Atrial synchronous left ventricular only pacing with VDD pacemaker system – A cost effective alternative to conventional cardiac resynchronization therapy

Introduction

Atrial synchronous left ventricular (LV) only pacing using two leads and VDD pacemaker could be a cost effective alternative to conventional cardiac resynchronization therapy (CRT).

Methods

We implanted right atrial (RA) and LV leads with VDD pulse generator (LV only pacing) in five carefully screened heart failure patients who could not afford conventional CRT. All had NYHA class III/IV symptoms despite maximal guideline directed medical therapy. The sensed atrioventricular delay was programmed to pre-excite the LV and achieve fusion beat. Response to treatment was assessed at 6 months.

Results

Four patients were males. The mean age was 58 ± 12 years. At follow up, there was improvement in electrocardiographic, and echocardiographic parameters: Mean QRS duration decreased from 174 ± 17 msec to 128 ± 10.9 msec (p = 0.009), LV end-diastolic diameter decreased from 73.2 ± 12 mm to 65.8 ± 9.6 mm (p = 0.026), LV end-systolic diameter decreased from 65 ± 12 mm to 54 ± 10 mm (p = 0.020). There was a trend towards reduction of LV end-systolic and end-diastolic volumes. LV ejection fraction improved from 25 ± 6% to 34 ± 6% (p = 0.013) and left atrial dimension reduced from 44 ± 4 mm to 39 ± 5 mm (p = 0.045). All patients improved clinically.

Conclusion

RA-LV pacing using VDD pacemaker is a safe and effective technique of CRT. This may be a cost effective alternative to conventional CRT for patients in developing countries.     

A comparison of sonourethrography and retrograde urethrography in evaluation of anterior urethral strictures

AIM: This prospective study was undertaken to evaluate the abnormalities of the male anterior urethra using high-resolution ultrasound (sonourethrography) and to compare the efficacy with that of retrograde urethrography (RGU) using operative findings as the gold standard. MATERIALS AND METHODS: Seventy patients with symptoms of lower urinary tract obstruction underwent RGU followed by sonourethrography. The sonologist was blinded to the findings of RGU. The parameters studied were compared with the intra-operative findings as gold standard, and the sensitivity, specificity and overall accuracy for the procedures were calculated. Chi-square test and kappa statistics were used where appropriate. RESULTS: All patients found to have urethral stricture disease by RGU were also detected by sonourethrography and confirmed intra-operatively. In the estimation of stricture length, RGU showed a lower sensitivity (60-80%) for lengths 1-4 cm, compared with sonourethrography (73.3-100%). Spongiofibrosis was detected by sonourethrography with a sensitivity of 77.3-83.3%. All the false tracts and calculi detected at sonourethrography were confirmed at surgery, whereas RGU showed a low sensitivity in their detection. The complications encountered during the procedures were pain, urethral bleeding and contrast intravasation. The frequency of pain during RGU was greater (p < 0.001); however, the difference in frequency of bleeding after the two procedures was not significant (p < 0.5). CONCLUSION: RGU and sonourethrography are equally efficacious in detection of anterior urethral strictures. Further characterization of strictures in terms of length, diameter and periurethral pathologies, like spongiofibrosis and false tracts, is done with greater sensitivity using sonourethrography as compared with RGU, with the added benefit of lower incidence of complications.     

Preceding standard therapy is the likely cause of MDS after autotransplants for multiple myeloma

Myelodysplastic syndromes (MDS) and acute myeloid leukaemia (AML) have been reported after autologous transplantation (AT) for lymphoma. It is not clear whether myeloablative therapy used in conjunction with autologous transplantation contributes to the development of MDS/AML or whether the conventional chemotherapy preceding the transplant, and administered over a prolonged period, causes these secondary malignancies. To address this issue, we examined 188 patients with multiple myeloma (MM) who had received AT. 71 patients with no more than one cycle of standard chemotherapy were enrolled in our Total Therapy program, designed to avoid exposure to alkylating agents prior to peripheral blood stem cell mobilization (group 1). The median duration of pre-transplant therapy in group 1 was 7.6 months and significantly shorter than the 24 months of 117 patients (group 2) with more prolonged conventional therapy ( P  = 0.0001). All seven patients developing MDS post-transplantation belonged to group 2 ( P  = 0.02); the median durations from initial therapy and first transplant were 66 months (range 38–86) and 24 months (range 9–39), respectively. Our findings provide evidence that prolonged standard-dose alkylating agent therapy prior to transplantation, rather than autotransplant-supported myeloablative treatment, is associated with development of MDS/AML. Stem cell damaging alkylator treatment should be avoided, not to compromise PBSC collection, but also to reduce the risk of treatment-related MDS/AML.     

Valvular heart disease in Antiphospholipid antibody syndrome: Isolated Tricuspid stenosis

Antiphospholipid antibody syndrome (APLS) is a rare disorder characterized by a hypercoagulable state. Manifestations include arterial or venous thrombosis, recurrent fetal wastage, coronary artery disease, valvular heart disease, dilated cardiomyopathy, pulmonary artery hypertension, and intracardiac thrombus. Most commonly mitral valve is affected followed by aortic and then tricuspid valve. In this report, a rare case of spontaneous aortic thrombosis with tricuspid stenosis uncomplicated by other valve lesions is presented with clinical and echocardiographic studies and computed tomographic images.     

Antibody response in pulmonary tuberculosis against recombinant 27kDa (MPT51, Rv3803c) protein of Mycobacterium tuberculosis

The objective of this study is to evaluate the recombinant 27kDa (MPT51, Rv3803c) antigen of M. tuberculosis H37Rv, expressed in E. coli in enzyme linked immunosorbent assays (ELISA) to estimate the IgG, IgA and IgM levels in sera from adult pulmonary tuberculosis patients and control groups. Sera from smear and culture positive tuberculosis patients (S + C +) were positive for anti-MPT51 IgG, IgA and IgM, with a sensitivity of 57%, 47% and 13%, respectively. The sensitivity of the test improved to a level of 71% for IgG+IgA without significantly compromising the specificity (IgG of 98%, IgG+IgA of 95%). Addition of IgM results did not enhance the sensitivity appreciably, over and above that of IgG+IgA (72% vs 71%). Among the smear-negative but culture-positive cases (S-C+), 34% were positive for IgG, while in smear and culture-negative but X-ray-positive cases (S-C-), 42% were positive for IgG. Polyethylene glycol precipitation (PEG) of the circulating immune complex (CIC) in sera was carried out. The CIC-bound antibodies to MPT51 were assessed using ELISA. Measuring the IgG+IgA combination positivities of the CIC-bound antibodies gave a poor sensitivity of 21%, 18% and 10%, respectively. The specificity of the assay by these combinations was maintained at 94%.     

Relationship of raised serum total and protein bound sialic acid levels with hyperinsulinemia and indices of insulin sensitivity and insulin resistance in non-diabetic normotensive obese subjects

AimsObesity is known to be associated with cardiovascular disease and interaction between inflammation and insulin resistance is reported to enhance the cardiovascular risk in these subjects. The present study was designed to assess indices of insulin sensitivity, insulin resistance and sialic acid levels and their association in non-diabetic normotensives obese subjects.Materials and methodsThe present study was conducted in 30 obese male subjects and results were compared with 30 subjects with normal body weight. Insulin, total sialic acid and protein bound sialic acid were estimated in all the subjects. Insulin resistance was calculated by using Homeostatic Model Assessment-insulin resistance formula. Insulin sensitivity was assessed by quantitative insulin check index and insulin sensitivity index.ResultsInsulin resistance, serum total and protein bound sialic acid levels were significantly increased in obese cases as compared to non-obese controls. Total sialic acid showed significant positive correlation with HOMA-IR (p < 0.01), BMI (p < 0.01), waist and hip circumference (p < 0.01) and negative correlation with QUICKI (p < 0.01) and insulin sensitivity index (p = 0.018). There was no significant correlation between protein bound sialic acid and indices of insulin resistance and insulin sensitivity.ConclusionSialic acid levels are elevated in obese subjects and its association with insulin resistance and reduced insulin sensitivity may enhance the cardiovascular risk in these subjects.     

Rapid particle agglutination test for human immunodeficiency virus: hospital-based evaluation

The performance of a rapid particle agglutination test for human immunodeficiency virus (HIV) (Capillus HIV type 1 [HIV-1]/HIV-2) on hospital samples is compared with enzyme-linked immunosorbent assays. The test had a sensitivity and specificity of 99 and 98.9%, respectively. In addition, the test was reactive on plasma samples from all individuals infected with HIV-1 subtype C. This test can safely be used for voluntary counseling and testing in India.     

Best practice in primary care pathology: review 4

This fourth best practice review examines four series of common primary care questions in laboratory medicine are examined in this review: (1) safety monitoring for three common drugs; (2) use of prostate-specific antigen; (3) investigation of vaginal discharge; and (4) investigation of subfertility. The review is presented in question-answer format, referenced for each question series. The recommendations represent a precis of the guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most of them are consensus based rather than evidence based. They will be updated periodically to take account of new information.     

Symphysis-fundal height measurement--a reliable parameter for assessment of fetal growth

Intrauterine growth retardation (IUGR) is one of the major causes of perinatal mortality in countries like India. Fundal height traditionally measured in relation to umbilicus and xiphisternum is of little value in predicting the fetal growth. Some workers have found that symphysis fundal height (SFH) measurements could be useful in screening pregnancies for growth retardation. A prospective study was taken up in 109 pregnant women attending the antenatal clinic of our Institution. Serial measurements of SFH, abdominal girth, double abdominal wall thickness (DAWT) and maternal weight gain were recorded. SFH measurements obtained were arranged on the basis of 10th, 50th and 90th percentile and represented graphically. Statistical analysis showed that the coefficient of variation was smallest for SFH as compared to abdominal girth and maternal weight gain. The babies (single born) delivered were between 2600 g and 3700 g irrespective of whether the maternal weight gain was 143 g/week or 424 g/week. The abdominal wall thickness had no influence on the measurement of SFH. An attempt was made to develop a nomogram of SFH for our population. This is a simple, reliable and inexpensive method in the screening of pregnancies for IUGR.     

Infant mortality in Pondicherry--an analysis of a cohort of 8185 births.

Infant mortality rate is one of the 12 global indicators for monitoring Health for All. Reliable data on infant mortality are not available for the majority of developing countries including India. To plan strategies for bringing down the rate and, later, to evaluate them, 'Cause Specific Rates' would be necessary. Pondicherry has achieved low rates of infant mortality. A study was conducted in the Anganwadis of Pondicherry to determine the causes of infant deaths. The 8185 children born between 1-4-1987 and 31-3-1988 in Pondicherry formed the study group. The Anganwadi workers collected information on the cause of death for the 222 children dying within the first year. The infant mortality rate was 27.1 per 1000 live births. Acute respiratory infections and diarrheal diseases accounted for 45% of the deaths.