- Case Study Presentation
Mrs. Vaishali P Thakkar, Miss. GD Koppikar
Mr. Lopes John 58 years old male, a Christian by community is a known case of Diabetes and Hypertension since 6-7 years. He has recently suffered with anterior wall myocardial infarction hence he is advised Coronary Angiography (CAG) by Dr. ED Borges. On further investigation he is advised Coronary Artery Bypass Grafting (CABG). All other blood and urine investigations are normal. Patient is switched over from Oral hypoglycaemic agents (OHA) to insulin for strict blood sugar control by Dr. S Kumar Chief Diabetologist from Surgery point of view. We prescribed him 1600 Kcal Diabetic Diet. His hospital diet recall (day 1) shows good compliance to the diet which shows that patient has consumed around 1400 Kcals and 55 gms protein.
He is operated for CABG by Dr. A Trivedi on 13/01/07.
His day 2 hospital recall on 18/01/07 shows that even on the 5th post-op day, he has consumed around 670 kcals and 20 gms protein. His home diet recall reflects his lifestyle which is typical of East Indian Christian whose staple diet is Non Vegetarian with minimum emphasis on vegetables and salad.
He is also a voracious eater, detail calculations of home diet recall suggests that he consumes around 2270 Kcals and 60 gms protein. This emphasizes the importance of Dietary counselling for the patient. On discharge, he is advised 1600 kcals Diabetic, low fat, high fibre, dietary cholesterol restricted to less than 200 mg/day diet keeping in mind his home diet recall, which would help him to adhere to the diet and also make it a welcome modification rather than punishment. Lifestyle modification techniques are taught to him by the dietician which will help him to accept these changes willingly and not revert to his original lifestyle.
- Morbidity and Mortality in Patients Admitted to Intensive Care Unit
SR Pandloskar, SV Joshi, HL Dhar
Background : To describe the outcome and the most frequent complications of patients in Intensive Care in Surgical and Non-Surgical group.
Design and Setting : Retrospective analysis of prospectively collected data of ICU.
Methods : Hundred patients in various age groups admitted to various specialities during January to April 2006 were included in this study. Patients were divided in two groups Surgical and Non-surgical. Surgical procedure includes PTCA with stent, CABG, Tumour excision and MVR. The clinical and laboratory data were collected at admission. Data recorded included; patient characteristics, underlying medical conditions responsible for ICU admission, need for ventilation, total duration of ICU stay and final outcome, and these data were analyzed for predicting survival using c2 test, odds ratio and t-test.
Results : One hundred patients were admitted to ICU from January 2006 to April 2006. Patients were divided into two groups Viz. Surgical group (n=60) and Non-surgical group (n=40). Mean age of patients in Surgical group was 52.25 ± 12.64 years and 54.18 ± 17.09 years in Non-surgical group. Male predominance was seen in both the groups (70% and 72.5% respectively). The average stay was not significant in either group (13.25 ± 1.89 Vs. 14.63 ± 2.11, p > 0.05). Comorbidity was seen in (61.67%) patients in Surgical group and 82.5% in Non-Surgical group; of which hypertension (30% Vs. 20%), diabetes mellitus (23.33% Vs. 20%), coronary artery disease (20% Vs.22.5%) and chronic kidney disease (1.67% Vs. 5%) difference was significantly higher in Non-Surgical group (p < 0.05). Raised LDH, SGOT, Serum Creatinine, Hyponatraemia and hypochloraemia were observed in both the groups. Mortality occurred in 13% of patients; which was significantly higher in both the groups. Mortality occurred in 13% of patients; which was significantly higher in Non-Surgical groups (5% Vs. 25%, p < 0.05) associated with raised LDH, Creatinine, SGOT, Urea, Blood Sugar and Hypocholesterolaemia, Hyponatraemia, Multi Organ System Failure (MOSF), acute renal failure and sepsis.
Conclusion : Presence of sepsis, MOSF and ventilation and cardiac ailments were correlated with higher mortality in patients in non surgical group.
- Surgial Outcome in Nonsmall Cell Lung Cancer : Hospital Based Study
Sanjeet Malik, SV Joshi, HL Dhar
Incidence of lung cancer has been increasing progressively, probably in relation with increasing cigarette smoking. Lung cancer is a major cause of cancer related death in developed countries and overall survival rate is still extremely poor. In literature, various risk factors in lung cancer are mentioned however, outcome of surgical cases along with biochemical markers are scarce.
Aim : To determine the outcome of patients operated and role of biochemical markers.
Methods : We analyzed 100 (Males - 76, Females - 24) consecutive patients (admitted during Jan 2005 - Dec 2005) with lung cancer in relation to surgical outcomes and various biochemical markers.
Results : Statistical analysis showed male preponderance however, males affected with lung cancer belonged to the higher age group than the females. Outcome of surgery in females (with no death) was better than in males where 8.7% died after surgical process. Significant high values of Lactic dehydrogenase were correlated with deaths (62.5%) during hospitalization compared to those who survived (15.22%). Significant high values of Alkaline phosphatase, LDH and metastasis were the main risk factors leading to deaths (37.5%).
Conclusion : Outcome of surgery was better in females (100% survival) compared to males (91.3%). LDH and alkaline phosphatase can be used as a biochemical marker in lung cancer. Diabetes mellitus, hypertension, metastasis along with anaemia, alkaline phosphatase and lactic dehydrogenase were the main risk factors leading to death during hospitalization.
- Sublingual Immunotherapy : A Novel Approach in the Treatment of Rhinitis
SV Joshi, DM Tripathi, HL Dhar
Specific allergen immunotherapy (SIT) involves the administration of allergen extracts to modify or abolish symptoms associated with atopic allergy. Allergen specific immunotherapy is a cornerstone in the management of respiratory allergy. The traditional subcutaneous route is burdened with the severe adverse reactions. In the present study, an attempt has been made to administer the allergen specific vaccine through oral route using multiple allergens in allergic bronchial asthma. The efficacy and safety with sublingual immunotherapy has already been reported in relation to allergic rhinitis.
Setting and Design : Clinical history, symptoms for the last 3 years with set criteria for immuno-modulation.
Material and Methods : A total number of 100 patients with rhinitis were scrutinized were subjected for detailed physical examination, family history, pulse, blood pressure, haemoglobin, stool examination and medication. Allergy skin testing with various allergens were performed by using modified skin prick test. Allergens showing reactions equivalent or more than positive control (histamine), symptoms before and after the therapy, Peak expiratory flow rate (PEFR), skin test, side effects and medications were studied in 45 patients.
Results and Conclusions : Our results of sublingual immunotherapy using multiple allergen showed significant reduction in symptoms, medication, modifying the natural course of the disease and reducing fresh sensitization. SLIT could be a viable alternative to SCIT, with the same rationale and indication. It could be used in association with proper pharmaco-therapy at the earlier stages of allergic bronchial asthma for optimal symptomatic relief.
- Interleukin-4 in Asthma - Comparison with Allergic Rhinitis with Respect to Exercise-induced Bronchospasm
R Mansi, SK Rajan, HL Dhar
Aim : To evaluate the role played by the inflammatory marker Interleukin-4 (IL-4) in nasobronchial allergy with respect to exercise-induced bronchospasm.
Study Design and Procedure : A prospective study which included 26 controls and 100 patients with nasobronchial allergy from the outpatient department of three tertiary care centres-Bombay Hospital trust, Bhatia Hospital and Mathadi Hospital, Mumbai city was carried out. The baseline Peak expiratory Flow Rate (PEFR) was recorded in all these subjects using Wright’s Mini Peak Flow Meter. These subjects were further subjected to exercise-testing. The Exercise-Induced Bronchospasm (EIB) index was calculated using Jones’ index. Post- exercise venous blood was collected from all the subjects and the cytokine IL-4 was estimated from the serum samples of these subjects by ELISA method. The levels of the cytokine IL-4 was correlated with the symptoms of nasobronchial allergy and with the EIB.
Results : The 26 controls were devoid of any symptoms of asthma, rhinitis or asthma and rhinitis. Out of 100 patients with nasobronchial allergy; 47 patients were asthmatics (21 with mild asthma; 26 with moderate asthma); 26 patients with rhinitis and 27 patients with both asthma and rhinitis. In the case of controls, EIB was positive (> 15%) in 6/26 (23.08%); 25/26 (96.15%) in moderate asthmatics; 19/21 (90.48%) in mild asthmatics; 9/26 (34.62%) in A.R. and in 24/27 (99.89%) in patients with asthma+A.R. IL-4 was normal (£ 5 pg/ml) in the serum of all the patients. EIB was correlated with serum IL-4 level.
Conclusion : EIB is a common occurrence in not only asthmatics but also in patients with rhinitis thereby necessitating to perform exercise-testing in these patients to avoid exercise-induced bronchospasm. The pro-inflammatory marker, cytokine: IL-4 plays an important role in determining the degree of inflammation in patients with nasobronchial allergy. The results of this study indicates that IL-4 is a specific marker of inflammation. Further studies are required to establish the clinical significance of this important inflammatory marker.
- Clinical and Biochemical Profile of Chronic Obstructive Pulmonary Disease (COPD) Patients
SA Biswas, SV Joshi, HL Dhar
Background : COPD is a heterogenous condition embracing several overlapping pathological processes. Variety of risk factors appear to increase the risk of developing COPD.
Design and Setting : Retrospective analysis of prospectively collected data of patients with COPD admitted to Bombay Hospital.
Methods : Eighty five patients in various age groups admitted to Bombay Hospital during January 2005 to October 2005 were included in this study. The clinical and laboratory data were collected at admission. Data recorded included; patient characteristics, underlying medical conditions, need for ventilation, total duration of hospital stay and final outcome. The data were analysed using odds ratio and t-test.
Results : Patients were divided into two groups viz. Males (Avg. Age 63.46% ± 12.17 years) and Females (Avg. Age 64.76% ± 15.56). Male predominance was seen in this series (75.29% and 24.71%) respectively. The average stay was not significant in either group (8.14% ± 7.26 vs 10.71% ± 8.35). Bronchial Asthma (25.88%), TB (22.35%), Pneumonia (9.41%), HT (40%), DM (16.47%), IHD (18.82%), Bronchiectasis (5.88%), Cor pulmonale (9.41%). Important comorbid conditions were Bronchial Asthma (23.43% vs. 33.33%), TB 23.43% vs. 19.04%), Pneumonia (9.37% vs 14.28), HT (59.37 vs. 28.57%), IHD (18.75% vs 19.04), Bronchiectasis (7.81 vs 4.76%). Significantly higher incidence in males was seen with regard to HT and Bronchiectasis in males. Raised LDH (23.43% vs. 33.33%), SGOT (20.31% vs 23.80%), Serum creatinine (59.75% vs 61.90%), Hyponatraemia (29.68% vs 52.38%) and Hypochloraemia (1.09 vs 66.66%) were observed in both the groups. Three males (3.5%) died during hospitalization associated with raised LDH, creatinine, SGOT, Urea, Hypocholesterolaemia, Hyponatraemia.
Conclusions : Deaths occurred only in males and were associated with raised LDH, creatinine, SGOT, SGPT, Alkaline phosphatase, Urea and low Cholesterol, Na, K, and Chloride. Though COPD is associated with smoking, and alcohol intake, it occurred in 24.70% of females. The mortality rate was 3.5%.
CELECOXIB AND RESTENOSIS
`These data suggest that the adjunctive use of celecoxib for 6 months after stent implantation in patients with coronary artery disease is safe and can reduce the need for revascularisation of the target lesion'
Drug-eluting stents can reduce neointimal hyperplasia in some coronary artery lesions, although restenosis remains a problem in practice. There are also concerns about long-term thrombotic complications after implantation of drug-eluting stents. Bon-Kwon Koo and colleagues assessed the use of the cyclo-oxygenase 2 inhibitor celecoxib to reduce restenosis of paclitaxel-eluting stents. The investigators report that adjuvant treatment with celecoxib reduces late luminal loss at 6 months in patients with paclitaxel-eluting stents without increasing the frequency of thrombotic cardiac events. In a Comment, Francesco Pelliccia and Vincenzo Pasceri state that although the strategy proposed by koo and colleagues is appealing and could be easily moved into clinical practice, several issues need to be addressed before anti-inflammatory drugs are proposed for everyday use.
N Engl J Med 2007; 356 : 1398
Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
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