Automated myocardial infarction and angina detection using second derivative of photoplethysmography

Photoplethysmography (PPG) based healthcare devices have gained enormous interest in the detection of cardiac abnormalities. Limited research has been implemented for myocardial infarction (MI) detection. Moreover, PPG-based detection of angina is still a research gap. PPG signals are not always informative. Therefore, this research work presents the use of PPG signals and their second derivative to evaluate myocardial infarction and angina using a novel set of morphological features. The obtained morphological features are fed onto the feed-forward artificial neural network for the identification of the type of MI and unstable angina (UA). The initial experiments have been carried out on non-ambulatory (public) subjects for feature extraction and later evaluated on ambulatory (self-generated) databases. The intended method attains accuracy, sensitivity, and specificity of 98%, 97%, 98% on the public database and 94%, 94%, 94% on the self-generated database. The result shows that the proposed set of features can detect MI and UA with significant accuracy.

Optimization of apricot (Prunus armeniaca L.) blended Aloe vera (Aloe barbadensis M.) based low-calorie beverage functionally enriched with aonla juice (Phyllanthus emblica L.)

The shift in food consumption pattern to accommodate an array of bioactive compounds in foods with minimum calorie intake has resulted in the development of many novel beverages in the last decade. In the present study, optimization of apricot (AP; 0-50%) blended Aloe vera (AV; 50-100%) based low-calorie beverage functionally enriched with aonla juice (AJ; 3,5,7,10%) using steviol glycoside (SG; 0-100%) was performed. The preliminary screening suggested that 40% addition of AP (AV-AP; 60:40) had an acceptable taste. While, for functional enrichment of squash, incorporation of 7% AJ with 40ºB TSS was optimized based on color, consistency, taste, and overall acceptability scores. The developed squash had higher ascorbic acid (26.83 mg/100 g), total phenols (68.77 mg/100 g), antioxidant potential (36.50%) and antimicrobial activity against Staphylococcus aureus (18.00 mm). The aloin content was recorded 0.9 ppm, well within the maximum permissible limits. Additionally, replacement of sucrose with stevioside up to 50 per cent resulted in equi-sweetness level without characteristic bitter aftertaste and a significant reduction in energy value from 142 kcal/100 g to 85.26 kcal/100 g. The developed beverage recorded a high amount of functional compounds with reduced energy values. The beverage can be a recommendation for general consumption for health- conscious people to cover their functional food desires.

Accuracy of global longitudinal and territorial longitudinal strain in determining myocardial viability in out of window period Anterior wall myocardial infarction patients

Funding Acknowledgements

Type of funding sources: None.

Background

Primary percutaneous intervention remains the principal treatment modality for anterior wall myocardial infarction (AWMI). However, a large fraction of patients especially in the developing countries present outside the window period (OWP) with no chest pain and akinetic left anterior descending (LAD) territory on echocardiography. Revascularization in these patients is primarily guided by viability status.

Purpose

This study was conducted to determine the accuracy of strain echocardiographic parameters compared to single-photon emission computed tomography (SPECT) in predicting myocardial viability in patients of AWMI presenting OWP.

Methods

All patients presenting with AWMI-OWP without ongoing chest pain and akinetic LAD territory on echocardiography from December 2020 to June 2021 were recruited. All patients underwent determination of both Global longitudinal strain (GLS) and territorial longitudinal strain (TLS) within 24-72 hours on AWMI. In addition, all underwent SPECT to determine the percentage of non-viable myocardium. On SPECT, a defect >5% myocardial territory showing severe reperfusion defect was considered as a marker of non-viability. 

Results

A total of 27 patients were recruited. The mean age of the population was 61.66 + 12.6 years. Acute left ventricular failure (LVF) and cardiogenic shock (CS) was present in 6 (22.2%) and 5 (18.5%) patients respectively. Out of 22 patients who underwent angiography, majority of the patients 19 (86%) had single vessel disease involving the LAD.

The mean left ventricular ejection fraction (LVEF) of the study group was 29.6 + 6.5%. The mean GLS and LAD territory TLS of the study group was -11.13 + 3.14% and -7.2 + 2.75% respectively. On SPECT, 8 (29.6%) patients had non-viable underlying myocardium.

Parameters that very significantly associated with non-viability on SPECT included past history of CAD (p = 0.004), smoking (p = 0.05) and presentation with LVF (p = 0.0008) and CS (p = 0.001).

The mean LVEF was significantly lower in the group with non-viability on SPECT (32.3 + 5.1% vs 23.1 + 4.5%; p < 0.001). Both GLS (-12.8 + 1.4% vs -7.1+ 2.3%; p < 0.001) and TLS (-8.7 + 1.4% vs -3.8 + 1.8%; p < 0.001) were significantly lower in group showing non-viability on SPECT.

On receiver operating curves, a GLS of > -10.45% and TLS of > -6.65%, both had a sensitivity of 87.5% and specificity of 89.5% in predicting non-viability on SPECT. Both showed good accuracy in predicting non-viability on overall quality model. (Figures 1 and 2)

Conclusion

Modalities like cardiac magnetic resonance, SPECT or positron emission tomography are resource dependent and take time to be performed. Hence, performing these investigations is challenging in unstable patients. Strain echocardiography provides GLS of the myocardium which has good sensitivity and specificity in predicting viability and can be performed safely and quickly in this high-risk group. Abstract Figure.  Abstract Figure. Overall quality model

Angiographic Profiles in Persistent Non-Valvular Atrial Fibrillation Patients

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Cardiology dept. PGIMER, Chandigarh

Background

The relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established. Atrial ischemia due to obstructive CAD has been identified as one of the key risk factors, leading to AF. However, sufficient evidence exists as to the presence of myocardial ischemia on stress imaging, even without the presence of obstructive CAD in AF patients. Slow flow and coronary tortuosity on angiogram can lead to downstream myocardial ischemia independent of CAD. 

Purpose

We aimed to delineate the angiographic profiles in AF patients with attention to slow flow and tortuosity leading to ischemia in those without obstructive CAD. 

Methods

The study was a nonrandomised, prospective, single-centre observational study of consecutive patients of persistent non valvular AF. Symptomatic patients despite optimal medical therapy (OMT) for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with known CAD or prior history of myocardial infarction were excluded. Further angiographic analysis was done in those without obstructive CAD to determine incidence of slow flow (>27 corrected TIMI frame count) and tortuosity (presence of ≥3 fixed bends in an epicardial artery). 

Results

A total of 70 patients were recruited and followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49). Hypertension (74%) was the commonest comorbidity followed by obesity (35%) and diabetes (30%). At CAG, 32/70 (46%) had obstructive CAD, 17/70 (24%) had non obstructive (<50-70% stenosis) CAD and 21/70 (30%) had normal coronaries without atherosclerosis. Amongst patients without obstructive CAD (n = 38) slow flow was seen in 16/38 (42%) and coronary tortuosity in 11/38 (29%) patients. There ware no differences in terms of death, HF and FVR hospitalisations or stroke at follow up between the obstructive CAD vs no obstructive CAD. However in patients without obstructive CAD, hospitalisations for FVR was significantly increased in those having slow flow on CAG, 9/12 (75%) vs 7/26 (27%) in those without slow flow (p value = 0.005). The mean TIMI frame count was also significantly higher in those with FVR hospitalisations 35.3 ± 11 vs 25.8 ± 8.9  (p value = 0.005). TIMI frame count >31 had a sensitivity of 83% and a specificity of 69% for predicting hospitalisations for FVR on ROC curve(AUC = 0.71). 

Conclusions

CAD is closely related to AF and majority (70%) of our patients had evidence of atherosclerotic CAD on CAG in our study. A large proportion of patients with no evidence of obstructive CAD on CAG had slow flow or coronary tortuosity. Significantly increased hospitalisation for FVR seen in the slow flow group shows its significance and may lead to newer treatment modalities in future. Further larger studies looking at these aspects on CAG may give further insight as to the nature and prognosis of these entities. Abstract Figure 1: Flow diagram showing the patie

Observational study of Covid-19 patients presenting with acute coronary syndrome at a tertiary care center in India

Aim

Patients with Covid-19 are theoretically at a higher risk of ACS, as respiratory infections can often lead to coronary endothelial damage and plaque rupture. Initial reports during start of pandemic suggested decrease in STEMI patients, however this has been explained by iatrophobia rather than actual decrease. Data on pathophysiology and outcome of patients presenting with ACS is scarce. We did a prospective observational study to study epidemiology and outcomes of Covid-19 patients with ACS.

Methods

A total of 654 patients were admitted with Covid-19 at PGIMER, Chandigarh from August 2020 to February 2021, 35 (5.3%) consecutive patients of ACS were enrolled into the study. Acute myocardial infarction was defined as per fourth universal definition of myocardial infarction. Diagnosis of Covid-19 was established using RT-PCR from nasopharyngeal swab. Angiographic assessment was done by two interventional cardiologists.

Results

Mean age of patients was 59.5±11.8 years, males comprised majority (80%) of study group. Most common risk factor was hypertension seen in around 70% followed by DM in 57% patients. Most common symptom at presentation was rest angina seen >90% while history of fever was present in only 31.4%. STEMI was most common ACS seen in 45.7% followed by USA in 23% patients. CS was present in 15% patients at presentation while another 5% developed shock in hospital. Oxygen requirement was required in over half the patients while 25% patients succumbed to illness in hospital.Thrombolysis was done in half the patients of STEMI. In view of Covid-19 disease 71.4% required dexamethasone and remdesivir. Coronary angiography was done in around 20% patients, which revealed obstructive CAD in 83% patients with 60% patients having 100% occlusion of IRA. Percutaneous intervention was done in 66% patients. Hypoalbuminemia was commonly seen patients with mean albumin of 3.3 gm/dL. Low T3 syndrome was most common thyroid function abnormality seen in 37.1%.On univariate analysis age, BNP levels and albumin were able to predict 30-day mortality.

Conclusion

ACS can be first presentation of patients with Covid-19 as shown by our study only 30% patients had prior history of fever. Our data reaffirms that patients with Covid-19 and ACS have worse prognosis. Interestingly mortality in our study was comparable to western study, despite low rate of angiography and intervention thus underscoring individualization of therapy. We believe Type-2 myocardial infarction is common in pathophysiology of patients who benefit most from medical therapy.

Funding Acknowledgement

Type of funding sources: None.

Cryopreservation of a threatened medicinal plant, Valeriana jatamansi Jones, using vitrification and assessment of biosynthetic stability of regenerants

BACKGROUND

Valeriana jatamansi Jones is a medicinal plant of the Himalayan region with high trade value. Since overexploitation of this wild species led it to be listed as threatened, a comprehensive conservation strategy is needed. Cryopreservation would be a useful complementary method to conventional conservation methods.

OBJECTIVE

To develop a cryopreservation protocol for V. jatamansi with maintenance of biosynthetic stability of regenerants.

MATERIALS AND METHODS

In vitro shoot tips were cryopreserved using vitrification with either PVS2 or PVS3 and the efficacy of the two cryoprotectant mixtures compared. Regenerated plantlets were evaluated by HPLC analysis for contents of four valepotriates viz. valtrate, acevaltrate, didrovaltrate and IVHD valtrate.

RESULTS

The highest shoot recovery (91.6%) after transfer to liquid nitrogen was obtained when shoot tips were treated with PVS2 at 0°C for 110 min, which was significantly higher than the highest recovery (73.3%) obtained using PVS3 for any duration tested. Evaluation of biosynthetic stability showed no variation in valepotriate contents between in vitro maintained and cryopreserved derived plantlets.

CONCLUSION

This protocol will be useful for the long-term conservation of this species as high frequency recovery and biosynthetic stability after cryopreservation were obtained.

Angiographic profiles in patients of persistent non-valvular atrial fibrillation from a tertiary care center in north india

Funding Acknowledgements

Type of funding sources: None.

Background

The relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established. Atrial ischemia due to obstructive CAD has been identified as one of the key risk factors, leading to AF. However, sufficient evidence exists as to the presence of myocardial ischemia on stress imaging, even without the presence of obstructive CAD in AF patients. Slow flow and coronary tortuosity on angiogram can lead to downstream myocardial ischemia independent of CAD.

Purpose

We aimed to delineate the angiographic profiles in AF patients with attention to slow flow and tortuosity leading to ischemia in those without obstructive CAD.

Methods

The study was a nonrandomised, prospective, single-centre observational study of consecutive patients of persistent non valvular AF. Symptomatic patients despite optimal medical therapy (OMT) for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with known CAD or prior history of myocardial infarction were excluded. Further angiographic analysis was done in those without obstructive CAD to determine incidence of slow flow (>27 corrected TIMI frame count) and tortuosity (presence of ≥3 fixed bends in an epicardial artery).

Results

A total of 70 patients were recruited and followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49). Hypertension (74%) was the commonest comorbidity followed by obesity (35%) and diabetes (30%). At CAG, 32/70 (45%) had obstructive CAD, 17/70 (24%) had non obstructive (<50-70% stenosis) CAD and 21/70 (30%) had normal coronaries without atherosclerosis. Amongst patients without obstructive CAD (n = 38) slow flow was seen in 16/38 (42%) and coronary tortuosity in 11/38 (29%) patients. There ware no differences in terms of death, HF and FVR hospitalisations or stroke at follow up between the obstructive CAD vs no obstructive CAD. However in patients without obstructive CAD, hospitalisations for FVR was significantly increased in those having slow flow on CAG, 9/12 (75%) vs 7/26 (27%) in those without slow flow (p value = 0.005). The mean TIMI frame count was also significantly higher in those with FVR hospitalisations 35.3 ± 11 vs 25.8 ± 8.9  (p value = 0.005). TIMI frame count >31 had a sensitivity of 83% and a specificity of 69% for predicting hospitalisations for FVR on ROC curve(AUC = 0.71).

Conclusions

CAD is closely related to AF and majority (70%) of our patients had evidence of atherosclerotic CAD on CAG in our study. A large proportion of patients with no evidence of obstructive CAD on CAG had slow flow or coronary tortuosity. Significantly increased hospitalisation for FVR seen in the slow flow group shows its significance and may lead to newer treatment modalities in future. Further larger studies looking at these aspects on CAG may give further insight as to the nature and prognosis of these entities.

Mycoflora and natural aflatoxin contamination in dried quince seeds from Jammu, India

Eighty two samples of dried quince seeds, obtained from the markets of Jammu province, were examined for mycoflora by different isolation techniques. A total of 27 fungal species belonging to 11 genera were recovered and identified from these samples. The predominant fungal genera encountered were Aspergillus, Penicillium and Fusarium. In view of the predominance of Aspergillus flavus, a known producer of aflatoxins, screening of the fungal contaminated samples was carried out for total aflatoxin levels using high performance liquid chromatography (HPLC). Twenty one aflatoxin positive samples contained 8.07-33.45 μg g(-1) and 0.05-3946.97 μg g(-1) AFB1 and AFB2 respectively. These results suggest that biochemical composition of dried quince seeds, along with climatic conditions of the region seem to be very favourable for aflatoxin production by toxigenic strains of A. flavus. Therefore, monitoring of aflatoxins in dried quince seeds is recommended for this region.

Effect of summer pruning and CPPU on yield and quality of kiwi fruit (Actinidia deliciosa)

A field experiment was conducted on bearing vines of kiwifruit cv. Abbott to find the effect of CPPU (N-(2- chloro-4-pyridyl)-N-phenylurea) and summer pruning on fruit yield, fruit size and quality. CPPU greatly stimulated fruit growth indicating that it can be a powerful tool for improving kiwifruit cropping. Application of CPPU at 10 ppm concentration was done by dipping the fruits for 10 sec in the aqueous solution of compound at petal fall and 30 days after petal fall. CPPU applied fruits increased size by 20-70 g over control. Summer pruning along with CPPU application proved to be more effective in obtaining fruits of high grades with increased fruit weight (95.37 g fruit(-1)) and high quality. Summer pruning, when done by pinching 1/5th at Petal Fall stage + CPPU dipping (10 ml(-1)) and pinching 1/5th continued till harvest, at one month interval resulted in increased fruit yield (54.80 kg vine(-1)), high TSS (17.60 Brix), high total sugar (9.85%), advanced ripening by one week and reduced flesh firmness.

Epidemiology of group A streptococcal pharyngitis & impetigo: a cross-sectional & follow up study in a rural community of northern India

BACKGROUND & OBJECTIVE

Group A streptococcus (GAS) causes a wide array of human diseases. Epidemiological picture of streptococcal infection in India is not complete. Hence, disease burden due to GAS in 5-15 yr old school children in northern India was studied and emm typing of GAS isolates was carried out to help in designing prevention strategies.

METHODS

A cross-sectional survey was carried out among 4249 school children (5-15 yr) from Raipur Rani Block of Panchkula district in Haryana during 2000-2002; 334 children were followed up fortnightly for one year. Standard clinical and microbiological procedures were used for collection of swabs from throat and skin and confirmation of GAS and its emm types.

RESULTS

Of the 4249 children studied, 658 (15.5%) had pharyngitis; 579 of them could be swabbed, of which 2.8 per cent had GAS. From 3591 children without pharyngitis, 3385 who could be swabbed, GAS was found in 1.3 per cent of them. Impetigo was rare (0.7%), but 7.1 per cent (2/28) children had GAS. In the followup study, 17.4 per cent (776/4447 child-contacts) had pharyngitis, 761 could be swabbed and 2.4 per cent had GAS; among those without pharyngitis, 2016 swabs could be taken and GAS was found in 1.3 per cent; whereas only 2.6 per cent (2/75) of skin sores had GAS. Three children had GAS pharyngitis twice during follow up. Fourteen different GAS emm types were found. emm 71, 77 and 81 constituted 69 per cent of the pharyngeal isolates. GAS pharyngitis and impetigo were more common in winters and summers respectively.

INTERPRETATION & CONCLUSION

In north India, pharyngitis was more common than impetigo. Most prevalent emm types of GAS in this region differ from those included in M protein-based vaccines.

Emergence of Virulence to Sr25 of Puccinia graminis f. sp. tritici on Wheat in India

Stem (black) rust, caused by Puccinia graminis Pers. f. sp. tritici Eriks. & Henn., is one of the most destructive diseases of wheat. It could be controlled through introgression of race-specific resistance genes. However, such kind of resistance is mostly short lived due to emergence of new virulences. For example, resistance genes Sr11, Sr24, Sr30, and Sr31 are no longer effective (2,4). Detection of new virulences has remained vital in the evaluation and identification of new sources of resistance. We report here the detection of virulence to Sr25, a gene from Thinopyrum elongatum (4), which had been effective or partially effective against stem rust worldwide, including race Ug99 (TTKSK) (4). A stem rust isolate collected in 2006 from Karnataka (southern India) produced susceptible reactions (infection type [IT] 3+ to 4) on the primary leaves of differential genotype 'Agatha' carrying Sr25 and susceptible check 'Agra Local' at 22 ± 2°C. To verify virulence to Sr25, single-pustule isolates from this sample were inoculated onto seedlings of 'Agrus', 'Agatha', 'RL6040' ('Thatcher' + Sr25), 'Superseri#1', 'Wheatear', and 'Morocco' + Sr25 (obtained from CIMMYT), which all carry Sr25. All these accessions were found susceptible (IT 3+ to 4) to this isolate, except Wheatear which expressed resistance (IT ;1), indicating the presence of additional gene(s). These genotypes are resistant (ITs ;1 to 2+) to Sr25-avirulent pathotypes. The new pathotype is avirulent to Sr11, 13, 14, 21, 22, 23, 24, 26, 27, 29, 31, 32, 33, 35, 37, 38, 39, 40, 43, and Tmp and virulent to Sr5, 6, 7a, 7b, 8a, 9a, 9b, 9d, 9e, 9f, 9g, 10, 12, 15, 16, 17, 18, 19, 20, 25, 28, 30, 34, 36, 42, Wld-1, and Gt at 22 ± 2°C. This pathotype has been designated as 58G13-3 and PKTSC according to the Indian nomenclature (1) and the North American system (3), respectively. It represents race 40 based on Stakman's differentials. It may have arisen from race 40 through mutation. The type culture of the pathotype has been added to the culture collection at Flowerdale, Shimla. Interestingly, 'Festiguay' (Sr30) was found resistant to this pathotype, indicating the presence of additional gene(s), whereas 'Webster' (Sr30) was susceptible. Adult plants of Agrus, Agatha, RL6040, Superseri#1, and Morocco+Sr25 also were susceptible, producing 20S to 60S responses. Sr25-avirulent pathotype 62G29 produced a TR (flecking in traces) response on these lines except Morocco + Sr25 that showed 20 to 40MR (moderately resistant) responses. In the same study however, adult plants of Thatcher showed a resistant reaction (10R to MR) at low (16 ± 2°C) and susceptible (20S) at high (22 ± 2°C) temperatures. Agatha and RL6040, having Thatcher as one of the parents, had similar responses. The detection of Sr25 virulence is significant since Sr25 is an important gene to be targeted for breeding wheat cultivars resistant to Ug99. We should use either adult plant resistance and/or pyramiding two or more genes for seedling resistance to enhance the field life of wheat cultivars. References: (1) P. Bahadur et al. Proc. Indian Acad. Sci. 95:29, 1985. (2) S. C. Bhardwaj et al. J. Wheat Res. 1:51, 2007. (3) Y. Jin et al. Plant Dis. 92:923, 2008. (4) R. P. Singh et al. CAB Rev. No. 054:1, 2006.

Evaluation of the ability of clinical research participants to comprehend informed consent form

BACKGROUND

The comprehension of informed consent is an integral part of clinical trials. Though India is rapidly becoming a hub of clinical trials very few studies have dealt with the issue of comprehension of informed consent by the patients participating in these trials.

METHODS

Patients who were invited to participate in a phase 3 multicentric trial of a novel lipid lowering agent were evaluated for comprehension score. The participants were explained about the structured consent form which included the question on background details for the study, design of the study, rights of the patients and miscellaneous aspects pertinent to the clinical trial. The questionnaire comprised of 24 items and each correct answer was assigned a score of 1. Total comprehension score (CS) was obtained by summing all the scores.

RESULTS

Participants were from diverse socio economic and educational backgrounds. The mean +/- SD CS achieved by the participants was 13.4 +/- 2.9; median 14(6 to 20). The highest correct responses were obtained for questions on background details (38%). For most of the categories the mean CS was more than 50%. Aspects related to design were mostly difficult to comprehend. No significant difference in the CS was noted between participants from different educational and socioeconomic groups. 8 patients refused to give consent, fear of adverse drug reactions (n = 3) and inability to follow up (n = 5) were the reasons cited by the patients.

CONCLUSION

In conclusion, CS of patients in trials conducted in developing countries can be reasonably good if the investigators explain the consent form in simple language to the participants and CS is not related to the educational status of the participants. Moreover, though a larger majority of patients agree to participate after knowing study details, some patients exercise their right to refuse.

Association of anticardiolipin antibodies levels with instent restenosis in patients with coronary artery disease

Present study was conducted to evaluate the association of IgG anticardiolipin antibodies with instent restenosis in patients having undergone percutaneous intervention with bare metal or drug eluting stents. Coronary artery disease patients with stent placement at least 6 months prior were screened for eligibility. 26 satisfied the inclusion/exclusion criteria. 10 patients with symptoms of restenosis, confirmed on check angiography served as cases and 16 without symptoms of restenosis served as control. Unpaired t- test was applied to ascertain the significance of any difference between control and study groups. Antibody levels were estimated on ELISA reader. The mean (+/- SD) anticardiolipin antibodies levels in cases and controls were 11.8 +/- 5.1 GPL/U/ml and 14.3 +/- 10.2 GPL/U/ml, respectively. The difference was not statistically significant (P > 0.05). In conclusion, we did not observe any significant correlation between the level of IgG aCL and instent restenosis.

Relapsing polychondritis in North India: a report of 10 patients

OBJECTIVE

Relapsing polychondritis (RP) is a rare autoimmune disorder characterized by recurrent episodes of inflammation and destruction of cartilaginous tissues. We describe the outcome of 10 patients followed up at the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, over the past 10 years.

METHODS

All the patients fulfilling the diagnostic criteria suggested by McAdam et al (Medicine (Baltimore) 1976;55:193-215) and modified by Damiani and Levine (Laryngoscope 1979;89;929-46) were included in the study. Detailed clinical features, investigations, treatment given, and outcome were recorded on file.

RESULTS

Six women and four men, mean age 48.1 years (range 26-65 years), met the criteria for diagnosis. The mean duration of symptoms, before diagnosis, was 27 months (range 1-72 months). Clinical features included auricular chondritis (100%), arthritis (80%), fever (50%), constitutional symptoms (50%), eye involvement (50%), hearing loss (40%), collapsed bridge of nose (30%), laryngotracheal involvement (20%), aortic dilatation (10%), and nephrotic syndrome (10%). Two patients had the MAGIC (mouth and genital ulcers with inflamed cartilage) syndrome. The number of episodes of cartilaginous inflammation varied from one to eight. Treatment included oral prednisolone (n = 9), intermittent 'pulse' cyclophosphamide (n = 2), and azathioprine (n = 2). One patient required tracheostomy and died later. The others are doing well. Mean duration of follow-up was 35.5 months (range 1-79 months).

CONCLUSIONS

The diagnosis of this potentially lethal condition is frequently delayed. Our series suggests that clinical manifestations of RP are similar in Caucasian, Oriental, and Asian populations. Laryngotracheal involvement was seen less frequently in our patients.

Re-use of explanted DDD pacemakers as VDD- clinical utility and cost effectiveness

Re-use of DDD pulse generators explanted from patients died of unrelated causes is associated with an additional cost of two transvenous leads if implanted as DDD itself, and high rate of infection according to some studies. We studied the clinical and economical aspects of reutilization of explanted DDD pacemakers programmed to VDD mode. Out of 28 patients who received VDD pacemaker during the period, October 2000- September 2001 in the Department of Cardiology, PGIMER, Chandigarh, 5 poor patients were implanted with explanted DDD pulse generators programmed to VDD mode. Each implantation was planned and carried out according to a standard protocol. The age ranged from 45 to 75 (mean-61) years. The indications for pacing were complete heart block (4) and second degree AV block (1). The clinical profile, costs and complications, if any were noted and followed up at regular intervals. The results were compared with patients who received new DDD pulse generators during this period. The additional cost for the atrial lead was not required in these patients. None of these patients had any local site infection. Compared to the two-lead system, the single lead system provided more rapid implantation and minimized complications associated with placement of an atrial lead. The explanted DDD pacemaker can be safely reused as VDD mode with same efficacy in selected patient population. This is associated with lower cost and complications compared to reimplantation as DDD itself.

Effect of different aspirin doses on platelet aggregation in patients with stable coronary artery disease

BACKGROUND

Aspirin is widely used as an antiplatelet agent in the primary and secondary prevention of cardiovascular disease. In order to spare prostacyclin formation and reduce gastrointestinal side-effects, very low doses of aspirin have been introduced. However, it remains unclear whether these low doses are equally effective with respect to inhibition of platelet aggregation.

AIMS

In a randomized, controlled study in 60 patients with stable coronary artery disease, the effects on platelet aggregation of five doses (50, 80, 100, 162.5 and 325 mg) of aspirin, which are widely used in clinical practice, given for 70 days, were investigated. Two reagents, adenosine diphosphate (ADP) and epinephrine, were used to induce platelet aggregation in platelet-rich plasma. An age- and sex-matched group of people without coronary artery disease served as the control.

RESULTS

ADP- and epinephrine-induced platelet aggregation was 78.2 +/- 12.8% and 76.7 +/- 15.5% of maximum aggregation in the control group. Aspirin inhibited platelet aggregation in a dose-dependent manner. Minimum platelet aggregation was observed at a dose of 325 mg aspirin (27.5 +/- 17.4% with ADP). Doses of 50 and 80 mg aspirin were much less effective in inhibiting platelet aggregation (59.1 +/- 11.4% and 50.3 +/- 12.1% with ADP, respectively). Doses of 100 and 162.5 mg aspirin produced significantly greater inhibition of platelet aggregation than lower doses (36.2 +/- 11.7% and 38.5 +/- 19.8% platelet aggregation with ADP, respectively).

CONCLUSION

Our results demonstrate that doses of aspirin less than 100 mg are not as effective at inhibiting platelet aggregation as doses greater than 100 mg.

A cardiac evoked response algorithm providing automatic threshold tracking for continuous capture verification: a single-center prospective study

BACKGROUND

The AutoCapture algorithm as implemented in Regency and Microny pacemakers (Pacesetter Inc., Sylmar, CA, USA) provides beat-by-beat monitoring of capture based on proper detection of the evoked response, provides high output back-up pulse when loss of capture occurs, performs periodic threshold evaluations and acquires the capture threshold data in a time-based event counter for later retrieval. The safety and efficacy of this algorithm was prospectively evaluated at a tertiary care hospital of north India.

METHODS AND RESULTS

Fifty-four patients (38 males, mean age 66+/-13 years) received a ventricular pacemaker model Regency SC+ with low polarization bipolar lead for high-grade atrioventricular block (n=42) and sick sinus syndrome (n=12). Evoked response and polarization signal were assessed initially at 24 hours postimplant, and follow-up measurements were systematically conducted at week 1 and months 1, 3 and 6. Further evaluation of eligible patients was performed at 6-monthly intervals. Lead implantation parameters were optimum in all patients. At 6 months, the algorithm was functional in 51 patients. The pacing threshold increased to 0.89+/-0.36 V (p<0.001) in the first month and stabilized thereafter. Significant saving of energy was accomplished by a constant output safety margin of 0.3 V instead of the traditional 100%. While the evoked response signal remained stable throughout the study period, the potential signal increased significantly from 0.6+/-0.7 mV to 1.0+/-0.6 mV (p<0.001) in the first month and remained steady subsequently. Back-up pacing in the event of exit block was confirmed in all 25 patients who underwent a 24-hour Holter test. Based on the suggested sense margins, ventricular undersensing was observed in 7 (28%) patients, the majority of whom had competitive cardiac rhythms. An elderly patient with pneumonic illness succumbed to pulmonary embolism at 6 months.

CONCLUSIONS

This large single-center experience on AutoCapture demonstrates the success of this algorithm in low-energy ventricular pacing without compromising the patient's safety.

A meta-analysis of controlled clinical trials comparing low-molecular weight heparins with unfractionated heparin in unstable angina

BACKGROUND

Unfractionated heparin has been used extensively for the treatment of unstable angina/non-Q wave myocardial infarction but it has several disadvantages. Low-molecular weight heparins are now recommended although they are 3-5 times costlier than unfractionated heparin since they are convinient to administer and do not require activated thromboplastin time monitoring. Whereas enoxaparin, a low-molecular weight heparin, has been demonstrated to be superior to unfractionated heparin, the results of other low-molecular weight heparins have not been so convincing.

METHOD AND RESULTS

Through manual, MEDLINE and EMBASE search, we identified five randomized trials (excluding enoxaparin trials) that compared low-molecular weight heparins with unfractionated heparin in unstable angina. The prespecified efficacy end point of interest included a composite of death, myocardial infarction, recurrent angina and urgent revascularization. The safety end point was taken as a composite of major hemorrhage, minor hemorrhage, thrombocytopenia, allergic reaction and any other adverse event. We calculated odds ratio (95% confidence interval) for each trial for the composite end point, and the pooled odds ratio (95%) confidence interval) was calculated using two established methods of meta-analysis, the Mantel-Haenszel-Peto method and the DerSirmonian-Laird method. Both the methods yielded similar odds ratio (95% confidence interval). Separate odds ratio were calculated for efficacy and safety end points. There was a nonsignificant reduction in the incidence of the composite efficacy end point: the odds ratio (95% confidence interval) was 0.83 (0.70-0.99: p=0.08). The odds ratio (95% confidence interval) for the safety data was 0.78 (0.69-1.26: p=0.33).

CONCLUSIONS

No statistically significant difference was observed when the efficacy and safety of low-molecular weight heparins were compared with those of unfractionated heparin. A cost-effectiveness analysis of low-molecular weight heparins versus unfractionated heparin must be done urgently to establish more firmly the place of low-molecular weight heparins in the management of unstable angina.

A randomized trial to compare the efficacy, safety, cost and platelet aggregation effects of enoxaparin and unfractionated heparin (the ESCAPEU trial)

OBJECTIVE

To compare the efficacy, safety, cost and effects on platelet aggregation of unfractionated heparin and low-molecular weight heparin in unstable angina patients.

PATIENTS AND METHODS

Ninety-three patients with unstable angina were randomized to receive either unfractionated heparin (UFH) or enoxaparin in an open design clinical trial with blinded end point evaluation. The effects of the heparins on platelet aggregation were also compared.

RESULTS

The composite end point of myocardial infarction, cardiac death, recurrent angina and need for intervention was observed in 62% of patients treated with UFH and in 37% of patients treated with enoxaparin (RR 1.7, 95% CI 0.75 to 3.71, p = 0.04). There was no difference in the frequency or severity of adverse events. A cost-effectiveness analysis showed both the heparins to be similar. Platelet aggregation was inhibited to a greater extent by UFH when compared to enoxaparin.

CONCLUSIONS

Enoxaparin appears to be superior in efficacy to UFH and similar to UFH in safety. No difference in costs was detected in this study. The greater inhibition of platelet aggregation observed in the case of UFH compared to enoxaparin indicates that there may be more bleeding complications with UFH.

Incidence of aflatoxin producing strains and aflatoxin contamination in dry fruit slices of quinces (Cydonia oblonga Mill.) from the Indian state of Jammu and Kashmir

An investigation was undertaken to obtain data on the occurrence of aflatoxins and the aflatoxin producing potential of Aspergillus flavus strains isolated from dry fruit slices of quinces produced in jammu and Kashmir, India. A total of 147 A. flavus isolates recovered from dr fruit slices were grown in liquid rice flour medium and screened for the production of various aflatoxins by thin layer chromatography. The results showed that 23.14% of the tested isolates were aflatoxigenic, producing aflatoxins B1 and B2 in varying amounts. Aflatoxins G1 and G2 were not detected. All 25 of the investigated market samples were also found to be aflatoxin B1 positive and the level of contamination ranged from 96 to 8164 micrograms/kg of the dry fruit which is quite high in comparison to the permissible level of 30 ppb. As per these results biochemical composition of dry fruit slices of quinces, along with climatic conditions seem to be very favourable for aflatoxin production by the toxigenic A. flavus strains. Therefore, monitoring of aflatoxins in dry fruit slices of quinces is recommended for this region.

Absenteeism among group-D employers

A study of absenteeism and man days lost in one hundred employees belonging to group "D" in a hospital at Jammu was conducted to explore the magnitude of problem of absenteeism and its remedy was sought. The study included the study of staffing pattern of the hospital, total group "D" employees, their jobs and work load and their attitudes, commencing from Sept. 1992 to Aug. 1995. Information regarding man days lost and man days schedule to work as records available in the hospital was used to calculate the trend, variations and fluctuations in absenteeism. For the purpose of calculations of absenteeism, nature of absence was divided into various headings like casual leave, sick leave, earned leave etc. A questionnaire was prepared and given to each employee and a detailed insight was sought with respect to his personality, social factors like accommodation, religious ceremonies, individual habits like drinking, gambling, job dissatisfaction and finally from the whole data absence rate, frequency rate and severity rate were calculated. From the observations it was concluded that absenteeism was more in females, in the age group of 33-45 years, married, in the months of Sept. to Nov. on Mondays and Saturdays and in Hindu backward classes. Though it seemed unreliable but all the employee opined that they were in harmony with their bosses and seemed satisfied with their jobs.

Monitoring ovarian cyclicity in postpartum Murrah buffalo through milk progesterone enzyme immunoassay

Milk samples were collected from Murrah buffalo between Day 30 and Day 120 post partum and analysed for progesterone concentration to monitor ovarian cyclicity. Progesterone levels were low (1 to 5 ng/ml) during the anestrous period. Levels were also low around estrus, but they began to increase at Day 6 postestrus; high levels (15 to 32 ng/ml) were maintained for different periods. There was a marked drop in progesterone level after Day 16 to 18 of the estrous cycle in those animals which returned to estrus. Progesterone levels remained high in buffalo which did not return to estrus, indicating that these animals were pregnant. Some of the progesterone cycles were not associated with the expression of estrus. This study indicated that a milk progesterone enzymoimmunoassay can be used to detect early pregnancy as well as conditions such as silent estrus and anovulatory estrus; it can thus help reduce the long intercalving period in buffalo.