Prevalence of coronary artery disease and coronary risk factors in Kerala, South India: a population survey - design and methods

BACKGROUND

There is paucity of reliable contemporary data on prevalence of coronary artery disease (CAD) and risk factors in Indians. Only a few studies on prevalence of CAD have been conducted in Kerala, a Southern Indian state. The main objective of the Cardiological Society of India Kerala Chapter Coronary Artery Disease and Its Risk Factors Prevalence Study (CSI Kerala CRP Study) was to determine the prevalence of CAD and risk factors of CAD in men and women aged 20-79 years in urban and rural settings of three geographical areas of Kerala.

METHODS

The design of the study was cross-sectional population survey. We estimated the sample size based on an anticipated prevalence of 7.4% of CAD for rural and 11% for urban Kerala. The derived sample sizes for rural and urban areas were 3000 and 2400, respectively. The urban areas for sampling constituted one ward each from three municipal corporations at different parts of the state. The rural sample was drawn from two panchayats each in the same districts as the urban sample. One adult from each household in the age group of 20-59 years was selected using Kish method. All subjects between 60 and 79 years were included from each household. A detailed questionnaire was administered to assess the risk factors, history of CAD, family history, educational status, socioeconomic status, dietary habits, physical activity and treatment for CAD; anthropometric measurements, blood pressure, electrocardiogram and fasting blood levels of glucose and lipids were recorded.

Cardiological Society of India practice guidelines for angiography in patients with renal dysfunction

PREAMBLE: The potential risk of contrast-induced acute kidney injury (CI-AKI) has made utilization of coronary angiography in the work-up for the diagnosis of coronary artery disease in CKD quite low.(1) This is in contrast to increasing prevalence and severity of CAD as the serum creatinine rises.(2) In fact most CKD patients will succumb to CAD and not to ESRD.(3) Thus the judicious use of CAG/PCI in this setting is of prime importance but underused. The CSI began to develop guidelines for Indian context as most guidelines are those developed by ACC/AHA or ESC. The aim was to assist the physicians in selecting the best management strategy for an individual patient under his care based on an expert committee who would review the current data and write the guidelines with relevance to the Indian context. The guidelines were developed initially in June 2010 as an initiative of Delhi CSI. Three interventional cardiologist (SB, AS, KKS), one nephrologist (SCT) and two clinical cardiologists (ST, RG) along with Dr. Roxana Mehran (New York) and Dr. Peter McCullough (Missouri), U.S.A.; were involved in a three-way teleconference to discuss/debate the data. This was presented by SB, and over the next two hours each data subset was debated/agreed/deleted and this resulted in the "Guidelines for CAG in Renal Dysfunction Patients". These were then written and re- circulated to all for final comments. Further, these guidelines were updated and additional Task Force Members nominated by Central CSI were involved in the formation of the final CSI Guidelines. Both (Roxana Mehran and Peter McCullough) reviewed these updated Guidelines in October 2012 and after incorporating the views of all the Task Force members-the final format is as it is presented in this final document.

Hepatic solitary fibrous tumor: report of a rare case

Solitary fibrous tumor (SFT) of the liver is an extremely rare neoplasm of mesenchymal origin. In the English literature, less than 40 cases of SFTs of the liver have been reported. The present case concerns a 34-year-old female who presented to us with complaint of dyspepsia. On examination, there was hepatomegaly. On ultrasound examination, an SOL in the liver was detected. Large tumor measuring 14.5 × 10 × 8 cm was resected. Microscopic evaluation of the tumor showed a well-circumscribed, low to moderately cellular tumor demonstrating spindle- and fibroblast-like cells within the collagenous stroma. Immunohistochemistry revealed diffuse strong cytoplasmic immunopositivity of CD34, Bcl2, and vimentin. A diagnosis of a benign SFT was given. The patient remained well 4 years after surgery. SFT is a rare mesenchymal neoplasm that occasionally involves the liver in adult patients. Most SFTs are benign, but some may have malignant histological features. With less than 40 reported cases in the literature, little can be said regarding its natural history or the benefits of adjuvant radio chemotherapy. Complete surgical resection remains the cornerstone of its treatment.

Isolation of acutely transforming subgroup J avian leukosis viruses that induce erythroblastosis and myelocytomatosis

Avian leukosis virus of subgroup J (ALV-J), isolated in the late 1980s, predominantly causes myelocytic myeloid leukosis in meat-type chickens. In the past few years, we have observed the occurrence of lesions indicative of erythroblastosis in ALV-J-infected flocks and, in this paper, we report the isolation of ALV-J strains from such flocks. Three of these isolates were acutely transforming viruses, as shown by their ability to transform bone marrow cell cultures. The bone marrow cultures transformed by these virus isolates were very similar to the myeloid cells transformed by the ALV-J strain 966. However, the infection of meat-type chickens with these isolates either as embryos or as 1-day-old chicks resulted in the induction of erythroblastosis as well as myelocytomatosis. Other histopathological changes observed in the inoculated birds included neoplastic lesions such as cholangioma and testicular cell tumour, and non-neoplastic lesions such as lymphomyeloid hyperplasia. This report demonstrates that highly oncogenic ALV-J, capable of inducing a different spectrum of disease other than the widely reported myelocytomatosis, could be established in naturally infected flocks.

Isolation of acutely transforming subgroup J avian leukosis viruses that induce erythroblastosis and myelocytomatosis

Avian leukosis virus of subgroup J (ALV-J), isolated in the late 1980s, predominantly causes myelocytic myeloid leukosis in meat-type chickens. In the past few years, we have observed the occurrence of lesions indicative of erythroblastosis in ALV-J-infected flocks and, in this paper, we report the isolation of ALV-J strains from such flocks. Three of these isolates were acutely transforming viruses, as shown by their ability to transform bone marrow cell cultures. The bone marrow cultures transformed by these virus isolates were very similar to the myeloid cells transformed by the ALV-J strain 966. However, the infection of meat-type chickens with these isolates either as embryos or as 1-day-old chicks resulted in the induction of erythroblastosis as well as myelocytomatosis. Other histopathological changes observed in the inoculated birds included neoplastic lesions such as cholangioma and testicular cell tumour, and non-neoplastic lesions such as lymphomyeloid hyperplasia. This report demonstrates that highly oncogenic ALV-J, capable of inducing a different spectrum of disease other than the widely reported myelocytomatosis, could be established in naturally infected flocks.

Subgroup J avian leukosis virus infection in turkeys: induction of rapid onset tumours by acutely transforming virus strain 966

Avian leukosis virus subgroup J (ALV-J), isolated in the late 1980s, predominantly causes myelocytic myeloid leukosis in meat-type chickens. In the past 10 years, ALV-J infection has become very widespread, causing serious problems to the chicken meat industry. Previously, we have shown that turkey cells can be infected in vitro with Rous sarcoma virus pseudotypes of ALV-J. In this paper, we extend those observations to show that turkey monocyte cultures can be transformed in vitro with acutely transforming ALV-J strain 966. We also show that turkeys are experimentally susceptible to infection with ALV-J prototype strain HPRS-103. However, neoplastic lesions were not observed in these birds, probably due to the short experimental period of 10 weeks. When inoculated into 1-day-old turkey poults, acutely transforming ALV-J strain 966 induced tumours between 3 and 4 weeks after infection. Most of the birds showed tumours involving the liver, with histopathological lesions of myelocytomatosis. The demonstration of the spread of HPRS-103 by contact among turkeys, although observed only at low levels in the present study, stresses the importance of segregation of turkey and chicken breeding operations to avoid the spread of ALV-J infection.

Shifting curves? Trends in thinness and obesity among Australian youth, 1985 to 2010

OBJECTIVE

To describe 25-year trends in the prevalence of ≤Grade 2 thinness and obesity among Australian children by sex, age and socioeconomic (SES) background.

METHODS

Cross-sectional surveys of New South Wales school-aged children aged 6.0-16.9 years conducted in 1985-1997-2004-2010 (n = 19 434). Height/weight were measured, and thinness and obesity were defined by international standards. SES was derived from children's residential postcode using the Australian Bureau of Statistics' Index of Relative Socioeconomic Disadvantage, most proximal to the survey year.

RESULTS

Since 1985, the prevalence of thinness has not varied by survey year. Age was not associated with thinness; however, thinness was lower among middle SES boys, compared with high SES (OR: 0.45, 95%CI: 0.21, 0.97). The prevalence of obesity trebled between 1985 and 1997 (1.7% vs. 5.1% P = 0.000); however, since 1997, obesity prevalence has not significantly changed. Since 1997, obesity was higher among younger compared with older girls (OR: 2.11, 95%CI: 1.48, 3.00) and SES was inversely associated with obesity in boys (OR: 2.05, 95%CI: 1.44, 2.92) and girls (OR: 1.86, 95%CI: 1.27, 2.74).

CONCLUSIONS

The apparent plateau in child obesity is a welcome finding; however, the SES gradients are of concern. If the obesity stabilization is associated with the impact of multiple lifestyle behavioural interventions, the findings suggest obesity programmes have done 'no harm', but potentially the dose/delivery of interventions has not been sufficient or appropriate to reduce child obesity levels.

Health care-associated native valve endocarditis: importance of non-nosocomial acquisition

BACKGROUND

The clinical profile and outcome of nosocomial and non-nosocomial health care-associated native valve endocarditis are not well defined.

OBJECTIVE

To compare the characteristics and outcomes of community-associated and nosocomial and non-nosocomial health care-associated native valve endocarditis.

DESIGN

Prospective cohort study.

SETTING

61 hospitals in 28 countries.

PATIENTS

Patients with definite native valve endocarditis and no history of injection drug use who were enrolled in the ICE-PCS (International Collaboration on Endocarditis Prospective Cohort Study) from June 2000 to August 2005.

MEASUREMENTS

Clinical and echocardiographic findings, microbiology, complications, and mortality.

RESULTS

Health care-associated native valve endocarditis was present in 557 (34%) of 1622 patients (303 with nosocomial infection [54%] and 254 with non-nosocomial infection [46%]). Staphylococcus aureus was the most common cause of health care-associated infection (nosocomial, 47%; non-nosocomial, 42%; P = 0.30); a high proportion of patients had methicillin-resistant S. aureus (nosocomial, 57%; non-nosocomial, 41%; P = 0.014). Fewer patients with health care-associated native valve endocarditis had cardiac surgery (41% vs. 51% of community-associated cases; P < 0.001), but more of the former patients died (25% vs. 13%; P < 0.001). Multivariable analysis confirmed greater mortality associated with health care-associated native valve endocarditis (incidence risk ratio, 1.28 [95% CI, 1.02 to 1.59]).

LIMITATIONS

Patients were treated at hospitals with cardiac surgery programs. The results may not be generalizable to patients receiving care in other types of facilities or to those with prosthetic valves or past injection drug use.

CONCLUSION

More than one third of cases of native valve endocarditis in non-injection drug users involve contact with health care, and non-nosocomial infection is common, especially in the United States. Clinicians should recognize that outpatients with extensive out-of-hospital health care contacts who develop endocarditis have clinical characteristics and outcomes similar to those of patients with nosocomial infection.

PRIMARY FUNDING SOURCE

None.

Tuberculosis associated with household crowding in a developed country

BACKGROUND

Tuberculosis (TB) remains an important infectious disease in New Zealand (NZ) and globally, but risk factors for transmission are still poorly understood. This research aimed to identify whether household crowding contributes to TB transmission in NZ.

METHODS

This ecological study used TB surveillance and census data to calculate TB incidence rates by census area unit (CAU). Census data were used to determine CAU characteristics including proportion of household crowding (a bedroom deficit of one or more), proportion of population who are migrants born in high-TB-incidence countries, median household income, and deprivation level. A negative binomial regression model was used to estimate the association between TB incidence and household crowding.

RESULTS

The analysis included 1898 notified TB cases for the 2000-4 period. Univariate analysis showed TB incidence at the CAU level was associated with household crowding, for the total population and for all ethnic and age groups. After adjusting for the covariates of household income, existing TB burden, and proportion of migrants from high-TB-incidence countries, multivariate analysis showed statistically significant associations between TB incidence and household crowding. The incidence rate ratio (IRR) was 1.05 (95% CI 1.02 to 1.08) in the total population and 1.08 (95% CI 1.04 to 1.12) for NZ-born people <40 years.

CONCLUSION

At the CAU level, TB incidence in NZ is associated with household crowding. An individual-based study (e.g. case-control) in recently infected cases (detected by molecular epidemiology techniques) is suggested to complement these findings. Reducing or eliminating household crowding could decrease TB incidence in NZ and globally.

Treatment outcome of neuro tuberculosis patients put on DOTS--an observation study from the field

BACKGROUND

Effectiveness of intermittent Short Course Chemotherapy for Neuro Tuberculosis has not been well studied. There are only few reported studies on this issue in the world literature under filed conditions. Neurologists all over India are reluctant to accept Directly Observed Treatment Short course for neuro tuberculosis since its introduction in India.

AIM

Assessing effectiveness of Revised National TB Control Programme (RNTCP-DOTS) regimens among neuro tuberculosis patients registered under the programme.

METHODS

All the neuro tuberculosis patients referred to RNTCP for treatment were included in the study. Study population included only those patients diagnosed at higher centre and referred to RNTCP during the period Jan - Dec 2002, Alappuzha District. Diagnostic Algorithm as per RNTCP guidelines was strictly followed and treatment outcome and follow-up status were taken from tuberculosis register. No pediatric age group was included in the study.

RESULTS

A total of 32 cases registered for DOTS regimen were included in the study, of whom 29 completed the treatment and all were asymptomatic at the end of treatment (85%). All patients received treatment as DOTS, but only 70% received actual DOTS. All patients were given nine months intermittent regimen as per RNTCP guidelines. Five patients died during the treatment (14%). This result shows that DOTS under field programme conditions are efficient in curing Neuro Tuberculosis.

CONCLUSION

Good result was obtained with intermittent short course chemotherapy under programme conditions in neurotuberculosis.

A Rare Association of Ebstein's Anomaly of Tricuspid Valve with Rheumatic Mitral Stenosis

Mitral valve abnormalities have been described in Ebstein's anomaly, but acquired rheumatic mitral valve disease is an extremely rare association. We describe a classical case of Ebstein's anomaly of tricuspid valve with severe rheumatic mitral stenosis. This patient had mild mitral regurgitation, pulmonary hypertension and atrial fibrillation.

Snare-assisted anterograde balloon mitral and aortic valvotomy using Inoue balloon catheter

We performed concurrent antegrade mitral and aortic valvotomy using Inoue dilatation catheter in 3 cases of combined rheumatic mitral and aortic stenosis. Following mitral valvotomy by standard procedure, aortic valve was crossed with the help of a floatation catheter. Stiff long length guide wire was fixed in descending aorta using a snare. Inoue catheter was threaded over the wire across the aortic valve and aortic valvotomy completed. Mitral valve area increased from mean 1 cm2 to 2 cm2; aortic gradient dropped from mean of 97 mm to 36 mm. Concurrent anterograde balloon mitral and aortic valvotomy may be effective and safe.

Congenital complete heart block and maternal connective tissue disease

Congenital complete heart block can be isolated or can occur in association with other structural heart diseases. Isolated congenital complete heart block (CCHB) is due to transplacental transfer of autoantibodies from mothers with connective tissue disease. Congenital heart block is usually complete, but incomplete blocks, sinus bradycardia and QTc prolongation are also reported. Anti SS A and Anti SS B antibodies transferred from mothers have inflammatory and arrhythmogenic effects in the fetal conduction system. Cardiac manifestations reported include dilated cardiomyopathy, endocardial fibroelastosis and mitral insufficiency. Low ventricular rate, QT prolongation and arrhythmias on monitoring are high risk features. CCHB has a mortality of 30%, and 60% of infants require pacemaker therapy. Fetal echocardiography is useful in early diagnosis. Prophylactic steroid therapy is controversial. Beta adrenergic agonists were tried in mothers with fetuses having congenital heart block to increase fetal heart rate. Early pacemaker therapy is indicated in patients with symptomatic bradycardia and ventricular dysfunction. The indications for pacing in congenital heart block continue to evolve with advances in techniques and most of these children will ultimately require permanent pacemakers by adulthood.