Improving the ACS Triage-Using High Sensitivity TroponinI and Copeptin for Early 'Rule-Out' of AMI.

Rule-out of acute myocardial infarction (AMI) in patients presenting with acute chest pain at the emergency department (ED) is a major challenge across the globe. Patients presenting very early with chest pain may provide a diagnostic challenge even when using a cardiac necrosis specific biomarker, high sensitivity troponin (hs-Tn) as they are elevated at 3-6 h after the symptom onset. Copeptin is a marker of acute hemodynamic stress which is released within few minutes of the occurrence of MI and is elevated immediately at the presentation of patients with AMI. This indicates a complementary pathophysiology and kinetics of these two biomarkers. Hence, we evaluated whether or not a protocol with combined testing of copeptin and hs-TnI at admission in patients presenting with chest pain within 6 h in low to intermediate risk and suspected ACS leads to an earlier diagnosis of AMI and thereby, aids to prevent a higher proportion of major adverse cardiac events than the current standard protocol followed in ED. A total of 148 patients as per the inclusion criterion were recruited for the study. The dual biomarker copeptin and hs-TnI allows a rule-out of AMI at presentation with a sensitivity of 100% and NPV of 99.8%. Hence, the use of dual biomarker in conjunction with clinical assessment may obviate the need for a prolonged stay in the ED and retesting hs-TnI after 2 h (for delta check) in more than two-thirds of the patients. The inclusion of these tests could have an impact on the economic burden of the ED without jeopardizing the outcome for the patient.

DRESS syndrome induced by imatinib.

Drug rash with eosinophilia and systemic symptoms (DRESS syndrome) is a severe, potentially life-threatening drug-induced hypersensitivity reaction characterized by cutaneous eruptions, fever, diffuse lymphadenopathy, along with eosinophilia and elevated liver enzymes. The severity and potential organ damage associated with DRESS mandates withdrawing the offending drug and provide a suitable replacement. We report a 55-year-old man who developed prolonged fever, generalized maculopapular rash and facial edema after 3 weeks of starting imatinib for chronic myeloid leukemia (CML). A diagnosis of DRESS was confirmed by eosinophilia and skin biopsy findings, along with a consistent RegiSCAR score. Imatinib was stopped and he was initiated on low-dose steroids, which led to complete resolution of rash and eosinophilia. A rechallenge with imatinib was positive, and he was switched to dasatinib for further therapy, following which he attained an optimal molecular response. DRESS following imatinib has only been reported in eight patients so far. In this report we summarize the current evidence for managing DRESS and its impact on the treatment of CML.

Myocarditis in admitted patients with dengue fever.

PURPOSE: Cardiac involvement in dengue fever is underdiagnosed due to low index of clinical suspicion and its contribution to hemodynamic instability in severe dengue is not well known. METHODS: A prospective observational study was conducted among admitted patients ≥ 14 years of age having confirmed dengue fever. Patients on medications affecting heart rhythm/rate, pre-existing heart disease and electrolyte abnormalities were excluded. A baseline electrocardiography (ECG), Trop-I and NT-proBNP were done for all patients. The biomarkers were measured using enzyme-linked fluorescent assay and recommended cut-off were used. Patients with elevated biomarkers underwent 2-dimensional echocardiography. Diagnosis of myocarditis was as per European Society of Cardiology (ESC) 2013 criteria. RESULTS: A total of 182 patients were recruited with mean age of 30 ± 12.6 years and 31% were females. Dengue with warning signs was present in 85 (47%) and severe dengue in 60 (33%) patients. ECG abnormalities were observed in 44 (24%) patients, biomarkers were elevated in 27 (15%) patients and 11 (6%) patients had echocardiographic abnormalities. According to ESC 2013 criteria, dengue fever with myocarditis was diagnosed in 13 [7.1% (95% CI 3.4-10.9)] patients. The patients with myocarditis were more likely to have shortness of breath, bleeding manifestations and higher respiratory rate at baseline. Clinical features of fluid overload were more common (69% vs. 1.7%, p < 0.01) and the duration of hospital stay longer in myocarditis group (7 ± 4.3 vs. 4.8 ± 1.9 days, p < 0.01). CONCLUSION: Myocarditis among admitted dengue patients is not uncommon and may lead to increased morbidity.

India's first successful intestinal transplant: the road traveled and the lessons learnt.

Intestinal transplant is a therapeutic challenge not just surgically but also logistically because of the multidisciplinary expertise and resources required. A large proportion of patients who undergo massive bowel resection and develop intestinal failure have poor outcome, because of inability to sustain long-term parenteral nutrition and limited availability of intestinal and multi-visceral transplantation facilities. We report the first successful isolated intestinal transplant from India.

Use of ABO-incompatible grafts in living donor liver transplantation--first report from India.

ABO incompatibility is the commonest reason for rejection of donors in living donor liver transplantation (LDLT). The donor pool could be expanded by 25 % to 35 % if the ABO barrier is overcome. In the absence of pre-conditioning, transplantation across the blood groups is fraught with the almost universal risk of antibody-mediated rejection (AMR) that rapidly leads to graft loss. However, AMR can be prevented by removal of preformed antibodies and reducing their production by B cells. We describe our initial experience of three cases of ABO-incompatible (ABO-i) LDLT: a 42-year-old male, an 8-month-old male and a 28-month-old female, all of blood group O+ who received blood group B + right lobe, B + left lateral segment, and A + left lateral segment liver grafts, respectively. Pre-LDLT conditioning included administration of anti-CD20 antibody (Rituximab(®)) to the adult 4 weeks prior, and four to seven sessions of double-filtration plasmapheresis to all, to remove preformed antibodies and achieve anti-donor blood group antibody (ADA) titers of ≤ 1:16 IgG and ≤ 1:8 IgM, respectively. In addition, cases 1 and 3 received mycophenolate mofetil for 7 days prior to LDLT. After LDLT, all three patients achieved normal graft function over 8-17 days with no evidence of AMR and without the need for further plasmapheresis. Postoperative complications included portal vein thrombosis (one successfully re-explored), CMV (one), Pseudomonas and Klebsiella sepsis (one each), and abdominal collection (one treated with percutaneous drainage). All are currently well with normal graft function and low ADA titers at 8, 16, and 19 months after ABO-i LDLT.

Imaging of the female urethral diverticulum.

Female urethral diverticulum is a localized out-pouching of the urethra that is becoming increasingly prevalent, but often poses a diagnostic challenge. Traditionally, conventional voiding cystourethrography has been used to make the preoperative diagnosis. With the development of higher-resolution images acquired through ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI), the anatomy and various abnormalities of the female urethra can be better elucidated. This article focuses on the imaging features of female urethral diverticulum, with emphasis on diagnostic pearls, particularly using MRI. Female urethral diverticulum can be best identified by their location in the posterolateral urethra and by their communication with the urethral lumen. Improved imaging techniques combined with increased physician awareness of urethral diverticulum will lead to more prompt and accurate diagnosis of this entity, leading to better treatment of affected patients.

Endoscopic and histopathological evaluation of preschool children with chronic diarrhoea.

Fifty-seven children with chronic diarrhoea, aged 1-5 years, were studied. Protein-energy malnutrition was present in 49 (85.9 per cent) children. Anaemia (89.5 per cent), presence of mucus and blood in stool (66.6 per cent), abdominal distension (52.6 per cent), and abdominal pain (28.1 per cent) were the common clinical findings at admission. The enteropathogens isolated from the stool of 68.4 per cent of patients were Escherichia coli (19.3 per cent), Candida albicans (12.3 per cent), E. histolytica (8.8 per cent), and Giardia lamblia (7 per cent). Secondary lactose intolerance was present in 21 per cent of children, endoscopic appearance was abnormal in 23.3 per cent of children and the commonest finding was chronic duodenitis (16.7 per cent). Abnormal histopathology was observed in 73.3 per cent of cases and villous atrophy with mononuclear cell infiltration (56.7 per cent) was the most common abnormality detected. The mean duration of diarrhoea had no impact on endoscopic appearance but it significantly affected the histopathological changes. However, no correlation was found in endoscopic and histopathological lesions in relation to malnutrition and aetiological agents.

Acardiac anomaly spectrum.

BACKGROUND: Acardiac anomaly spectrum is a rare congenital malformation found in monozygotic twin pregnancy. Besides the absence of heart, the condition is associated with variable grades of developmental disruption. Thus, no two cases are similar. METHODS: This case report is based on physical examination and autopsy findings. RESULTS: The twin had acardia and partial development of head and face. There was complete absence of upper extremities. CONCLUSIONS: The twin reversed arterial perfusion (TRAP) theory is the most accepted etiology of the disorder. Normally, the cephalic pole is the most severely affected, being most distal to the retrograde perfusion. In acardia, partial development of head, face, and brain is usually associated with the development of the upper extremities. However, in the present case, there was extensive cephalic development in the absence of upper extremity development.

Serum magnesium levels in protein-energy malnutrition.

Serum magnesium levels were measured by atomic absorption spectrophotometry in 46 malnourished and 12 healthy children, aged 3 months to 5 years. The nutritional status of children was classified in relation to weight for age and height for age using the Indian Academy of Pediatrics and the Waterlow classifications, respectively. NCHS data were used for the purposes of comparison. Serum magnesium levels were significantly low in children with moderate (weight for age 61-70 per cent) and severe (weight < or = 60 per cent) malnutrition, and in children with marked linear growth retardation (height for age < 85 per cent). Nearly half of the marasmic children had serum magnesium levels in the hypomagnesemic range (below 1.56 mg/dl). Serum magnesium levels had significant correlations with height for age and serum albumin.

Blood lead levels in children with neurological disorders.

Blood lead levels were measured by atomic absorption spectrometry in 82 children suffering from various neurological disorders (cerebral palsy 42, seizure disorders 35, acute encephalopathy of unknown origin 5) and in 28 healthy children, aged 1 to 12 years. Mean blood lead levels were 11.96 +/- 10.97 micrograms/dl in control children and 19.30 +/- 17.65 micrograms/dl in children with neurological disorders. A significant number of control children as well as those who had neurological disorders were found to have blood lead concentrations of > or = 10 micrograms/dl and > or = 20 micrograms/dl, the cut-off limits for lead poisoning and medical evaluation, respectively. Blood lead levels were, statistically, elevated in children with cerebral palsy compared to controls. Children with pica behaviour exhibited higher blood lead concentrations.

Fetal growth in maternal anaemia.

The effect of maternal iron deficiency anemia on fetal growth was studied in 54 anaemic (haemoglobin < 11.0 g/dl) mothers. Twenty-two mothers served as controls (haemoglobin > or = 11.0 g/dl). All the women had singleton live births at term gestation. The maternal iron status was assessed by serum ferritin estimation. The birth weight, head circumference, chest circumference, mid-arm circumference, and crown heel length were significantly low in infants born to women with moderate (haemoglobin 6.1 +/- 8.5 g/dl) and severe anaemia (haemoglobin < or = 6.0 g/dl), in comparison to infants born to non-anaemic women. Similarly, birth weight, mid-arm circumference, and crown-heel length were significantly low in infants of women with depleted iron stores (serum ferritin < 10 micrograms/l) than in infants of women with serum ferritin levels of 20 micrograms/l or more. All indices of fetal growth showed linear relationships with maternal haemoglobin, as well as with serum ferritin. The growth retarding effect of maternal anaemia was more on fetal birth weight and mid-arm circumference than on other anthropometric indices of the newborn.

Fetal iron status in maternal anemia.

Hemoglobin, serum iron, transferrin saturation and ferritin were measured on paired maternal and cord blood samples in 54 anemic (hemoglobin < 110 g/L) and 22 non-anemic (hemoglobin > or = 110 g/L) pregnant women at term gestation. The levels of hemoglobin, serum iron, transferrin saturation and ferritin were significantly low in the cord blood of anemic women, suggesting that iron supply to the fetus was reduced in maternal anemia. The linear relationships of these parameters with both maternal hemoglobin and maternal serum ferritin indicated that the fetus extracted iron in amounts proportional to the levels available in the mother. Infants of mothers with moderate and severe anemia had significantly lower cord serum ferritin levels and hence poor iron stores at birth. It is concluded that iron deficiency anemia during pregnancy adversely affects the iron endowment of the infant at birth.

Serum, zinc and copper levels in children with protein energy malnutrition.

Serum zinc and copper were measured by atomic absorption spectrophotometry in 58 children (3 months-5 years); of these, 46 children had protein energy malnutrition (PEM), and 12 children served as controls. The levels of serum zinc and copper were found to be significantly low in children with severe malnutrition (grades III and IV PEM). There was a significant positive correlation between serum zinc and height-for-age (r = 0.8809, p < 0.001). Serum copper was found low only in children exhibiting marked linear growth retardation (height-for-age < 85% of the normal). Hypoalbuminemia (serum albumin < 2.5 g/dl), and anemia (hemoglobin < or = 8.0 g/dl) in malnourished children were associated with significant decline in serum zinc and copper levels, respectively.

Biochemical abnormalities in neonatal seizures.

Early diagnosis and appropriate treatment of biochemical abnormalities accompanying neonatal seizures is important for effective seizure control and to avoid further brain damage. The present study was carried out on 35 neonates to determine the frequency of various biochemical abnormalities in neonatal seizures. Diagnostic evaluation included estimation of levels of serum calcium, phosphorus, magnesium, sodium, potassium, zinc, and blood glucose. Two-thirds of the neonates with seizures had biochemical disturbances in their sera. A variety of abnormalities occurred in asphyxiated infants, including hyponatremia, hypoglycemia, hypocalcemia, and hypomagnesemia. Primary metabolic disorders accounted for one-forth of the cases of neonatal seizures, the most common being hypoglycemia, hypoglycemia/hypocalcemia, and hypocalcemia/hyperphosphatemia. Inappropriate intrauterine growth, inadequate feeding, and feeding with cow's milk were the main risk factors for primary metabolic seizures. Hyponatremia was a frequent finding in seizures resulting from brain damage like birth asphyxia, meningitis, and intracranial hemorrhage. No infant had hypernatremia, hyperkalemia, hypokalemia, or low serum zinc.

Quantitation of T cells in venous blood of healthy neonates.

Quantitation of T Cells in blood is the part of the diagnostic workup for cellular immunity. Specimens of venous blood were collected within 24 hours of birth from 51 healthy, appropriate for gestational age infants. T lymphocytes were identified on the basis of their ability to form rosettes with sheep erythrocytes. The lymphocytes were harvested from peripheral venous blood, which is considered to be more representative of the immune status in the newborn than the cord blood. In the newborn infants the proportion in T cells was found to be considerably diminished in comparison to previously reported values for adults. Preterm infants, especially those with gestational age of 34 wk or less had significantly lower percentage of T cells in their blood as compared with term infants. The proportion of T cells was statistically reduced in infants weighing 2000 g or less in contrast to those weighing 2500 g or more.

Maternal mortality -- aetiological factors: analytic study from a teaching hospital of Punjab.

PIP: A review of maternal deaths at Rajendra Hospital, Punjab, from January 1978 to December 1991 yielded important data for the planning of maternal health services in this area of India, During the 14 year study period, there were 33,160 births and 339 deaths, for a maternal mortality rate of 1002/100,000 live births. Women who had received no prenatal care accounted for 47.4% of deliveries but 92.8% of maternal deaths. In addition, a disproportionate number of deaths involved rural women (74.6%) and poor women (76.4%). 57.8% of maternal deaths involved women 21-30 years of age; 37.1% occurred among primigravidas. Direct obstetrical causes were considered the etiologic factor in 83.1% of these deaths. Primary among these causes were sepsis (37.1%), obstetric hemorrhage (26.2%), hypertensive disorders of pregnancy (21.4%), and obstructed labor (15.3%). 30.6% of deaths occurred during pregnancy, 50.3% during labor, and 19.1% in the postpartum period. Indirect obstetrical causes, notably severe anemia and anesthesia complications, were implicated in 15.3% of the maternal deaths. Critical analysis of the maternal deaths in this series suggested that 89.6% were totally preventable, 9.6% were probably preventable, and only 0.8% were not avoidable. Factors that would reduce the high rate of maternal mortality in this region include more widespread use of prenatal care, training of traditional birth attendants in asepsis, referral of high-risk pregnancies, and improved transportation in rural areas.^ieng