The role of cardiovascular magnetic resonance imaging with T1 and T2 mapping in sudden cardiac death survivors

Background

Sudden cardiac death (SCD) in the adult population is poorly studied, although determining its etiology is crucial for management and prognosis [1]. Cardiovascular magnetic resonance imaging (CMR) is being increasingly utilized in SCD survivors [1,2]. The role of late gadolinium enhancement (LGE) imaging in patients with recent SCD and no significant coronary artery disease (CAD) is well established, but there is no data on the additive role of T1 and T2 mapping [1–3].

Purpose

This is a retrospective study to assess the role of CMR including T1 and T2 mapping in SCD survivors.

Methods

Between 01/2016 and 12/2019, we retrospectively analyzed patients who underwent CMR on a Siemens Magnetom Avanto 1.5 T scanner within 4 weeks of SCD. CMR protocol included cine imaging, T1 and T2 mapping, and LGE imaging. Native and post-contrast myocardial T1 values were measured within the septum on the mid short axis (SAX) and extracellular volume fraction was calculated using the standard formula. T2 values were measured in six mid segments on the mid SAX map. Additional measurements were performed if long axis T2 maps were available. Clinical data, electrocardiography (ECG), transthoracic echocardiography (TTE), coronary computed tomography angiography (CCTA), and left heart catheterization (LHC) were reviewed from the electronic health record. An ischemic evaluation was performed in 33 (94%) of patients.

Results

A total of 35 patients who underwent CMR for SCD were included for analysis (mean age 46.9±14.1 years; 20 (57%) male). SCD etiology was established based on clinical data, ECG, TTE, CCTA, and LHC in 9 (26%) patients. CMR provided the most probable SCD etiology in an additional 20 (57%) patients with T1 and T2 mapping abnormalities seen in 18 (51%) patients. Diagnoses determined by CMR included myocarditis (35%), hypertrophic cardiomyopathy (CMP) (20%), left ventricular non-compaction CMP (15%), dilated CMP (10%), takotsubo CMP (5%), and myocardial infarction with non-obstructive CAD (15%) (Table, Figure). Elevated native T1 was seen in 15 (43%) (mean T1 1069±60 ms; site specific normal <1080 ms), elevated ECV in 16 (46%) (30±7%; site specific normal <29%), and elevated native T2 in 22 (63%) patients (65±10 ms; site specific normal <60 ms). LGE was present in 31 (89%) patients. The etiology of SCD remained unknown in 6 (17%) patients despite extensive testing including CMR.

Conclusions

CMR has significant diagnostic and prognostic value in assessing SCD etiology compared to non-CMR based evaluation. Myocarditis is a common underdiagnosed cause of SCD in adult patients well seen in a CMR protocol with T1 and T2 mapping. Myocardial inflammation monitoring in SCD survivors with serial CMRs using T1 and T2 mapping could influence clinical decision making by justifying pharmacotherapy modification and timing of ICD implantation. To conclude, CMR with T1 and T2 mapping provides high diagnostic yield in the investigation of SCD etiology.

Funding Acknowledgement

Type of funding sources: None.

Rapid cardiovascular magnetic resonance protocol utilizing compressed sensing real-time imaging during the COVID-19 pandemic

Funding Acknowledgements

Type of funding sources: None.

Background

Coronavirus Disease 2019 (COVID-19) poses many workflow challenges for healthcare systems. Elective cardiovascular magnetic resonance (CMR) exams were postponed until safety protocols were instituted. Since reopening, imaging labs are managing COVID-19 safety triaging, exam backlog, and increased referrals, thus innovative solutions for process improvement are needed.

Purpose

An accelerated compressed sensing (CS) real-time (RT) technique offers dynamic cardiac imaging with high spatial and temporal resolution without image degradation. We sought to evaluate the efficiency of a rapid RT CMR protocol with a goal to decrease scan time without compromising study quality and comprehensiveness.

Methods

We retrospectively evaluated 219 CMRs (Siemens Magnetom Sola 1.5T) performed 09/01/2020 - 10/15/2020. After excluding 81 exams due to heterogeneous protocols (Figure 1), we analyzed 138 CMR exams using standard cardiomyopathy or myocarditis protocols. CMR studies utilized either a rapid RT short axis (SAX) cine (spatial resolution of 2.5 mm2 or better and temporal resolution of 55 ms or better) or standard breath-held (BH) SAX cine protocol (Figure 2).  Protocols were chosen by the interpreting physician. Previous internal quality control demonstrated similar volumetric quantification between RT and BH SAX cines. RT cines were reconstructed inline using a CS-based method.  We analyzed the length of time needed to complete each protocol and the number of series performed. Statistical analysis included student t-test with p value <0.05 considered significant.

Results

Of 138 analyzed CMR exams, there were 23 rapid protocols and 115 standard protocols performed. The mean image acquisition time for the rapid protocol was significantly shorter at 26 ± 6 minutes (range 18-44 min) vs 33 ± 6 minutes (range 22-49 min) for the standard protocol, p < 0.001. This represents a mean relative reduction in scan time of 21%. More time was saved in rapid myocarditis (scan time 25 ± 6 min vs 34 ± 6 min, p = 0.01; relative time reduction 26%) vs rapid cardiomyopathy protocols (scan time 27 ± 6 min vs 31 ± 6 min, p = 0.04; relative time reduction 13%). There was no significant difference in the number of series performed (62 ± 14 series in rapid vs 67 ± 11 series in standard protocols, p = 0.09).  T1 and T2 maps constituted the same percentage of acquired images regardless of protocol used (T1 maps 1.8% vs 1.7% for cardiomyopathy, 1.4% vs 1.4% for myocarditis in standard vs rapid protocols respectively; T2 maps 1.8% vs 1.7% for cardiomyopathy, 5.6% vs 5.8% for myocarditis in standard vs rapid protocols respectively).

Conclusions

A rapid CMR protocol utilizing a CS-based RT imaging is significantly shorter as compared to the standard protocol with adequate diagnostic quality. Rapid CMR protocols are an effective tool for process improvement during the COVID-19 pandemic.

A phase 1 trial of imatinib, bevacizumab, and metronomic cyclophosphamide in advanced colorectal cancer

Background:

This phase 1 clinical trial was conducted to determine the safety, maximum-tolerated dose (MTD), and pharmacokinetics of imatinib, bevacizumab, and metronomic cyclophosphamide in patients with advanced colorectal cancer (CRC).

Methods:

Patients with refractory stage IV CRC were treated with bevacizumab 5 mg kg⁻¹ i.v. every 2 weeks (fixed dose) plus oral cyclophosphamide q.d. and imatinib q.d. or b.i.d. in 28-day cycles with 3+3 dose escalation. Response was assessed every two cycles. Pharmacokinetics of imatinib and cyclophosphamide and circulating tumour, endothelial, and immune cell subsets were measured.

Results:

Thirty-five patients were enrolled. Maximum-tolerated doses were cyclophosphamide 50 mg q.d., imatinib 400 mg q.d., and bevacizumab 5 mg kg⁻¹ i.v. every 2 weeks. Dose-limiting toxicities (DLTs) included nausea/vomiting, neutropaenia, hyponatraemia, fistula, and haematuria. The DLT window required expansion to 42 days (1.5 cycles) to capture delayed toxicities. Imatinib exposure increased insignificantly after adding cyclophosphamide. Seven patients (20%) experienced stable disease for >6 months. Circulating tumour, endothelial, or immune cells were not associated with progression-free survival.

Conclusion:

The combination of metronomic cyclophosphamide, imatinib, and bevacizumab is safe and tolerable without significant drug interactions. A subset of patients experienced prolonged stable disease independent of dose level.

Spontaneous resolution of sinoatrial exit block and atrioventricular dissociation in a child with dengue fever

Cardiac rhythm abnormalities, including ventricular arrhythmia, atrial fibrillation and atrioventricular block, have been observed during the acute stage of dengue haemorrhagic fever. Atrioventricular or complete heart block can be fatal and may require a temporary pacemaker. We report a ten-year-old girl who presented with dengue haemorrhagic fever with sinoatrial block and atrioventricular dissociation that had a spontaneous resolution.

Study of different methods of susceptibility testing of M. tuberculosis

This communication is on a multi-centre collaborative study carried out by New Delhi Tuberculosis (NDTB) Centre, Delhi, to compare the different methods of drug susceptibility testing (DST) of Mycobacterium tuberculosis for Streptomycin, Rifampicin, Isoniazid and Ethambutol in various accredited laboratories 40 samples (selected by simple random sampling technique) from sputum positive out-patients presenting between December 2004 and January 2005 were collected at New Delhi Tuberculosis Centre from 24 males and 16 females (age ranging from 18 to 55 years) were taken up for culture and susceptibility testing. The proportion method of DST done at NDTB Centre was taken as standard for comparing the other methods after it was found to have a good agreement with the proportion method performed at Tuberculosis Research Centre, Chennai (Kappa coefficient 0.75 to 1). All 40 sub-cultures were processed for DST by the resistance ratio and proportion methods at NDTB Centre. Also, the 40 sub-cultures were sent to Central JALMA Institute for Leprosy (JALMA), Agra that used the resistance ratio method and 25 sub-cultures were transported to National Institute of Communicable Diseases (NICD), Delhi for performing the Bactec 460TB method. The resistance ratio and proportion methods were compared both intra-laboratory (NDTB Centre) and inter-laboratory (NDTB Centre and JALMA). The sensitivity and specificity of the resistance ratio method compared to the proportion method both inter and intra-laboratory, were very high for all the drugs (except Ethambutol inter-laboratory). This was corroborated by the good agreement between the resistance ratio performed at the two centres. Bactec 460TB method, on the other hand, did not have acceptable measures of validity (sensitivity and specificity) compared to the proportion method for Streptomycin and Ethambutol. Both resistance ratio method & proportion method are comparable and either can be used for making clinical decisions. But Bactec 460 method, despite yielding early results loses out on validity.

Disseminated cryptococcosis in an HIV-negative patient

A young, unmarried, immunocompetent female presented with complaints of fever and altered sensorium, along with lesions over the face and trunk. A provisional diagnosis of disseminated herpes simplex with giant molluscum contagiosum was made. However, cutaneous biopsy of the lesions showed numerous cryptococcal organisms which stained positive to periodic acid-Schiff. This case is reported to sensitise physicians to keep cryptococcosis as a differential diagnosis in such types of skin lesions, as the lesions resemble that of molluscum contagiosum very closely.

Tuberculosis of the ilium: a case report

A twenty year old man presented with pain in the upper part of right hip. CT scan showed multiple osteolytic areas in the right ilium, suggesting malignancy. CT guided needle biopsy was done and diagnosis of tuberculosis was made. The patient was cured with medical management only. Isolated tuberculosis of the ilium is an extremely rare condition. It is important to have a high clinical suspicion to diagnose early and manage the patient without surgical intervention.

Outcome of multi-drug resistant tuberculosis cases treated by individualized regimens at a tertiary level clinic

AIM

To determine the clinical, radiological and drug resistance profile as well as the factors associated with treatment outcome of Multi-Drug Resistant Tuberculosis (MDR-TB).

MATERIAL AND METHODS

All newly diagnosed patients with pulmonary MDR-TB from August 2002 to December 2004 enrolled at New Delhi Tuberculosis Centre, were included in the study. They were followed up clinically, radiologically and bacteriologically by sputum smear, culture and Drug Susceptibility Testing (DST) at regular intervals. According to their DST pattern and previous history of Anti-Tubercular Treatment (ATT), individualized treatment regimens were tailored for each patient.

RESULTS

Out of total 27 bacteriologically proven cases of MDR-TB included in this study, 19 were males (mean age and weight 38.5 years and 52.6 kgs, respectively) and eight females (mean age and weight 34.3 years and 40.7 kgs, respectively). A majority (18) were residents of Delhi and the rest hailed from different parts of North India. All of them had a history of previous treatment ranging from six to 34 months. Cavity on chest X-rays was seen in 81%, while 44% showed extensive involvement. The patients received at least four "second line drugs" during their treatment with a mean of 6.2 anti-tubercular drugs during their intensive phase. Of the 27 patients, 13 were cured, 10 defaulted, one died, one is still on treatment and two were referred for surgery. Radiological improvement was observed in two third of cases and chest X-ray of two patients showed a complete resolution. Six predictors were identified for successful outcome of MDR-TB. They include weight gain at six months, culture conversion, radiological improvement during treatment, disease with M. tuberculosis strains exhibiting resistance to less than or up to three anti-tubercular drugs, use of less than or up to three second line drugs in treatment and no change of regimen during treatment.

CONCLUSION

Default from treatment was observed to be a major challenge in the treatment of MDR-TB due to long duration and expense of ATT.

Cardiotoxic Manifestations of Yellow Oleander (Thevetia nerifolia) Poisoning and its Treatment: A Case Report

A 30-year-'old female came to the hospital with complaints of vomiting, drowsiness and bradycardia after ingesting five seeds of yellow oleander (Thevetia nerifolia - pila kaner) with the intent of committing suicide. Whereas the usual complication is hyperkalemia, she was suffering from hypokalemia. She responded to conventional treatment, consisting of atropine and correction of electrolytes. This report discusses the cardiotoxic and neurotoxic manifestations of yellow oleander poisoning, its early diagnosis and prompt treatment. We would like to emphasize the importance of taking an electrocardiogram in all cases of poisoning.

A phase II study of gemcitabine (GEM) given at fixed-dose rate (FDR) infusion, low-dose cisplatin (CDDP), and bevacizumab in metastatic pancreatic cancer (PanCa)

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Background: The objectives of this study are to determine safety and efficacy in pts with metastatic PanCa treated with a novel combination consisting of FDR GEM, low-dose CDDP, and BEV. We present here interim results of the first 35 pts. Methods: Chemotherapy-naive pts with histologically confirmed PanCa and documented extrapancreatic metastases received the following: GEM 1000 mg/m2 at FDR infusion (10 mg/m2/min), CDDP 20 mg/m2, and BEV 10 mg/kg, all administered on dd 1 and 15 of a 28-dd cycle. Pts were monitored by CT scans every 2 cycles and monthly serum CA19–9 measurements. Results: 35 pts (15M,20F; median age 60 y.o. [range 39–85]; ECOG PS 0–1) have been enrolled betw 6/2004 and 1/2006 (med f/u, 288 dd; range, 50–542). 18 pts remain alive, with 7 still undergoing study rx. Pts received a median of 4 cycles of rx (range, 0.5–12). Reasons for study discontinuation: 15 pts had progressive dz (med # of cycles, 6; range, 0.5–10); 2 pts completed max # of allowable rx cycles (twelve); 2 pts came off rx 2 o to cumulative asthenia after plateau in response with 8 and 10 cycles of rx. Other major events inc. 2 bowel perforations, one associated with placement of a duodenal stent; 3 major GI bleeds; 1 malignant HTN; and 1 stroke-like sx. 3 pts d/c’ed rx 2o to prolonged rx delays (two persistent bowel obstruction, one grade 3 renal/liver function abnls). Addn grade 3/4 toxicities inc. 7 pts with LFT abnls (20%), 4 with HTN (11.4%), and 3 with thromboembolic events (8.6%). Hematologic toxicities were rare (grade 3/4 neutropenia 5.7%, plts 2.9%). 7 pts (20%) required dose reduction of GEM and 2 required d/c of CDDP. No rx-associated deaths were observed. 7 of 33 evaluable pts (21.2%) have had an unconfirmed response (1 CR, 6 PR) and 15 pts (45.5%) have had stable dz for > 2 cycles, inc. 2 with minor response, for an overall dz control rate of 66.7%. 13 of 21 pts (61.9%) with elev. baseline CA19–9 levels (≥2X ULN) have had ≥50% biomarker decline during rx. Updated efficacy data will be presented at the meeting. Conclusions: The toxicity profile observed in this trial is similar to that previously reported with other BEV-containing regimens. Rates of disease control and CA 19–9 response are encouraging, suggesting this combination is deserving of further study.

[Table: see text]

Health related quality of life (HRQL) scoring (DR-12 score) in tuberculosis--additional evaluative tool under DOTS

The study was conducted among patients diagnosed as pulmonary or extra pulmonary tuberculosis attending DOTS facilities at New Delhi Tuberculosis Centre, Delhi. The objectives of the study are; to evaluate the impairment of health related quality of life in patients of tuberculosis by evolving a HRQL questionnaire (DR-12 score) and to validate the new scoring method by making serial assessments of health related quality of life of the patients during anti-tubercular therapy initially, at the end of intensive phase (IP) and at the completion of treatment. Seventy eight consecutive patients aged between 15-60 years put on DOTS treatment at New Delhi Tuberculosis Centre, Delhi were subjected to a HRQL questionnaire (DR-12 score) at 0 week, 8 weeks and at the completion of treatment. The new scoring method contained questions on twelve parameters related to symptoms, physiological, psychological and social well-being of TB patients. The patients were asked to evaluate these twelve parameters on a score of 1-3. All the individual parameters were equally weighted. The data so obtained regarding these scores was analysed using unpaired t-test, paired t-test, one way Anova test and Pearson corelation coefficient test. The patients who converted at the end of intensive phase had a significantly higher gain in scores as against, those who failed to convert even after extension of intensive phase (p=0.019). Significantly higher scores were observed among those who had a favourable outcome as against those who had unfavourable outcome at the completion of treatment (p=0.029). Thus, DR-12 score was found to have a strong construct validity and useful additional evaluative tool for patients under DOTS therapy.

Role of Terminalia arjuna in ischaemic mitral regurgitation

The bark powder of Terminalia arjuna, an indigenous plant has been found to have antianginal, decongestive and hypolipidemic effect. We planned a study to evaluate the role of T. arjuna in ischemic mitral regurgitation (IMR) following acute myocardial infarction (AMI). 40 patients with fresh AMI showing IMR were randomly divided into 2 groups of 20 each. They were given placebo or 500 mg of T. arjuna in addition to anti-ischemic treatment. After 1 and 3 months of follow up, patients receiving adjuvant T. arjuna showed significant decrease in IMR, improvement in E/A ratio and considerable reduction in anginal frequency.

Adverse drug reactions observed during DOTS

A total of 8.37% of the 1195 patients treated at NDTB Centre with DOTS under RNTCP between January 2002 to June 2003 presented with adverse drug reactions. Patients showing any sort of adverse reactions were studied in detail by personal interviews and a semi-structured questionnaire. The profile of patients presenting with adverse reactions showed that majority of the patients (53%) had gastrointestinal reactions, the commonest presenting complaint being nausea and vomiting. General aches and pains were complained by about 35% and giddiness was the presenting complaint in 27% irrespective of the use of streptomycin, although giddiness was observed more often in Category II patients (59%). Skin rash and itching was complained by about 17% of patients and 11% complained of arthralgia, while only 1% had hepatotoxicity during treatment. Majority of the adverse reactions (67%) were observed within the first four weeks of treatment and only 0.25% of patients treated with DOTS had interruption of treatment for short periods.

Prevalence of initial drug resistance to M. tuberculosis in new sputum positive RNTCP patients

There is an increased prevalence of drug resistant M. tuberculosis strains and of these, multi drug resistant organisms are of particular concern. With the implementation of Revised National Tuberculosis Control Programme (RNTCP) allover the state of Delhi, Initial drug resistance (IDR) to Isoniazid and Rifampicin assumes great importance and needs to be monitored on a regular basis. We undertook to study the IDR against the first line essential drugs i.e. Isoniazid (H), Rifampicin (R), Ethambutol (E) and Streptomycin (S) from April 1999 to March 2000 in newly diagnosed sputum positive cases of pulmonary tuberculosis attending TB clinics under RNTCP in Delhi. A total of 157 consecutive new smear positive patients attending TB clinics under RNTCP were taken into the study. All sputum samples were subjected to culture and drug sensitivity tests on LJ medium after decontamination of samples by Petroff's method. Resistance was expressed as the percentage of colonies that grow on critical concentration of the drugs. To determine the proportion of resistance, the number of colonies on the control and the number of colonies on the drug medium were determined. A total of 94.77% samples were sensitive to the four first line essential drugs and IDR to any drug was 5.22%. The resistance to Rifampicin alone was nil but the resistance to Isoniazid alone was 2.24%. Combined resistance to both Rifampicin and Isoniazid was 2.98 %. The incidence of resistance to first line drugs in tuberculosis is not very high among new sputum positive patients attending TB clinics under RNTCP.

Health care seeking pattern of tuberculosis patients attending an urban TB clinic in Delhi

The study of pattern of health care seeking of tuberculosis patients is important for identification of factors which might influence delayed reporting of tuberculosis cases, especially the open pulmonary cases. Consecutive 301 pulmonary TB patients, belonging to any of the categories under RNTCP, diagnosed at New Delhi Tuberculosis Centre or its sub-centres over a six-month period were assessed for health care seeking pattern. "Delay" was defined as the time over 3 weeks that a case took to report to the area TB facility. 43.2% patients reported to the TB health facility on their own and others were referred by government hospitals (34.9%) and general practitioners (21.9%). Median delay over 3 weeks was 2.69 weeks for all three categories combined, with a significantly higher delay (3.41 weeks) for retreatment cases as compared to new cases (2.13 weeks). No significant differences were observed in health seeking delay in relation to sex, income, literacy status and source of referral and sputum status. Extensive health education activities can reduce this period of delay in health seeking and result in reduction of transmission of tuberculosis to healthy members of the family and community.

Comparison of laparoscopic, open, and converted appendectomy for perforated appendicitis

BACKGROUND

Perforated appendicitis is associated with a significant risk of postoperative abdominal and wound infection. Only a few controversial studies evaluate the role of laparoscopy in perforated appendicitis. The significance of conversion from laparoscopy to open appendectomy for perforated appendicitis is not well defined. Statistical analysis was performed using Student's t-test.

METHODS

Data on 52 patients with perforated appendicitis were prospectively collected and retrospectively reviewed. Among these patients, 18 had laparoscopic appendectomies (LA); 24 had open appendectomies (OA); and 10 had converted appendectomies (CA). The indications for either method were based on the attending surgeons's philosophy. Laparoscopic appendectomy was performed using a retrograde stapler technique. Operative time, hospital stay, ability to tolerate a liquid diet, and postoperative infectious complications were documented.

RESULTS

No statistically significant difference in the operative time in minutes was found between the LA (114 +/- 29.3), CA (120.0 +/- 32.2), and OA (105.8 +/- 64.1) groups (p = NS). There was no statistically significance difference in length of stay (days) between the LA (9.2 +/- 4.1), OA (10.5 +/- 3.3), and CA (10.0 +/- 1.8) groups. The wound infection rate was less frequent in the LA group (0%) than in 0A (14%) and CA (10%) groups. The rate of intra-abdominal abscess infections (IAAs) and ileus were 22% and 28%, respectively, in LA group, 38% and 29%, respectively, in OA group, and 60% and 50%, respectively, in CA group.

CONCLUSIONS

No difference in the rate of postoperative intra-abdominal abscesses exists between laparoscopic and open appendectomy for perforated appendicitis. Wound infections and ileus complicate the postoperative course of patients after laparoscopic appendectomy less frequently than after open appendectomy. The conversion of laparoscopic to open appendectomy for perforated appendicitis is associated with increased postoperative morbidity.

Continuous thoracic epidural anesthesia with 0.2% ropivacaine versus general anesthesia for perioperative management of modified radical mastectomy

We evaluated in this prospective study the effectiveness of continuous thoracic epidural anesthesia (TEA) and postoperative analgesia with ropivacaine and compared it with general anesthesia (GA) and opioids for pain relief, side effects, postanesthesia recovery, and hospital discharge after modified radical mastectomy. Sixty ASA physical status II and III patients undergoing mastectomy were randomly assigned to two study groups of 30 patients each. In the TEA group, an epidural catheter was inserted at T6-7, and 5--10 mL of 0.2% ropivacaine was injected to maintain anesthesia and to continuously administer adequate analgesia for 48 h. GA was induced with IV 1--2 mg of midazolam or 50--100 microg/mL of fentanyl followed by 50--150 mg of propofol and was maintained with sevoflurane and 50% N(2)O in oxygen. The Aldrete score system was used to evaluate postanesthesia recovery, a verbal rating scale was used for assessment of pain intensity, and a postanesthesia discharge scoring system was used for discharge home. The demographic data and side effects (except for nausea and vomiting) (GA 43%, TEA 10%, P = 0.0074) and discharge home were similar in both groups. However, the number of patients ready for discharge from the recovery room during the first postanesthesia hour (Aldrete score of 10) was significantly larger after TEA (80%) than after GA (33%) (P = 0.0006). GA patients experienced significantly more (P < 0.001) substantial pain than TEA patients on Day 0 (70%), Day 1 (53%), and Day 2 (27%) after the surgery. Patient satisfaction was greater with TEA (70%) than with GA (30%) (P < 0.001). We conclude that TEA with ropivacaine provides better postoperative pain relief and less nausea and vomiting, facilitates postanesthesia recovery, and gives greater patient satisfaction than GA.

Ambient air pollution and chronic respiratory morbidity in Delhi

The authors conducted a cross-sectional study among residents of Delhi to determine the role of ambient air pollution in chronic respiratory morbidity in Delhi. The authors selected a random, stratified sample (N = 4,171) of permanent residents who were 18+ y of age and who lived near 1 of the 9 permanent air quality monitoring stations in the city. Air-quality data for the past 10 y were obtained; data were based on the differences in total suspended particulates, and the study areas were categorized into lower- and higher-pollution zones. A standardized questionnaire was administered, clinical examination was carried out, and spirometry followed. The authors assessed chronic respiratory morbidity by (a) prevalence of chronic respiratory symptoms (i.e., chronic cough, phlegm, breathlessness, and wheezing) and airway diseases (i.e., chronic obstructive pulmonary disease/chronic bronchitis and bronchial asthma); and (b) lung function results in asymptomatic nonsmoking subjects in the two pollution zones. A multiple logistic regression identified the determinants of chronic symptoms. Smoking, male sex, increasing age, and lower socioeconomic status were strong independent risk factors for occurrence of chronic respiratory symptoms. In the comparison of nonsmoking residents of lower- and higher-pollution zones--stratified according to socioeconomic levels and sex--chronic cough, chronic phlegm, and dyspnea (but not wheezing) were significantly more common in the higher-pollution zone in only some of the strata. Furthermore, prevalence rates of bronchial asthma, chronic obstructive pulmonary disease, and chronic bronchitis among residents in the two pollution zones were not significantly different. Nonetheless, lung function of asymptomatic nonsmokers was consistently and significantly better among both male and female residents of the lower-pollution zone.

Patterns of smoking in Delhi and comparison of chronic respiratory morbidity among beedi and cigarette smokers

Tobacco smoking is common in developing countries including India with beedi and cigarette smoking being the main types. A community-based study carried out to study the chronic respiratory morbidity in the urban areas of Delhi was analyzed to determine the patterns of tobacco smoking and to compare the chronic respiratory morbidity among beedi and cigarette smokers. A random, stratified sample was selected from among the permanent residents, aged above 18 years, from nine clusters in Delhi. A standardized respiratory symptoms questionnaire was administered and clinical examination carried out followed by spirometry. The questionnaire included a detailed smoking history including type of smoking, number of cigarettes smoked per day and number of years the person had smoking. Chronic respiratory morbidity in beedi and cigarette smokers was measured in terms of prevalence of chronic respiratory symptoms (chronic cough, phlegm, breathlessness and wheezing) and by lung function results. It was observed that nearly 40% of adult males were current smokers. Beedi smoking was overall the commonest type of smoking in the community. Cigarette smoking was more common in the higher income groups and among the graduates and postgraduates. Beedi smoking was the main form of smoking among the lower and middle-income groups and among the illiterates and the less educated people. Very few female subjects admitted to smoking. The prevalence of symptomatics (those having one or more of chronic chest symptoms) was significantly higher in beedi smokers as compared to cigarette smokers in those smoking greater than 2.5 pack years. Prevalence of wheezing was however not significantly different. Multiple logistic regression analysis revealed type of smoking to be a significant independent determinant of occurrence of respiratory symptoms with the odds for occurrence of symptoms being 1.67 times greater in beedi smokers as compared to cigarette smokers. Lung function (FEV1/FVC and FEV1% predicted) showed significantly greater airways obstruction in beedi smokers as compared to cigarette smokers. It was concluded that the beedi smoking was as or more likely to cause clinical and functional impairment of lungs compared to cigarette smoking.

Risk factors for development of bronchial asthma in children in Delhi

BACKGROUND

Information on the magnitude of the problem of childhood asthma in India and the factors influencing its occurrence is inadequate.

OBJECTIVE

To measure the prevalence of asthma in schoolchildren in Delhi and study the factors determining its occurrence.

METHODS

A questionnaire-based study carried out in nine randomly selected schools in Delhi. The age range was 5 to 17 years. The questionnaires were distributed to all the children (n = 21,367) for answering by either parent. The key questions relate to complaints of recurrent wheezing in the past, during the immediate last 1-year, and also wheezing exclusively induced by exercise or colds. In all, 19,456 questionnaires were received back (response rate 91%). Out of these, 18,955 were complete and analyzed.

RESULTS

The prevalence of current asthma was 11.9% while past asthma was reported by 3.4% of children. Exclusive exercise-induced asthma was reported by 2.1% while that associated with colds by 2.4% of children. Boys had a significantly higher prevalence of current asthma as compared with girls (12.8% and 10.7%, respectively). Multiple logistic regression analysis showed that male sex, a positive family history of atopic disorders, and the presence of smokers in the family were significant factors influencing the development of asthma while economic class, air pollution (total suspended particulates), and type of domestic kitchen fuel were not.

CONCLUSIONS

The prevalence of current asthma in children in Delhi is 11.9%. Significant risk factors for its development are male sex, a positive family history of atopic disorders, and the presence of smokers in the family.

Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus

Laparoscopic cholecystectomy has become the gold standard in the care of patients with cholelithiasis. A standard laparoscopic cholecystectomy employs three trocar incisions outside the umbilicus, which are a source of potential wound complications and an undesirable cosmetic outcome. We describe here a modification of the laparoscopic cholecystectomy which utilizes two transumbilical trocars and two transabdominal gallbladder stay sutures and does not require abdominal wall incisions outside the umbilicus. When technically feasible, this technique results in superior cosmesis and may reduce postoperative wound complications.

Prevalence of bronchial asthma in schoolchildren in Delhi

There is a paucity of information on the prevalence of asthma in children in India. Some evidence suggests that asthma is less common in developing than in the developed countries. The present study was carried out to estimate its current magnitude in children in Delhi. The questionnaire-based study was carried out in two randomly selected schools in Delhi. All the children were eligible. The age range was 4-17 years. The questionnaires were distributed to all the children present (n = 2867) to be answered by either parent. The key questions were related to complaints of recurrent wheezing in the past, in the last 1 year, and also wheezing exclusively induced by exercise or colds. In all, 2609 questionnaires were completed and returned (response rate 91%). There was a slight excess of males (54%). The prevalence of current asthma was 11.6% and past asthma was reported by 4.1% of children, giving a cumulative prevalence of 15.7%. Exclusive exercise-induced asthma was 2.8% and that associated with colds, 2.3%. The current prevalence of all wheezing was thus 16.7% and cumulative prevalence was 20.8%. While there was no sex-related difference in prevalence, wheezers were the highest in the 9-13 year age group. A significant association was found between the prevalence of wheezing and a family history of asthma (odds ratio 3.65) and presence of smokers in the family (odds ratio 1.62). When both the above factors combined, the odds ratio for risk of asthma was 4.58. There was no significant association with any economic class. Only 11% of asthmatics had been labeled so by their physicians. The prevalence of bronchial asthma and wheezing in children in Delhi is quite high and comparable to that reported from several developed countries. A positive family history of asthma and presence of smokers in the family emerged as significant risk factors.

Serum insulin-like growth factors and their binding proteins in patients with hepatic failure and after liver transplantation

The liver is the major source of circulating insulin-like growth factor-I and -II (IGF-I and IGF-II) and several of their binding proteins (BPs). This study examined the effects of end-stage liver disease (ESLD) and subsequent liver transplantation (LT) on serum levels of these growth factors and their BPs in four children and six adults for up to 2 years. Serum IGF-I and IGF-II were quantified by radioimmunoassay (RIA), IGFBP-3 by immunoradiometric assay (IRMA), and changes in IGFBP-1, -2, -3, and -4 were estimated by Western ligand blotting (WLB). In severe hepatic disease, serum concentrations of IGF-I (10 +/- 5 ng/mL) and IGF-II (126 +/- 32 ng/mL) were significantly (P < .01) less than in normal controls (170 +/- 37 and 590 +/- 41 ng/mL, respectively). One year following LT, the mean levels of IGF-I (344 +/- 55 ng/mL) and IGF-II (627 +/- 38 ng/mL) were within normal limits and remained so for the duration of the study. Patients exhibited considerable variation not only in the rate of achieving normal IGF-I and IGF-II concentrations, but also in the ultimate height and stability of these peptide levels. Serum IGFBP-3 in hepatic failure (580 +/- 140 ng/mL) was significantly (P < .05) lower than in controls (2,900 +/- 220 ng/mL) and increased to normal levels (3,650 +/- 360 ng/mL) 2 to 14 weeks after LT. Serum levels of IGFBP-1, -2, and -4 before and after LT were variable but usually remained within normal limits compared with control sera. The decreases observed in IGF-I, IGF-II, and IGFBP-3 in patients with hepatic failure and their subsequent restoration after LT probably result primarily from the reduced number of functional hepatocytes in ESLD and their subsequent replacement by healthy hepatic tissue. These changes may also result from hormonal alterations and nutritional deficiencies known to exist in patients with severe liver dysfunction, which are corrected by LT. We conclude that LT in patients with severe hepatic insufficiency enhances the potential for normal cell growth and replication by restoring serum IGF-I, IGF-II, and IGFBP-3 concentrations to normal concomitantly with the improvement in hormonal and nutritional status.

Survival in metastatic ocular melanoma

Of 35 patients with metastatic ocular melanoma, 71.4% manifested liver involvement either initially (45.7%) or later in the course of the disease (25.7%). With liver involvement, the median survival was 2.2 months, whereas with pulmonary involvement it was 19.2 months after the first evidence of metastatic disease (P less than 0.01). Survival after recurrence varied also with age, those younger than 50 years having median survival of 14 months, with those 50 years or older having median survival 3.5 months (P less than 0.01). It also varied with the patient's sex, males having median survival 3 months after recurrence, and females 10.4 months (P less than 0.05). Younger patients and females had also longer disease-free intervals prior to recurrence. Surgical removal of metastases, when feasible, in combination with chemotherapy, seems to offer improved palliation, since a subsequent median survival thus of 18.4 months was observed with 3/15 patients alive disease-free 1 to 3 years later, while the median survival of 20 patients not treated with surgery was 2.5 months. Most of this difference in survival, however, is due to a difference in tumor load between the two groups, with patients subjected to surgery having lesser amounts of tumor and/or more favorable sites.

Extensive resections of isolated metastasis from carcinoma of the colon and rectum

The results of this study show that hepatic resection for metastatic carcinoma of the colon and rectum is an effective treatment modality. The duration and quality of survival are better than those achieved by an other treatment modalities. The results of this study also show that hepatic resection is a safe procedure; however, a 50 per cent, two of four, mortality rate in patients undergoing a trisegmentectomy for metastatic disease points toward a need for better selection of patients. Adjuvant chemotherapy following hepatic resection has not been shown to be of any benefit in this series.

Electrophoresis of buffalo (bos bubalis) serum proteins including immunoglobulins

Antigenic components of buffalo (Bos bubalis) serum, which were also components of buffalo colostrum, seminal plasma, milk whey, saliva, and tears, were investigated by the ager gel diffusion test and immunoelectrophoresis. Immunoglobulins of buffalo serum were identified by immunoelectrophoresis employing rabbit-anti-buffalo serum and rabbit-anti-buffalo gamma-globulin. Based on immunoelectrophoretic patterns immunoglobulin G (IgG), IgGA, and IgM were detected both in the serum and colostrum of buffaloes. Tears contained both IgG and IgM. Cross-reactions of buffalo serum with seminal plasma, saliva, and milk whey were observed only in the IgG region. By polyacrylamide gel electrophoresis, lipoprotein (5.2% +/- 0.41), IgM (11.4% +/- 3.1), IgG (9.4% +/- 0.98), haptoglobin 21.8% +/- 3.73), transferrin (10.4% +/- 2.15), ceruloplasmin (7.8% +/- 1.3), postalbumin (20.8% +/- 2.09), and albumin (13.7% +/- 0.75) were identified provisionally.