Clinical profile, risk factors and aetiology of young stroke: a tertiary care hospital based study from the Sub-Himalayan region in North India

Background: Rapid urbanisation of rural areas is predicted to increase the incidence of risk factors for vascular events like stroke. There is scarcity of literature addressing issue of stroke from Sub-Himalayan region in North India.Methods:The study was conducted in the department of medicine, R. P. govt. medical college, Kangra, Himachal Pradesh. Consecutive patients between the age of 15-45 years presenting with signs and symptoms of stroke in a duration of one year were included in the study. CT scan-head and lipid profile was done in all patients. Other relevant investigations to rule out aetiology were undertaken.Results: Thirty two patients with the mean age of 41.1 ± 5.41 years were recruited. The incidence of stroke in young forming 8.55% of the total stroke patients (374). There were larger proportion of male patients with a ratio of 3:1.16   patients (50%) presented between 6 am and 12 pm in the   morning hours of day. Maximum patients presented in winter months from November to January. Average delay of presentation to hospital was 30.8 hours. 19 patients (59.3%) presented with infarct. Most common symptom reported was weakness in 18 (56.2%). Predominant traditional risk factors observed was hypertension in 18 (53.1%). Hyperhomocysteinemia was seen in 4 patients (12.5%). Primary antiphospholipid antibody syndrome was seen in 2 (6.25%).Conclusion:This study demonstrated predominant presence of conventional risk factors in young strokes. There was substantial time delay of presentation. Majority of patients presented in winter months. Prevention of vascular risk factors as well as issue of factors leading to delay in presentation needs to be addressed.

Comparison of efficacy of azilsartan with olmesartan in patients of hypertension: randomized controlled trial

Background: Azilsartan and olmesartan are members of ARBs, used in the management of hypertension. Objective was to evaluate efficacy of azilsartan with olmesartan in patients of hypertension. Methods: A randomized, prospective, open label, comparative study was carried out in Pharmacology and Medicine department at Dr. RPGMC Kangra at Tanda, HP. The study stretched over one year and blood pressure was monitored at first, third and sixth month. Out of 69 patients, 35 patients in group A were prescribed tablet azilsartan 40 mg/day and 34 patients in group B patients were prescribed tablet olmesartan 20 mg/day. Tablet chlorthalidone 12.5 mg/day was add on in both the groups. Data was presented as mean+SD. Student’s t test was used and p value <0.05 was considered significant. Results: In group A, systolic blood pressure (SBP) values improved from baseline of 153±10 mmHg to 111±18 mmHg (p<0.001) at 3 months and 109±6.1 mmHg (p<0.001) at 6 months and diastolic blood pressure (DBP) values from baseline of 87±7 mmHg to 67.1±4.6 mmHg (p<0.001) at 3 months and 67.6±2.5 mmHg (p < 0.001) at 6 months. In group B, SBP values improved from baseline of 154±8.5 mmHg to 127±3.6 mmHg (p<0.001) at 3 months and 123±4 mmHg (p<0.001) at 6 months and DBP values from baseline of 85±6.5mm Hg to 75.7±3.3 mmHg (p<0.001) at 3 months and 73±3.3 mmHg (p<0.001) at 6 months. On intergroup comparison improvement in hypertension was better in azilsartan group (p<0.001). Conclusions: The study concluded that azilsartan is significantly better than olmesartan in controlling the hypertension

Snakebite presenting as acute coronary syndrome: An interesting diagnosis and management

Snakebite is a common presentation in India, especially in the Sub-Himalayan region. The most common presentation of snakebiteis neurotoxic and hematologic complications. Acute coronary syndrome after a snakebite is rare. This case report explicitly explainsa patient presenting as acute coronary syndrome after a snakebite with dynamic electrocardiogram changes. Later on, the anti-snakevenom therapy was given to the patient and her condition improved. It should be kept in mind that, since the pathology of snakebiteinducedmyocardial infarction is different, its management will also be different

Study of the profile of stroke in a tertiary-care hospital in the sub-Himalayan region in north India

Background: Rapid urbanization of rural areas is predicted to increase the incidence of risk factors for vascular events such as stroke among the ruralites. A different culture, beliefs, terrain, and climatic conditions of Himachal Pradesh may have an impact on the profile of stroke. Objectives: To study the profile and the various risk factors of stroke in the sub-Himalayan region of north India. Material and Methods: It was an observational cross-sectional study conducted at the Department of Medicine, R.P. Government Medical College, Kangra, Himachal Pradesh, for a duration of 12 months, from June 2012 to May 2013. Consecutive patients presenting to the hospital with signs and symptoms of stroke were included in the study. Detailed history and clinical examination was carried out in all patients. CT scan, routine blood examination, and lipid profile were evaluated in all patients. Results: Total number of patients who presented with stroke in a year was 374. It formed 4.0% of the total hospital admissions in medical wards. The mean age of stroke patients was 66.17±12.9 years. Of the total patients, 254 (67.9%) were males and 120 (32%) were females; 127 patients (33.9%) presented between 6 am and 12 pm. The majority of patients presented in winter months, from November to January. Average delay in the presentation to hospital was 29 h. Only 79 (21.1%) patients presented within 3 h. Among the patients, 342 (91.4%) belonged to rural area, 61.4% had an infarct, and 38.6% had intracerebral bleed. The most common symptoms reported were weakness in 276 (73%) followed by speech abnormality in 53%. Hypertension as a risk factor was found in 174 (46.5%); 155 patients (41.4%) were smokers; and diabetes was present in 61 patients (16.4%). Average cholesterol level was 176±54.99 mg/dl, and average triglyceride level was 339 mg/dl. Conclusions: The major strength in our study was the predominance of rural population. The state has witnessed an increase in the incidence of stroke. Elderly population is predominantly affected. Average delay in presentation was 29 h, which is substantially high. Majority of the events occurred in winter months

Lymphocytic hypophysitis masquerading as transient secondary hyperadrenalism followed by panhypopituitarism

Lymphocytic hypophysitis (LH) is a rare inflammatory disease of the pituitary gland. This condition strikingly shows femalepreponderance and commonly affects women during pregnancy or in the post-partum period. It’s a clinical presentation and radiologicalfeatures may mimic pituitary adenoma. Though its treatment modality is uncertain steroid remains the 1st option for treatment. Here,we report an unusual case of LHin a 21-year-old female patient where initially, the patient presented with hyperadrenalism andsecondary hyperthyroidism followed by pan-hypopituitarism (Addisonian crisis) which is attributed to initial autoimmune destructionof the gland followed by subsequent fibrosis. Thus, it is a rare case report which exquisitely explains this rare presentation and suchcases should be investigated thoroughly since there are many differential and response to steroids is remarkable

Influence of sex on the profile of acute coronary syndrome: a tertiary care hospital based study from the Sub-Himalayan region in North India

Background: Coronary events presents about ten years later in women than men. There exist distinct gender differences in terms of presentation of symptoms, validity of diagnostic tests and complications. Methods: The study was conducted in the department of medicine R.P. Govt. Medical College (RPGMC) Himachal Pradesh. Consecutive 300 patients of acute coronary syndrome from June 2011 to June 2012 were included in the study. Demographical profile was recorded with focused clinical examination and relevant investigation with lipid profile was done.Results:Among the study population of 300 individuals, 201 (67%) were males and 99 (33%) were females. The mean age among male patients was 61.3±11.7 years and in female patients the mean age was 65.6±11.20 years. 68.8% of females presented after 60 yrs of age. Dyslipidemia was the commonest risk factor followed by hypertension and obesity. 12.2% of female patients were smokers. Chest pain was the commonest presenting symptom seen in 82% cases. There was mean delay of 31.0±54.5 hrs in the presentation of females for treatment. ST Elevated Myocardial Infarction occurred less frequently in females.Conclusions: Acute coronary syndrome is more age dependent in females. The predominance of dyslipidemia, hypertension and obesity as risk factors gives a message for primary care physicians to create awareness for the prevention of Acute Coronary Syndrome. The atypical symptoms should be recognised early which should further prevent the delay in presentation.

Hospital acquired acute renal failure

Background: Acute renal failure has continued to attract interest and stimulate investigators .This is in part, a reflection of many clinical entities that can result in an acute renal failure. HAARF is an important cause of morbidity and mortality and is associated with the ten fold increase in the risk of death during the hospitalization.14 Despite advances in diagnosis and management it still carries a high mortality. HAARF is associated with grave consequences. Some of the clinical setting leading to HAARF can be limited by monitoring of renal function, better control of infection, avoiding nephrotoxic drugs and initiation of therapy at the earliest. Present study is proposed to evaluate the incidence, etiological factors and measures to reduce the incidence of HAARF.Methods:All patients were admitted to RPGMC from Dec. 2010 to APRIL 2014. They were screened for the development of the ARF during their hospital stay. The parameters of Prakash et al. were taken for the diagnosis of HAARF.  Results:In our present study HAARF was diagnosed in 88 patients of 56904 admission during 40 month period, representing 0.15% of the admission. Predisposing factors were present in 64 % of the patients. They were elderly age >60 years (22.72%), DM (13.64%), pre-existing renal disease (13.64%) and HTN (4.54%). It was due to nephrotoxic dugs in 45.45%, decreased renal perfusion in 22.72%, infections in 13.64%, hepatorenal syndrome 9.09% surgery in 4.54% and Weil’s disease in 4.54 %. Among the nephrotoxic drugs antibiotics were the most common and NSAIDs were the second most common etiological factors. Decrease renal perfusion secondary to volume depletion and heart failure were equally responsible for HAARF in 9.09% each. Septicemia was responsible for 4.54% of cases. Oliguric renal failure was seen in the 31.82% where as nonoliguric renal failure was seen in 50% of cases. Great majority of non oliguric renal failure was due to nephrotoxic drugs. Oliguric patients have longer duration of hospital stay and high mortality as compared to the non oliguric renal failure. A high s. creatinine and high urea levels at the time of admission were associated with the earlier development of HAARF. Oliguria and anuric patients had a longer duration of hospital stay. Overall mortality of HAARF was 18.18% and nephrotoxic drugs responsible for one half of the total mortality.Conclusion:High risk group patients for HAARF needs meticulous monitoring during hospital stay. Hospitalized patients on nephrotoxic drugs should have frequent renal function tests. Proper fluid and electrolyte balance in hospitalized patients needs special emphasis to avoid HAARF.   

A study to compare the efficacy of intermittent versus continuous regimen of pantaprazole in the management of upper gastrointestinal bleed (non variceal)

Background: UGI bleeding is defined as bleeding that occurs in the digestive tract proximal to the ligament of treitz. Intermittent dosage regimen IV bolus and high dose IV continuous infusion forms helps in achieving and maintaining this pH goal of more than 6 which forms optimal environment for peptic ulcer healing and clot stabilization to occur. Theoretically, high-dose IV continuous infusion should provide the most potent acid suppression. Aims and objective was to compare the efficacy of intermittent dose of pantoprazole given for 3 days i.e. 40mg intravenous twice a day versus continuous infusion dose of pantaprazole i.e. 80mg intravenous bolus followed by 8mg/hour for first 72hours in the treatment of UGI bleed.Methods: Patients of UGI bleed were randomly assigned to receive either continuous or intermittent regimen of pantaprazole as a part of management.Results: Among 118 patients of peptic ulcer disease, 7 patients had rebleed and 111 patients had no rebleed.3 patients among 59 patients who received continuous regimen and 4 patients among 59 patients who received intermittent regimen had rebleed with a total of 7 patients among 118 patients. Among 118 patients only 2 patients of the total had need for surgery for stabilization. Among 59 patients who received continuous regimen 2 patients needed surgery while none of the 59 patients who received intermittent regimen needed for surgery. Of the 118 patients 10 patients had mortality at the end of 30 day period. In both the regimes 5 patients died.Conclusions: The difference between Rockall score of the intermittent and continuous regimen group was statistically insignificant. The incidence of rebleed was 5.1 % for continuous and 6.7% for intermittent regimen which was statiscally insignificant. The incidence of mortality was similar 8.5%in both regimen

Assessment of pulmonary function in patients with type 2 diabetes mellitus: a case-control study

Background:As other microvascular complications, respiratory involvement is far less studied among patients with type-2 Diabetes Mellitus (DM). Objective: to study the extent of pulmonary function limitation among patients with type-2 DM.  Methods:Hospital based matched case-control study.Results:Total of 90 cases and 90 controls matched for age, sex, height and weight were recruited. Patients with DM had neuropathy [63.3% (57; male=27: Female: 30)], retinopathy [44.4% (40; male=22: Female: 18)], nephropathy [41.1% (37; male=17: Female: 20)] and microalbuminuria [14.4% (13; male=5: Female: 8)]. All cases and 88 controls observed with FEV1:FVC ratio of >70.0%, further assessment for delineation of normal and restrictive pattern patients with high level of predicted values of FEV1 as compare to FVC showed that significantly (P = 0.00) more (Cases: 76.6%; Controls: 42.2%) cases had FEV1 >FVC predicted levels as compare to controls, means among diabetics odds of restrictive pattern of lung abnormality is four times (OR: 4.4; CI: 2.3-8.5) more as compare to non-diabetics. In addition a long duration of DM was significantly (r: 0.39; P = 0.00) positively correlated with lung dysfunction.  Conclusion: Patients with type 2 DM patients as compare to its controls observed with restrictive pattern of lung dysfunction.

Study of LV functions in patients of subclinical hypothyroidism in patients coming to rural medical college of Sub-Himalayan region of India

Background:Subclinical hypothyroidism (SCH) is a common disorder and has been implicated in increased cardiovascular morbidity and mortality. Therefore, it is important to study the effect of SCH on cardiac morphology and function. Thus, present study titled “Study of LV functions in patients of subclinical hypothyroidism in patients coming to rural medical of sub-Himalayan region of India” was conducted in the department of medicine, Rajinder Prasad government medical Tanda over a period of three years from December, 2010 to November, 2013 to study left ventricular function in subclinical hypothyroidism.Methods: The study was conducted in the department of medicine, Rajinder Prasad government medical Tanda over a period of three years from December, 2010 to November, 2013 to study left ventricular function in subclinical hypothyroidism. The data was analysed using computer software Epi-info version 6.0 and SPSS version 12.0 for Windows. Descriptive characteristics were presented as percentages for quantitative variables including measurement of thyroid hormones and ejection fraction. Mean and standard deviation were reported.Results:Diastolic parameters were markedly altered, mainly isovolumic relaxation time, which was increased and reduction of E/A wave ratio (1.Conclusions:Implication for echocardiography in SCH patients observed were that early recognition of silent diastolic dysfunction can be done. We can institute L-thyroxinee therapy which has been found to reverse diastolic dysfunction of heart along with improvement in lipid levels, decreased systemic vascular resistance, diastolic hypertension and coagulation profile. SCH, invariably affects heart and sooner or later and leads to diastolic dysfunction. Early recognition by echocardiography and then treatment with L-thyroxinee is indicated.