Blood pressure variability in hypertension patients in Indian clinical settings

Funding Acknowledgements

Type of funding sources: None.

Background

 Blood pressure variability (BPV) is a potential predictor for complications such as coronary artery disease, heart failure, stroke, and all-cause death, independently of mean blood pressure (BP) in patients with hypertension.(1)

Objective

 The survey was carried out to seek the opinion of Indian clinicians on the burden, measurement  and management of BPV in patients with hypertension.

Method

 This PAN-India survey used a structured web-based objective questionnaire that was administered to 200 clinicians via google forms. The responses were analyzed descriptively.

Results

 This study suggests that >80% of the clinicians reported that 10-40% of their hypertensive patients experience BPV while 13% and 6.5% respectively, reported having BPV issues in <10% and >40% of their patients.

A large majority of the clinicians (88.5%) agreed that effective control of BPV in hypertensive patients exerts benefits to prevent complications like target organ damage, cardiovascular disease and mortality.

A combination of home and office BP monitoring was the most recommended approach for the measurement of BPV by 28% of the clinicians, followed by home monitoring (23%) > ambulatory monitoring (22.5%) > combination of ambulatory and office monitoring (21%) > office monitoring (4.5%) of BP. A majority of clinicians opted for angiotensin receptor blocker (ARB) + calcium channel blocker (CCB), ARB + beta blocker (BB) and ARB + diuretic as most preferred antihypertensive combination for effective control of BP and BPV (Figure 1). In particular, the clinicians opined for Telmisartan + Amlodipine (45.5%) > Telmisartan + Chorthalidone (27%) > Telmisartan + Cilnidipine (14%) > Telmisartan + Hydrochlorothiazide (13%) as the preferred antihypertensive combinations.

41% and 30.5% of the clinicians reported that they would shift their patients with high BPV to a dual and a triple combination of antihypertensives, respectively followed by increasing the antihypertensive dose (18%) and shifting to new antihypertensive medication (8.5%).

Conclusion

 The survey underlined the considerable prevalence of BPV in hypertensive individuals and that its control can be beneficial in reducing the risk of future complications. The study also reflects that both home and office BP monitoring are important to identify BPV while ARBs particularly, Telmisartan in combination with CCB or a diuretic is the preferred regimen for effective control of BP and BPV. Abstract Figure 1

Impact of genetic potential for residual feed intake and diet fed during early- to mid-gestation in beef heifers on carcass characteristics and meat quality attributes of their castrated male offspring

Carcass attributes of steers were examined for influences of selection for residual feed intake (RFI), and exposure to different levels of prenatal nutrition. Heifers characterized for RFI corrected for backfat were mated to bulls with genetic potential for either High-RFI or Low-RFI, such that the progeny were expected to be H/H or L/L RFI (sire/dam). Pregnant heifers were assigned to a low diet (Ldiet; 0.40 kg/d ADG), or moderate diet (Mdiet; 0.57 kg/d ADG), from 30 to 150 days of gestation, after which all heifers were managed similarly. Steer offspring (n = 23) were also managed similarly until slaughter. Dressing percentage of steers from H-RFI dams/sires exposed to Ldiet during gestation was lower than all other groups (P = 0.02). Marbling was greater for steers from H-RFI parents, as was fat content of longissimus thoracis et lumborum and triceps brachii (P ≤ 0.02). Results suggest that parental selection for RFI and prenatal maternal diet can influence carcass characteristics of progeny.

Ayurvedic Balarista ameliorate anti-arthritic activity in adjuvant induced arthritic rats by inhibiting pro-inflammatory cytokines and oxidative stress

BACKGROUND AND AIM

Balarista is a fermented ayurvedic liquid preparation recommended as a good therapy for the treatment of rheumatoid arthritis. In the present investigation, the anti-arthritic activity of in-house Balarista formulation and marketed M1, M2, M3 and M4 Balarista formulations at the dose of 2.31 ml/kg were studied on Complete Freund's adjuvant-induced arthritic rat model.

EXPERIMENTAL PROCEDURE

Measurement of paw diameter, arthritic index, arthritic score, and body weight were made to assess the anti-arthritic activity. Alterations in hematological and biochemical parameters were carried out to ascertain the disease progression. The inflammatory mediators (TNF-α, IL-1β, and IL-6) were measured by the ELISA method. The oxidative stress parameters were evaluated in tissues of joint, liver, spleen and kidney. The histological and radiological changes in the ankle joint of rats were also studied.

RESULTS AND CONCLUSION

Administration of in-house and marketed formulations exhibited significant anti-arthritic activity by reducing all the arthritic parameters. The anomalous alterations in hematological and biochemical parameters were remarkably restored. The expression level of serum pro-inflammatory cytokines was significantly suppressed in treated animals. The oxidative stress, indicated by an increase in lipid peroxidation, decreased in antioxidant enzyme i.e. superoxide dismutase and catalase along with non-enzymatic reduced glutathione in tissues, were strongly counteracted by the formulation. Abnormal changes in arthritic ankle joints shown by X-ray and histological examination were significantly protected by the formulation. The present study suggests that the administration of in-house and marketed Balarista formulations have produced a significant anti-arthritic effect by inhibiting free radicals and inflammatory cytokines.

Cytohistological correlation in pituitary tumor and immunological assessment with the help of Ki-67

Background:

Tumors of the pituitary gland and sellar region represent approximately 10–15% of all brain tumors. Pituitary adenoma (PA), the most common pathology of the pituitary gland, can be effectively subclassified only with the help of immunohistochemistry (IHC). This is important and needed for individual patient management.

Aims and Objectives:

The objective of the study was to analyze the importance of intraoperative imprint smear cytology and correlating with final histopathological diagnosis. Furthermore, to classify the different types of PA with the help of IHC, prolactin (PRL), adrenocorticotropic hormone (ACTH), and growth hormone (GH) and to predict the benign, atypical, or malignant nature of the tumor with the help of prognostic marker Ki-67.

Materials and Methods:

A prospective study was done in 34 cases. The patients whose pituitary gland samples are referred from the endocrine and the neurosurgery department to the pathology department for histopathological examinations were selected. We have studied the clinical features, radiology and touch imprint cytology, histopathology, and IHC with the help of PRL, ACTH, GH, and Ki-67 of PA over 2 years.

Results:

In our study, we had 32 cases of PA of 34 cases over a span of 2 years. We have seen that there is a correlation between cytological and histological diagnosis of the subtypes of PA in 62% cases, and the Kappa statistics show a moderate extent of agreement (Kappa - 0.320, 95% confidence interval = 0.031–0.609). Ki-67 when compared to the radiological grading showed a high degree of comparability (Chi-square test: P < 0.001). All cases with invasion had a higher Ki-67. On using the Fisher's exact test, we found that the Ki-67 expression with GH-producing adenomas and ACTH-producing adenomas was comparable (P = 1.000) while in PRL-producing adenomas too this was not significant (P = 0.269).

Conclusion:

PA can be effectively classified with the help of IHC. Intraoperative cytology is important in diagnosing PA, but histopathology remains the gold standard in diagnosing and differentiating PA from other pathologies of the pituitary gland. The radiological grading together with immunological classification and the prognostic markers of Ki-67 is important in deciding the benign or atypical nature of the adenomas thus helping in better patient management.

Phrenic Nerve Palsy in Severe Tetanus

Unilateral or bilateral raised hemidiaphragms were observed on chest X-ray in three patients with severe tetanus. Diaphragmatic movement was absent on ultrasonography and fluoroscopy. Nerve conduction study confirmed phrenic nerve palsy. Bilateral involvement caused delayed weaning from the ventilator, whereas unilateral involvement was asymptomatic. There was complete recovery from phrenic nerve palsy in all patients.

Hospital referral of detainees during police custody in Amsterdam, The Netherlands

This study describes how many detainees have been referred to emergency departments for further evaluation or emergency care while in police custody in Amsterdam (years 2012/2013). It provides insights into the diagnoses assigned by forensic doctors and hospital specialists and the appropriateness of the referrals. We made use of the electronic registration system of the Forensic Medicine Department of the Public Health Service Amsterdam. This department is in charge of the medical care for detainees in the Amsterdam region. Hospital diagnoses were obtained through collaboration with several Amsterdam-based hospitals. According to our results, in 1.5% of all consultations performed, the detainee was referred to hospital. The most frequent reasons for referral were injuries (66%), intoxication/withdrawal (11%) and cardiac problems (7%). In 18% of all referrals, hospital admission (defined as at least one night in the hospital) was the consequence. After review of hospital files, the indication for referral as stated by the forensic physician was confirmed in 77% of all cases. A minority of referrals was considered unnecessary (7%). The identified cases allow for a discussion of cases of over-referral. Future research should focus on the problem of under-referral and associated health risks.

In situ XPS study of the surface chemistry of MAPI solar cells under operating conditions in vacuum

Organic–inorganic hybrid perovskite solar cells achieved a record efficiency of almost 23% in only a short time span of time.

Incidental Thyroid Carcinoma in Patients Treated Surgically for Presumably Benign Thyroid Disease

Incidental Thyroid Carcinoma (ITC) is quite high as been reported in the world's Journal. This study reviews the frequency of the ITC in patients treated surgically for otherwise benign Thyroid disease in one of the Endocrine surgery unit of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. This study was developed by the investigating the outcome of one hundred and twenty seven patient who underwent partial or total thyroidectomy for benign thyroid pathology in a single Endocrine Surgery Unit of BSMMU from January 2011 to July 2015. This observational study was done to find out the actual incidence of thyroid malignancy among the patients admitted for surgical management with thyroid pathology. All patients underwent at least FNAC and Ultrasonography of the Neck before surgery. Patients with undetermined cytology and follicular nodules were excluded from the study. Overall 19(14.96%) incidental thyroid carcinoma was recorded. Among the ITC 11(8.66%) Papillary Carcinoma, 7(5.51%) Follicular Carcinoma & 1(0.79%) is poorly differentiated carcinoma. The Overall incidence of papillary carcinoma is higher among the incidental carcinoma of Thyroid. Increased incidence associated with follicular adenoma present as an isolated thyroid nodules or multifocal lesion and should be considered malignant potential and total thyroidectomy would be the right choice as surgical management of the both cases. In case of multinodular goiter, total thyroidectomy is currently practiced in majority of the centers and our observations reinforced the attitude further.

[Recognising positional asphyxia: not always the cause of death in victims in an unusual position]

Deceased individuals may be found in a position that raises the question of whether or not the individual died from being in that position. We describe 3 victims of 35, 84 and 54 years of age, respectively. All were found in an unusual position that may have impeded breathing. Breathing may be impaired by compression of the thoracic wall or by extrathoracic airway obstruction caused by the position. Reduced independence, with causes varying from dementia to inebriation, is a risk factor for positional asphyxia. Restraining a person in the so-called "hogtie position" does not lead to positional asphyxia. Positional asphyxiation in individuals dying in the hogtie position must not be confused with excited delirium syndrome (EDS). On the other hand, the diagnosis of positional asphyxia must be seriously considered in deceased individuals found in a position that may impede breathing.

Successful management of a refractory case of postoperative herniorrhaphy pain with extended duration pulsed radiofrequency

Chronic postsurgical pain (CPSP) is a distressful condition following hernia surgery. A 25-year-old, 55 kg male patient presented with severe pain on the right side of the lower abdomen that radiated to the testicle and the inner side of the thigh. Patient was symptomatic since 5 months following inguinal herniorrhaphy surgery. The pain was not relieved with pharmacological and interventional nerve blocks. An ultrasound-guided ilioinguinal-iliohypogastric (II-IH) block with extended duration (42°C, four cycles of 120 s each) pulsed radiofrequency (PRF) and a diagnostic genital branch of genitofemoral nerve (GGFN) block provided pain relief. After 1-month, an extended duration PRF in GGFN resulted in complete resolution of symptoms. During a regular follow-up of 9 months, patient reported an improved quality-of-life. We believe the successful management of CPSP following hernia repair with single extended duration PRF of II-IH and GGFN has not been described in the literature.

A study of the incidence and causation of deafness among the children in the tribal population of Manipur and its prevention

In a clinico-audiological study of 6,674 children in 24 tribal villages in the hills of Manipur in a total population of 18,565, the incidence of deafness is found to be 6.62% The incidence of the conductive deafness is 98.64% and that of the sensori-neural is 1.35%. Episodes of cold attacks and running nose are found to be precursurs of the prevalent conductive deafness. Preventive measures are worked out.

Total proctocolectomy with ileal pouch-anal anastomosis by stapling technique

An ileal pouch-anal anastomosis (IPAA) has become the gold standard procedure for ulcerative colitis and familial adenomatous polyposis coli. Construction of an ileal pouch reservoir is now standard, usually in the form of J pouch. The aim of this study was to assess the outcome of ileal pouch-anal anastomosis by stapling technique after total proctocolectomy. This prospective observational study of six patients who underwent proctocolectomy followed by an ileal pouch-anal anastomosis by stapling technique. Whole colon and rectum was mobilized and resected; J pouch created by GIA device and pouch-anal anastomosis done by staplers. All patients were continent. Patients with familial adenomatous polyposis (FAP) and ulcerative colitis showed excellent outcome regarding their disease after proctocolectomy. The ileal pouch-anal anastomosis has become a feasible alternative to the conventional permanent ileostomy after total proctocolectomy. Satisfactory results have been reported, although the procedure is associated with considerable morbidity. Excision of all the affected mucosa is an essential part of the procedure. Our experience with the ileal pouch-anal anastomosis using stapling devices without mucosectomy.

Collagen content and architecture of the puboischiofemoralis muscle in male chicks and broilers with different growth rates on various nutritional planes

1. Various growth rates of chickens were induced with different nutritional regimes, and the collagen content and architecture of the medial part of the puboischiofemoralis muscle were compared among 21-d-old chicks and 80- or 95-d-old broilers. 2. The percentage muscle weight relative to live weight increased from chicks to 80-d-old broilers and the 95-d-old broilers attained the largest percentage. An inter-relationship of the percentage muscle weight and the growth rates of birds could not be determined. 3. Collagen concentration was related to the growth rates for the first 21 d post hatching and maintained the same level during the later stages up to 80 d. The 95-d-old broilers, that were subjected to early rapid growth followed by restricted later growth, had the highest collagen content. 4. On SEM (Scanning Electron Microscopy) photographs, endomysial honeycombs were small and encircled by perimysia of a collagen network with small mesh size. Thin and thick perimysia were distinguished and the expanded portion of thick perimysia was also observed. Generally, the perimysia were made up of rough collagen tissue where fatty tissue developed, especially in the broilers. 5. Perimysial collagen fibres with mainly transverse striation were divided into two fundamental types, wide collagen platelets and narrow cords. With growth from the chick to broiler stage, features of the collagen fibres did not change regardless of expansion of the thick perimysia. Endomysia increased slightly from thin to thick meshwork as growth progressed. However, the collagen architecture of the muscle in broilers did not change under different nutritional regimes. 6. In conclusion, the puboischiofemoralis muscle of chickens develops relative to live weight when later growth is limited in broilers, but the collagen architecture is not affected by the different growth rates.

Non-adenomatous non-epithelial carcinoma (hemangiopericytoma) of prostate treated with conservative surgery followed by adjuvant chemoradiation

Hemangiopericytoma is a malignant vascular tumour of soft tissue. Microscopically, the tumour shows tightly packed cellular areas surrounding thin-walled branching blood vessels. Traditionally these tumours are treated using wide surgical excision. Only a very few cases of hemangiopericytoma of the prostate have been described worldwide. The feasibility of managing such a case with a combination of conservative surgery and adjuvant anti-malignancy treatment is unexplored. Here, we report a case of hemangiopericytoma of the prostate treated with local excision, with preservation of prostate, followed by adjuvant radiotherapy (40 Gy in 20 fractions to pelvis followed by 24 Gy in 12 fractions as boost to prostate) and chemotherapy (doxorubicin and iphosphamide). Post-treatment computed tomography scan after 4 weeks showed regression of pelvic lymph nodes and a normal-appearing prostate. Levels of serum prostate-specific and carcinogenic embryonic antigen were normal throughout the period of treatment. To date, followup has been uneventful, except for occasional bouts of diarrhea.We conclude that conservative surgery followed by adjuvant radiation and chemotherapy, with subsequent close follow-up, may adequately control localized disease in selected cases of hemangiopericytoma of the prostate. The role of conservative surgery in tumours located at other sites has yet to be defined.

A retrospective study of recurrent chlamydia infection in men and women: is there a role for targeted screening for those at risk?

Chalmydia trachomatis remains the commonest sexually transmitted infection (STI) in the UK. This study identifies those at risk of recurrent infection (RI) attending a central genitourinary clinic, time to subsequent reinfection and duration of at-risk behaviour for the consideration of targeted chlamydia screening. From 1995 to 2005, a total of 14,011 patients' were diagnosed with chlamydia and 1743 (12.4%) had RI, classified as a repeat infection greater than three months after initial diagnosis. Individual risk factors for both sexes include young age <25, two or more partners and failure to attend for test of cure (TOC) and previous STI. Men of non-White ethnicity, symptoms and those self-referred were also at risk. Combined risk factors for both sexes were non-White ethnicity, symptoms, young age, previous STI and two or more partners. Attendance for TOC considerably reduced RI rates in men (odds ratio [OR] = 0.549; 95% confidence interval [CI] 0.359-0.840). Mean time to first and last reinfection in men was 1.91 and 2.49 years, in women 1.76 and 1.92 years. One in eight individuals with chlamydia infection are at risk of RI, the majority of which will occur within two years of initial presentation. These individuals have identifiable risk factors facilitating targeted re-screening, enhanced follow-up and support for behavioural change.

Collagen content and architecture of the Iliotibialis lateralis muscle in male chicks and broilers with different growth rates fed on different nutritional planes

1. Varying growth rates in chickens were induced by different nutritional regimes. The collagen content and architecture of iliotibialis lateralis (ITL) muscle were compared among 21-d-old chick types and broiler types at 80 or 95 d of age. 2. Relative size of ITL muscle was greater in the rapid growing (1.16% of live weight) than the slow growing chicks (1.02% of live weight). The 80-d-old broilers with a compensatory growth phase after an earlier slow growth period produced ITL muscle at 1.65-1.69% of live weight. The ITL muscle in 80- and 95-d-old broilers with restricted later growth after an earlier rapid growth period was 1.29 and 1.49% of live weight, respectively. 3. Collagen content of ITL muscle did not differ between chick types and also among the broiler types. However, collagen concentration decreased from 6.00-6.51 mg/g in the chicks to 3.33-4.00 mg/g in the broilers. 4. Thick and thin perimysia and honeycomb endomysia were viewed by scanning electron microscope (SEM) photography. In the perimysia, a central wide layer of longitudinal collagen fibres and peripheral narrow band of transverse fibres were distinguished. Collagen baskets of adipocytes were observed in the perimysia. 5. Perimysial collagen fibres markedly increased in number and formed a larger fibre cluster during growth from chicks to broilers. Endomysia changed from thin to thicker meshwork with growth. However, the collagen architecture of the muscle in broilers did not change under different nutritional regimes. 6. In conclusion, ITL muscle of chicken develops optimally when body growth is enhanced, but the collagen content and architecture in broilers are not affected by different growth processes.

The responsiveness and validity of the CAMPHOR Utility Index

The aim of the present study was to validate and determine the minimal important difference (MID) and responsiveness of the Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) Utility Index, a new tool enabling cost utility analyses. CAMPHOR, 6-min walking test (6MWT) and New York Heart Association (NYHA) data for 869 pulmonary hypertension patients (545 (63%) female; mean+/-SD age 56.6+/-15.4 yrs) from three centres were analysed. Utility was correlated with 6MWT data and calculated by NYHA class to assess validity. Effect sizes were calculated for those with two CAMPHOR assessments. Distribution and anchor-based MIDs were calculated. Analyses were carried out in patients receiving bosentan in order to determine whether or not those remaining in NYHA class III following treatment improved. The Utility Index distinguished between adjacent NYHA classes and correlated with 6MWT results. CAMPHOR subscales and utility were as responsive as the 6MWT (effect sizes ranged 0.31-0.69 for the CAMPHOR and 0.16-0.34 for the 6MWT). The within-group MID for the Utility Index was estimated to be approximately 0.09. Patients remaining in NYHA class III experienced, on average, a significant improvement (CAMPHOR Utility Index and functioning), which exceeded the MID. The CAMPHOR Utility Index is valid and responsive to change. Patients can experience significant and important improvements even if they do not improve on the basis of traditional outcomes, such as NYHA functional class.

Autopsies following death due to traumatic injuries in The Netherlands: an evaluation of current practice

INTRODUCTION

Because of a steady decline in the number of autopsies following death due to traumatic injuries, valuable information concerning possible missed injuries and potential improvements in management is lost. This retrospective study describes current practice in the Amsterdam region of the Netherlands regarding such autopsies, and their rates.

METHOD

The current protocols for autopsies were reviewed. Data from government databases and hospitals for the year 2005 were collected. For all patients included that died an unnatural death due to traumatic injury, causes of death and recommendations for autopsy were reviewed. The number of clinical and medico-legal autopsies was determined.

RESULTS

Of 872 registered unnatural deaths, 414 were due to traumatic injuries; 63% of these died before reaching hospital and 37% died in hospital. There were more male deaths, and average age was 54 years. In 23% an autopsy was advised by the medical examiners, more often for pre-hospital deaths. The rate of autopsies was 46% when advice was given for a medico-legal autopsy.

CONCLUSION

The rates of both medico-legal and clinically desirable autopsies are very low. Currently, the system in Amsterdam focuses mainly on the former, and the latter with its attendant educational aspects is largely ignored. The role of the government should be expanded to optimise the autopsy system in unnatural deaths following traumatic injuries.

Valproic acid enhances etoposide induced cytotoxicity in neuroblastoma cells

20010

Background: Metastastic neuroblastoma is resistant to treatment and prolonged response is difficult to achieve therefore new therapies are necessary. Etoposide, a topoisomerase II inhibitor is often used for its treatment. Valproic acid (VPA) has histone deacetylase inhibitor (HDI) activity. Epigenetic alterations described in neuroblastoma tumors make VPA a good candidate to evaluate for potentiation of etoposide-mediated cytotoxicity. We evaluate the effects of VPA in combination with etoposide in neuroblastoma cells. Methods: Human neuroblastoma cell lines SKNAS and SKNSH were incubated with 1.5 mM VPA and increasing concentrations of etoposide from 1x10-6 to 1 mM. Cell viability assay were measured with MTT assays. Results: We observed that VPA and etoposide independently decreased cell viability in a time and concentration dependent manner. The co-incubation with both drugs greatly enhanced the cytotoxicity of etoposide. IC50 for SKNSH cells treated with etoposide were approximately 1x10–3, 1.8x10–4, and 3x10- 5mM at 24, 72 and 96 hours, respectively. With the addition of VPA we found that cell viability was reduced approximately by 10 fold at each time point. At 72 and 96 hours 100 percent cell death was achieved at 0.1 mM of etoposide. IC50 for SKNAS cells treated with etoposide were approximately 1.8x10–3 mM and 6x10–4 mM at 72 and 96 hours, respectively. With the addition of VPA, IC50s were reduced by approximately 5 fold at the same exposure times. Further confirmation of synergistic activity was demonstrated with the use of the fraction product method of Webb formula. Conclusions: Our results demonstrate that VPA potentiates the cytotoxic effects of etoposide on neuroblastoma cells. by altering gene expression and rendering the cells more sensitive to etoposide induced cell death. Finally, since these agents have a proven track record of safety and efficacy in patients with neuroblastoma, this data supports the use of this combination in a phase I trial in patients with neuroblastoma.

No significant financial relationships to disclose.

[Unexplained deaths in minors in the Amsterdam-Zaandam region in 1990-2004 and the estimated number that will be considered for further investigation into the cause of death (the NODO procedure)]

OBJECTIVE

To determine how often deceased minors are examined by a forensic physician and the rate of unexplained deaths, and to estimate how often further investigation into the cause of death (the so-called NODO procedure) would be initiated.

DESIGN

Descriptive, retrospective study.

METHOD

Statistics Netherlands (CBS) provided the number of deceased minors and the manner as well as cause of death for the Amsterdam-Zaandam region in the period 1990-2004. Data regarding residence, age, year of death, manner of death and cause of death were collected for all post-mortem examinations performed on minors during the same period using the registration system of the Department of Forensic Medicine of the Amsterdam Municipal Health Services.

RESULTS

A total of 2134 minors living in the Amsterdam-Zaandam region died in the period 1990-2004, according to the CBS. In this 15-year period the CBS registered 140 deaths (7%) that remained unexplained after post-mortem examination: 91 were registered as natural deaths due to unknown or unclear causes and 49 were registered as sudden infant death syndrome. In 306 cases (14%) the post-mortem examination was performed by municipal forensic physicians. Of these cases, 61 (20%) remained unexplained after post-mortem examination. In the remaining cases, post-mortem examination was performed by the treating physician.

CONCLUSION

The estimated annual number of cases that will be referred for the NODO procedure in the Amsterdam-Zaandam region is at least 10: 4 based on unexplained deaths after examination by a municipal forensic physician and 6 based on natural deaths with no known cause of death according to the treating physician. Nationwide, at least 125 of the expected 1800 childhood deaths will be referred annually.

Systemic sclerosis associated pulmonary hypertension: improved survival in the current era

OBJECTIVES

To measure survival, haemodynamic function and functional class in patients with systemic sclerosis associated pulmonary arterial hypertension (SSc-PAH) in two treatment eras.

METHODS

Six year longitudinal study of 92 consecutive patients with SSc-PAH diagnosed by cardiac catheterisation. Data were collected both prospectively and retrospectively. Patients were given basic treatment (diuretics, digoxin, oxygen and warfarin). Where clinically indicated, a prostanoid was used as advanced treatment (historical control group). From 2002, the range of treatments available expanded to include bosentan, which was generally the preferred treatment (current treatment era group). Survival was measured from the date of diagnosis of pulmonary hypertension by cardiac catheterisation. Six minute walking distance and haemodynamic function were measured at the time of diagnosis and at least one month after treatment was started.

RESULTS

The historical control group comprised 47 patients, all of whom received basic treatment; 27 of these were also treated with prostanoids. The current treatment era group comprised 45 patients, all of whom received bosentan as preferred treatment. Kaplan-Meier survival in the historical control group was 68% at one year and 47% at two years. Survival in the current treatment era group was 81% and 71% (p = 0.016) at one and two years, respectively. Pulmonary vascular resistance increased in the historical control group (by 147 dyn.s.cm(-5)), whereas in the current treatment era group, it remained stable over an average of nine months (decrease of 16 dyn x s x cm(-5), p < 0.006).

CONCLUSION

Survival of selected patients with SSc-PAH has improved in the current treatment era. In contrast to patients treated historically with basic drugs and prostanoids, patients treated in the current treatment era had improved survival associated with a lack of deterioration in cardiac haemodynamic function.

Cardiac sarcoidosis: an uncommon presentation of sarcoidosis in India

Cardiac involvement in sarcoidosis is uncommon. The manifestations of cardiac sarcoidosis are protean and vary from benign ectopics to life threatening ventricular tachycardias. High index of suspcion and early aggressive intervention is required for the diagnosis and treatment of this condition. Early diagnosis is essential since ventricular tachycardia is the most common terminal event in these patients if left untreated. Corticosteroids are needed early in these patients which along with other antiarrhythmic management strategies including intracardiac defibrillator form the backbone of treatment. We describe four patients who were diagnosed to have pulmonary and cardiac sarcoidosis. Their varied presentations highlight the difficulties that may occur in the diagnosis. Furthermore, the need for proper management is stressed, as a delay in diagnosis may be fatal.

[Legal and practical aspects of perinatal death]

There is some debate as to whether the Dutch Burial Act applies to neonatal deaths after a gestation of less than 24 weeks. It is recommended that the Act be considered applicable in these situations, leading to a compulsory (external) post mortem examination, the issue of an official death certificate, and registration of the birth and death at the official registry office, followed by burial or cremation according to the law. The Act should be amended to this effect. It is also recommended that the Burial Act no longer apply in cases of known intra-uterine death before 24 weeks of gestation where birth takes place after 24 weeks. The stipulated cut-off point in the Act for defining a miscarriage as opposed to a birth or stillbirth, i.e. 24 weeks of gestation, should preferably be replaced by the international (WHO) criterion of a birth weight of 500 g, as this will lead to less ambiguity and a better comparison of Dutch and international data concerning perinatal mortality.

Death certificates in Germany, England, The Netherlands, Belgium and the USA

Every country has its own legal system regarding post mortem examinations and death certificates. The authorities want to know the cause and the manner of death of their citizens and especially whether someone is responsible for the death of someone else. In this article a comparison is made between the legal regulations in the Netherlands, Belgium, Germany, England and the USA. Specific attention is given to the following aspects: which official performs the post mortem exam, what is the role of the attending physician by issuing the death certificate and how is the privacy of the deceased protected.

Unilateral pulmonary agenesis: an uncommon cause of lower zone lung opacity

Congenital abnormalities of the lung are rare and are often misdiagnosed. We report the case of a young girl who was initially diagnosed to have pleural effusion with collapse. After detailed evaluation including computerised tomographic (CT) scan and fiberoptic bronchoscopy, a final diagnosis of unilateral pulmonary agenesis was made. This condition must be suspected in differential diagnosis in a young person presenting with features of lung collapse.