Right atrial mural thrombi: An autopsy study of an under-diagnosed complication at an unusual site.

BACKGROUND: Right atrial mural thrombi (RAMT) are often seen in association with cardiac diseases or foreign bodies. Unusual locations at the flutter isthmus and the atrial appendage prompted us to evaluate our 2-year autopsy data on such thrombi. MATERIALS AND METHODS: In the 2-year retrospective autopsy, the clinical and autopsy records of patients with RAMT were reviewed, with particular reference to the presence of central venous catheter (CVC), its site of insertion, its type, material and size, its duration of placement, and the drugs infused through the catheter. RESULTS: Of the 940 autopsies performed in 2 years, RAMT was seen in 24 hearts and was related to an insertion of a CVC in 23 patients (95.8%). The risk and/or associated factors for this complication were tunneled and polyethylene catheters, Intensive Care Unit admission, infused drugs, underlying cardiac diseases, and pregnancy. A noteworthy feature was the location of the thrombi in the flutter isthmus in 16 hearts (66.7%) and atrial appendage in another six hearts. Localized endocarditis/myocarditis and pulmonary thromboembolism were observed in six and four patients, respectively. CONCLUSIONS: This autopsy study, which has a high incidence of catheter-related RAMT, does not reflect the true incidence but reiterates the importance of guided insertion of central venous and prompt recognition of thrombus formation.

Altered Sensorium in a Young Male: Marchiafava Bignami Disease Revisited.

Marchiafava Bignami disease (MBD) is a rare and devastating complication of chronic alcoholism. Degeneration of the corpus callosum is the hallmark feature of MBD. Early diagnosis of MBD by its typical "Sandwich Sign" on magnetic resonance imaging (MRI). Prompt institution of treatment and strict alcohol abstinence can cause regression of changes and hence, clinical improvement. Here we report the case of a young chronic alcoholic male admitted with altered sensorium and his further course in ward.

Fish gall bladder consumption presenting as acute renal failure.

A forty two year old male was admitted with history of anuria and breathlessness following consumption of raw rohu fish gall bladder. He had azotemia and required hemodialysis. His renal failure improved over a period of about four weeks. Incidences have been reported from South East Asian countries associating consumption of raw rohu fish gall bladder with acute renal failure.

Allopurinol Induced DRESS Syndrome.

A 45 years old female on allopurinol for 3 months presented with itching, rash, facial oedema and eosinophilia with hepatic and renal dysfunction. Skin biopsy revealed interface dermatitis, suggesting the diagnosis of DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) syndrome.

Risk stratification, prevalence by hand-held microdoppler and in-hospital mortality of deep venous thrombosis in indoor geriatric population.

OBJECTIVE: To screen indoor geriatric patients for deep venous thrombosis (DVT) risk, assess them for the presence of DVT with hand-held microdoppler (HHMD) and correlate DVT risk score with inpatient mortality. METHODS: 111 patients (> or = 60 years) admitted for > or = 72 hours [51 patients from intensive care unit (ICU) and 60 patients from general medical wards (GMW)] over 15 months were included. Patients with suspected venous thromboembolic disease on admission were excluded. On admission, patients were screened with HHMD for the presence of DVT; those with evidence of lower limb DVT were excluded. DVT risk was stratified using the SMART Tool and patients classified into mild (1), moderate (2), high (3-4) and very high (> or = 5) risk groups. Patients were screened periodically clinically and with HHMD for DVT till discharge. The effect of thromboprophylaxis (heparin) on all-cause mortality was correlated. Levene's test for equality of variances and Pearson's Chi-square test were used for statistical analysis. RESULTS: Mean risk score (SMART TOOL) in study group was 5.15. Among 111 patients, 75 (67.56%) had high to very high risk for DVT. Immobilization, sepsis, heart failure, and acute coronary syndrome were most common risk factors for DVT. Only 2.7% of indoor geriatric patients had clinical evidence of DVT while 13.5% had presumptive evidence of DVT as detected by HHMD. The mean risk score for DVT in expired patients was higher than in discharged patients (p = 0.052). ICU patients receiving thromboprophylaxis had significantly lower mortality (9.5%) compared to those who did not (50%). (p = 0.004). Patients with presumptive evidence of DVT on HHMD had significantly higher mortality (53.33 percent) compared to those without evidence of DVT (15.62 percent); p < 0.05. CONCLUSIONS: Indoor geriatric patients constitute high risk group for DVT. There could be an increased risk of mortality in patients with presumptive evidence of DVT on HHMD.

Antihypertensive efficacy of metoprolol XL/low dose chlorthalidone (6.25 mg) combination: a randomized, comparative study in indian patients with mild-to-moderate essential hypertension.

OBJECTIVE: High blood pressure is one of the most important risk factors, directly responsible for increasing the cardiovascular morbidity and mortality. The primary objective was to evaluate the efficacy of metoprolol XL/chlorthalidone against metoprolol XL/hydrochlorothiazide with respect to mean fall in systolic and diastolic blood pressure. The secondary objective was to compare the response rates and to evaluate the tolerability of study medications in patients with mild-to-moderate essential hypertension. METHODS: Total 130 eligible patients (65: metoprolol XL 25 mg/chlorthalidone 6.25 mg; 65: metoprolol XL 25 mg/HCTZ 12.5 mg) were enrolled in this randomized, comparative, multicentric, 12-weeks study. Sixty-two patients from each group completed the study. After 4-weeks of treatment, non-responders from chlorthalidone 6.25 mg combination group were shifted to metoprolol XL 50 mg/chlorthalidone 12.5 mg and non-responders from HCTZ 12.5 mg combination group were escalated to metoprolol XL 50 mg/HCTZ 12.5 mg. RESULTS: The study treatment groups were comparable with respect to demography and baseline disease characteristics. Both the starting therapies were comparable with respect to mean fall in SBP (p = 0.788) and DBP (p = 0.939), and response rates (p = 1.0) after 4-weeks of therapy. Also both the step-up therapies showed similar mean fall in SBP (p = 0.277) and DBP (p = 0.507) at the end of 12-weeks. However, significantly more number of patients from chlorthalidone 12.5 mg/metoprolol XL 50 mg group responded to therapy as compared to that from HCTZ 12.5 mg/metoprolol XL 50 mg group (p = 0.045). All the reported adverse events were of mild-to-moderate intensity. There were no clinically significant trends in electrolytes (Na (+), K(+), Cl(-)) and fasting blood sugar, evident across the treatment groups. CONCLUSION: Chlorthalidone in combination with metoprolol XL is as effective and well tolerated as widely used combination of metoprolol XL/HCTZ, thus providing an alternative therapeutic option.

Clinical effectiveness of low-dose chlorthalidone (6.25 mg) + atenolol combination in stage I hypertensive patients: a multicenter, randomized, controlled study.

OBJECTIVE: To compare the efficacy and safety of low-dose chlorthalidone + atenolol combination with atenolol and atenolol + amlodipine combination in stage I hypertensive patients uncontrolled on active run-in monotherapy. METHODS: Newly diagnosed stage I hypertensive patients were randomized to active run-in monotherapy either with atenolol 25 mg (98/300) or chlorthalidone 6.25 mg (100/300) or amlodipine 2.5 mg (102/300). A total of 282/300 patients (atenolol 92, chlorthalidone 91, amlodipine 99) completed the active run-in phase successfully. Patients uncontrolled on active run-in monotherapy (atenolol 33, chlorthalidone 45, amlodipine 47) received the study treatment, namely atenolol 50 mg alone, chlorthalidone 6.25 mg+atenolol 25 mg and atenolol 25 mg+amlodipine 2.5 mg, respectively. Efficacy of the therapy was evaluated by BP measurement at weeks 12 and 20 post-therapy. RESULTS: Post-active run-in monotherapies, the study treatment groups showed a significant fall in mean SBP and DBP from baseline (p<0.05). The mean fall in SBP and DBP was comparable for study treatments (atenolol 50 mg, atenolol 25 mg+chlorthalidone 6.25 mg and atenolol 25 mg+amlodipine 2.5 mg) (p=0.337 for SBP and p=0.054 for DBP) at week 12 and (p=0.744 for SBP and p=0.855 for DBP) at week 20; also, the percentage of responders was comparable for the three study treatment groups (p=0.799) indicating that the low-dose chlorthalidone+atenolol combination is noninferior to the high-dose atenolol alone and atenolol+amlodipine combination. No serious laboratory/clinical adverse events were reported in this study. CONCLUSION: Chlorthalidone 6.25 mg in combination with atenolol 25 mg is effective and safe in stage I (JNC 7) essential hypertensive patients. This low dose of chlorthalidone could reduce dose-related concerns over metabolic adverse effects and may lead to wider usage of this proven antihypertensive agent in combination therapy.

Study of leukocytic hydrolytic enzymes in patients with acute stage of coronary heart disease.

BACKGROUND: Coronary heart disease (CHD) is a major killer worldwide. Atherosclerosis, which is the basis of CHD, is believed to be an inflammatory disorder. Though various aspects of atherosclerosis are extensively studied, leukocytic hydrolytic enzymes are not studied very well with respect to CHD. AIM: This study was planned to assess changes associated with leukocytic hydrolases in CHD patients. SETTING AND DESIGN: A tertiary care hospital; case-control study. MATERIALS AND METHODS: 106 patients with acute myocardial infarction, 60 patients with unstable angina and 45 healthy controls were included in the study. Acid phosphatase, lysozyme, adenosine deaminase (ADA) and cathepsin-G levels were estimated from leukocytes. Reduced glutathione (GSH) and malondialdehyde (MDA) levels were measured. STATISTICAL ANALYSIS: Statistical comparison of data was done using student's t-test (unpaired). Correlation difference was calculated by using Pearson correlation coefficient. RESULTS: Significantly higher levels of acid phosphatase, lysozyme, ADA with lower levels of cathepsin G in leukocytes were observed in CHD group. We also found significantly higher levels of serum MDA with lower concentrations of blood GSH in CHD group. In diabetic CHD group, significantly higher levels of leukocytic acid phosphatase, lysozyme, ADA and serum MDA with lower levels of cathepsin G and blood GSH were observed. CONCLUSIONS: Our study indicates that leukocyte hydrolytic enzymes, mainly acid phosphatase, lysozyme and ADA were more active in CHD patients and may contribute to inflammation related with CHD. Its also indicates that leukocyte cathepsin-G may have antiinflammatory role.

Antioxidant status in patients with acute myocardial infarction.

Free radicals play an important role in the pathogenesis of tissue damage in many clinical disorders, including atherosclerosis. Antioxidants protect the body from damage caused by free radicals. In this study we investigated oxidative stress, antioxidants and inflammatory molecules in patients with acute myocardial infarction. This study has been carried out on 106 patients with acute myocardial infarction, (89 men and 17 females). The control group consisted of 50 healthy, age-matched subjects (40 men and 10 females). Levels of Glucose, lipid profile, glutathione reduced, glutathione peroxidase, Superoxide dismutase, Glycosylated hemoglobin, fibrinogen, vitamin C, vitamin E, malondialdehyde, ceruloplasmin, adenosine deaminase, lysozyme and sialic acid were measured. Malondialdehyde and ceruloplasmin levels were significantly high and antioxidants such as vitamin C, vitamin E, glutathione reduced, glutathione peroxidase and superoxide dismutase were significantly decreased in diabetic and non-diabetic AMI patients as compared with control (p<0.001). Inflammatory markers showed significant rise in diabetic patients as compared with controls. Our results clearly show increased inflammation and oxidative stress in patients with acute myocardial infarction. Depression of antioxidant system in these patients confirms this conclusion.

Early maturation as a risk factor for aggression and delinquency in adolescent girls: A review.

Early physical maturation has long been considered a risk factor for the development of delinquent girls. The basis of this relationship has not been fully explored or understood. This review summarises the current literature and research on early physical maturation in adolescent females and places it within a developmental perspective. The process of early physical maturation is also placed within a biopsychosocial model so that risk and protective factors arising from the biological, social, family, education and peer environments can be ascertained. A complex model of maturation and environmental-social interaction is constructed and currently supported by research, but it is clear that a great deal of further work is necessary to fully understand this process.

Magnetic resonance urography (MRU) versus intravenous urography (IVU) in obstructive uropathy: a prospective study of 30 cases.

AIM: Intravenous Urography (IVU) as a diagnostic modality has limitations in patients of obstructive uropathy with impaired renal function. Our aim was to study the technique and diagnostic accuracy of Magnetic Resonance Urography (MRU) in obstructive uropathy and to correlate the findings with IVU. METHODOLOGY: Forty-eight patients, selected over a six-month period, based on mild to severe pelvicalyceal dilatation on screening ultrasonography, underwent an IVU; those having non-obstructive dilatation were excluded (18 patients). Thirty patients (age range 10 to 75 years) with definite obstructive dilatation underwent MRU. These were obtained using an open MRI unit (Siemens Magnetom Open Viva) with low-dose gadolinium-DTPA (0.01 mmol/kg body weight) using various MRI sequences. MRU studies were classified as 'excellent' or 'diagnostic' and data generated was compared with that of IVU. RESULTS: MRU studies were 'excellent' in twelve and 'diagnostic' in eighteen patients. Of the sixty pelvicalyceal systems (PCS) evaluated in thirty patients, there were thirty-seven calculi, nine pelvi-ureteric junction (PUJ) obstructions, six with impaired renal function, four malrotated kidneys and one each of horseshoe kidney, pancake kidney, pelvic mass (endometriomas), duplex moieties, ureterocele and vesico-ureteric reflux. MRU better depicted moderate-severe PCS dilatation, staghorn and urethral calculi, impaired renal function, extrinsic ureteric and PUJ obstruction. IVU better depicted small calculi and mild PCS dilatation. CONCLUSIONS: In these thirty patients of obstructive uropathy, low magnetic field, open MRI units and low-dose Gd-DTPA provided cost-effective MRU studies with excellent diagnostic utility. MRU scored over IVU in patients with moderate-severe dilatation, staghorn and urethral calculi, impaired renal function, extrinsic ureteric and PUJ obstruction.

Papillary carcinoma of thyroid presenting as posterior mediastinal mass with superior vena cava syndrome.

Enlarged thyroid with retrosternal extension presenting as anterior mediastinal mass is known. Superior vena cava (SVC) syndrome due to direct invasion from a primary thyroid malignancy is a rare phenomenon. We present a unique case of papillary carcinoma of thyroid extending into the posterior mediastinum with superior vena cava syndrome along with internal jugular and azygous vein thrombosis.

Role of multidetector CT virtual bronchoscopy in the evaluation of post-tracheostomy tracheal stenosis--a preliminary study.

AIM: To study the technique and utility of virtual bronchoscopy (virtual reality endobronchial simulation, VRES) as a tool to evaluate post-tracheostomy tracheal stenoses and to correlate the findings of virtual and invasive bronchoscopy and to follow-up treated lesions or those currently under treatment that were initially diagnosed with VRES. METHODOLOGY: This prospective study comprised nine patients in the age group 13 to 65 years presenting with breathlessness and stridor following one or multiple tracheostomies. They underwent plain CT using a multidetector CT (MDCT) scanner (Siemens Volume Zoom) using narrow (1 mm) collimation. These thin slice images were post-processed using an Irix-based workstation with a 'Fly-Through' endoscopy application. These patients also underwent a rigid (three patients) or fiberoptic (six patients) bronchoscopy. RESULTS: Of the nine patients that underwent VRES, five were found to have stenoses, three had obstructing granulation tissue, one had an obstructing membrane and one had synechiae. The invasive bronchoscopic findings supported the VRES diagnosis in all but one case of stenosis, one of granulation tissue and the case with synechiae. Membranes and synechiae were relatively difficult to diagnose without the corresponding axial and multiplanar images. VRES achieved a higher sensitivity, while invasive bronchoscopy a higher specificity. CONCLUSIONS: VRES proved to be comparable to invasive bronchoscopy in the depiction of post-tracheostomy tracheal stenoses, with a notable advantage in critical stenoses in that the airway distal to the stenosis could be assessed with VRES but not with invasive bronchoscopy. A preliminary VRES was found to be of assistance in the selection of patients for the more invasive therapeutic procedures such as laser ablation of granulation tissue and its follow-up.

Postpartum psychosis in a case of sheehan's syndrome.

This case report describes a case of a 23 years old female who presented with clinical features of postpartum psychosis (Psychotic disorder not otherwise specified, DSM-IV). On investigation she was found to be suffering from Sheehan's syndrome (postpartum pituitary infarction). It was interesting to note that all the clinical features of Sheehan's syndrome and psychosis improved with hormone replacement therapy and she did not require treatment with antipsychotic medications.