Pattern of Traumatic Injuries in Patients with Tramadol Poisoning: A Cross-Sectional Study in a Tertiary Care Hospital

Objective

This study aimed to investigate the incidence and pattern of tramadol-induced seizures and injuries in patients admitted to the hospital.

Methods

The cross-sectional study included 300 patients with alleged tramadol intoxication. Demographic information, tramadol dosage and duration of abuse, co-existing illicit drug abuse, hospital stay length, and occurrence of seizures and trauma (type and site of injuries) were collected. Different statistical tests, including the Mann-Whitney U-test, Pearson's Chi-square test, and Student's t-test, were conducted to compare the patients with and without seizures, trauma, and co-ingestion of illicit drugs. The analysis was performed using SPSS software (version 21.0). A p value of less than 0.05 was considered statistically significant.

Results

The average patient's age was 24.66±5.64 years, with males comprising 84.3% of the sample. The mean tramadol dose and duration of abuse were 1339.3±1310.2 mg and 2.43±1.35 years, respectively. Seizures were observed in 66% of patients, with men having a higher incidence (69.6% vs. 46.8%; p=0.004). Trauma was reported in 23% of patients, accounting for 35.4% of seizure cases. All trauma patients had experienced seizures, with the head and neck being the most prevalent injury sites (55.1%), typically presenting as abrasions (55.9%). Patients with seizures and trauma had an average hospital stay of 1.73±0.94 days, which was significantly longer.

Conclusion

Trauma occurs in more than one-third of tramadol-induced seizures, highlighting the need to perform physical examinations to detect and localize injuries. Tramadol-associated traumas prolonged hospitalization times and thus required prompt attention to prevent further injuries during pre-hospital handling and transferring to hospitals.

The effect of coronavirus infection on QT and QTc intervals of hospitalized patients in Qazvin, Iran

Electrocardiographic (ECG) changes have been investigated in the condition of coronavirus disease (COVID-19) indicating that COVID-19 infection exacerbates arrhythmias and triggers conduction abnormalities. However, the specific type of ECG abnormalities in COVID-19 and their impact on mortality fail to have been fully elucidated. The present retrospective, tertiary care hospital-based cross-sectional study was conducted by reviewing the medical records of all patients diagnosed with COVID-19 infection who were admitted to Booali Sina Hospital in Qazvin, Iran from March to July 2020. Demographic information, length of hospital stay, treatment outcome, and electrocardiographic information (heart rate, QTc interval, arrhythmias, and blocks) were extracted from the medical records of the patients. Finally, a total of 231 patients were enrolled in the study. Atrial fibrillation was a common arrhythmia, and the left anterior fascicular block was a common cardiac conduction defect other than sinus arrhythmia. The deceased patients were significantly older than the recovered ones (71 ± 14 vs. 57 ± 16 years, p < 0.001). Longer hospital stay (p = 0.036), non-sinus rhythm (p < 0.001), bundle and node blocks (p = 0.002), ST-T waves changes (p = 0.003), and Tachycardia (p = 0.024) were significantly prevalent in the deceased group. In baseline ECGs, no significant difference was observed in terms of the absolute size of QT; however, a prolonged QTc in the deceased was about twice of the recovered patients (using Bazett, Sagie, and Fridericia’s formula). Serial ECGs are recommended to be taken from all hospitalized patients with COVID-19 due to increased in-hospital mortality in patients with prolonged QTc interval, non-sinus rhythms, ST-T changes, tachycardia, and bundle, and node blocks.

Factors Determining Primary Coronary Slow Flow Phenomenon among Opium Users and Non-users: A Case Control Study in Northern Iran

Background

Coronary slow flow phenomenon (CSFP) represents a clinical entity with recurrent chest pain leading to living impairment. The present study aimed to investigate whether opium use correlates with primary CSFP.

Methods

This study included Iranian patients with suspected coronary artery disease who underwent myocardial perfusion imaging. Coronary blood flow was measured quantitatively using the thrombolysis in myocardial infarction (TIMI) frame count and slow flow was defined as TIMI grade 2 standard deviations. Age and clinical conditions including diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLP), history of chest pain, and opium use were recorded. First, the characteristics of the two groups were compared and then the main analyses were conducted to examine the relationship between CSFP and opium use. Data were analyzed using t test and chi-square test via SPSS 25.0. The significance level was set at P<0.05.

Findings

This study was conducted on 44 male patients with documented CSFP who had no stenotic lesions and 134 control group male patients who had normal coronary arteries with normal flow. The mean age was similar in the two groups (54.25 vs.52.69, P=0.474). Two groups were significantly different in terms of history of chest pain (P=0.003), but there was no significant difference in HTN (P=0.084), DM (P=0.284), HLP (P=0.183), smoking (P=0.696), and opium use (P=0.107).

Conclusion

This study indicated that opium use is not associated with primary CSFP.

Evaluation of domperidone efficacy to prevent aspiration pneumonia in patients with acute ischemic stroke: a randomized clinical trial

BACKGROUND AND AIM

Aspiration pneumonia is an essential complication of acute ischemic stroke (AIS), which is responsible for increased three-fold mortality within a month. There is an interest towards the effect of prokinetics on prevention of stroke-associated pneumonia. The present study aimed to investigate the effect of domperidone to prevent pneumonia in patients with AIS.

METHODS

In this randomized clinical trial, 150 patients with AIS were assigned to receive either domperidone 10 mg daily or placebo during hospitalization. The clinical outcomes including of aspiration pneumonia occurrence, gastrointestinal discomfort, the need for intensive care unit admission, the length of hospitalization, final mRs, and mortality were then evaluated in both groups.

RESULTS

150 [Mean age 67.5 ± 13.5 years, 90 men and 60 women] were randomized in a 1:1 ratio. Both groups were similar in terms of baseline characteristics. The domperidone group experienced significantly less dysphagia, nausea and vomiting, and aspiration pneumonia (P < 0.005). Although domperidone did not considerably reduce the mortality (P = 0.978), it resulted in lower mean mRS and shorter length of hospitalization (P < 0.001).

CONCLUSION

Domperidone is an effective and well tolerated agent which could be considered as a promising agent to prevent stroke-associated pneumonia leading to a better clinical recovery.

Wound healing using Semelil: A structured review with focus on diabetic foot ulcers

Diabetic Foot Ulcer (DFU) is a common complication of diabetes mellitus. Among the various non-invasive treatment modalities used for the improvement of DFUs healing, topical herbal therapies a regaining an increasing body of interest. Semelil has been introduced for diabetic foot ulcers management and has been formulated by Iranian scientists in recent years. In this report, the authors review the literature and discuss wound healing with focus on DFUs with Semelil. This review shows no complications with the application of Semelil and consensus on positive effects of the medication was found. In summary, our review showed that Semelil may be a valuable non-invasive treatment for the wound healing in DFUs patients and reduce the wound size during 4 week’s period without major adverse side effects.

Comparison of elevated cardiac troponin I with SAPS-II and APACHE-II score in predicting outcome of severe intoxications

Background and Aims:

To date, different methods have been invented to risk-stratify critically ill patients, however, there is a paucity of information regarding assessing the severity of poisonings. This study was designed to determine the comparative efficacy of Simplified Acute Physiology Score-II (SAPS-II) and Acute Physiology and Chronic Health Evaluation-II (APACHE-II)score with cardiac troponin I (cTnI) in predicting severe intoxication outcomes.

Methods:

This was a prospective study conducted on patients who fulfilled defined severe intoxication criteria necessitating intensive care unit (ICU) admission over a period of 6 months. SAPS-II and APACHE-II scores were calculated and cTnI concentrations were measured. These indicators were compared to determine which has the better ability to prognosticate mortality and complications.

Results:

A total of 55 cases (median age, 35 [24-49] years) were enroled. Eight patients (14.5%) died. Mean SAPS-II, median APACHE-II score and median cTnI concentrations were 32.05 ± 11.24, 13 [10-17] and 0.008 [0.002-0.300] ng/ml, respectively, which were significantly different between the survivors and non-survivors. Receiver operating characteristics curve results of SAPS-II, APACHE-II score and cTnI concentrations in predicting mortality were 0.945, 0.932 and 0.763 and in predicting complications were 0.779, 0.739 and 0.727, respectively. High cTnI concentration (>0.37 ng/ml) correlated with soft clinical outcomes, including length of ventilatory support, length of ICU stay and length of hospital stay (LOS) (r: 0.928, 0.881 and 0.735 respectively; all P < 0.001).

Conclusion:

SAPS-II scores were superior in predicting death and complications, while cTnI correlated more closely with soft clinical outcomes, such as the length of ventilator support, length of ICU stay or LOS.

Finasteride in hospitalized adult males with COVID-19: A risk factor for severity of the disease or an adjunct treatment: A randomized controlled clinical trial

Background: There is controversy about the efficacy of 5-alpha-reductase inhibitors in COVID-19 patients. Some assumed that finasteride might be a risk factor for deterioration and others proposed it as a possible adjunct treatment for moderate to severe COVID-19 infection in the elderly.

Methods: We performed a randomized controlled clinical trial (registration ID IRCT20200505047318N1) on 80 hospitalized male patients aged ≥50 years diagnosed with COVID-19 pneumonia in a tertiary hospital in Qazvin (Iran) from April to July 2020. The patients were randomized into one of the 2 treatment groups using simple randomization. Treatment group patients underwent routine drug therapy and 5 mg finasteride once daily for 7 days. The primary endpoint was mortality rate and length of hospital stay (LOS), and secondary endpoints were peripheral capillary oxygen saturation, respiratory rate, and inflammatory markers changes. The study protocol was approved by the medical ethics committee of Qazvin University of Medical Sciences (registration ID IR.QUMS.REC.1399.080). Data were analyzed by statistical tests and SPSS version 25. Also, p<0.05 was considered to be statistically significant.

Results: We found a significant difference on O2 saturation among the 2 study groups on fifth day compared with the admission time (p= 0.018). The results did not show significant differences in mortality rate (2.5% vs 10%; p= 0.166) and LOS (p= 0.866) between patients in the finasteride and the control group.

Conclusion: A short course of finasteride administration partially improves O2 saturation but does not influence other outcomes in hospitalized male patients aged ≥50 years with COVID-19 pneumonia. Further research in a large scale with longer follow-up is required to help clarify the role of finasteride in this setting.

Opium-associated QT Interval Prolongation: A Cross-sectional Comparative Study

Background

Toxicity and side effects of long-term use of opioids are well studied, but little information exists regarding electrophysiological disturbances of opium consumption. While natural opium has been regarded safe to a great extent among traditional communities, concerns are emerging owing to the available evidence of QT prolongation that have been exposed during recent outcome surveillance of patients under opioid use. Potential QT prolonging interactions would raise a higher level of such concern in opium users during COVID pandemic and warrant attention.

Materials and methods

This study was designed to detect the prevalence of QTc prolongation among opium users and nonusers. Two groups were compared with regard to gender, age, and median QTc interval. Normal and prolonged QTc intervals of user group were compared with respect to age, sex, dose of opium consumption, and duration of opium consumption.

Results

123 opium users and 39 controls were investigated. Median QTc interval in opium user and non-user group was 460 vs 386 milliseconds, respectively (p value < 0.001). In all, 59.3%, (95% CI: 50.51–67.62%) of cases and none of non-user had prolonged QTc interval (p value < 0.001). There was no significance between normal and prolonged QTc intervals with respect to dose and duration of opium use.

Conclusion

This study indicated that opium consumption is associated with QTc prolongation. This prolongation does not relate to dose and duration of opium use. Further study is propounded to assess the clinical significance of these results and to determine risk rating of opium compared to other opioids in this regard.

How to cite this article

Javadi HR, Mirakbari SM, Allami A, Yazdi Z, Katebi K. Opium-associated QT Interval Prolongation: A Cross-sectional Comparative Study. Indian J Crit Care Med 2021;25(1):43–47.

A Death Case Report in an Adult Woman With COVID-19 after Septoplasty

The mortality rate of Coronavirus Decease 2019 (COVID-19) is very high, but specific situations can increase the rate including severe hypoxemia, multiple organ injury, and thromboembolic events in various organs. Another factor is the stress caused after surgery that require general anesthesia. This study aims to report a case of death in an adult woman with COVID-19 infection who had underwent septoplasty and admitted to hospital after worsening of her general condition and treated when diagnosed with COVID-19. One day after admission, she was intubated due to progressive respiratory failure and deceased following bradycardia and cardiac arrest. It seems that the elective surgery should be avoided in patients infected with COVID-19 and should be postponed until complete recovery. Moreover, the possibility of this infection should be considered in all candidates for surgery with subtle respiratory symptoms.

Changes in plasma lipid and in-hospital deaths in patients with sepsis

Background: Lipid profiles are infrequently measured in clinical management of sepsis patients. Sepsis leads to significant alterations in the metabolism of lipids. The aim of the present study was to determine whether changes in plasma lipid concentrations during sepsis treatment were associated with clinical outcome.

Methods: In this study, 74 adult septic patients were included in this prospective observational study from January to December 2017. Patients taking lipid lowering agents were excluded. A detailed medical history was obtained and clinical examination was performed. Serum total cholesterol (STC) and its fractions [low-and high-density lipoprotein] and triglyceride levels were measured in the morning of the first day after admission and then once weekly. The primary outcomes of the study were in-hospital mortality, and hospital stay and hypocholesterolemia were defined as STC levels < 50 mg/dL. Manne-Whitney U and chi-squared tests were used for data analysis, and significance level was set at p<0.05.

Results: In this study, 78.4% (CI 95%: 67.3-87.1) of patients had hypocholesterolemia. During the study period, 21.6% (CI 95%: 12.9- 32.7) of patients died. All lipid (except TG) concentrations continuously decreased in deceased sepsis patients but increased in recovering patient (p value for STC (p=0.004), LDL (p=0.006), HDL (p=0.010), and TG (p=0.052)). The serum lipids concentration was not associated with length of hospital stay (p value for STC (p=0.524), LDL (p=0.813), HDL (p=0.799) and TG (p=0.581)).

Conclusion: In this study it was found that the additional decline of lipid profile was significantly associated with increased mortality rate of sepsis patients. Thus, the clinically termed 'the lipaemia of sepsis' is not true in all situations.

Cystic Tuberculosis of Superior Lateral Part of the Left Thigh

Abstract- As dissemination of Tuberculosis (TB) to soft tissue is not a usual finding, sometimes it is not considered for differential diagnosis and, if so, is overlooked by most health care professionals. Although rare, TB should be considered in the differential diagnosis of cysts of the thigh, especially in endemic areas. We report the case of an 80-year-old female presented with cyst with purulent discharge in her lateral left thigh that was persistent to other surgical and antibiotic treatments. Polymerase chain reaction (PCR) showed positive results for TB. Anti-tubercular therapy had promising results. Our case serves to highlight the importance of considering a reactivated TB infection in individuals with chronic discharge, especially if symptoms are not classic or fail to respond to conventional therapy. Histological study and MRI are useful tools to guide diagnosis, with confirmation provided by PCR.

Long-term immunogenicity of hepatitis B vaccine and impact of a booster dose on health care

Background: Accidental exposure to sharp instruments is an important problem for health care students. Thus, the aim of this study was to determine the rate of immunity in health care students 2 decades after national neonatal hepatitis B (HB) vaccination.

Methods: All junior students attending medicine, nursing and midwifery schools were screened for anti-HBs. One dose of hepatitis B vaccine was offered to all participants who did not have antibodies to HB surface antigen (anti-HBs) of > 10 IU/L; then, they were tested for anti-HBs after a month. The participants were classified into 3 groups: postboosting nonimmune, postboosting immune, and preboosting immune. Chi square test and ANOVA were used for data analysis.

Results: In the first step, 65.20% of participants did not show immunity, but after receiving a booster dose, only 6.0% remained nonimmune. The mean age of nonimmune students was significantly higher than that of students who had postboosting immune and preboosting immune status (p=0.001 and 0.002, respectively). Also, the mean injection time from last shot was higher in postboosting immune group compared to preboosting immune group (p<0.001). Also, prebooster anti-HBs level was significantly different among participants with suboptimal response and those who developed anamnestic response, indicating preserved immune memory (p=0.001).

Conclusion: High anamnestic response to HBV booster dose indicates sufficient immunity to HBV in the majority of health care students. However, identifying students who cannot respond to a booster dose of vaccine seems to be necessary at the beginning of health care courses.

Comparison of the Effect of Two Kinds of Iranian Honey and Diphenhydramine on Nocturnal Cough and the Sleep Quality in Coughing Children and Their Parents

Coughing in a child induced by upper respiratory tract infections (URTIs) can be a problem, both for the child and its parents. Current studies show a lack of proven efficacy for over-the counter (OTC) medications, but promising data support the use of honey for children. The aim of this study was to compare the effects of two kinds of Iranian honey with diphenhydramine (DPH) on nocturnal pediatric coughs and the sleep quality of children and their parents. This was a clinical trial (registered in IRCT; No.: 28.20.7932, 15 October 2013). The study consisted of 87 patients. All the parents completed a standard previously validated questionnaire. The children were randomly assigned to one of three treatment groups: Group 1, Honey type 1 (Kimia Company, Iran) (n = 42), Group 2, Honey type 2 (Shahde-Golha, Iran) (n = 25), and Group 3, DPH (n = 20). Each group received double doses of the respective treatments on two successive nights. A second survey was then administered via a telephone interview in which the parents were asked the same questions. The mean scores for all aspects of coughs were significantly decreased in each group before and after the treatment. All three treatments improved the cough and sleep scores. Honey type 1 was superior to DPH in improving all aspects of coughs, except the frequency, and Honey type 2 was more effective than DPH in improving all aspects of coughs, except the sleep quality of the child. There was no significant difference between Honey type 1 and 2 in any aspects of cough relief in the present study. The results suggest that honey may provide better cough relief than DPH in children and improve the sleep quality of children and their parents.

Efficacy of zinc sulphate on in-hospital outcome of community-acquired pneumonia in people aged 50 years and over

SETTING

Some studies have reported a beneficial effect of zinc sulphate in children with community-acquired pneumonia (CAP).

OBJECTIVE

To evaluate the effect of adjuvant zinc therapy in adult hospitalised CAP patients aged ⩾50 years on standard antibiotic treatment.

METHODS

In a randomised double-blind placebo-controlled clinical trial, 91 hospitalised patients diagnosed with CAP using standard clinical and radiological criteria were randomised to receive 220 mg (110 mg twice daily) zinc sulphate for 4 days or placebo, in addition to antibiotics. The primary endpoint was length of hospital stay, and secondary endpoints were time to normalisation of oxygen saturation, respiratory rate and temperature. Disease severity was scored using CURB-65 (mental Confusion, Urea >20 mg/dl, Respiratory rate ⩾30/min, low Blood pressure and age ⩾65 years)

RESULTS

The results did not show significant differences in length of hospital stay, time to normalisation of respiratory rate and oxygen saturation between patients in the zinc sulphate and placebo groups (P = 0.18, 0.65 and 0.26, respectively).

CONCLUSION

A short course of zinc supplementation does not improve outcome in hospitalised patients aged ⩾50 years with CAP. In this setting, it should not be recommended as routine adjunctive treatment.

Comparison between the Outcomes of Intracoronary and Intravenous Administration of Eptifibatide during Primary Percutaneous Coronary Intervention in Patients with Acute ST-Elevation Myocardial Infarction

AIM

To compare the outcomes of intracoronary (IC) and intravenous (IV) administration of eptifibatide during primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI).

METHODS

In this prospective double-blind randomized clinical trial, 76 patients with STEMI selected for PPCI were randomly assigned in two groups to receive either IC or IV bolus of eptifibatide. The primary end point was coronary perfusion assessment by thrombolysis in myocardial infarction (TIMI) flow grade (TFG), TIMI perfusion grade (TPG), and corrected TIMI frame count (cTFC). Secondary end points were left ventricular ejection fraction (LVEF) restoration, ST-segment elevation resolution, and in-hospital major cardiovascular adverse events (MACEs) (including recurrent MI, need for target vessel revascularization (TVR), stroke, and death resulting from any cause) until discharge.

RESULTS

Assessment revealed significantly better TFG (95% CI: 1.01-10.26, OR=3.224, P=0.042), more TFG 3 (65.79% vs. 86.11% in IV and IC groups, respectively), better TPG (P=0.024), more achieved TPG 3 and TPG 2＋3 (TPG 3: 44.74% vs. 72.22% and TPG 2＋3: 78.95% vs. 94.44% in the IV and IC groups, respectively) with better cTFC in the IC group (37.33±15.84 vs. 32.53± 20.71 in the IV and IC groups, respectively; P=0.034). LVEF was better restored in the IC group (6.21±8.61% vs. 14.72±5.34% in the IV and IC groups, respectively; P＜0.001) and the ST-segment elevation resolution was better achieved in the IC administration (95% CI: -22.55 to -6.23, P=0.001). There were no recurrent MI, stroke, or need for TVR among patients during the in-hospital stay.

CONCLUSIONS

IC administration of eptifibatide during PPCI in patients with STEMI in comparison with IV administration of eptifibatide is associated with significantly better coronary reperfusion and improved clinical outcomes (IRCT2012090510751N1).

Varicella immunity in Iran: an age-stratified systematic review and meta-analysis

OBJECTIVES

To generate synthesized information on the epidemiology of VZV infection, as well as an estimation of prevalence of age-specific antibody in Iranian less than 40.

MATERIAL AND METHODS

After exclusion of irrelevant and overlapping reports, 15 papers were included (from nine major cities). Studies were pooled according to the heterogeneity test results. Random effect model methods were used for meta-analysis where significant heterogeneity was observed (age 1-16years).For other age groups, fixed model were used.

RESULTS

Significant heterogeneity was observed in prevalence rates of all childhood age-groups. The seropositivity prevalence increased steeply from the age of 1-5 to 6-10 [from 21.9% (95% CI; 10.8-33.1) to 42.1 %(95% CI; 33.6-50.6)]. At the age of 11 15, 59.4% (95% CI; 46.1-72.8) of children showed to be infected. The rate of seropositivity was more than 87% in individuals of 40 and older.

CONCLUSION

The varicella seroeprevalence in Iran is in accordance with average tropical and temperate areas. Comparison of conducted studies during 2003 to 2011 didn't show any alteration in VZV seroprovalence in Iran.

Opium dependency and in-hospital outcome of acute myocardial infarction

BACKGROUND

Impact of substance abuse on outcome of hospitalized patients with acute myocardial infarction (MI) is a frequent question. Available studies show disagreements over its impact, thus we performed this study to find a clear answer.

METHODS

In a cross sectional study, 304 patients (include 152 consecutive opium dependents and equal number of independents) with acute MI admitted to coronary care units (CCU) in Bou-Ali Sina Hospital of Qazvin University of Medical Science were enrolled. Data on demographics (e.g. age, sex and education), identified MI risk factor (smoking and diabetes), clinical findings (e.g. Killip class and in-hospital mortality), ECG findings (e.g. localization of infarction and arrhythmia), echocardiographic examinations (e.g. ejection fraction and regional wall motion abnormality) and laboratory findings (lipid profile, glycemic situation) were gathered.

RESULTS

The mean age was 63.01±12 years for opium users and 64.3± 10 for non-users. Educational level was higher in patients who used opium. No significant differences were found between opium users and non-users in rate of hypertension, diabetes mellitus, hyperlipidemia, and cigarette smoking. The mean duration of experienced chest pain in hospital stay was significantly higher in non-opium users compared to opium users (1.78± 0.63 vs.1.52±0.54) (p< 0.001). Higher Killip class and arrhythmia have been identified as the most important independent predictors of early in-hospital mortality (in both groups).

CONCLUSION

The higher Killip class and age identified as the most important independent predictors of early in-hospital mortality and addiction do not act as a major risk or protecting factor in this context. Nevertheless, we believe that a more comprehensive study with follow up of patients should be carried out for evaluation of opium addicted patients, their outcome after MI, and a better decision making for their treatment.

[Apolipoprotein E and angiotensin-converting enzyme gene polymorphisms as risk factors of coronary disease]

The objective of this study was to test the hypothesis that apo E (RFLP, HhaI) and/or angiotensin-converting enzyme (ACE) (ins16del) are associated with higher risk for coronary heart disease. We investigated 250 patients who underwent complete cardiac examination comprising coronary angioplasty and biological analysis (CT, HDLc, LDLc, TG, apo A and apo B). Prevalence of the alleles of apo E and ACE was assessed by molecular analysis. Patients without stenosis or with non-significant stenosis (> 50% of the vascular lumen) were used as reference group (141 patients). Those presenting a significant stenosis of the coronary artery (. 50% of the vascular lumen) were considered as cases (109 patients). The relative frequency of the e 4 allele was significantly higher in cases than in reference group (p > 0.02). A strong association have been found between coronary heart disease and apo E polymorphism (2 = 8.91; p > 0.05). The presence of the e 4 allele increase the risk of atherosclerosis (RR = 2.71; IC95%: 1.25-5.90; p > 0.02) compared to e 3 allele. Also, subjects with D allele were more frequent in cases than in reference group (p > 0.001). A significant association was noted between ACE polymorphism and coronary heart disease (2 = 42.15; p > 0.001). This relationship was positive (rho de Spearman = 0.39; p > 0.01). With D/D homozygotes patients, the RR for coronary heart disease was 19.10 (p > 0.001), while The RR with I/D heterozygotes was 6.91 (p > 0.001) compared to I/I homozygotes. A significant interaction have been shown up between D/D genotype and arterial hypertension (HTA) (2 de Wald = 16.10; p > 0.001). The multivariate analysis showed that the chronic smoking, diabetes, hypoapolipoproteinemia A, interactive effects between D/D and HTA, I/D and obesity, and between D/D and hypertriglyceridemia were the major significant factors to take into consideration in our population. We also note that subjects with both D and e 4 alleles were presenting a high risk to coronary heart disease (RR = 5.93; IC95%: 2.00-17.55; p > 0.01). Thus, those two alleles (4 and D) appears to be important cardiovascular risk factors in the moroccan population.

[Homocysteine, lipoprotein (a): risk factors for coronary heart disease]

Our data suggest that the hyperhomocysteinemia and/or increased plasma level of lipoprotein Lp(a) are risk factors for coronary heart disease. We investigated 178 patients who underwent complete cardiac examination comprising coronary angiography and biological analysis (CT, HDL-c, LDL-c, TG, and apoAI, apoB, homocysteine and Lp(a)). Patients presenting a significant stenosis of the coronary artery ( 50% of the vascular lumen) were considered as cases (113 patients). Those without stenosis or with non-significant stenosis (< 50% of the vascular lumen) were used as controls (65 subjects). Homocysteinemia was significantly higher in cases than in control subjects (8.26 mol/L (2.34 versus 17.85 (2.34, p < 0.001). A strong association between coronary heart disease and homocystein has been found (Eta(2) = 0.76). The OR were 0.16 when homocystein level was lower than 15 mol/L, and 27.78 when homocysteine level was upper than or equal to 15 mol/L. The RR was 5.16 (95% IC = 3.66-6.66, p < 0.001). Even though there was a significant correlation between tabagic impregnation and homocysteinemia (Spermann's rho = 0.37, p < 0.05), there was no interactive effect between these two factors and coronary disease (Wald khi2 = 0.086, p > 0.05). Therefore, no association was found between homocyteinemia and other coronary heart disease risk factors. The Lp(a) levels were significantly higher in cases than in controls subjects (188 (84 mg/L in control subjects versus 590 (199 in cases, p < 0.001). A stronger relationship was noted between coronary heart disease and Lp(a) (Eta (2) = 0.66). The OR were 0.09 when lipoprotein (a) levels were lower than 350 mg/L, and 5,88 when Lp(a) levels were higher than or equal to 350 mg/L. The estimate RR was 6.47 (95% IC = 4.39-8.55, p < 0.001). The level of Lp(a) was positively correlated with the severity of coronary heart disease (Spermann's rho = 0.95, p < 0.001). A weak correlation between Lp(a) and LDL-c was observed (Spermann's rho = 0.12, p = 0.048). But the multivariate analysis didn't show interactive effect between these two factors and coronary disease (khi2 de Wald = 0.264, p > 0.05). No association was noted between Lp(a) and the others risk factors. Moreover, a positive correlation between the levels of homocysteine and those of Lp(a) was found (Spermann's rho = 0.54, p < 0.001). In contrast their effect on coronary heart disease seems to be independant (Wald khi2 = 2.957, p > 0.05). Thus, these two parameters appear as independant risk factors for coronary heart disease.