DNA ploidy and proliferative index of cardiac myxoma

Cardiac myxoma is the commonest tumour of heart. The histogenesis of this lesion is controversial as its origin has often been debated between the thrombogenic and neoplastic theories. We analysed DNA ploidy and proliferation indices of 30 cardiac myxomas which include 25 sporadic and five familial cases by image cytometry and proliferating cell nuclear antigen immunostaining. Of the 25 cases, 18 were aneuploid, three diploid and four tetraploid. Four of the five familial cases including the recurrent lesions were aneuploid. Poor tissue preservation precluded ploidy analysis in one familial case. The proliferation index of the sporadic cases ranged from 0.4 to 36.1 percent. The familial cases showed proliferation index between 10.2 and 22 percent. In addition to cardiac myxoma, proliferation index was assessed in 10 cardiac thrombi where it ranged from three to 58 percent. This study suggests that cardiac myxoma can be best interpreted as a neoplasm with a slow growth potential.

Root development in relation to impacted mesiodens

Presented here is a case of 7 years 6 month old child with an apically impacted mesiodens in relation to the developing root of right upper central incisor. The removal of mesiodens was deferred in order to avoid disturbance in the natural development of the upper central incisor. Serial X-rays are presented and case is discussed.

Enzyme-linked immunosorbent assay and immunoblot study in Takayasu's arteritis patients

Takayasu's arteritis or non-specific aortoarteritis is an inflammatory and stenotic disease of the aorta of questionable aetiology. Immunopathogenic mechanism, the precise nature of which is uncertain, is often suspected to be one of the basic causes of this disease. The present study was designed to estimate the antiaorta antibody titre in Takayasu's arteritis patients and to further locate the antigen in the vessel wall. Thirty clinically and angiographically proven cases of Takayasu's arteritis patients with appropriate controls were studied. Antiaorta antibody titres were estimated using Enzyme-Linked Immunosorbent Assay method. The controls included patients of vascular diseases other than Takayasu's arteritis, autoimmune diseases like rheumatoid arthritis and systemic lupus erythematosis and normal healthy individuals. Absorbance value at 492 nm at a dilution of 1:500 of the patients' sera was expressed as the antiaorta, antibody titre. There was significant difference (p < 0.005) between the mean value of the antibody titre in patients (0.471 +/- 0.073) and patients of other vascular diseases (0.209 +/- .056); autoimmune diseases (0.143 +/- .024); and, controls (0.108 +/- 0.012). Collagenase treatment of the aorta resulted in the fall of the antibody titre of aortitis patients (0.162 +/- 0.036) suggesting that the collagen might be one of the components responsible for autoantigenecity of aorta resulting in aortitis. The aortic extract was further subjected to 10 percent sodium dodecyle sulphate-polyacrylamide gel electrophoresis and immunoblot was done with Takayasu's arteritis patients' sera as well as controls' sera. The sera in 80 percent of Takayasu's arteritis patients immunoprecipitated a protein of molecular weight 45,000 (45 kilodalton) whereas only 15 percent patients of autoimmune disease group showed precipitation band though of lower molecular weight. Normal human sera gave no immunoprecipitation band. The precise nature of the antigen still needs to be identified.

Effect of endothelial cells on the lymphoproliferative response in Takayasu's arteritis

Takayasu's arteritis, also known as 'non-specific aortoarteritis' is an inflammatory disease of the aorta and its major branches. It also involves the pulmonary artery. The aetiology of the disease is not known so far. Abnormalities of the endothelial cells in terms of their structure and function are seen in the pathology of a number of diseases affecting the blood vessel wall. However, involvement of the endothelial cells in non-specific aortoarteritis is not known. In an effort to identify the role of endothelial cells in the pathogenesis of Takayasu's arteritis, peripheral blood lymphocytes isolated from the blood of patients suffering from Takayasu's arteritis were cultured in the presence of endothelial cells alone and in the presence of mitogens concanavalin-A and phytohaemagglutinin-P. The peripheral blood lymphocytes of patients with Takayasu's arteritis showed a significantly decreased blastogenic response to the mitogen concanavalin-A when cultured in the presence of endothelial cells. Our result thus suggests that endothelial cells may probably induce an inhibitory effect on the lymphocytes in patients with Takayasu's arteritis.

Pathology of cardiac transplantation--the initial experience

BACKGROUND

Cardiac transplantation has recently been started in India at the All India Institute of Medical Sciences, New Delhi. All transplants are monitored by right ventricular endomyocardial biopsies. This study describes our initial experience with the histopathological assessment of post-transplant endomyocardial biopsies.

METHODS

Fifty-four endomyocardial biopsies from 8 transplanted hearts were reviewed. At least 3 haematoxylin-eosin and Masson trichrome stained sections were available on each biopsy. Special stains and immunohistochemistry were done as required. Biopsies were graded for rejection using the grading system of the International Society for Heart and Lung Transplantation. Infection, 'Quilty' effect, biopsy site, ischaemia and reperfusion injury were also assessed.

RESULTS

There was no evidence of rejection in 34 biopsies. Eleven biopsies showed mild rejection. Only 9/54 biopsies from 4 of the transplant recipients had clinically significant grades of rejection. Biopsy sites were present in 13/54 biopsies. Ischaemia was present in the first biopsy after transplantation in 4 recipients. There was no evidence of viral or parasitic infection. 'Quilty' lesions were seen in 14/54 biopsies from 5 transplant recipients. Four of these 5 recipients had 'Quilty' lesions on more than 1 biopsy.

CONCLUSIONS

The low rejection rate at our centre is consistent with reports from around the world. Endomyocardial biopsy has been a safe, convenient and useful method for diagnosing rejection and monitoring the postoperative course of cardiac transplants at our centre.

Serial echocardiography in transplanted heart: an initial report of five cases

Role of echocardiography including Doppler is established in selection of donor and in the care of patients after cardiac transplantation. Its value for recognition of transplant rejection is however still evolving. We present here, serial echocardiographic findings in five male patients, aged 22 to 46 years who underwent cardiac transplantation at our institution. There was no appreciable change on follow-up in the left ventricular dimensions, thickness of left ventricular posterior wall and interventricular septum and left ventricular systolic function. Transient pericardial effusion was noted in two patients. Trivial to mild mitral and tricuspid regurgitation was observed. The diastolic function of the left ventricle, as assessed by mitral valve inflow wave pattern, was normal in four patients. However in the fifth patient, there was evidence of diastolic dysfunction of the left ventricle and this change was accompanied by rejection episode (IIIB changes) in the endomyocardial biopsy. With resolution of rejection in biopsy, the diastolic function by Doppler also returned to normal. We conclude that echocardiography has a definite role in the general care of patients after cardiac transplantation. Transient small pericardial effusion and mild atrioventricular valve regurgitation are common after the operation. Echocardiography may also be of use in recognition of rejection episode by demonstrating evidence of diastolic dysfunction of the left ventricle. Currently, endomyocardial biopsy remains the gold standard for diagnosis of rejection.

Hemodynamic predictors of early intolerance and long-term effects of propranolol in dilated cardiomyopathy

BACKGROUND

Fifty-six patients with dilated cardiomyopathy (DCM) (aged 14-68 years) and background therapy of angiotensin-converting enzyme inhibitors, diuretics, and digoxin were given an initial challenge of propranolol in gradually increasing doses. These patients were studied noninvasively and hemodynamically and subjected to right ventricle biopsy.

METHODS AND RESULTS

Forty-four patients tolerated propranolol and received the drug for 6 months; 12 patients deteriorated after starting the drug with worsening of congestive heart failure and/or hypotension. The patients who did not tolerate propranolol had higher left ventricular end-diastolic dimension (73 +/- 8 vs 66 +/- 8 mm, P < .05), and severe mitral regurgitation was more common. Hemodynamically these patients had higher heart rate, right ventricular end-diastolic pressure, mean pulmonary artery pressure, mean pulmonary artery wedge pressure, and left ventricular end-diastolic pressure (102 +/- 16 vs 89 +/- 12 beats/min, 15 +/- 7 vs 9 +/- 4, 39 +/- 16 vs 31 +/- 12, 28 +/- 8 vs 21 +/- 8, 28 +/- 8 vs 22 +/- 8 mmHg, respectively, P < .01). These patients had a significantly lower cardiac index (1.9 +/- 0.6 vs 2.5 +/- 0.6 L/min/m2, P < .01). Forty patients completed 6 months follow-up evaluation and were further subjected to repeat noninvasive and hemodynamic study. There was a significant improvement in New York Heart Association class, cardiothoracic ratio, and left ventricular end-diastolic dimension (68% vs 62%, 66 +/- 8 vs 62 +/- 7 mm, respectively, P < .01), while the ejection fraction (EF) rose from 23 to 35% (P < .001). Hemodynamically, there was a significant decrease in heart rate, right ventricular end-diastolic pressure, mean pulmonary artery pressure, mean pulmonary artery wedge pressure, and left ventricular end-diastolic pressure (91 +/- 14 vs 71 +/- 5 beats/min, 9 +/- 4 vs 5 +/- 3, 32 +/- 11 vs 22 +/- 7, 25 +/- 9 vs 17 +/- 8, 21 +/- 7 vs 14 +/- 4 mmHg, P < .05). The cardiac index rose from 2.3 +/- 0.6 to 3.2 +/- 0.7 L/min/m2 (P < .01).

CONCLUSIONS

Propranolol in dilated cardiomyopathy is associated with significant intolerance. Those who tolerate propranolol seem to have long-term beneficial effects. This study is limited as it is uncontrolled and nonrandomized.

Sertoli Leydig cell tumor with malignant heterologous elements and raised alpha-fetoprotein: a case report

A case of a Sertoli Leydig cell tumor in a young female with virilizing symptoms and an androgenic endocrine profile with raised serum alpha-fetoprotein is presented. The tumor consisted predominantly of malignant epithelial and mesenchymal heterologous elements. Such a combination in the same tumor has to the best of our knowledge not been previously reported in English literature. The Leydig cells were immunohistochemically positive for alpha-fetoprotein. Sertoli Leydig cell tumors should be included in the differential diagnosis of tumors with raised alpha-fetoprotein. Chemotherapy in addition to surgery has been recommended for these tumors.

Morphological evaluation of endomyocardial biopsy

Endomyocardial biopsy (EMB) has evolved as a simple and safe procedure with minimal morbidity and mortality. It is performed via the transvascular approach and can be done either as an individual procedure or, more commonly, at the time of routine cardiac catheterization. Sequential biopsies can be performed without ill-effects. Conventionally, the right ventricle is biopsied through the transvenous approach. It has been shown that biopsies from the right side are adequately representative if the disease is biventricular. The left ventricle can be biopsied in disease states affecting that chamber, viz. left ventricular tumour or predominant involvement of the left ventricle in endomyocardial fibrosis. For proper evaluation, biopsy pieces need to be handled and processed carefully. A large amount of valuable information can be retrieved from routinely processed tissue-a process which can be done in all laboratories. Important indications for EMB include diagnosis and monitoring of cardiac allograft rejection, adriamycin toxicity and diagnosis and follow up of myocarditis. Pathologists need to be aware of inherent artefacts of the biopsy procedure and should interpret these with caution. Thus, EMB provides useful information for diagnosis, follow up, monitoring of therapy and studying the evolution of several cardiac disorders.

Phenotypic characterization of cellular components of cardiac myxoma: a light microscopy and immunohistochemistry study

Cardiac myxoma is the most common primary tumor of the heart. A detailed evaluation of cell types in 41 cardiac myxomas by light microscopy and in 30 cases by immunohistochemistry was made. Reactivity to the various antisera were observed in the surface lining cells, the stromal myxoma cells and the cells in the perivascular location. Factor VIII-related antigen (FVIIIR-Ag) and Ulex europaeus agglutinin (UEA-1), both endothelial markers, were positive in 23 cases each. UEA-1 was found to be a more sensitive marker than factor VIII. Desmin and myoglobin were positive in 16 and 24 cases, respectively. Reactivity for cytokeratin was noted in ten cases, one of which showed glandular differentiation. Vimentin and S-100 positivity was obtained in 16 and 14 cases respectively. Thus, cardiac myxoma appears to arise from multipotent cells which have the potential to differentiate along several mesenchymal cells or epithelial cells and may also concurrently exhibit reactivity for both mesenchymal and epithelial markers.

The nature and significance of liver cell vacuolation following hepatocellular injury--an analysis based on observations on rats rendered tolerant to hepatotoxic damage

Swelling with nonlipid cytoplasmic vacuolation of diffusely distributed hepatocytes is seen consistently after mild acute and subacute liver injury. Several lines of evidence point to the possibility that this change may reflect a cellular adaptation beneficial to the host, rather than a degenerative change. The nature and significance of this morphological manifestation were tested in batches of albino rats given small doses of a variety of hepatotoxins, some of which were subsequently challenged with a large highly necrogenic dose of carbon tetrachloride (CCl4). Morphological and biochemical investigations showed that cytoplasmic vacuolation of liver cells following low doses of toxins was due to excess accumulation of glycogen, predominantly of the monoparticulate form. These cells lacked features of degeneration or regeneration and were much less susceptible to injury by the large dose CCl4, as assessed by structural and serum enzyme analyses. This tolerance to toxic damage seemed to be associated with excess accumulation of intracellular glycogen. We conclude from these and other observations on animal and human livers that many of the vacuolated hepatocytes seen in liver injury are cells adaptively altered to resist further insult rather than cells undergoing hydropic degeneration, as is commonly believed.

Basaloid-squamous carcinoma. A distinct histopathological entity

Basaloid Squamous Carcinoma (BSC) is an uncommon aggressive neoplasm occurring in the upper aerodigestive tract. Lung as a primary site has only recently been reported. A combination of microscopic features is required to make a diagnosis and to differentiate it from other more common malignancies in these sites. Three cases of BSC including one in the lung are reported. There are no prior published reports of this neoplasms in Indian literature. The study highlights the typical microscopic features and the diagnostic difficulties which may be encountered.

Assessment of antiretroviral therapy by plasma viral load testing: standard and ICD HIV-1 p24 antigen and viral RNA (QC-PCR) assays compared

To assess the utility of quantitative competitive-polymerase chain reaction (QC-PCR) measurements of plasma human immunodeficiency virus type 1 (HIV-1) RNA and other viral load markers for assessment of antiretroviral therapy, we used archived cryopreserved specimens from a randomized controlled clinical trial of 135 patients (CD4+ T cell count < or = 500/mm3), comparing zidovudine (500 mg/day) versus the nonnucleoside reverse transcriptase inhibitor L-697, 661 (50, 300, or 1,000 mg daily). We evaluated treatment-associated changes in plasma viral load by standard and immune complex-dissociated (ICD) HIV-1 p24 antigen assays, and, in a representative subset of patients (n = 46), by QC-PCR determination of virion-associated HIV-1 RNA. At baseline, HIV-1 RNA was quantifiable by QC-PCR in all patients tested (100%), whereas standard and ICD HIV-1 p24 antigen tests were positive (> or = 30 pg/ml) in 42% and 56%, respectively. All viral load parameters showed significant decreases from baseline within 1 week of initiation of zidovudine, as measured by standard p24 antigen assay, ICD p24 assay, and QC-PCR. At 1 week, patients treated with either 300 or 1,000 mg/day of L-697,661 showed significant decreases from baseline in plasma standard and ICD p24 antigen and QC-PCR-determined HIV-1 RNA levels. Whereas viral load decreases seen with zidovudine were sustained for the duration of treatment, plasma viral markers often returned to pretreatment levels despite ongoing L-697,661 treatment, with evidence of the emergence of drug-resistant virus. Whereas standard p24, ICD p24, and viral RNA levels changed similarly in response to treatment, the superior sensitivity and available dynamic range of plasma viral RNA assays like QC-PCR analysis provide an advantage for clinical monitoring of plasma viral load, allowing tracking of treatment-related changes even in patients with earlier stage disease and lower levels of viral load.

Immunohistochemical characterisation and quantitative evaluation of lymphomononuclear cells in dilated cardiomyopathy-an endomyocardial biopsy study

Endomyocardial biopsies (EMB) from patients of dilated cardiomyopathy (DCM) and normal hearts were evaluated for infiltration by lymphomononuclear cells. Cryostat sections from cases of DCM were stained with antisera against leucocyte common antigen (LCA), Pan T lymphocytes and macrophages. Paraffin sections from patients of DCM and normal hearts were also stained with a panel of antisera against LCA, and macrophage markers namely, lysozyme, alpha-1-antitrypsin (AAT) and alpha-1-antichymotrypsin (ACT). The stained cells were quantitated and expressed as number of cells/mm2. Comparisons were made between the number of lymphomononuclear cells in hematoxylin and eosin stained sections and those stained by various markers. Light microscopic evaluation of paraffin sections of EMB in all cases of DCM showed mild to moderate hypertrophy of the myocardium in 20 and 10 patients respectively. Only mild focal myonecrosis was observed in 14 patients. These foci showed minimal infiltration by lymphomononuclear cells. In normal hearts, occasional small foci of lymphomononuclear cells were seen within the interstitium. The number of LCA positive cells in the frozen section from cases of DCM were more (7.03 +/- 3.15/mm2) than the number of cells in the corresponding paraffin sections (5.26 +/- 1.14/mm2), thus indicating that antigens are possibly better preserved in frozen sections. In normal hearts, the number of cells staining positively with LCA were almost identical (4.81 +/- 1.14/mm2) to those seen in paraffin sections of cases of DCM (5.26 +/- 1.61/mm2).(ABSTRACT TRUNCATED AT 250 WORDS)

Colonoscopy for unexplained lower gastrointestinal bleeding in a tropical country

Two hundred and forty consecutive patients with recurrent lower gastrointestinal bleeding were studied by colonoscopic examination. These included 187 adults and 53 children. The procedure was successful either in identifying the lesion or in excluding it up to the cecum in 216 (90% patients). The source of bleeding was identified in 138 (74%) adults and 43 (81%) Children. Predominant lesions in adults were nonspecific colitis and ulcers (58%), polyps (19%), cancer (10%), rectal varices (4%) and tuberculosis (3%). Juvenile polyps (77%) and nonspecific colitis and ulcers (23%) were the cause of bleeding in children. Both in adults and children, 92% of these lesions involved the left colon. Rectum and sigmoid colon were mainly involved. Diffuse lesions were seen when nonspecific colitis and ulcers were the source of bleeding. Thus colonoscopic examination was useful in localizing the cause of rectal bleeding and the predominant lesions were different from those reported in the Western hemisphere.

Recurrent, biatrial, familial cardiac myxomas

A case of familial, recurrent, biatrial cardiac myxoma is reported. Histiological examination of a recurrent myxoma revealed prominent glandular differentiation.

Ultrastructural and histological study of endomyocardial biopsies from patients of dilated cardiomyopathy--a comparative evaluation and their clinical correlation

Morphological studies of dilated cardiomyopathy reveal nonspecific light and electron microscopic features. This study was designed to perform a comprehensive qualitative and semi-quantitative evaluation of histological and ultrastructural parameters in endomyocardial biopsies in 20 cases of DCM. Semi-quantitation of parameters increases the accuracy and precision of evaluation by reducing interobserver variation in assessment. The semi-quantitative score ratios in our study were further correlated with the clinical and hemodynamic data to identify parameter(s) of prognostic significance. In the histological evaluation, myofibre hypertrophy appeared to be the most frequent (95%) and severely affected parameter followed by myocardial degeneration (70%). The ultrastructural features were more diffuse, impressive and severely altered. The most prominent features were mitochondrial degeneration and myofibrillar lysis seen in 100% of our cases. Severe mitochondrial degeneration appeared to be an indicator of poor prognosis in DCM as it was seen in patients with the lowest left ventricular ejection fraction obtained angiographically. Moreover, unlike the light microscopic evaluation, ultrastructural score ratios correlated significantly with the ejection fraction.

Endomyocardial biopsy--technical aspects experience and current status. An Indian perspective

Our study ellucidates the utility of endomyocardial biopsy (EMB) in various cardiac-muscle disorders seen in a tropical country like India. The procedure has been successfully performed in 501 patients (572 procedures) at our centre from April 1985 to December 1992. This included 60 infants and children. The indications were dilated cardiomyopathy (DCM) in 214, non-specific aortoarteritis in 91, rheumatic heart disease in 75, restrictive cardiomyopathy in 45, constrictive pericarditis in 14 and miscellaneous in 62 patients. There was no mortality, however, one patient developed cardiac tamponade and another sustained ventricular tachycardia requiring cardioversion. There was transient atrial fibrillation in six patients and all these had acute rheumatic heart disease. Transient complete heart block occurred in six patients with underlying left-bundle branch-block. Histological examination of EMB revealed myocarditis in 34/214 (15.4%) patients in DCM group and helped in following up these cases on immunosuppressive treatment. In the presence of restrictive haemodynamics it could identify amyloidosis in four patients. It was also helpful in differentiating between endomyocardial fibrosis and chronic constrictive pericarditis. In patients with non-specific aorto-arteritis significant histological changes of inflammatory myocarditis were observed in patients especially in congestive heart failure. Furthermore, it was helpful in identifying the nature of cardiac tumour in one patient. Its utility has also been evaluated in disorders, including rheumatic heart disease, peripartum cardiomyopathy and systemic disorders like systemic lupus erythematosis. Even in the absence of cardiac-transplant programmes at national level we have found EMB to be a useful investigation in a tropical country like India.

Does endomyocardial biopsy aid in the diagnosis of active rheumatic carditis?

BACKGROUND

Carditis is the only component of rheumatic fever that leads to permanent disability. The diagnosis of carditis is presently made by using composite clinical criteria based on the revised Jones' criteria. Since myocardial involvement is an important component of rheumatic carditis, right ventricular endomyocardial biopsies were performed in 54 patients with clinical acute rheumatic fever and quiescent rheumatic heart disease to evaluate the role of biopsy for the diagnosis of rheumatic carditis.

METHODS AND RESULTS

In 11 of the 54 patients, clinical consensus was certain about rheumatic fever and carditis based on the revised Jones' criteria (group 1). Histomorphological abnormalities in these patients were scarce. The diagnostic features of rheumatic myocarditis including Aschoff nodules or histiocytic aggregates were encountered in 3 patients (27%). Lymphocytic infiltration was sparse. A majority of patients demonstrated myocyte degeneration, interstitial degeneration, or occasional interstitial mononuclear cell infiltration, but since these histopathological lesions may occur in other conditions also, they were considered nondiagnostic. In 33 of the 54 patients with preexisting rheumatic heart disease, the diagnosis of carditis was suspected based on varied clinical presentations. Since previous cardiac findings were not available in these patients, the clinical diagnosis of carditis could not be made without equivocation (group 2). Twenty-three patients presented with unexplained acute onset of congestive heart failure and evidence of recent streptococcal infection (group 2A). While 13 of them had one or more other major manifestations, 10 patients had only minor manifestations. Mimetic carditis was suspected in the remaining 10 of 33 patients based on carditis having occurred in previous episodes of rheumatic fever (group 2B). The endomyocardial biopsy provided confirmatory evidence of rheumatic myocarditis in 9 patients of group 2A but in none of the 10 patients with suspected mimetic carditis. Nondiagnostic myocyte or interstitial alterations were frequently observed in group 2. Ten of the 54 patients had no clinical evidence of active carditis (group 3). No histological alterations diagnostic of rheumatic carditis were noted in these patients. Twenty-two follow-up biopsies were performed in the first 10 consecutive patients. Diagnostic histiocytic aggregates or Aschoff nodules were observed in initial biopsies in 4 of 10 patients, and nonspecific myocyte or interstitial alterations were observed in 9. All patients with diagnostic changes in initial biopsy demonstrated fibrohistiocytic nodules in 6- or 12-week biopsy samples. Nondiagnostic alterations, similar to those seen in acute cases, were present in 5 of 8 patients at 6 weeks, 5 of 8 patients at 12 weeks, and 3 of the 6 patients at 24 weeks despite the presumed adequate immunosuppressive therapy. No complications related to biopsy were encountered.

CONCLUSIONS

The present study highlights the low frequency of diagnostic features in the biopsy specimens of patients with definite clinical rheumatic carditis. Although such alterations are not observed in patients with chronic rheumatic heart disease, endomyocardial biopsy does not appear to provide additional diagnostic information where clinical consensus is certain about diagnosis of rheumatic carditis. Our study, however, substantiates the concept of carditis underlying unexplained congestive heart failure of acute onset in patients with preexisting rheumatic heart disease and elevated antistreptolysin-O titers.

Amlodipine in mild and moderate hypertension: initial Indian experience

In an open, non-comparative, variable-dose study, 20 outpatients with mild to moderate essential hypertension were treated with 5-10 mg amlodipine once daily for 4 weeks, after their blood pressures had stabilized on placebo. Amlodipine produced a significant decrease in blood pressure (P < 0.05) from the initial mean of 162/100 mm Hg to 139/85 mm Hg at 4 weeks. 80% of the patients reached the goal diastolic blood pressure of < or = 90 mm Hg with a once-daily dose of 5 mg amlodipine within 2 weeks. The remaining 20% also attained the goal diastolic blood pressure within 4 weeks, with a one-step increase in the dose to 10 mg at 2 weeks. Amlodipine maintained blood pressure reduction throughout the 24-hours dosing interval with a once-daily dose. Notably, no side effects were observed; pulse rate, electrocardiogram, and laboratory parameters were not significantly altered with therapy. Amlodipine in a single daily dose of 5-10 mg is effective and well tolerated in the treatment of patients with mild to moderate hypertension.

Clinical profile of biopsy proven idiopathic myocarditis

We studied 20 patients in detail (age: 27 months to 45 years, mean 22 years; 15 males, 5 females) of idiopathic myocarditis histologically confirmed by endomyocardial biopsy. None of these patients had evidence of active or previous rheumatic fever. The commonest mode of presentation was congestive heart failure (16 patients) followed by arrhythmias (seven patients--five of whom had associated congestive heart failure) and chest pain resembling myocardial infarction (two patients). Ten patients had a history of preceding upper respiratory infection. Only one of these patients had a significant rising serum titre for Coxsackie B3 virus. Throat and rectal swabs for virus culture were negative in all patients. The electrocardiogram was abnormal in all patients, with a prolonged corrected QT-interval being the commonest abnormality (14 patients). Serial electrocardiographic patterns of evolving myocardial infarction occurred in three patients. Echocardiographic left ventricular end diastolic dimension (4.15 +/- 1.01 cm/m2) and end systolic dimension (3.37 +/- 1.03 cm/m2) were increased in 15 of the 18 patients studied. Pericardial involvement occurred in only one patient. Radionuclide ventriculography showed a reduced left ventricular ejection fraction (< 50%) in 17 patients, global hypokinesia in 12 patients and regional wall motion abnormalities in five patients. Left ventricular and right ventricular end diastolic pressures were elevated in 15 and 11 patients, respectively.

An enzyme linked immunosorbent assay for detection of anti-aorta antibodies in Takayasu arteritis patients

Thirty cases of clinically and angiographically proven non-specific aortoarteritis with appropriate controls were studied. Antiaorta antibody titres were estimated using enzyme linked immunosorbent assay (ELISA) method. The controls included patients of vascular diseases other than non-specific aortoarteritis, autoimmune diseases (rheumatoid arthritis and systemic lupus erythematosis), and normal healthy individuals. An absorbance value at 492 nm at a dilution of 1:500 of patients' sera was expressed as the antiaorta antibody titre. There was a significant difference (P < 0.005) between the mean value of the antibody titre of non-specific aortoarteritis patients (0.471 +/- 0.073) and patients of other vascular diseases (0.209 +/- 0.056), autoimmune disease patients (0.143 +/- 0.024) and controls (0.108 +/- 0.012). Collagenase treatment of the aorta resulted in the fall of the antibody titre of aortitis patients (0.162 +/- 0.036) suggesting that the collagen might be one of the components responsible for autoantigenecity of the aorta resulting in aortitis. The precise nature of the antigen needs to be identified.

Non-specific aortoarteritis: long-term follow-up on immunosuppressive therapy

Thirteen patients with non-specific aortoarteritis and endomyocardial biopsy evidence of myocarditis were followed-up on immunosuppressive therapy comprising of prednisolone and cyclophosphamide in addition to conventional treatment for hypertension and/or congestive heart failure. Serial determinations of erythrocyte sedimentation rate, chest roentgenogram, radionuclide ventriculogram and hemodynamic study including endomyocardial biopsy were carried out at 12, 24 and 52 weeks of therapy. Arterial lesions were also assessed by digital subtraction angiography at 0 and 52 weeks of immunosuppressive therapy. At the end of a year of treatment all patients with congestive heart failure (10/13) showed symptomatic improvement by at least one New York Heart Association (NYHA) class. There was a significant fall in erythrocyte sedimentation rate (48 +/- 12 mm/1st h to 31 +/- 12 mm/1st h, P < 0.05), pulmonary artery pressure (32 +/- 14 mmHg to 20 +/- 9 mmHg, P < 0.05), left ventricular filling pressure (20 +/- 11 mmHg to 11 +/- 7 mmHg, P < 0.05) and increase in left ventricle ejection fraction (39 +/- 16% to 51 +/- 14%, P < 0.05) associated with resolution of morphological changes on endomyocardial biopsy. Arterial lesions remained static with neither progression nor appearance of new lesions. No significant complications of therapy were noticed in any patient. Our uncontrolled observations suggest that immunosuppressive therapy is safe and results in clinical, hemodynamic and myocardial morphological improvement in a subset of patients with non-specific aortoarteritis and associated myocarditis.