Hydroxyurea Induced Perimalleolar Ulcers

Hydroxyurea (HU) is an antineoplastic drug commonly used to treat chronic myeloproliferative disorders. Common dermatological side effects include hyperpigmentation, scaling, erythema, alopecia, desquamation of face and hands. Leg ulceration following HU therapy is less common and very few cases have been reported so far. Objective of this paper is to increase the awareness of hydroxyurea induced leg ulcers which will aid in the early diagnosis and appropriate treatment. The first case was a chronic myeloid leukemia (CML) patient on HU 1.5 g/day for 5 yr, who had bilateral painful perimalleolar ulcers for 6 months. The second case was a CML patient on HU 1.5 g/day for 3 yr who developed bilateral lateral malleolar ulcers. Third case was a polycythemia vera (PV) patient on HU 1 g/day for 5 yr who presented with painful medial malleolar ulcer of 2 months. The last case of our report was an elderly PV patient on HU 1.5 g/day for 2 yr and presented with lateral malleolar ulcer which persisted on reducing the dose of HU. In all the 4 cases the ulcers healed on stopping HU. Our report confirms the association of chronic hydroxyurea therapy and perimalleolar ulcers which respond promptly after discontinuation of the drug. The heightened awareness among the physicians will promote early diagnosis and prompt relief from the agonizing ulcers

Open-labeled randomized controlled trial to evaluate the 1-year clinical outcomes of polymer-free sirolimus-eluting coronary stents as compared with biodegradable polymer-based sirolimus-eluting coronary stents

Background: Head to head trials of clinical outcomes of sirolimus eluting polymer free vs. biodegradable polymer stents are lacking. Methods: Single centre prospective open labeled randomised controlled clinical trial. Basis for sample size calculation was the rate of MACE from the ISAR TEST 3 trial in which the absolute difference was 10.25% with a standard deviation of 0.24. Assuming null hypothesis, 80% power and 5% alpha error, to detect a 10% difference, adjusting for 10% loss of follow up, sample size was 204. Inclusion criteria: Patients with stable coronary artery disease or recent acute coronary syndrome ( >1 week from the date of STEMI), being taken up for elective angioplasty. End points: Primary end point was MACE at 1 year and secondary end points at the end of 1 year were cardiac death, urgent target lesion revascularization, acute coronary syndrome, stroke and in-stent re-stenosis. Results: 204 patients were enrolled between January 2013 to July 2014, 91 in the polymer-free group and 113 in the biodegradable polymer group. Baseline characteristics were comparable between both groups. 21 patients (10.29%), were lost to follow up. MACE at 1 year were comparable in both the groups 3 of 85(3.52%) in the polymer-free group and 3 of 98(3.06%) in the biodegradable polymer group, p = 0.859. The secondary end points were also comparable between the two groups- Death- 1 of 85(1.17%) vs. 2 of 98(2.04%), p = 0.646, Stroke 0 of 85 vs. 2 of 98(2.04%), p = 0.185 and acute coronary syndrome – 2 of 85(2.35%) vs. 1 of 98(1.02%), p = 0.204. There were no instances of urgent target lesion re-vascularisation or definite stent thrombosis in either groups. In stent re-stenosis was found in 7 of 85(8.2%) in the polymer-free group vs. 6 of 98(6.12%) in the biodegradable polymer group. Conclusion: The 1 year MACE rates are comparable in patients who underwent elective coronary revascularization using sirolimus eluting polymer-free and biodegradable polymer stents. Keywords: Polymer-free, Biodegradable polymer, Stent thrombosis, Sirolimus, Randomised controlled tria

Geographical variation in the clinical presentation of endomyocardial fibrosis in India?

Objectives: To compare the clinical presentation, clinical profile and survival of two groups of endomyocardial fibrosis patients. Methods: The study was a prospective cohort study, or a prospective case series, comparing all consecutive echocardiographically proven patients with endomyocardial fibrosis seen in Medical College Trivandrum with the patients seen in Medical College Hospital, Alappuzha(Alleppey) (or TD Medical College). In all patients the clinical details like age, sex, type of endomyocardial fibrosis, the presence of anaemia, eosinophilia, neutrophilia and type of rhythm(Sinus or atrial fibrillation) etc were compared by both simple X2 and by Kaplan Meier survival curves. Results: The mean age and the sex distribution was same in both places Briefly the incidence of biventricular endomyocardial fibrosis was more from Trivandrum than Alleppey, 64.9% vs 14.3% (p < 0.0.001), the incidence of atrial fibrillation was more in Trivandrum 44.2% vs 16.3%. (p < 0.001)The overall survival of Trivandrum patients was poorer (p < 0.0001). The six year survival was 61% in the Trivandrum population whereas it was 91.5% in the Alleppey population. Conclusions: These differences may have been due to the better nutrition of the Alleppey patients due to a higher exposure to fish compared to the Trivandrum population. Better nutrition would protect against Magnesium deficiency and prevent the absorption of Cerium in the patients from Alleppey, compared to those from Trivandrum

Predictors of no- reflow during primary angioplasty for acute myocardial infarction, from Medical College Hospital, Trivandrum

Background: Primary angioplasty (PCI) for acute myocardial infarction is associated with no-reflow phenomenon, in about 5–25% of cases. Here we analysed the factors predicting no reflow . Methods: This was a case control study of consecutive patients with acute myocardial infarction who underwent Primary PCI from August 2014 to February 2015. Results: Of 181 patients who underwent primary PCI, 47 (25.9%) showed an angiographic no-reflow phenomenon. The mean age was 59.19 ± 10.25 years and females were 11%. Univariate predictors of no reflow were age >60 years (OR = 6.146, 95%CI 2.937–12.86, P = 06 h (OR = 21.94, 95%CI 9.402–51.2, P = < 0.001), low initial TIMI flow (≤1) (OR = 12.12, 95%CI 4.117–35.65, P < 0.001), low initial TMPG flow (≤1) (OR = 36.19, 95%CI 4.847–270.2, P < 0.001) a high thrombus burden (OR = 11.04,95%CI 5.124–23.8, P < 0.001), a long target lesion (OR = 8.54, 95%CI 3.794–19.23, P < 0.001), Killip Class III/IV(OR = 2.937,95%CI 1.112–7.756,P = 0.025) and overlap stenting(OR = 3.733,95%CI 1.186–11.75,P = 0.017). Multiple stepwise logistic regression analysis predictors were: longer reperfusion time > 6 h (OR = 13.844, 95%CI 3.214–59.636, P = 60 years (OR = 8.886, 95%CI 2.145–36.80, P = 0.003), a long target lesion (OR = 8.637, 95%CI 1.975–37.768, P = 0.004), low initial TIMI flow (≤1) (OR = 20.861, 95%CI 1.739–250.290, P = 0.017). Conclusions: It is important to minimize trauma to the vessel, avoid repetitive balloon dilatations use direct stenting and use the shortest stent if possible