Upload
jincymariyam
View
221
Download
0
Embed Size (px)
Citation preview
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
1/26
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE,
KARNATAKA
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 NAME OF THE CANDIDATEAND ADDRESS
DR. GAURAV SHIREESH BABAR,
P.G IN (M.D) GENERAL MEDICINE,
DEPT.OF MEDICINE
A.I.M.S., B.G.NAGARA.,
MANDYA DISTRICT-57!!"
# NAME OF THE INSTITUTION ADICHUNCHANAGIRI INSTITUTE
OF MEDICAL SCIENCES,
B.G.NAGARA.$ COURSE OF STUDY AND
SUBJECT
M.D. IN GENERAL MEDICINE
! DATE OF ADMISSION TO THE
COURSE
$%&MAY #''7
5 TITLE OF THE TOPIC A STUDY OF C-REACTIVE
PROTEIN IN ACUTE ISCHEMIC
STROKE
* BRIEF RESUME OF INTENDED
+ORK
*. NEED FOR THE STUDY
*.# REVIE+ OF LITERATURE
*.$ OBJECTIVES OF THE STUDY
*.! INCLUSION AND
EXCLUSION CRITERIA
APPENDIX-
APPENDIX-A
APPENDIX-B
APPENDIX-C
APPENDIX-D
7 MATERIALS AND METHODS
7. SOURCE OF DATA
7.# METHOD OF COLLECTION
OF DATA (INCLUDING
SAMPLING PROCEDURES ANY)
APPENDIX-II
APPENDIX-IIA
APPENDIX-IIB
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
2/26
7.$ DOES STUDY REUIRED
ANY INVESTIGATIONS OR
INVESTIGATIONS TO BE
CONDUCTED ON PATIENTS
OR OTHER ANIMALS, IF SO PLEASE DESCRIBE BRIEFLY
7.! HAS ETHICAL CLEARANCE
BEEN OBTAINED FROM
YOUR INSTITUTION IN
CASE OF 7.$
YES
APPENDIX-IIC
YES
APPENDIX-IID
" PROFORMA AND LIST OF
REFERENCES
APPENDIX-III
SIGNATURE OF THECANDIDATE
' REMARKS OF THE GUIDE THIS STUDY IS TO KNO+ THE
ASSOCIATION BET+EEN CRP
LEVEL IN ISCHEMIC STROKE AND
THIS IF FOR+ARDED TO RGUHS
. NAME OF THE GUIDE DR. CHETAN KUMAR J G
PROFESSORDEPT. OF GENERAL MEDICINE
A.I.M.S., B.G. NAGARA.
.# SIGNATURE OF THE GUIDE
.$ CO-GUIDE --------------
.! SIGNATURE OF CO-GUIDE
-------------
.5 HEAD OF THE
DEPARTMENT
DR. PADMANABHA M C
PROFESSOR HOD
DEPT.OF GENERAL MEDICINE
A.I.M.S., B.G.NAGARA.
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
3/26
.* SIGNATURE OF
HEAD OF
THE DEARTMENT
# #. REMARKS OF THE
CHAIRMAN
AND
PRINCIPAL
#.# SIGNATURE
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
4/26
APPENDIX
*. BRIEF RESUME OF THE INTENDED +ORK
APPENDIX A
*.. NEED FOR THE STUDY
Ischemic stroke is a common problem faced day to day . The burden of stroke on
the community is best reflected by the incidence. There is increasing mortality and
morbidity with stroke. It has been found convincingly that in ischemic stroke, there
will be rise in acute phase reactants like C- Reactive protein 1!,"!,#! and $%R.
&therosclerosis is recogni'ed as an inflammatory process rather than a mere
obstructive one.
Increased CR( production is a feature of noninfective as well as infective
disease and CR( binds to a wide range of autogenous products. )ipids and
phospholipids, polycations and polyanions all of which are constituents of cells and
likely to be abnormally e*posed in or released from damaged tissues. In +ivo
binding of CR( to necrotic cells has been described and contribute to resolution and
repair. owever, the main role of CR(, for which it evolved and has been conserved
is to recogni'e in the plasma the potentially to*ic autogenous materials released
from damaged tissues to bind them and thereby to deto*ify them and or facilitate
their clearance!,/!,0!.
APPENDIX-IB
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
5/26
*.# REVIE+ OF LITERATURE
&very and his collaborators characteri'ed the C-reactive material as a protein
which reuired calcium ions for its reaction with C(% and introduced the term
2acute phase3 to refer to serum from patients acutely ill with infectious disease and
containing the C-reactive protein
)ofstrom independently described a non-specific capsular swelling reaction
of some strains of pneumococci when mi*ed with acute phase sera and subseuently
showed that the substance responsible was CR(4! . e detected CR( in non-
infectious as well as infectious conditions5
Inflammation is an important feature of atheroma and is associated with
activation and proliferation of macrophages, endothelial cells and smooth muscle
cells.
6ultiple studies additionally confirm that most vascular events occur among
individuals without evidence of very high cholesterol levels and that the
intermediate risk group is large, heterogenous and in need of better methods for risk
stratification.
7f potential novel risk factors presently available, high sensitivity C-reactive
protein hs CR(!, a marker of low grade vascular inflammation, is among the most
promising prospective epidemiologic studies consistently demonstrate that hsCR(
adds independent prognostic information at all levels of )8) cholesterol and at all
levels of the 9ramingham Risk %core. In the year since publication of the
C8C&&:Centre for 8isease Control and (revention&merican eart &ssociation;
report, abundant data have emerged not only confirming the ability of hs CR(:high
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
6/26
sensitivity CR(; to add prognostic information to the 9ramingham Risk %core but
also linking hs CR( to metabolic syndrome and the development of incident type "
diabetes.
In addition, the 9ramingham eart study itself has provided evidence that
hsCR( independently predicts thrombotic events in the cerebral circulation.
9inally within the 9ramingham eart study, data have also been presented
that demonstrate the ability of hsCR( to predict stroke risk independently of the
9ramingham covariates. &fter ad?.??4! for each
increasing uartile of hsCR( 1?!.
Thus, measures of inflammation such as hsCR( seem to provide independent
and complementary information on risk beyond that achievable by direct measures
of atherosclerotic burden.
APPENDIX C
*.$. OBJECTIVES OF STUDY
.To study the association of C-Reactive protein CR(! level rise in patients of acute
ischemic stroke.
#. To study the short term prognostic value of CR( level in patients of acute ischemic
stroke.
$.To compare CR( and $%R levels in patients of acute ischemic stroke.
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
7/26
APPENDIX D
0. INCLUSION CRITERIA
(atients of first ischemic stroke admitted within A"hrs of symptom
onset and age and se* matched healthy controls .
. EXCLUSION CRITERIA
o &cute infectious disease
o &ll patients of stable or unstable angina, acute myocardial infarction.
o Immunological disorders.
o Bnown or suspected neoplastic disorders
o Recent:less than # months;ma
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
8/26
APPENDIX IIB
7.# METHOD OF COLLECTION OF DATA
SAMPLE SI/E0
/? cases will be studied with eual number of healthy controls.
PROTOCOL OF THE STUDY0
9or every case and control selected, clinical data and results of routine
investigations will be prospectively recorded. In both cases and controls, blood for
CR( and $%R will be taken by performing venipuncture and estimation will be
done in Clinical 6icrobiology )aboratory, & I 6 % F.E Dagar.
P1234614 0 C - reactive protein and $%R estimation.
P1839:40
The CR( is a rapid slide agglutination procedure for the direct detection and
semiuantitation of C-reactive protein. The reagent, a late* particle suspension
coated with specific antihuman C- reactive protein antibodies, agglutinates in the
presence of CR( in patients serum.
P1234614 6;:&;&
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
9/26
1. 7ne drop of serum placed in circled area of slide with the help of disposable
serum dropper.
". 7ne drop of CR( late* antigen added to above drop and mi*ed well with
disposable applicator stick.
#. 7bserved for agglutination by rocking the slide gently back and forth upto to
"min using a bright source of light.
S4=>6;8&;&
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
10/26
Third GGGGGGGGGGGGGG. 1H4
9ourth GGGGGGGGGGGGGG 1H10
9ifth GGGGGGGGGGGGGGG 1H#"
%i*th GGGGGGGGGGGGGGG 1H0
C;:36:;&280
Concentration of CR( in serum can be calculated.
CR( ?.0 * highest dilution of serum showing agglutination
%ensitivity > ?.0 mgd).
The detection limit of this test is ?-0 mgdl. therefore, values of less than ?.0
mgd) will be taken as normal concentration of CR(. +alues of more than ?.0
mgd) will be taken as elevated CR(.
ESR LEVEL ESTIMATION511
6$T785
The International Committee for %tandardi'ation in ematology IC%!
recommends the use of the Jestergren method.
$thylenediaminetetraacetic acid $8T&! anticoagulated blood sample is preferably
diluted in a large bore tube before using the Jestergren tube.Jith this modified
JestergrenKs method, there is an e*cellent correlation with the IC% reference. Flood
samples can be stored for up to " hours at LC, but not at room temperature, withoutaffecting the Jestergren level.
FACTORS AFFECTING THE TEST@#,$
$rythrocyte aggregation is affected by two ma
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
11/26
frictional forces around the red cell. The erythrocytes normally have net negative charges
and, therefore, repel each other. igh molecular weight proteins, especially when
positively charged, increase viscosity and favor rouleau* formation and thus would raise
the $%R. 9ibrinogen, the most abundant acute phase reactant, has the greatest effect on
the elevation of $%R when compared with other acute phase proteins.
7n the other hand, a change in the frictional forces around the red blood cell can affect
the $%R. & drop in the red cell number, as in anemia, slightly elevates the $%R since this
also physically interferes with rouleau* formation. 6acrocytosis with a small surface-to-
volume ratio have charge relative to their mass and thus sediment more rapidly.
Dormal values are 1/ mmhr or less for men and "? mmhr or less for women.
PROFORMA
S&6 2 S416= C28348&1;&28 2 C-14;3&
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
12/26
P14%48&8 C2=9:;8&%0
1. Jeakness of H Right upper limb Right lower limb )eft upper limb )eft
lower limb. %ince MMMMMMMM
". 8eviation of mouthH (resent &bsent5 to left right, since MMMMMMMMM
#. <ered level of consciousness5 (resent &bsent5 sinceMMMMMMMMMMM
H%&21 2 914%48&8 32=9:;8&%0
1. Jeakness of right upper limb right lower limb left upper limb left lower
limb5 (resent &bsent
7nset H sudden gradual 7ver minutes ours 8ays
8uring activity at rest while asleep
". Inability to speak altered speech H (resent &bsent
#. istory of altered level of consciousnessH (resent &bsent
. istory of eadache H (resent absent
/. istory of vomiting H (resent absent
0. istory of convulsionsH (resent absent
A. istory of sensory disturbancesH (resent absent
4. istory of bowel bladder disturbance H (resent absent
@. istory of swaying H (resent absent
1?. istory of loss of vision diplopia change in voice nasal regurgitation
P;%& H%&210
8iabetes mellitus Ischemic heart disease Claudication ypertension
6igraine R8 Trauma to head and spine stroke Transient Ischemic &ttack R&
&% 7%
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
13/26
F;=: %&210
%troke hypertension sudden death diabetes I8
P41%28;: H%&210
8iet +eg 6i*ed
&ppetite Eood (oor
%leep %ound 8isturbed
6artial status married unmarried
Fowel regular altered
Fladder regular altered
abits %moker alcoholic tobacco chewer
7bstetric and menstrual history in females!H
&ge of menarche
Cycles regular irregular
&ge of menopause
P%3;: E;=8;&280
1. 8ecubitus
". Fuilt H Jell built moderately built poorly built
#. %tate of Dutrition H over weight normal under weight
. ydration status H Jell hydrated 8ehydrated
/. $yes H (losis leterus (allor &rcus senilis B9 ring cataract
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
14/26
0. $ars
A. 7ral cavity
4. )ymphadencopathy (resent &bsent
(edal $dema
@. $*amination of peripheral vessels and neck vessels
V&;: D;&;0
(ulse rateH Respiratory rateH
Flood pressureH TemperatureH
S%&4=;&3 E;=8;&280
1. Dervous system e*aminationH
a. anded ness right left
b. 6ental status e*amination
i. 6emory H Intact lost
If alertH
ii. 6emory H Intact lost
iii. 7rientation H (resent &bsent5 if present to time
place person
iv. %peech and language H Dormal aphasic dysarthric
c. Cranial nerves e*amination
i. 1stcranial nerve sense of smell H (reserve altered lost
ii. "ndcranial nerve acuty of vision normal reduced
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
15/26
9ield of vision normal reduced
Colour vision normal altered
7ptic fundus e*amination H
Dormal abnormal
iii. #rd, thand 0thCranial nervesH
1. 7cular movements full range restricted
". %uint present absent
#. Dystagmus present absent
. (tosis (resent &bsent
/. (upils si'e Right
)eft
)ight Refle* Right5 &ccommodation refle* Right
)eft )eft
iv. /thcranial nerve nerveH
1. 6otor
". %ensory
#. %ecretory function
. Refle*es
a. corneal (resent absent
b. Con
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
16/26
1. 6otor
". %ensory
#. %ecretory
vi. 4thcranial nerves
1. RinneKs test
". JeberKs test
vii. @thand 1?thcranial nerves
1. (alatal refle* vula central deviates to leftH right
side
". Eag refle* (resent absente*aggerated
viii. 11thcranial nerve
1. (ower in sternoceidomastoid and trepi'ius muscle
i*. 1"thcranial nerve
d. 6otor system e*aminationH
Right )eft
) )) ) ))
a. Dutrition
b. Tone
c. (ower
d. Coordination
e. Involuntary movementsH (resent absent
f. Refle*esH Right )eft
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
17/26
a. %uperficial
i. &bdominal
ii. Cremastric
iii. (lantar
b. 8eep
i. Ficeps
ii. Triceps
iii. %upinator
iv. Bnee
v. &nkle
c. (rimitive refle* (resent &bsent
d. %ensory system e*aminationH
Right )eft
Touch
(ain
Temperature
+ibration
Noint sense
Cortical sensation
e. Cerebrallar system e*aminationH
Right )eft
9inger Dose test
Bnee eel test
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
18/26
8ysdiadokinesia
g. E&ITH
h. %igns of &utonomic 8isturbances (resent&bsent
i. %igns of 6eningeal iriitation
Deck RigidityBernings signFrud'enski sign
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
19/26
I8
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
20/26
S8;&614 2 G64
APPENDIX-IIC
7.$ DOES THE STUDY REUIRE ANY INVESTIGATIONS ORINTERVENTION TO BE CONDUCTED ON PATIENTS OR
OTHER ANIMALS, IF SO PLEASE DISCRIBE BRIEFLY
YES
CT %can ead plain of the patient
C-Reactive protein CR(! of patient and age and se* matched healthy controls
$%R of patient and age and se* matched healthy controls
APPENDIX-IID
7.! HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM
YOUR INSTITUTION IN CASE OF 7.$
YES
APPENDIX-III
".' LIST OF REFERANCES
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
21/26
1. 8i Dapoli 6, (apa 9, Focola +. 2(rognostic Influence of increased CR( and
fibrinogen levels in ischemic stroke3. %troke "??15#"H1##-1#4.
". Nialal I, 8evara< %. 2Inflammation and atherosclerosis5 the value of the high
sensitivity c-reactive protein assay as a risk marker3. &m N. Clin (athol.
"??1H8ecH110H %upplH%1?4-1/
#. &garwal 6(, %ingh DR, Baur IR. 2C-Reactive (rotein in acute cerebral
infarction3. N&(I. +ol/158ec "??#
. Beith J. 6uir, 68, 6RC(5 Christopher N. Jeir, F%C5 Jafa &lwan, 6RC
(ath5 et al. 2C-Reactive protein and outcome after ischemic stroke3. %troke
1@@@5#?H@41-@4/.
/. 8hami
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
22/26
1?. Datalia % .Roast, (hilip & Jolf, Carlos %, Base et al,KK(lasma concentration
of C- reactive protein and risk of ischemic stroke and trancient ischemic
attackKK. The 9ramingham %tudy. %troke Dov "??15#"5"/A/-"/A@.
11. International Council for %tandardi'ation in aematology $*pert (anel on Flood
Rheology!H IC% recommendations for measurement of erythrocyte sedimentation
rate. N Clin (athol 1@@#5 0H1@4-"?4
1". Thomas R8, Jestengard NC, ay B), et alH Calibration and validation for
erythrocyte sedimentation tests. &rch (athol )ab 6ed 1@@#5 11AHA1@-A"#
1#. %mith $6, %amadian %H se of the erythrocyte sedimentation rate in the elderly. Fr N
osp 6ed 1@@5 /1H#@-#@A
APPENDIX-IID
PROFORMA APPLICATION FOR ETHICS COMMITTEE APPROVAL
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
23/26
SECTION A
A. T&:4 2 &4 %&6 A STUDY OF C-REACTIVE
PROTEIN IN ACUTE ISCHEMIC
STROKE
B. P1839;: 8
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
24/26
D24% &4 %&6 8
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
25/26
-9;%4 284 ;8 &2 3:83;: &1;:%.
-4941=48&;: 6%4 8-9;&48&% ;8 4;:&
8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE
26/26
L. +:: &4383;: 861%8 4:9 4 14>614
21 &4 %&; 2 2%9&;:, 4%,
:: & 8&41414 & &41 6&4%
:: 26 14316& 2&41 %&; 21 &4 61;&282 &4 %&6
I 4%