Primary Prophylaxis Patterns for Hepatic Encephalopathy in Patients with Liver Cirrhosis: What are the Current Prescribing Trends in Specialty Practice?

INTRODUCTION: Hepatic encephalopathy (HE) is a significant complication of severe chronic liver insufficiency characterized by altered sensorium, motor, and cognitive dysfunction. This was a cross-sectional multicenter, epidemiological study to understand the prescribing pattern for primary prophylaxis of overt HE (OHE) in patients with cirrhosis in India. METHODS: The study was conducted at eight centers across different geographical regions of India. A total of 200 patients (100%) were screened, of which 197 (98.50%) met all the inclusion criteria. The prescribing pattern of the physicians was studied by calculating the percentage (subject to availability of sufficient data) of OHE-naïve patients with cirrhosis who were prescribed with different classes of drugs as primary prophylaxis of HE (such as lactulose, rifaximin, neomycin, sodium benzoate, and L-ornithine L- aspartate). The risk factors responsible for initiation of primary prophylaxis of HE was also determined. RESULTS: All the 197 patients (100%) were prescribed with prophylactic treatment. The factors that were considered by treating physicians to pose a risk for precipitating OHE for which prophylaxis was initiated were constipation in 111 (56.35%), infections in 51 (25.89%) and gastrointestinal bleeding in 35 (17.77%). Of the total 197 patients, 122 (61.93%) patients were prescribed a monotherapy, and 75 (38.07%) were prescribed a combination therapy. Of the patients on combination therapy, 68 (34.52%) patients were prescribed with two primary prophylaxis agents (dual therapy), and seven (3.55%) patients were prescribed with three primary prophylaxis agents (triple therapy). Lactulose was the most commonly prescribed agent for primary prophylaxis, followed by rifaximin. CONCLUSION: These findings may guide recommendations on primary prophylaxis for OHE in patients with liver cirrhosis that may help reduce the occurrence of first episode of overt HE, and thereby prevent subsequent cognitive impairment in these patients.

Indian monsoon derailed by a North Atlantic wavetrain.

The forecast of Indian monsoon droughts has been predicated on the notion of a season-long rainfall deficit linked to a warm equatorial Pacific. Here we show that nearly half of all droughts over the past century differ from this paradigm in that they (i) occur when Pacific temperatures are near-neutral and (ii) are subseasonal phenomena, characterized by an abrupt decline in late-season rainfall. This severe subseasonal rainfall deficit can be associated with a Rossby wave from mid-latitudes. Specifically, we find that the interaction of upper-level winds with an episodic North Atlantic vorticity anomaly results in a wavetrain that curves toward East Asia, disrupting the monsoon. This atmospheric teleconnection offers an avenue for improved predictability of droughts, especially in the absence of telltale signatures in the Pacific.

Fingerprint of volcanic forcing on the ENSO-Indian monsoon coupling.

Coupling of the El Niño-Southern Oscillation (ENSO) and Indian monsoon (IM) is central to seasonal summer monsoon rainfall predictions over the Indian subcontinent, although a nonstationary relationship between the two nonlinear phenomena can limit seasonal predictability. Radiative effects of volcanic aerosols injected into the stratosphere during large volcanic eruptions (LVEs) tend to alter ENSO evolution; however, their impact on ENSO-IM coupling remains unclear. Here, we investigate how LVEs influence the nonlinear behavior of the ENSO and IM dynamical systems using historical data, 25 paleoclimate reconstructions, last-millennium climate simulations, large-ensemble targeted climate sensitivity experiments, and advanced analysis techniques. Our findings show that LVEs promote a significantly enhanced phase-synchronization of the ENSO and IM oscillations, due to an increase in the angular frequency of ENSO. The results also shed innovative insights into the physical mechanism underlying the LVE-induced enhancement of ENSO-IM coupling and strengthen the prospects for improved seasonal monsoon predictions.

Contents of Chromium and Arsenic in Tea (Camellia sinensis L.): Extent of Transfer into Tea Infusion and Health Consequence.

Tea (Camellia sinensis L.) is the most popular beverage in the world after water. Due to acidophilic nature of tea plant, it has inherent tendency to uptake metals/metalloids including the toxic ones from the soil which is of great concern worldwide. In this study, level of chromium (Cr) and arsenic (As) were assessed in four hundred ninety-seven (497) black tea samples collected from six tea growing regions of Assam and North Bengal, India. The average concentration of Cr and As in the tested black tea samples was 10.33 and 0.11 µg g-1, respectively. Since tea is consumed as a beverage, transfer of Cr and As from black tea to its hot water extract (also known as tea infusion) was also accessed. The amount of Cr and As determined in the tea infusion was much less (< 0.20 to 1.38 µg g-1 for Cr and < 3.60 to 34.79 µg kg-1 for As) than those in the black teas with the transfer rate up to 5.96% and 8.53%, respectively. The present study showed that values of hazard quotient were well below one suggesting that intake of Cr and As from consumption of five cups of tea equivalent to 10 g black tea would not impose any health hazard.

Indian consensus on gastroesophageal reflux disease in adults: A position statement of the Indian Society of Gastroenterology.

The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Helicobacter pylori is thought to have a negative relation with GERD; H. pylori negative patients have higher grade of symptoms of GERD and esophagitis. Less than 10% of GERD patients in India have erosive esophagitis. In patients with occasional or mild symptoms, antacids and histamine H2 receptor blockers (H2RAs) may be used, and proton pump inhibitors (PPI) should be used in patients with frequent or severe symptoms. Prokinetics have limited proven role in management of GERD.

A Modal Rendition of ENSO Diversity.

The El Nino and Southern Oscillation (ENSO) 'diversity' has been considered as a major factor limiting its predictability, a critical need for disaster mitigation associated with the trademark climatic swings of the ENSO. Improving climate models for ENSO forecasts relies on deeper understanding of the ENSO diversity but currently at a nascent stage. Here, we show that the ENSO diversity thought previously as 'complex,' arises largely as varied contributions from three leading modes of the ENSO to a given event. The ENSO 'slow manifold' can be fully described by three leading predictable modes, a quasi-quadrennial mode (QQD), a quasi-biennial (QB) mode and a decadal modulation of the quasi-biennial (DQB). The modal description of ENSO provides a framework for understanding the predictability of and global teleconnections with the ENSO. We further demonstrate it to be a useful framework for understanding biases of climate models in simulating and predicting the ENSO. Therefore, skillful prediction of all shades of ENSO depends critically on the coupled models' ability to simulate the three modes with fidelity, providing basis for optimism for future of ENSO forecasts.

Indian guidelines on imaging of the small intestine in Crohn's disease: A joint Indian Society of Gastroenterology and Indian Radiology and Imaging Association consensus statement.

The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients suspected to have or having Crohn's disease. The 29 consensus statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.

Non-invasively Measured Carotid Artery Intima-Medial Thickness May Be a More Useful Marker of Coronary Artery Disease in Diabetic than Non-Diabetic Patients.

Carotid intima-medial thickness has long been proposed as a surrogate marker of atherosclerotic vascular disease in other vascular beds, most notably the coronary arteries with its practical implications. This observational study aimed at exploring the relationship of a hypothetical stronger relationship of carotid intima-medial thickness with coronary artery disease in diabetic patients than non-diabetic counterparts. Thirty diabetic patients and 74 non-diabetic patients who were referred for coronary angiogram in the Departments of Cardiology Bangabandhu Sheikh Mujib Medical University and Combined Military Hospital, Dhaka Cantonment, Bangladesh from January, 2002 and December, 2003 were studied. Carotid ultrasound was done to determine intima-medial thickness and coronary angiogram to detect coronary artery lesions. Background demographic data and cardiovascular risk factors were determined. Of the 30 diabetic patients 24 subjects had CAD. Twenty two of these 24 patients showed increased carotid IMT. None of the patients without CAD had shown carotid artery intima-medial thickening (sensitivity 91% specificity 100%). In contrast, in the non-diabetic group 44 patients out of 63 with CAD showed increased carotid artery IMT. Four of the 11 non-diabetic patients without CAD showed positive carotid ultrasound study results (sensitivity 70%, specificity 63%). This study showed a strong association of coronary artery disease with carotid intima-medial thickness in diabetic patients compared to non-diabetic subjects. This finding may be applicable for Bangladeshi diabetic population. This surrogate marker of coronary artery disease can be useful in the management of diabetes as regards their prevention of coronary artery disease. The practical and clinical implications of these findings might be the pioneer study in diabetic subjects and need to be further determined in a larger community level study.

Imaging of the small intestine in Crohn's disease: Joint position statement of the Indian Society of Gastroenterology and Indian Radiological and Imaging Association.

The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients with suspected or known Crohn's disease. These 29 position statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.

Drug susceptibility of rapid and slow growing non-tuberculous mycobacteria isolated from symptomatics for pulmonary tuberculosis, Central India.

BACKGROUND: Non-tuberculous mycobacteria (NTM) are emerging as important pathogens. Their treatment also differs from that of Mycobacterium tuberculosis. In India, any datum on them is scarce as species identification and drug susceptibility are not performed in most laboratories. Susceptibility also differs from one geographic area to another, and in our country, there are no data even to guide the clinicians to start treatment empirically. METHODOLOGY: The present study endeavours to generate drug susceptibility data on NTM isolated from sputum samples collected and stored from 6445 symptomatics for pulmonary tuberculosis during a prevalence survey and from specimens received from the hospital. Isolates were not necessarily associated with the disease. Species were identified and antibiotic susceptibility was performed using micro-broth dilution technique as per the standard Clinical and Laboratory Standards Institute guidelines. RESULTS: A total of 65 NTM with 11 species were identified, of which 27 belonged to Mycobacterium fortuitum complex, 14 Mycobacterium gordonae, 9 Mycobacterium avium, 7 Mycobacterium flavescens, 4 Mycobacterium scrofulaceum and one each of others. Sensitivity to amikacin for M. fortuitum was 95.22% (20 out of 21), followed by ciprofloxacin (76.19%) and clarithromycin (71.42%). All the 9 M. avium isolates, 11 of M. gordonae (78.57%), 5 of M. flavescens and 2 of M. scrofulaceum were sensitive to clarithromycin. All NTM were resistant to first-line antitubercular drugs except 8, which were sensitive to streptomycin. CONCLUSIONS: Drug sensitivity of NTM varies from species to species. While amikacin was the best for rapidly growing mycobacteria, clarithromycin was the most active drug against M. avium and other slow growers.

Chronic hepatitis C virus infection in India: Regional demographics and distribution of viral genotypes.

BACKGROUND AND AIMS: Although chronic hepatitis C virus (HCV) infection affects millions of people in India, few studies have assessed host, viral, and disease characteristics of chronically infected patients at national and regional levels. Such information is critical to support large scale screening and treatment initiatives for chronic HCV infection in India. METHODS: Patients with known chronic HCV infection making routine or for-cause visits to the participating study centers were enrolled in this observational study. Patients attended a single outpatient visit during which demographics and medical history were collected, a physical examination was performed, and blood and urine samples were collected for laboratory assessments. Samples were analyzed to determine HCV genotypes and subtypes, and genotypes of interferon lambda 3 (IFNL3) single nucleotide polymorphism. No therapeutic interventions were administered. RESULTS: We enrolled 500 patients at 19 centers, categorized into four geographic regions (North, South, East, and West). All patients self-identified as Indian, and most (66 %) were male. Genotype 3 was the most common genotype overall (54 %); however, its prevalence varied greatly by region, ranging from 34 % in the South to 69 % in the East. Genotypes 1 (24 %) and 4 (6 %) were the next most common, and HCV genotype could not be determined for 16 % of patients. CONCLUSIONS: This prospective survey suggests that demographics, viral, and host factors in patients with chronic HCV infection are highly variable in India and pose significant challenges for the implementation of broad-scale screening and treatment initiatives.

In vitro and clinical evaluation of OATP-mediated drug interaction potential of sacubitril/valsartan (LCZ696).

WHAT IS KNOWN AND OBJECTIVE: Sacubitril/valsartan (LCZ696) has been recently approved for the treatment of heart failure (HF) patients with reduced ejection fraction. Several HF patients receive statins as co-medication. METHODS: Because clearance of statins is meditated via OATP1B1/1B3, the inhibition potential of these transporters by LCZ696 analytes was evaluated in vitro. Furthermore, an open-label, fixed-sequence clinical study was conducted to determine the effect of LCZ696 on the exposure of simvastatin and its active metabolite simvastatin acid. In this clinical study, 26 healthy subjects received simvastatin 40 mg alone or in combination with LCZ696 or after 1 or 2 h of LCZ696 dosing. RESULTS AND DISCUSSION: Although no significant inhibition by LBQ657 (an active metabolite of sacubitril) and valsartan was observed, sacubitril inhibited OATP1B1 and OATP1B3 in vitro, with IC50 of 1·91 and 3·81 µm, respectively. Upon co-administration of simvastatin with LCZ696, the Cmax of simvastatin and simvastatin acid decreased by 7% and 13%, respectively. When administered 1 h after LCZ696 dosing, the corresponding Cmax of simvastatin and simvastatin acid decreased by 16% and 4%, respectively. When administered 2 h after LCZ696 dosing, the Cmax of simvastatin decreased by 33% and that of simvastatin acid increased by 16%. However, no notable changes were observed in the AUCs of simvastatin or simvastatin acid upon co-administration or time-separated administration with LCZ696. No notable impact of simvastatin co-administration was observed on the pharmacokinetics of LCZ696 analytes. LCZ696 and simvastatin were generally well tolerated when administered alone or in combination. WHAT IS NEW AND CONCLUSIONS: Overall, the results of this study suggest that although sacubitril inhibited OATP1B1 and OATP1B3 in vitro, it does not translate into any clinically relevant in vivo effect.

Pulmonary function in young females of Kolkata, India - Revisited.

Rapid economic and industrial growths imposed significant impact on human health including the pulmonary health. Questions were raised regarding the validity of the existing prediction norms of pulmonary function tests (PFTs) in a particular population. The present study was conducted to investigate the applicability of the existing norms for PFTs in young healthy non-smoking female university students of Kolkata, India. Significant difference was noted in vital capacity (VC), forced vital capacity (FVC), and forced expiratory volume in 1 s (FEV1) when the present data were compared with the earlier study in similar population. Correlation statistic revealed significant relationship of age and body height with all the PFT parameters. Body mass had significant correlation with VC, FVC, FEV1 as a percentage of FVC (FEV1%), and peak expiratory flow rate (PEFR). Regression equations have been computed for predicting PFTs from age and body height. There has been a change of PFTs in the studied population for the last couple of decades due to increased environmental pollution in the course of economical and industrial developments. Regression equations computed in this study are not only recommended to predict PFT parameters in the studied population, but they are also considered more reliable owing to their substantially smaller standard error of estimate than those proposed in the previous study.

Drying of Indian subcontinent by rapid Indian Ocean warming and a weakening land-sea thermal gradient.

There are large uncertainties looming over the status and fate of the South Asian summer monsoon, with several studies debating whether the monsoon is weakening or strengthening in a changing climate. Our analysis using multiple observed datasets demonstrates a significant weakening trend in summer rainfall during 1901-2012 over the central-east and northern regions of India, along the Ganges-Brahmaputra-Meghna basins and the Himalayan foothills, where agriculture is still largely rain-fed. Earlier studies have suggested an increase in moisture availability and land-sea thermal gradient in the tropics due to anthropogenic warming, favouring an increase in tropical rainfall. Here we show that the land-sea thermal gradient over South Asia has been decreasing, due to rapid warming in the Indian Ocean and a relatively subdued warming over the subcontinent. Using long-term observations and coupled model experiments, we provide compelling evidence that the enhanced Indian Ocean warming potentially weakens the land-sea thermal contrast, dampens the summer monsoon Hadley circulation, and thereby reduces the rainfall over parts of South Asia.

Comparison of Manning, Rome I, II, and III, and Asian diagnostic criteria: report of the Multicentric Indian Irritable Bowel Syndrome (MIIBS) study.

BACKGROUND: Attempts to diagnose and subtype irritable bowel syndrome (IBS) by symptom-based criteria have limitations, as these are developed in the West and might not be applicable in other populations. OBJECTIVES: This study aimed to compare different criteria for diagnosing and subtyping of IBS in India. METHOD: Manning's and the Rome I, II, and III criteria as well as the Asian criteria were applied to 1,618 patients (from 17 centers in India) with chronic lower gastrointestinal (GI) symptoms with no alarm features and negative investigations. RESULTS: Of 1,618 patients (aged 37.5 [SD 12.6] years; 71.2% male), 1,476 (91.2%), 1,098 (67.9%), 649 (40.1%), 849 (52.5%), and 1,206 (74.5%) fulfilled Manning's, Rome I, II, and III, and the Asian criteria, respectively. The most common reason for not fulfilling the criteria was absence of the following symptoms: "more frequent stools with onset of pain," "loose stool with onset of pain," "relief of pain with passage of stool," "other abdominal discomfort/bloating," and, in a minority, not meeting the duration criterion of 3 months/12 weeks. By stool frequency, constipation-predominant IBS (<3 stools/week) was diagnosed in 319 (19.7%), diarrhea-predominant IBS (>3 stools/day) in 43 (2.7%), and unclassified in 1,256 (77.6%). By Bristol stool form, constipation, diarrhea, and unclassified were diagnosed in 655 (40.5%), 709 (43.8%), and 254 (15.7%) patients, respectively. By their own perception, 462 (28.6%), 541 (33.4%), and 452 (27.9%) patients reported constipation-predominant, diarrhea-predominant, and alternating types, respectively. CONCLUSION: By Manning's and the Asian criteria, a diagnosis of IBS was made frequently among Indian patients with chronic functional lower GI symptoms with no alarm features; the Rome II criteria gave the lowest yield. By the stool frequency criteria, a majority of patients had unclassified pattern, unlike by the stool form and patients' perception of their symptoms.

Survey of inflammatory bowel diseases in India.

INTRODUCTION: Inflammatory bowel disease (IBD), both ulcerative colitis (UC) and Crohn's disease (CD), once thought to be uncommon, is now seen commonly in India. The Indian Society of Gastroenterology (ISG) Task Force on IBD decided to collate data on the clinical spectrum of IBD currently prevailing in India. METHODS: An open call to members of ISG was given through publication of a proforma questionnaire in the Indian Journal of Gastroenterology and the web portal of ISG. The proforma contained questions related with demographic features, family history, risk factors, clinical manifestations and characteristics, course of disease, and pattern of treatment of IBD. RESULTS: Of 1,255 filled questionnaires received, 96 were rejected and 1,159 (92.3 %) were analyzed. This comprised data on 745 (64.3 %) patients with UC, 409 (35.3 %) with CD, and 5 with indeterminate colitis. The median duration of illness was longer in patients with CD (48 months) compared to those with UC (24 months) (p = 0.002). More than one half of patients (UC 51.6 %, CD 56.9 %) had one or more extraintestinal symptoms. A definite family history of IBD was present in 2.9 % (UC 2.3 % and CD 4.6 %; p = 0.12). The extent of disease in UC was pancolitis 42.8 %, left-sided colitis 38.8 %, and proctitis alone in 18.3 %. The extent of disease involvement in CD was both small and large intestine in 39.6 %, colon alone in 31.4 % and small intestine alone in 28.9 %. Stricturing and fistulizing disease were noted in 18.8 % and 4.4 % of patients with CD respectively. Chronic continuous and intermittent disease course were present in 35.5 % and 47.2 % of UC patients respectively, and in 23.1 % and 68.8 % of CD patients. Four percent of patients with UC had undergone colectomy, while 15.2 % of patients with CD underwent surgical intervention. CONCLUSIONS: The present survey provides a reasonable picture of the demographic features and clinical manifestations of Indian patients with IBD, their risk factors, course of disease, and the treatment given to them.

Interaction between dyslipidaemia, oxidative stress and inflammatory response in patients with angiographically proven coronary artery disease.

INTRODUCTION: Coronary artery disease (CAD) is emerging as the biggest killer of the 21st century. A number of theories have been postulated to explain the aetiology of atherosclerosis. The present study attempts to elucidate the interaction, if any, between inflammation, oxidative stress and dyslipidaemia in CAD. METHODS: A total of 753 patients undergoing angiography were evaluated and 476 were included in the study. The parameters studied included complete lipid profile, and apolipoprotein B, ferritin and nitric oxide (NO) levels. Statistical analysis was carried out to determine the interrelationship between these parameters and the best predictor of CAD risk. Cut-off points were determined from the receiver operating characteristics curves, and the specificity, sensitivity, positive predictive value, negative predictive value, odds ratio and confidence intervals were calculated. RESULTS: The levels of the parameters studied increased with the stenotic state and a positive correlation was observed between ferritin, NO and apolipoprotein B. NO emerged as the most reliable predictor of CAD, with an area under the curve of 0.992 and sensitivity and specificity of 97 and 98%, respectively. CONCLUSION: Environmental and genetic risk factors for CAD interact in a highly complex manner to initiate the atherosclerotic process. These risk factors should be considered mutually inclusive, not exclusive when devising pharmacological interventions, as multi-factorial risk management is the cornerstone of CAD management.

Assessment of insulin resistance, dyslipidemia and inflammatory response in North Indian male patients with angiographically proven coronary artery disease.

AIM: Coronary artery disease (CAD) is a leading cause of morbidity and mortality in the developed world and is rapidly assuming epidemic proportions in developing countries, including India. Extensive research has proven the role of multiple etiologies such as dyslipidemia, inflammation, endothelial dysfunction and insulin resistance in the pathogenesis of CAD. The following study was undertaken to determine a possible inter-relationship between insulin resistance, inflammation and dyslipidemia, which are important risk factors for CAD in the atherosclerosis-prone north Indian male population. METHODS: The present study was conducted in 100 patients of myocardial infarction diagnosed on electrocardiographic and biochemical criteria, who subsequently underwent coronary angiography and 100 age matched healthy controls. The parameters that were evaluated include lipid profile, hsCRP, apolipoprotein B, insulin levels and HOMA-IR. RESULTS: Significantly higher serum levels of cholesterol, triglycerides, LDL and apolipoprotein B was observed in the patients as compared to the controls. On further classification, the dyslipidemia was marked in the patients with triple vessel disease as compared to single and double vessel disease. Similar pattern was observed for insulin resistance and CRP. Upon plotting the ROC curves, hsCRP emerged as the strongest predictor for CAD followed by apolipoprotein B. A significantly positive correlation was discerned between apolipoprotein B, CRP and HOMA-IR. CONCLUSION: The present study illustrates interplay between insulin resistance, inflammation and dyslipidemia in the CAD prone north Indian population. It also highlights the superiority of hs CRP in risk stratification of patients with angiographically proven CAD.

Inflammation and dyslipidaemia: a possible interplay between established risk factors in North Indian males with coronary artery disease.

OBJECTIVES: Coronary artery disease (CAD) is a leading cause of morbidity and mortality in the developed world and is rapidly assuming epidemic proportions in developing countries, including India. This has led to extensive research to determine the risk factors and the pathways that may predispose to the elevated risk of this disease. Important among them include lipoproteins, homocysteine, lipoprotein (a), pro-inflammatory cytokines and others. The following study was undertaken to determine a possible inter-relationship between inflammation and dyslipidaemia, which are important risk factors for CAD in the atherosclerosis-prone North Indian male population. METHODS: The study groups comprised 150 clinically assessed North Indian male patients with acute myocardial infarction (AMI), diagnosed on electrocardiographic and biochemical criteria, and 150 healthy controls. Apolipoprotein-AI (Apo-AI), apolipoprotein-B (Apo-B) and C-reactive protein (CRP) levels were estimated using kits based on the immunoturbidimetric assay from Randox, UK. Tumour necrosis factor-alpha (TNF-alpha) and lipoprotein (a) were assayed using commercially available ELISA kits from Diaclone Research, Belgium and Innogenetics, Belgium, respectively. RESULTS: The patients with AMI showed highly significant elevations in the levels of total serum cholesterol, triglycerides, LDL cholesterol, Apo-B and a significant decline in HDL cholesterol, compared with healthy controls. Significantly elevated serum levels of inflammatory markers, TNF-alpha and CRP were seen in patients with AMI, compared to the control subjects. A significantly positive correlation of TNF-alpha was observed with lipoprotein (a) in patients with CAD. CONCLUSION: The data clearly underlines a possible interplay between inflammation and dyslipidaemia in the pathogenesis of CAD in the Indian context. This insight into the aetiopathogenesis of CAD will prove highly beneficial for devising better preventive measures and pharmacological interventions for CAD.