for use with any of the Indian population. AIMS: The purpose of this study was to validate the applicability of the 20-m MST in Indian adult female. MATERIALS AND METHODS: For application of direct method cross over design was followed. For validity of the results repeatability was used. METHODS AND MATERIAL: 32 female university students (age range 20.4 approximately 24.8 years) from three different universities of West Bengal, India were recruited for the study. Direct estimation of VO2 max comprised treadmill exercise followed by expired gas analysis by scholander micro-gas analyzer whereas VO2 max was indirectly predicted by the 20-m MST. STATISTICAL ANALYSIS: Paired t-test, Pearson's product moment correlation, linear regression statistics and Bland and Altman approach for limit of agreement were adopted for statistical analysis of the data. RESULTS: The difference between the mean (SD) VO2 max values of direct measurement (VO2 max = 32.84 +/- 2.92 ml/kg/min) and the 20-m MST (SPVO2 max = 32.60 +/- 3.40 ml/kg/min) was statistically insignificant (p>0.10). Limits of agreement analysis also suggest that the 20-m MST can be applied for use with the studied population. CONCLUSIONS: The results suggest that the application of the present form of the 20-m MST be justified in the studied population. For better prediction of VO2 max a new equation has been computed based on present data for use with Indian female university students.

MRI total sagittal abdominal diameter as a predictor of metabolic syndrome compared to visceral fat at L4-L5 level.

OBJECTIVE: To compare associations between anteroposterior (AP) diameter or sagittal abdominal diameter - a measure of total central fat, and visceral fat alone with the metabolic syndrome as defined by ATPIII criteria. RESEARCH DESIGN AND METHODS: Twenty-four Caucasian male with type 2 diabetes and 24 non-diabetic Caucasian male subjects [body mass index (BMI) (+/-SD): 32.23 +/- 7.52 kg/m(2), age (+/-SD): 51.35 +/- 13.80 years] were studied by magnetic resonance imaging (MRI) scan to measure central fat at L4-L5 level. The visceral and total central adipose tissue was calculated in cm(2) and total sagittal MRI diameter and visceral sagittal MRI diameters in cm. Components of the ATPIII definition of the metabolic syndrome and circulating adipocytokine concentrations were also measured. RESULTS: MRI total sagittal abdominal diameter was positively associated with waist circumference in controls (r=0.62, p=0.007) and in diabetic subjects (r=0.81, p<0.001). Binary logistic regression analysis showed that MRI-calculated total sagittal diameter (r=0.61, p=0.002) was a more significant predictor of the adverse metabolic profile of the metabolic syndrome than MRI-assessed visceral fat. Receiver operating characteristic curves revealed that MRI-calculated total sagittal diameter most effectively identified subjects with the metabolic syndrome. CONCLUSIONS: MRI-calculated total sagittal abdominal diameter is a non-validated MRI method that predicts the adverse metabolic profile of the ATPIII definition of the metabolic syndrome. Antero-posterior fat is a dimension of central fat that seems to be more closely associated with cardiovascular risk compared to visceral fat.