Journal of Acute Disease

190-194

Authors: Sonal Kaushal Ginoya , Samira N. Parikh

Objective: To compare the value of HEART and TIMI scores in predicting major adverse cardiovascular events (MACEs) of patients with chest pain in the emergency department at a tertiary care hospital in Ahmedabad, a city in western India. Methods: A prospective study was conducted on chest pain patients from January to December 2019. All adult patients with non-traumatic chest pain presenting to the emergency department were included, and their HEART and TIMI scores were evaluated. The patients were followed up within 4 weeks for monitoring any major adverse cardiac events or death. The receiver-operating characteristics (ROC) curve was used to determine the value of HEART and TIMI scores in predicting MACEs. Besides, the specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of the two scores were assessed and compared. Results: A total of 350 patients were evaluated [mean age (55.03±16.6) years, 56.6% of males]. HEART score had the highest predictive value of MACEs with an area under the curve (AUC) of 0.98, followed by the TIMI score with an AUC of 0.92. HEART score had the highest specificity of 98.0% (95% CI: 96.4%-99.6%), the sensitivity of 75.0% (95% CI: 70.7%-79.3%), and PPV of 97.0% (95% CI: 94.1%-99.9%) and NPV of 82.5% (95% CI: 74.6%- 90.4%) for low-risk patients. TIMI score had a specificity of 95.0% (95% CI: 92.4%-97.6%), sensitivity of 75.0% (95% CI: 69.4%- 80.6%), PPV of 92.3% (95% CI: 88.1%-96.5%) and NPV of 82.3% (95% CI: 73.8%-90.8%) for low-risk patients. Conclusions: HEART score is an easier and more practical triage instrument to identify chest pain patients with low-risk for MACEs compared to TIMI score. Patients with high HEART scores have a higher risk of MACEs and require early therapeutic intervention and aggressive management.

202-207

Authors: Erdal Yavuz1 , Kasim Turgut1 , Umut Gulacti1 , Ugur Lok1 , Erman Altunisik2

Objective: To determine the characteristics and risk factors of drug dependence among patients who were administered drugs with addictive potential (DAP) in an emergency department (ED). Methods: This retrospective cross-sectional study included patients who were administered DAP 3 or more times in the emergency room between September 1, 2019 and March 1, 2020. The demographic and baseline information were recorded. All the prescibed DAP, the reasons to use these drugs, secondary drug dependence, the department where DAP were first prescribed, types of doctors who preferred to prescribed DAP, and the risk factors for the development of drug dependence were determined. Results: A total of 3 000 patients were screened from medical records, and among them, 80 patients developed drug dependence. Drug dependence only developed for tramadol (n=57, 71.3%), diazepam (n=11, 13.8%), and biperiden (n=12, 15.0%). Tramadol was the most frequently prescribed drug (n=57, 71.3%). The most common reason for drug dependence was psychiatric disorders (n=29, 36.3%). Drug dependence developed in renal colic patients due to the administration of tramadol (n=7, 100%). On the contrary, dependence to biperiden were mainly developed in patients with psychiatric complaints (n=12, 41.4%). The rate of secondary drug dependence was 15% (n=12). Of the Biperiden users, 41.7% developed secondary drug dependence on diazepam. Most DAP were first prescribed in the ED (n=52, 65%), and the specialist preferred to prescribe DAP (n=43, 53.8%). For the development of dependence, the presence of renal colic (OR: 3.387, 95% confidence interval (CI): 1.473-7.788, P=0.004) and low back pain (OR: 5.778, 95% CI: 2.779-12.014, P<0.001) were the risk factors. Conclusions: Most DAP were first prescribed in the ED compared to other departments, and specialist are preferred to use DAP. Tramadol is the most commonly used drugs caused drugdependence. Psychiatric disorder patients are easier to develope drug dependence. Furthermore, renal colic and low back pain patients needs more attention to avert drug dependence

216-220

Authors: Hong-wei Zhang1 , Li-you Wei1 , Ji-xuan Wang1 , Shu-zheng Liu1 , Dan Xing1 , Rui Zhang1 , Hui Guo1 , Li-juan Chen1 , Jing Zhang2

Objective: To observe the effect of Xuebijing , a complex traditional Chinese preparation, on inflammation and prognosis of patients with pneumonia. Methods: The patients with ventilator-associated pneumonia in the intensive care unit (ICU) were randomly divided into the control group and the treatment group with 35 cases in each group. Both groups were given routine treatment such as anti-inflammatory drugs, rehydration, expectorant, and nutritional support, while the treatment group was additionally given Xuebijing injection. Serum C-reactive protein (CRP), clinical pulmonary infection score (CPIS), acute physiology, and chronic health score Ⅱ (APACHEⅡ) were recorded before treatment, the 3rd and 7th day after treatment. The duration of antibiotic use, mechanical ventilation, ICU stay, and mortality during 28 days was recorded. Results: There was no significant difference in CRP, CPIS, and APACHEⅡ between the two groups before treatment (P>0.05). The improvement of CRP, CPIS, and APACHEⅡ in the treatment group was better than those in the control group on the 3 and 7 days after treatment, and the differences were statistically significant (P<0.05). The duration of antibiotic use, mechanical ventilation, and ICU stay in the treatment group were less than those in the control group (P<0.05). The 28-day mortality of the treatment group was lower than that of the control group, but the difference was not statistically significant (P>0.05). Conclusions: Xuebijing injection can improve the inflammatory indexes of patients with ventilator-associated pneumonia, and can partly improve the prognosis.

142-146

Authors: Vahid Bay1,2, Aziz Rezapour3 , Mehdi Jafari1 , Mohammad Reza Maleki1 , Irvan Masoudi Asl

Objective: To determine the healthcare utilization patterns and estimate the economic burden of animal bites in Golestan province, north part of Iran. Methods: This cross-sectional study was performed based on the data of 12 181 animal-bite patients from Golestan province who were referred to the rabies prophylaxis centers between March 2019 and March 2020. The study was a societal perspective, and all patients were investigated by census method. The micro-costing method with a bottom-up approach as well as the human capital approach were used to estimate the economic burden. Results: In our study, the economic burden caused by animal bites was estimated at $1 383 639 (275 354 672 060 Rials). The largest share of costs was related to direct healthcare costs, direct nonhealthcare costs, and indirect costs accouting for 91%, 5%, and 4%, respectively. In addition, the average cost of a animal-bite patient was estimated at $113.5 (22 605 260 Rials) (The average cost of a case in type 2 and 3 exposures was $45 and $412.8, respectively). The largest share of direct healthcare costs was related to immunoglobulin, vaccine, and personnel expenses accounting for 61.3%, 19.8%, and 11.65%, respectively. Conclusions: Our study shows that animal bites in Golestan province, north of Iran impose a high economic burden on the communities, especially the healthcare system, which indicates the need to review management and control programs of animal bites and rabies based on animal-bite patterns of the area.

150-154

Authors: Abolfazl Mohammadbeigi1 , Shahram Arsang-Jang2 , Ehsan Sharifipour3 , Alireza Koohpaei4 , Mostafa Vahedian5 , Narges Mohammadsalehi1 , Masoud Jafaresmaeili6 , Moharam Karami6 , Siamak Mohebi7

Objective: To identify the incidence rate, relative risk, hotspot regions and incidence trend of COVID-19 in Qom province, northwest part of Iran in the first stage of the pandemic. Methods: The study included 1 125 officially reported PCRconfirmed cases of COVID-19 from 20 February 2020 to 20 April 2020 in 90 regions in Qom city, Iran. The Bayesian hierarchical spatial model was used to model the relative risk of COVID-19 in Qom city, and the segmented regression model was used to estimate the trend of COVID-19 incidence rate. The Poisson distribution was applied for the observed number of COVID-19, and independent Gamma prior was used for inference on log-relative risk parameters of the model. Results: The total incidence rate of COVID-19 was estimated at 89.5 per 100 000 persons in Qom city (95% CI: 84.3, 95.1). According to the results of the Bayesian hierarchical spatial model and posterior probabilities, 43.33% of the regions in Qom city have relative risk greater than 1; however, only 11.11% of them were significantly greater than 1. Based on Geographic Information Systems (GIS) spatial analysis, 10 spatial clusters were detected as active and emerging hotspot areas in the south and central parts of the city. The downward trend was estimated 10 days after the reporting of the first case (February 7, 2020); however, the incidence rate was decreased by an average of 4.24% per day (95% CI: −10.7, −3.5). Conclusions: Spatial clusters with high incidence rates of COVID-19 in Qom city were in the south and central regions due to the high population density. The GIS could depict the spatial hotspot clusters of COVID-19 for timely surveillance and decision-making as a way to contain the disease.

162-168

Authors: Priyanka Rajmohan1 , Ponnu Jose1 , Jubina Bency Anthoora Thodi1 , Joe Thomas1 , Lucy Raphael1 , Swathi Krishna1 , Unnikrishnan Uttumadathil Gopinathan1 , Praveenlal Kuttichira2

Objective: To study the transmission dynamics of coronavirus disease 2019 (COVID-19) among 101 confirmed cases and their 387 household contacts and to determine risk factors associated with secondary attack among the household contacts. Methods: A prospective cohort study was conducted from January 1st 2021 to February 28th 2021, among 101 SARS-CoV-2 cases and 387 household contacts who were followed up for 14 days from the last day of contact with the index case of COVID-19. The dynamics of disease transmission was estimated, and factors affecting transmission risk were analyzed. Besides, the association between various factors and household secondary attack rate was determined. Results: The median incubation period was found to be 5 days, and the observed reproductive number (R) was found to be 1.63 (95% CI: 1.28-1.98). The mean household secondary attack rate was 40.7%. Contacts with comorbidities like diabetes mellitus, hypertension, dyslipidemia, and hypothyroidism had significantly higher attack rates (P<0.05). Conclusions: As new variants of SARS-CoV-2 emerges, it is crucial to know the trasmission dynamics. This study shows a high secondary attack rate of COVID-19 among household contacts that must be closely monitored.

173-176

Authors: Slawomir Wajman1 , Magdalena Gewartowska2 , Robert Antoniak3 , Marek Stanczyk1

Rationale: We present a case of appendicitis with an uncommon course due to rare anatomical location of the appendix in the right retroperitoneal space below the diaphragm and above the liver. Patient’s concern: A 32-year-old, previously healthy male with a history of congenital diaphragmatic hernia repair in childhood, presented with 3 days of mild, colicky, central abdominal pain associated with fever, nausea and vomiting. At presentation, pain was localized to the right lower quadrant. Diagnosis: Even though diagnosis of appendicitis was clear, we decided to confirm it with computer tomography (CT). CT revealed elevation of the right dome of the diaphragm and perforated appendix located above the liver. Intervention: Appendectomy was performed via right subcostal approach instead of usual incision in the right lower quadrant. Outcome: Patient recovered well and was discharged on the 5th day after operation. Lessons: Previous congenital diaphragmatic hermia repair may change the location of the appendix. The appendix at rare locations could lead to an uncommon course of appendicitis. On this very note, surgeons should have a high index of suspicion, and CT may help avoid inadvertent complications.

98-106

Authors: Rouhullah Dehghani1, Hamid Kassiri2, Iman Khodkar3, Saina Karami3

Sandfly fever is a febrile emerging arboviral illness which is a huge threat posed to public health. Sandfly fever viruses (Sicilian, Naples, and Toscana) are endemic to the Mediterranean region. Evidence suggests an increase in the activity of sandfly-borne phleboviruses and their extension to other places. The infection is relatively benign but may cause severe clinical manifestations and complications. Sandfly fever viruses belongs to the genus Phlebovirus (family Bunyaviridae), and the four main serotypes include sandfly fever Sicilian virus, sandfly fever Naples virus, sandfly fever Cyprus virus, and Toscana virus. Sandfly fever has flu-like symptoms such as fever, headache, photophobia, malaise, myalgia, and retro-orbital pain. The incubation period of the disease is 4-8 days, and the patient usually recovers within a week. The first infection provides the host with immunity. Sandfly fever viruses are transmitted through the bites of infected female sandflies, thus, the epidemiology of sandfly fever is closely related to the presence and activity of sandfly species that act as the vectors for transmission. Cases and outbreaks of the disease have been reported worldwide for more than 100 years. All in all, this disease is important for nonendemic countries because it is a travel-related and/or imported illness.

112-116

Authors: Abubakar Muhammed Shakur1, Nuhu Abubakar Garba2, Ibrahim Ahmadu1, Daniel Apollos3, Aminu Wada4, Safiya Garba Abdullahi1, Abdulsalam Mohammed4, Mustafa O. Asani1, Ibrahim Aliyu1

Objective: To determine if there was any difference in SpO2 readings during exchange blood transfusion (EBT). Methods: A prospective cross-sectional study of neonates with severe neonatal jaundice requiring EBT was conducted. Oxygen saturation was recorded before, immediately and 15 minutes after EBT by using a pulse oximeter. Results: This study included 30 neonates with 20 males and 10 females. The age ranged from 1 to 12 days with a mean of (5.4 ± 2.9) days. Pre-EBT SpO2 ranged from 90% to 98% with a mean value of (94.3 ± 2.2)%; SpO2 in the end of EBT ranged from 85% to 99% with a mean value of (94.1 ± 3.2)%; SpO2 at 15 minutes after EBT ranged from 77% to 99% with a mean value of (94.8 ± 4.1)%. There was no significant difference between SpO2 values at onset of EBT and either immediately or 15 minutes after EBT (P=0.770 and 0.422, respectively). SpO2 showed no significant difference between neonates who were infused with blood of different storage times (<24 h or ≥24 h) at the onset of EBT (P=0.584), immediately (P>0.999) and 15 minutes after EBT (P=0.887). Besides, SpO2 values were compariable in neonates with hematocrit <45% or ≥45% at the onset of EBT (P=0.284), immediately (P=0.118) and 15 minutes after EBT (P=0.868). Conclusions: EBT does not affect SpO2 in neonates.

122-125

Authors: Nik Mohd Noor Nik-Nurfarhana1,2, Ahmad Shahrudin Azima1,2, Khonji Ismaeel-Mohamed1,3, Embong Zunaina1,2

Rationale: Diffuse unilateral subacute neuroretinitis is a form of posterior uveitis and has a few clinical presentations according to the onset of presentation. Patients’ concern: A girl (5-year-old) and 2 boys (both 12-year-old) were included in this report. Upon presentation, the visual acuity ranges from 6/12 to 6/60. All three cases had different symptoms (case 1: floaters; case 2: eye redness and pain; case 3: central scotoma). All of them had variable posterior uveitis features (case 1: vitritis and focal retinitis; case 2: subretinal larva track; case 3: choroiditis). Diagnosis: Diffuse unilateral subacute neuroretinitis. Intervention: All 3 patients were treated with oral albendazole. Outcome: All patients showed remarkable resolution of inflammatory reactions of the eye and also improvement of vision. Lesson: High index of suspicion should be made for children and young adults who are previously healthy but presented with suddenly onset of reduced vision with clinical features of posterior uveitis of variable degree. Clinical features together with a full blood picture can help to diagnose the problem when other parameters are negative.

130-132

Authors: Jayabal Pandiaraja1, Arumugam Shalini2

Rationale: Chronic myeloid leukaemia is a myeloproliferative disorder due to clonal hyperproliferation of myeloid cells within the bone marrow. It can present both pro- and anti-thrombotic states. CML has different presentations within the gastrointestinal tract. Patient’s concern: A 40-year-old non-diabetic and non-hypertensive male complained of abdominal pain with nausea and emesis for 1 day. Besides, he had a history of abdominal distension and fever for 1 day. Diagnosis: Acute small bowel gangrene due to chronic myeloid leukaemia. Intervention: A limited resection of small intestine with ileostomy and mucus fistula. Outcome: After 3 months following surgery the patient underwent stoma closure. The patient was followed up for more than 3 years postoperatively. During the follow-up, the patient was asymptomatic without any recurrence of the disease. Lesson: Chronic myeloid leukaemia should be considered as one of the causes for small intestine gangrene when there is increased leukocyte count, splenomegaly without evidence of atherosclerotic occlusion or systemic emboli from the heart.

57-61

Authors: Effect of tranexamic acid on the treatment of patients with upper gastrointestinal bleeding: A double-blinded randomized controlled clinical trial

Objective: To determine the efficacy of tranexamic acid (TXA) in the management of acute upper gastrointestinal (GI) bleeding. Methods: A total of 70 patients with acute upper GI bleeding were included in this double-blinded randomized controlled clinical trial from September 2018 to December 2018. Patients were divided into the control group (received fluid therapy and intravenous infusion of pantoprazole, 35 cases) and the TXA group (received intravenous TXA besides the treatment of control group, 35 cases). Rebleeding, admission duration, and need for blood transfusion were compared between the two groups. Results: Fifteen patients (42.9%) in the TXA group and 10 patients (28.6%) in the control group stayed in hospital for more than 3 days during their admission (P=0.21). Rebleeding occurred in 8 patients (22.9%) and 5 patients (14.3%) of the TXA group and the control group, respectively (P=0.35). More patients in the TXA group (21 cases, 60%) received blood transfusion than the control group (8 cases, 22.9%) (P=0.02). Conclusions: TXA did not improve the outcome of patients with acute upper GI bleeding.

71-77

Authors: Olfa Chakroun-Walha , Fadhila Issaoui, Abdennour Nasri, Haifa Bradai, Ayman Farroukh, Rim Karray, Mouna Jerbi, Noureddine Rekik

Objective: To identify the early predictors of severe envenomation in the southern region of Tunisia. Methods: It was a retrospective monocentric study including consecutive patients admitted to the emergency department for snakebite envenomation. Snakebite envenomation was defined by a history of snakebite. Predictors of severe envenomation were determined by univariate and multivariate analyses. Results: Our sample consisted of 109 patients aged 30 (20-44) years with a 1.1:1 sex-ratio (56 males and 53 females). During the 24-hour surveillance period, 25 patients developed severe envenomation (22.9%). The in-hospital mortality rate was 4.6% (n=5). The independent predictors of severe snakebite envenomation were leucocyte count over 11550/mm3 (OR: 18.7, 95% CI: 3.3-107.8), creatine kinase over 155 IU/L (OR: 6.16, 95% CI: 1.1-35.6), and/or tourniquet before arrival to the ED (OR: 32.14, 95% CI: 3.5-295.9). Conclusions: This study emphasizes the importance of early evaluation of snakebite envenomation. Further studies are required to approve a severity scale proper to snakebite envenomation in Tunisia.

83-86

Authors: Amol Andhale1 , Amol Bhawane1 , Sourya Acharya1 , Samarth Shukla2 , Akhilesh Annadatha1 , Vidyashree Hulkoti1

Rationale: Coexistence of anti-glomerular basement membrane (anti-GBM) disease with anti-neutrophil cytoplasmic antibody (ANCA) in a case of glomerulonephritis is often identified as a “double-positive” disease. Interestingly, the majority of “double positive” ANCA is myeloperoxidase (MPO)-ANCA and some of the MPO-ANCA positive cases showed intrarenal arteritis, suggesting an ANCA-associated kidney lesion. Proteinase 3-ANCA positive diseases are also rarely reported. Patients positive for all three antibodies, i.e., triple-positive patients, are extremely rare. Patient’s Concern: A 53 year-old female presented with anasarca and oliguria of 2 months’ duration. Diagnosis: Pauci-immune type renal limited crescentic glomerulonephritis positive for MPO-ANCA, proteinase 3-ANCA, and anti-GBM antibody (triple-positive). Interventions: Intravenous high dose cyclophosphamide, oral azathioprine, intravenous methylprednisolone, and plasma exchange as per British Health Professionals in Rheumatology Guidelines. Outcomes: After one-month follow-up, anasarca and proteinuria were lessened, serum creatinine was normalized, titers of MPOANCA levels were decreased, and anti-GBM antibody levels were normalized. Lessons: Triple-positive renal limited vasculitis is rare and response to combined immunosuppressive therapy and plasma exchange can contribute to successful remission.

91-92

Authors: Christine, Pui Sum Ho1 , Sunny, Chi Li Au2 , Simon, Tak Chuen Ko2

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8-11

Authors: Farhan Haroon, Sajid Younus, Asif Peracha, Nouman Memon, Naveed Memon

Objective: To assess the utility and validation of the Surgical Apgar Score (SAS) in predicting postoperative complications of hip fractures. Methods: This prospective observational study included patients who received operations for hip fractures from 1st March 2017 to 30th June 2018 at the Department of Orthopedic Surgery, Liaquat National Hospital and Medical College. Patients were followed at the outpatient department, and complications and mortality were recorded through phone calls. The predictability of SAS for postoperative complications was assessed. Results: SAS≤4 was found as a significant predictor for postoperative pulmonary (P=0.008) and cardiac complications (P=0.042) as well as blood transfusion required to optimize postoperative hemoglobin (P=0.03) in the patients with hip fractures. Conclusions: SAS provides reliable feedback information about patients’ postoperative risk during the surgery. Hip fracture patients with scores≤4 should be monitored for major complications both during the hospital admission and after the discharge. KEYWORDS: Hip fractures; Surgical Apgar Score; Postoperative outcomes 1. Introduction The term “hip fracture” most commonly refers to the femoral neck and trochanteric fractures including intertrochanteric and subtrochanteric fractures or a combination of both. In the geriatric population, hip fractures usually occur due to minor trauma because of osteoporotic bones. Hip fracture is a major public health problem in the Asian population, which is usually associated with significant postoperative systemic complications and high mortality due to the burden of major surgery in a morbid patient[1]. For these postoperative complications, physicians need predictive tools to analyze the perioperative risk. Several algorithms have been employed for perioperative risk assessment, for example, the American Society of Anesthesiologists Physical Status Classification System (ASA classification)[2,3], the Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity[4] and Surgical Outcome Risk Tool[5]. According to Sakan et al., Surgical Apgar Score (SAS) has been shown as a proven independent predictor of major postoperative complications and mortality within 30 d after different types of surgery[6]. SAS is a simple and objective predictive tool, with three easily calculated variables, namely estimated blood loss, lowest heart rate, and lowest mean arterial pressure. These variables are derived after surgery from intraoperative anesthesia records[7]. Sakan et al. performed a retrospective study on the implementation of SAS on 43 hip fracture patients and concluded that the score≤4 was a significant predictor for the major postoperative complications within 30 d of surgery[6]. Gawande et al. performed a retrospective study on Apgar Scores for surgery on 303 patients and concluded that a 10-point score was significantly associated with major complications or death within 30 d after surgery[8]

17-22

Authors: Fatih Uzer1, Begum Uzer2, Fatma Mutlu Kukul Guven2, Idris Kirhan3, Nilay Coplu4

Objective: To investigate the chest radiography findings, hematological values and the risk factors of the mortality of coronavirus disease 2019 (COVID-19). Methods: Patients who were diagnosed with COVID-19 in a secondary-level state hospital in Turkey from March to April 2020 were included in the study. COVID-19 diagnosis was confirmed by reverse transcriptase-polymerase chain reaction. Initial routine blood tests and chest radiography findings were examined. The relationship between chest radiography findings and hematological values and risk factors of the mortality of COVID-19 were assessed. Results: In total, 94 patients with confirmed COVID-19 diagnosis were included in the study. Among them, 33 patients did not have lung involvement (RALE score of 0), and 42 had moderate lung involvement (RALE score of 1 to 4), and 19 had severe lung involvement (RALE score of 5 to 8). Patients with higher RALE scores were significantly elder (P=0.000) and had significantly lower lymphocyte count (P=0.032). Patients in need of intensive care had a lower mean number of platelets compared to patients who did not require intensive care (P=0.007). The receiver operating characteristic analysis revealed that RALE score (P=0.005), age (P=0.002), duration of symptoms (P=0.006), neutrophil-lymphocyte ratio (P=0.007), and lymphocyte percentage (P=0.012) were significantly associated with the risk of mortality. Conclusions: Patients with severe lung involvement have lower lymphocyte values and ratios. Age, RALE score, duration of symptoms, neutrophils/lymphocytes ratio, lymphocytes percentage are risk factors of mortality of COVID-19.

28-35

Authors: Johnson Oshiobugie Momoh1,2, Akinniyi Adediran Osuntoki2, Osaretin Albert Taiwo Ebuehi2, Olusola Ajibaye3

Objective: To evaluate the influence of –250G>A (rs2070895) polymorphism in hepatic lipase gene (LIPC) promoter on plasma lipid parameters of ischemic stroke patients. Methods: A total of 100 stroke patients and 100 control subjects matched for sex (59 men and 41 women) and age were selected. Hepatic lipase activity and lipid profiles were measured while lipoprotein ratios were calculated. Genotyping of the –250G>A promoter polymorphism of the LIPC was performed by the polymerase chain reaction and restriction fragment length polymorphism method combined with 2% gel electrophoresis and then confirmed by direct sequencing. The LIPC promoter gene sequencing data were compared with refseqNG011465.1 LIPC from GenBank. Results: The frequencies of GG, GA and AA genotypes of LIPC rs2070895 polymorphism were 39%, 45% and 16% for the control, 10%, 37% and 53% for the stroke subjects (P<0.0001), respectively. The frequencies of G and A alleles were 61.5% and 38.5% for the control, and 28.5% and 71.5% for the stroke subjects (P<0.0001). Our study shows that the mutant allele of the LIPC promoter was associated with dyslipidemia, lower hepatic lipase activity, and this variation contributed to the increased defective plasma highdensity lipoprotein-cholesterol (HDL-C), HDL2-C and HDL3-C concentration for both subjects. The control subjects had 6 single nucleotide polymorphism and 6 amino acid substitutions while the stroke subjects had 32 single nucleotide polymorphism and 20 amino acid substitutions. Conclusions: LIPC –250G>A polymorphism can influence plasma lipid profiles and lipoprotein ratios in patients with ischemic stroke.

39-41

Authors: Santosh Kumar Swain, Alok Das, Satyabrata Acharya, Nibi Shajahan, Rohit Agrawala

Rationale: Cavernous internal carotid artery (ICA) pseudoaneurysm caused by non-penetrating head trauma is a rare cause of massive epistaxis. The sudden onset of epistaxis due to such a fatal aneurysm protruding into the sphenoid sinus is extremely rare in clinical practice. The management is often challenging because of anatomical inaccessibility of the bleeding point. Patient’s concern: A 42-year-old man with a history of head trauma showing an ICA aneurysm eroding the sphenoid sinus followed by massive epistaxis. Diagnosis: A computerized tomography (CT) scan showed a fracture in the sphenoid sinus. CT angiogram revealed cavernous ICA pseudoaneurysm. Interventions: Endovascular coil embolization. Outcomes: The patient recovered well and was discharged without any neurological deficits Lessons: Cavernous ICA pseudoaneurysm may lead to a lifethreatening situation. If a patient has a history of head trauma, posttraumatic cavernous ICA pseudoaneurysm should be considered a differential diagnosis of massive epistaxis.

45-46

Authors: Vishal Mangal, Kaminder bir Kaur

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