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   Table of Contents - Current issue
September-December 2019
Volume 5 | Issue 3
Page Nos. 135-227

Online since Friday, December 20, 2019

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From Angina to Leptospirosis p. 135
Sandeep Seth, Shyamal K Goswami
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Application of Bayesian Analysis in Medical Diagnosis p. 136
Vivek Verma, Ashwani Kumar Mishra, Rajiv Narang
In this work, we outlined the application of the Bayesian technique for integrating the results of multiple tests while treating any disease. We provided an overview of the fundamental concept of Bayesian analysis in making an inference about a phenomenon using a concordance between available information and prior knowledge. An attempt is being made to demonstrate the applicability using core aspects, viz., nature of probability, parameters, and inferential procedure used to draw inference about the population characteristic under both paradigms. Here, we tried to sketch the underlying steps and assumptions regarding use of the Bayes theorem and the analytical techniques that can be used to analyze and interpret medical data while treating any disease.
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Cardiology update – Third quarter Highly accessed article p. 142
Satyavir Yadav
In continuation of previous updates this article contains some recent trials which includes CAPTURE study that showed benefits of carotid filter in stroke prevention,THEMIS study showed that in stable CAD patients ticagrelor plus aspirin had a lower incidence of ischemic cardiovascular events but a higher incidence of major bleeding than aspirin alone, AMBER study concluded that potassium binder patiromer enabled more patients to continue treatment with spironolactone with less hyperkalaemia.
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Acute Myocardial Infarction: Bedside Case Discussion p. 146
Bharath Raj Kidambi, Sai Krishna Reddy, Vijay Surampalli
This is a bedside case discussion of a patient presenting with acute myocardial infarction. The symptoms and signs are discussed. The choices at each stage, the electrocardiogram (ECG), the angiogram, and the therapeutic findings are discussed in detail. The context with reference to India is also discussed. The differential diagnosis of the history of presentation is also discussed. ECG localization of myocardial infarction, management of acute coronary occlusion, and medical management of myocardial infarction are discussed.
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Platelet Blockage: Prasugrel versus Ticagrelor: Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 5 p. 154
Venkatakrishnan Ramakumar
The Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 5 trial randomized patients with acute coronary syndrome for whom invasive treatment was planned to ticagrelor versus prasugrel. At 1-year, prasugrel was associated with a 2.4% absolute reduction in the primary outcome. The trial suggests that prasugrel may be superior to ticagrelor in reducing the thrombotic outcomes. It could be that once daily dosing with prasugrel and higher rate of drug discontinuation in the ticagrelor group may be the mechanism.
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Types of sampling in research p. 157
Pooja Bhardwaj
Sampling is one of the most important factors which determines the accuracy of a study. This article review the sampling techniques used in research including Probability sampling techniques, which include simple random sampling, systematic random sampling and stratified random sampling and Non-probability sampling, which include quota sampling, self-selection sampling, convenience sampling, snowball sampling and purposive sampling.
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History of medicine – William heberden p. 164
Shivani Vashista
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Evaluation of Serum Vitamin D Level as a Prognostic Marker in the Clinical Manifestation of Acute Coronary Syndrome Patients p. 166
Hiren Anghan, Jayesh Prajapati, Iva Vipul Patel, Senthilraj Thangasami, Nikunj Patel
Introduction: Epidemiologic studies have shown a strong association between Vitamin D deficiency and cardiovascular risk factors, myocardial infarction, and all-cause cardiovascular mortality. The purpose of this study was to determine the clinical implications of serum Vitamin D levels in an unselected cohort of acute coronary syndrome (ACS) patients at the time of hospital admission. Methods: This was a prospective observational study which enrolled a total of 310 patients from December 2015 to March 2018. The consecutive in-hospital patients with ACS diagnosed by the typical history of angina, electrocardiography changes, with or without cardiac enzymes were included in the study. The primary endpoint of the study was all-cause death during hospitalization. The secondary endpoint was the in-hospital incidence of major adverse cardiac events (MACEs). Results: The number of patients with diabetes and dyslipidemia was significantly higher in the Vitamin D-deficient group (46.7%, P = 0.04 and 45.4%, P = <0.001, respectively). The blood glucose, hemoglobin A1C, low-density lipoprotein, and total cholesterol were significantly higher in Vitamin D-deficient group (P = 0.045, 0.048, 0.013, and 0.024, respectively). There was no any relation of mortality and MACE between normal Vitamin D and Vitamin D deficiency patients. Conclusion: Vitamin D deficiency and insufficiency were common in patients with the ACS. In the current study, ACS patients with diabetes and dyslipidemia were strongly associated with Vitamin D deficiency, but there was no correlation between Vitamin D deficiency and ACS outcomes.
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Impact on variation in the direction of cuff bladder on blood pressure readings p. 171
Bukar Alhaji Grema, Ismail Inuwa Mohammed, Godpower Chinedu Michael, Ibrahim Aliyu
Introduction: Elevated blood pressure (BP)/hypertension contributes significantly to global morbidity and mortality. It is a silent killer; therefore, earlier diagnosis is imperative. A simple instrument called sphygmomanometer measures BP. Getting an accurate and precise reading is essential for making the diagnosis. Our study sorts to determine if there is any significant change in BP readings when the bladder cuff is inverted during BP measurement. Materials and Methods: This was a cross-sectional study involving 540 individuals who were consecutively recruited from the outpatient clinics over a year period. BP was measured with a mercury sphygmomanometer in three postures of sitting, standing, and supine comparing the standard protocol (control) and our designed protocol of inverted cuff (test). Results: The mean systolic and diastolic BP for all the postures for both sexes were significantly corresponding for both test positions in majority of the age groups; all observed differences in means were <5 mmHg which is within the acceptable limit. The Bland–Altman plot showed significant agreement for the control and test positions in diastole and systole in all the three postures. The mean of the differences of the control and test procedures were −0.38 ± 2.70, 0.27 ± 2.18 (diastole and systole in sitting); −0.46 ± 2.88, 0.09 ± 1.58 (diastole and systole in standing); −0.62 ± 3.14, 0.09 ± 1.82 (diastole and systole in supine). Conclusion: Our test procedure showed agreement with the standard protocol of cuff positioning. Therefore, it could be used interchangeably.
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The Satisfaction Levels of Heart Transplant Recipients Seeking Posttransplant Medical Care at a Tertiary Care Government Hospital: A Questionnaire-Based Study p. 178
Sarvesh Pal Singh, Manoj Kumar Sahu, Sandeep Seth, Milind Padmakar Hote
Background: India is a country of approximately 1.35 billion people. Heart transplant surgery is resource intensive requiring extensive efforts both on the part of the patient and the treating physician. This study was designed to assess the satisfaction level of heart transplant recipients seeking post transplant medical care at our hospital. Methods: Twenty heart transplant recipients who are in our follow up participated in this study anonymously. The quality of medical care was evaluated by using Long Form Patient Satisfaction Questionnaire III (RAND Healthcare, CA). Results: All the grouped items - general satisfaction (82.4%), technical competence (82.4%), interpersonal aspects (79.1%), communication (84%), financial aspects (76.7%), time spent with the doctor (84%) and access to care (77.3%) had similar satisfaction levels. The aspects of “communication” and “time spent with the doctor” had maximum satisfaction levels at 84%. Conclusion: The average satisfaction level of heart transplant recipients for the medical care they receive at AIIMS, New Delhi (as evaluated by the help of long form patient satisfaction questionnaire III) was 80%.
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Identifying the Prevalence of the Life-threatening Atrial Fibrillation Using a Smartphone-Based Wireless Electrocardiography Device: An Observational Study Highly accessed article p. 186
Esha Dyundi, Prashant Gupta, Robin Choudhary
Background: Atrial Fibrillation (AF) is one of the most common types of arrhythmia across the world. Yet, many cases remain undiagnosed making it difficult to estimate the exact prevalence of AF. Aims: This observational study was done to understand the feasibility of a hand-held electrocardiography (ECG) device – SanketLife – in detecting AF cases. Materials and Methods: In the study, ECG data collected from the device for a period of 2 months were evaluated to detect AF cases. The device took 12-lead and single-lead ECG recordings in various health-care settings including self-monitoring done by patients at their homes and in diagnostic laboratories using the device for screening as well as hospitals using the device in their outpatient departments. The reports were saved in SanketLife Cloud and evaluated anonymously by a certified ECG expert and the findings were further confirmed by a cardiologist to evaluate AF or any other findings in the ECG. Results: SanketLife effectively captured AF cases and demonstrated the feasibility of using such a device in any care setting being clinical or home monitoring. Conclusion: The study concluded that the device can be used for regular monitoring by patients suffering from chronic AF. In health-care settings ranging from primary care to tertiary care, the device can be beneficial.
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Prevalence and Determinants of Hyperuricemia in South Indian Adult Patients with Stable Coronary Artery Disease p. 191
Saklesh Patil, Govindan Vijayaraghavan, CC Kartha
Background: There is paucity of studies on the prevalence of hyperuricemia in Indian patients with coronary artery disease (CAD). Population differences have been observed in both the prevalence and relationship of hyperuricemia with CAD risk factors in previous studies. Objectives: Our study objectives were to analyze the prevalence and determinants of hyperuricemia in south Indian patients with stable and angiographic evidence of CAD. Methods: Study subjects were 520 patients with stable CAD. Severity of CAD was assessed by estimating the Gensini score. Patients in heart failure, those who had a recent myocardial infarction (< 7 days ), or liver disease or impaired renal function (GFR < 30ml/min), and those with hematological or oncological disorders were excluded from the study. Medical and dietitic history, clinical and laboratory data of patients were recorded. Hyperuricemia was diagnosed based on cut off values of ≥7mg/dl of serum uric acid in men and ≥ 6.5 mg/dl of serum uric acid in women. Results: Hyperuricemia was present in 242 patients (46.5%; 95% CI : 42.29-50.84%). A significant association (P < 0.001) was seen between hyperuricemia and consumption of a diet which could influence serum uric acid levels as well as history of regular alcohol consumption. There was no statistically significant association between hyperuricemia and intake of diuretics, presence of either diabetes or hypertension and serum cholesterol levels. Serum triglyceride levels were significantly more in those with hyperuricemia than in those with normal serum uric acid levels (P 0.03). There was no correlation between serum uric acid levels and presence or absence of urinary calculi. The mean Gensini score was 22.57 ± 9.99 in patients with hyperuricemia (n = 242) and the score was 9.42 ± 4.77 in those with normal serum uric acid levels (n = 278). This significant difference (P < 0.001) between the two groups indicate a more severe degree of severity of CAD in patients with hyperuricemia. Conclusion: Our study indicates a high prevalence of hyperuricemia in south Indian patients with stable CAD and that hyperuricemia is associated with severity of CAD, though it does not correlate with conventional risk factors such as diabetes, hypertension and elevated cholesterol levels.
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Peripheral arterial disease in antiretroviral therapy naïve HIV infected patients – A single centre case control study from Eastern India p. 197
Dibbendhu Khanra, Anindya Mukherjee, Arunansu Talukdar, Anindya Mukherjee, SK Sinha
Background and Objectives: Human immunodeficiency virus (HIV)-induced endothelial dysfunction leads to premature atherosclerosis, which may manifest as peripheral arterial disease (PAD) of the lower limbs. Studies are not available on the prevalence of PAD among antiretroviral therapy (ART)-naïve HIV-infected population. The objective was to explore the prevalence of PAD among HIV seropositive cases and to determine the relation of PAD with HIV infectivity and with CD4 count. Materials and Methods: This hospital-based case-control study included 100 newly diagnosed HIV seropositive ART naïve cases (age 20–49 years) and 100 HIV seronegative frequency or group matched controls. Demographic, clinical and routine laboratory parameters, and ankle-brachial pressure index (ABI) were studied. PAD was diagnosed by Doppler study of lower limb arteries. Results: The prevalence of PAD was significantly more among HIV-infected cases (71%) in comparison to HIV-negative controls (P < 0.001). Abnormalities in ABI were present among 75% (53/71) of total PAD cases in our study. Among the cases of PAD, 53% (38/71) patients were asymptomatic. The mean CD4 count among the HIV-positive PAD cases was 220 cells/dl. HIV seropositivity was found to be significantly associated with the development of PAD. Male gender, concurrent tuberculosis, and low CD4 count came out to be individually associated with PAD among HIV seropositive cases in multivariate analysis. Conclusions: The prevalence of symptomatic and asymptomatic PAD was high among ART-naïve HIV-infected cases of relatively younger age group. Future studies should validate the Doppler findings suggestive of PAD among HIV seropositive patients with different inflammatory markers. Prospective studies on Doppler evaluation of endothelial dysfunction among asymptomatic HIV patients should be undertaken to establish or disprove the role of ART.
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Cor Triatriatum Sinister Presenting with Acute Myocardial Infarction p. 208
Dibbendhu Khanra, Shishir Soni, Ramlal Ola, Bhanu Duggal
A case of Cor Triatriatum Sinister presenting with acute myocardial infarction is described. The patient underwemt a successful coronary angioplasty.
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Intercoronary fistula: Rarest of rare coronary anomaly p. 213
Sunil Nichaldas Gurmukhani, Nikita Chaturvedi, Nishit Saradava, Samkit Mutha, Sanjay Shah, Tejas Patel
Coronary artery fistulas are rare but fascinating anomalies. It is defined as an abnormal direct vascular connection from coronary artery to a cardiac chamber or major central blood vessel without an intervening capillary bed. Among all coronary fistulas, intercoronary fistula without obstructive coronary artery disease is extremely rare. Such huge intercoronary fistula without any obstructive coronary artery disease is not described previously in literature to best of our knowledge. Clinical significance and future implications of these anomalies is unknown and subject of debate.
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Coronary Dissection or Pseudoaneurysm? An Ambiguity Resolved by Optical Coherence Tomography p. 215
Pradyot Tiwari, Tejas Patel, Sanjay Shah
Coronary angiographic appearance of ambiguous-looking lesions can be deciphered by the use of optical coherence tomography. An apparent pseudoaneurysm on coronary angiography turned out to be a coronary dissection associated with aneurysm formation.
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Leptospirosis: A Diagnostic Challenge at Autopsy: Report of Two Cases p. 217
Sharada R Rane, Varsha Bhatia
Leptospirosis is an important sporadic zoonotic disease. This disease is caused by the spirochete leptospira icterohemorrhagica. In India, leptospirosis has always remained a major health concern, particularly during monsoons. This disease mainly affects vital organs such as the lung, kidney, and heart. Acute respiratory distress syndrome and acute renal failure mainly contribute to the mortality in patients, but cardiac involvement leading to death still remains an underestimated critical clinical factor. We report here two autopsy cases and highlight histopathological changes in heart which helped us in diagnosing in correlation with other organ findings the final cause of death as leptospirosis.
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Navigating an Extremely Tortuous and Diseased Subclavian Artery: Use of an Altered Tiger Catheter p. 221
Pradyot Tiwari, Sanjay Shah, Tejas Patel
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Ego is the Enemy p. 223
Udbhav Seth
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Platypnea–Orthodeoxia syndrome: Revisiting the enigmatical hypoxemia! p. 225
Rohan Magoon, Neeti Makhija, Subhajit Sahoo, Devishree Das
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Professor SD Seth: A Tribute p. 227
Subir K Maulik
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