Journal of the Association of Physicians of India

An interesting and rare case of name syndrome is reported here. A young patient presented with stroke (left side hemiperesis due to cardiac embolic stroke) and cutaneous lesions. Further investigations revealed that left atrial myxoma was the cause of cardioembolic stroke. Skin lesions were also present which included, nevi, ephelides and neurofibroma hence diagnosis of "NAME SYNDROME" was made.

Complication in 1000 consecutive Tread Mill Tests (TMT) done at the Cardiology Centre of Command Hospital (SC) Pune are reported. The tests were done following Bruce Protocol and analysed based on Selzer's criteria. Complications were noted in 18 cases (1.8%) which included ventricular fibrillation, ventricular tachycardia, atrial fibrillation, malignant VPBs, conduction disturbances, asystole following hyperventilation (HV), complete SA block following HV, atrial flutter following HV, hypotension and severe angina requiring ICCU care. No acute myocardial infarctions or deaths were noted. Coronary arteriography (CART) was done in 50 (5.0%) selected cases including 10 with complications. It is concluded that TMT is a safe procedure if carried out after proper patient selection and under supervision of an experienced and efficient team.

The aim of the study was to assess the relationship between depression and diabetic complications among urban south Indian type 2 diabetic subjects [T2DM]. T2DM subjects [n = 847] were recruited from the Chennai Urban Rural Epidemiology Study [CURES], a population based study in Chennai (formerly Madras) in South India. A previously validated depression questionnaire [PHQ-12 item] was administered. Four field stereo retinal colour photography was done and diabetic retinopathy [DR] was classified according to the Early Treatment Diabetic Retinopathy Study grading system. Neuropathy was diagnosed if the vibratory perception threshold of the right great toe, measured by biothesiometry, was > or = 20. Nephropathy was diagnosed if urinary albumin excretion was > or = 300 microg/mg creatinine. Peripheral vascular disease [PVD] was diagnosed if an ankle-brachial index was < 0.9. Coronary artery disease [CAD] was diagnosed based on a past history of documented myocardial infarction and/or electrocardiographic evidence of Q wave and/or ST segment changes. Of the 847 T2DM studied, 198 (23.4%) were found have depression. The prevalence of depression was significantly higher among diabetic subjects with DR (35.0% vs 21.1%, p < 0.001), neuropathy (28.4% vs 15.9%, p = 0.023), nephropathy (35.6% vs 24.5%, p = 0.04) and PVD (48.0% vs 27.4%, p < 0.001) as compared to subjects without these complications. DR, neuropathy, nephropathy, and PVD were associated with depression even after adjusting for age, gender, duration of diabetes and glycated haemoglobin. DR (Odds ratio [OR] = 2.19, Confidence interval [CI]:1.45-3.51, p < 0.001) was associated with depression even after adjusting for neuropathy and nephropathy. There was also a significant association between depression and neuropathy, after adjusting for retinopathy and nephropathy (OR = 2.07, CI: 1.41-3.04, p < 0.001). There was a significant association of depression with nephropathy but this was lost (OR = 1.71, CI: 0.87-3.35, p = 0.119) after adjustment for retinopathy. PVD (OR = 3.52, CI: 1.94-6.40, p < 0.001) remained significantly associated with depression even after adjusting for CAD. However, there was no significant association of depression with CAD (OR = 0.73, CI: 0.42 -1.27, p = 0.264). Among Asian Indians, the prevalence of depression is higher in T2DM subjects with retinopathy, neuropathy, nephropathy and PVD compared to those without the respective complications.

A prospective clinical and histopathological study of 103 patients with lymphomas is reported. Of these, 72 (69.9%) had non-Hodgkin's lymphoma (NHL) and 31 (30.1%) had Hodgkin's lymphoma (HL). The median age at presentation was 34 and 43 years for Hodgkin's and non-Hodgkin's lymphoma respectively, which is lower than that seen in the West. Fever and superficial lymphadenopathy were the commonest presenting features and 'B' symptoms were present in over 60% of both groups. Seventy-five per cent of NHL and 64.5% of HL presented in stages III and IV of the disease.

A total of 31,266 autopsies and 1556 renal biopsies were scrutinised over a period of 19 years (1968-1986) retrospectively and prospectively, with an aim to study the incidence and pattern of renal amyloidosis in western India. A total of 104 cases with amyloidosis were detected, 41 from the autopsy series (0.1%) and 63 from biopsies (4%). Secondary amyloidosis was seen in 83.7% and primary amyloidosis in 11.5%. The interval between the onset of predisposing disease and first evidence of amyloidosis varied from 2 months to 31 years. Tuberculosis of various organs was the main cause of secondary amyloidosis (72.4%). Nephrotic syndrome was a common mode of presentation (71.4%). Besides kidneys, which were involved in all cases, the liver, spleen and adrenals were other commonly involved organs at autopsy. Renal failure was the leading cause of death (34.1%).

Urine samples from 1048 cases clinically suspected to have urinary tract infection were examined for bacteriological culture and antibiotic sensitivity. Of 1048 cultures, 530 (50.5%) were sterile, 163 (15.5%) showed the presence of nonpathogenic bacteria and 11 (1%) revealed nonsignificant bacteriuria with Escherichia coli. Significant bacteriuria (more than 10(5)/ml) was found in the remaining 344 (32.8%) cases. Escherichia coli was the predominant pathogen isolated from 170 (16.2%) samples; Klebsiella aerogenes was the next in order, found in 46 (4.3%) cases. Streptococcus pyogenes was isolated in 37 (3.5%), Pseudomonas aeruginosa in 29 (2.7%), Proteus mirabilis in 26 (2.4%), Streptococcus faecalis in 21 (2.0%), Staphylococcus aureus in 12 (1%) and Citrobacter freundii in 3 cases. Nalidixic acid was the most effective drug against gram negative organisms. Nitrofurantoin was the next antibiotic of choice, whereas cephalexin was the third drug in order of sensitivity. Ampicillin was the first drug of choice in infection with gram positive cocci, followed by nitrofurantoin, tetracycline, cephalexin and cephaloridine. The results of sensitivity tests emphasise the problem of multiple drug resistance in our community.

The clinical profile of one hundred and six biopsy proved patients with sarcoidosis is reported from New Delhi. The disease occurred more frequently in males (68 of the 106; 64%) in their fifth decade. Dry cough (83%), exertional dyspnoea (61%), fever (56%) and joint pains (44%) were frequent symptoms. Hepatomegaly (45%), peripheral lymphadenopathy (45%), cutaneous involvement (42%), presence of crepitations (36%) were frequent signs. In addition, ocular symptoms (18%), parotid gland enlargement (12%), facial nerve palsy (8%) were observed. Audible wheeze was present in nine patients. Radiologically, 25 (24%), 67 (63%) and 14 (13%) of patients belonged to stage I, II and III respectively at presentation. More than one sibling was involved in six families. Pulmonary functions revealed mixed obstructive and restrictive ventilatory defect. However, obstructive ventilatory defect was predominant. Systemic steroids were used in 81 patients who regularly followed up. Frequent relapses occurred on tapering off or stopping the corticosteroids in 21 patients. History of malaise (p < 0.05), presence of crepitations (p < 0.05), wheezing (p < 0.05), peripheral blood eosinophilia (p < 0.05) and FEV1/FVC (%) < 65% of the predicted value (p < 0.05), were independent predictors of relapse. Hyperuricaemia, hitherto unreported in patients with sarcoidosis was observed in 41% of patients for whom values were available. Two patients died; one from cardiomyopathy and another from stroke. In summary, constitutional symptoms such as fever, weight loss and pulmonary infiltrates, were more frequently encountered in Indian patients with sarcoidosis as compared to western studies. A high index of clinical suspicion and histopathological confirmation early in the illness are required to ascertain the diagnosis lest these patients will get treated as tuberculosis with potentially hepatotoxic drugs.

Clinical and haemodynamic profile of 107 adult patients above the age of 15 years with TOF was analysed. Cardiac catherization and selective cine-angiography were performed in all cases. Infundibular pulmonary stenosis, mal-alignment type of ventricular septal defect, mitral-aortic fibrous continuity and equal systolic pressures in both the ventricles and aorta were considered mandatory for the diagnosis of Tetralogy of Fallot. Aortic regurgitation was seen in 26 cases (24%), tricuspid regurgitation in 22 cases (21%), absent pulmonary valve in 3 cases (3%), branch pulmonary artery stenosis in 9 case (8.4%), major aortopulmonary collaterals in 15 cases (14%), right atrial pressure was more than 10 mmHg in 10 cases (11%) and right ventricular end diastolic pressure more than 9 mmHg in 73 cases (68%). The left ventricular end diastolic pressure was above 13 mmHg in 58 cases (54%).

The clinical profile of 109 cases of bronchogenic carcinoma has been studied. Definite histopathological typing of malignancy was possible in 61 patients, squamous cell carcinoma being the commonest tumour in 27 followed by small cell carcinoma in 16, adenocarcinoma in 11 and large cell carcinoma in 7. Another 23 patients showed changes suggestive of malignancy on histological/cytological examination. Definitive diagnosis was obtained in half of the patients by bronchial biopsy, in 16% by bronchial aspiration fluid cytology, in 13% by pleural biopsy, in 11% by lymph node biopsy and in others by pleural fluid cytology, lung biopsy and skin biopsy. Commonest radiological involvement among different cell types was hilar involvement in small cell carcinoma in 62%, evidence of bronchial obstruction (collapse/consolidation) in squamous cell carcinoma in 56%, peripheral mass in adenocarcinoma in 54% and cavitation in a mass in squamous cell carcinoma in 15% cases.

Eleven patients of apical hypertrophic cardiomyopathy were studied by clinical, electrocardiography, systolic and diastolic time intervals, echocardiographic and pulsed Doppler methods. The patients were between 20-55 years of age. There were 10 males and 1 female. Chest discomfort was the predominant symptom. ECG revealed giant T wave inversion in precordial leads in six cases, LAHB and LBBB in 2 cases and abnormal Q waves in 2 cases. Systolic function was normal. However indices of diastolic function (IVRT, RF wave, a/H, LAEI) were abnormal. There was marked increase in the thickness of left ventricle towards the appex (septum 30.4 +/- 3 mm, LVPW 23.2 +/- 7 mm with cavity obliteration). SAM of AML was not observed. Doppler flow studies across aortic and mitral valves were normal.

Metabolics syndrome is common in SE Asian. An hypothesis that aberrant expression of perilipins and 11-beta-hydroxysteroid dehydrogenase-1 (11-beta-HSD-1) enzyme plays a significant role in the development of metabolic syndrome X in Indians is proposed. Thus, methods designed to target perilipins and 11-beta-HSD-1 may form a novel approach in the prevention and management of metabolic syndrome X.

Patterns of rheumatic diseases and antirheumatic drug usage in different regions of India were analysed. The data was collected from a post-marketing surveillance of diclofenac sodium (Voveran) in 11931 patients. The common conditions were-rheumatoid arthritis (RA) 28.1%, osteoarthrosis (OA) 24.8%, soft-tissue rheumatism 12.4%, cervical spondylosis 6%, ankylosing spondylitis (AS) 3.5%, gout 2%. East zone had a significantly lower proportion of osteoarthritis (20.9%). The age distribution and sex ratios of RA, OA and AS were in line with literature reports. The severity of illness was moderate in 62% and duration was more than 6 months in 50.2%. Data on NSAID usage showed a preponderance of combinations and ibuprofen. There were no significant differences in NSAID usage across diseases or regions.

There is only scanty data on tissue Doppler imaging (TDI) of 'normal' adults. Twenty eight asymptomatic adults (20-45 yrs) without cardiovascular risk factors, clinic BP < or = 120/80mmHg and normal echocardiographic examination were evaluated by tissue Doppler imaging to find normal reference values in this population. There was significant heterogeneity in TDI velocities and duration of different segments of left ventricle (LV). Sa and Ea velocities were lower at medial mitral annulus and middle part of interventricular septum (IVS) than at lateral mitral annulus and middle part of left ventricular lateral wall. Isovolumic contraction time (IVCT) was significantly less at lateral mitral annulus and mid part of lateral wall of LV. Isovolumic relaxation time (IVRT) was significantly less at lateral mitral annulus. Aa velocity was lower at middle part of IVS. E/Ea velocity ratio was significantly lower at lateral mitral annulus. Ea/Aa velocity ratio was always more than 1. Relatively higher values were recorded at lateral mitral annulus and mid part of left lateral wall. Myocardial performance index values were higher at mid segments than at annulus. Our data provides reference values of TDI for healthy normal adults and may help in the detection of onset of early diastolic dysfunction in this age group.