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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE ANNEXURE-II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1. 2. 3. 4. Name of the candidate and address Name of the institution Course of study and subject Date of admission of the course Dr. VEDANT KULSHRESTHA POST GRADUATE STUDENT DEPT OF FORENSIC MEDICINE BANGALORE MEDICAL COLLEGE & RESEARCH INSTITUTE, BANGALORE BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, BANGALORE MD FORENSIC MEDICINE 30/08/2013 5. Title: “STUDY OF CARDIAC PATHOLOGY IN YOUNG ADULTS- AN AUTOPSY BASED PROSPECTIVE STUDY”. 6. Brief resume of the intended work 6.1 Need for the study: Cardiovascular disease is now the most common cause of death worldwide.1 The causes of sudden cardiac death differ greatly among various age groups. In individuals > 40 years old, atherosclerotic coronary heart disease is the most common cause. Between 1 to 40 years of age, the causes of sudden cardiac death are commonly hypertrophic cardiomyopathy, myocarditis, congenital heart disease, arrhythmogenic right ventricular dysplasia/ cardiomyopathy etc.2 The sudden death in apparently healthy young individuals is always a devastating and shocking event. The incidence of sudden deaths in young due to various cardiac pathologies has wide variations in different parts of the world. Very few studies are done in India to know the incidence of various cardiac pathologies in young adults. Now because of change in lifestyle and habits, many cardiac pathologies are noticed in comparatively younger age group even in a developing country like India and some of these cardiac pathologies are inheritable. We have noticed that many cardiac pathologies are occurring in young IT professionals because of their sedentary lifestyles, smoking and drinking (alcohol) habits. Hence we, at the department of Forensic Medicine, Bangalore Medical College & Research Institute, are doing an autopsy based prospective study in young adults dying due to various reasons, to know the incidence of various cardiac pathologies in young adults and various factors responsible for it so that we can counsel the close family members of the deceased to go through essential investigations and take preventive measures. In this way we can protect the close family members from fatal inheritable cardiac pathologies. 6.2 Review of literature: Coronary atherosclerosis is sometimes called ‘the Captain of the Men of Death’. This is certainly the most frequent cause of sudden death in Western societies. Cardiomyopathies account for the second largest number of sudden deaths after coronary artery disease. Among them Dilated cardiomyopathy ( DCM ) is the most common cause of congestive heart failure.3 According to a report on medical certification of cause of death 2011 by Government of Karnataka, a total of 123221 medically certified deaths were reported in Karnataka state of India in the year 2011. Among them 26987 were young adults of age group 15-44 years, died due to various reasons. Out of them 16773 were male and 10214 were female. It was also seen that total 4499 (12.18%) deaths were due to diseases of circulatory system in age group 15-44 years. Out of them 3081 were male and 1418 were female. Among various cardiac diseases 1127 males and 339 females died due to Ischemic heart diseases, 245 males and 313 females died due to chronic Rheumatic heart disease, 18 males and 10 females died due to Hypertensive heart diseases and 476 males and 219 females died due to other forms of heart diseases.4 In a study done by Chugh et al in US, they analysed 13 years (1984-1996) of autopsy series of sudden cardiac death and found that women aged 35 to 44 years constituted 32% of all women in the series in contrast to men, who constituted 24% of total male cases. There was a higher proportion of significant coronary artery disease in men compared to women. Most patients had evidence of ≥ 1 nonspecific structural cardiac abnormalities like mitral valve prolapsed, left ventricular hypertrophy and non-specific myocardial interstitial fibrosis.5 In a study done by Ogeng’o et al in Nairobi from December 2005 to November 2009, they found that cardiovascular causes comprised 13.2% of all autopsy cases. Among various cardiac pathologies most common was myocardial infarction (18.7%) and next common was cardiomyopathy (17.2%).6 Sarita Nibhoria et al did a study in Faridkot, Punjab between 2009 and 2011. A wide spectrum of heart diseases were diagnosed during the study which revealed maximum cases of cardiomegaly (16%) followed by myocardial infarction (14%), mural thrombus (06%), fibrosis (06%), and a rare diagnosis of neutrophilic myocarditis.7 Alessandra Doolan et al did a study in Australia between 1994 and 2002 to know the cause of sudden cardiac deaths in young Australians aged ≤ 35 years. The cause of sudden death in this age group was not established in 31% of cases and was presumed to be due to primary arrhythmogenic disorders. Coronary artery disease occurred in 24%, hypertrophic cardiomyopathy/ unexplained left ventricular hypertrophy in 15%, and myocarditis in 12%.8 6.3 Objectives of the study: 1. To know the incidence of various cardiac pathologies in young adults dying due to various reasons. 2. To know the epidemiological aspects of cardiac pathology. 3. To know the factors responsible for the cardiac pathology. 4. Counseling the close family members of the deceased about requirement of essential investigations and preventive measures in case of inheritable cardiac pathology in the deceased. 7. Materials and methods: 7.1 Study design: Prospective study. 7.2 Study area: Department of Forensic Medicine, Victoria Hospital, Bangalore Medical College and Research Institute (BMC & RI), Bangalore. 7.3 Source of data: 1. Young adults aged between 18 to 40 years dying due to various reasons, subjected for Medico legal autopsy at department of forensic medicine, Victoria hospital, Bangalore Medical College & Research Institute, Bangalore. 2. History obtained from close relatives of the deceased through questionnaire. 3. Gross examination reports of the autopsied hearts at department of forensic medicine, Victoria hospital, Bangalore Medical College & Research Institute, Bangalore. 4. Histopathological examination reports of the autopsied hearts sent to department of pathology, Victoria hospital, Bangalore Medical College & Research Institute, Bangalore. 7.4 Inclusion criteria: 1. Young adults aged between 18 to 40 years dying due to various reasons like road traffic accidents, poisoning, burns, hanging, sudden natural deaths, assaults etc. 2. Both sexes (Male and Female) and Transgenders. 7.5 Exclusion criteria: 1. Individuals aged less than 18 years and more than 40 years. 2. Decomposed bodies. 3. Extensively mutilated bodies. 4. Cases in which there is mechanical injury to the heart. 5. Unknown bodies. 7.6 Study period: November 2013 to May 2015. 7.7 Study sample size: 200 Cases. About 4000 medico legal autopsies are conducted every year in Victoria hospital, Bangalore Medical College & Research Institute. Last year in 2012 total 3876 autopsies were conducted, among them about 2245 cases were young adults between 18 to 40 years age group died due to various reasons. 7.8 Sampling method: Simple random sampling. 7.9 Methodology for data collection: In each case history will be taken from close relatives of the deceased about occupation, significant past medical illness, personal history including lifestyle and habits of the deceased through a questionnaire. Then thorough post mortem examination will be conducted. After removing the heart, each heart will be grossed adopting the traditional method of opening the heart in the direction of flow. The parameters which will be recorded are weight of heart, left ventricular wall thickness, right ventricular wall thickness, inter ventricular septum thickness, condition of valves, condition of main vessels including right & left coronaries, aorta & pulmonary trunk, assessment of chamber size and assessment of papillary muscles & chordiae tendinae. The patency of the four major epicardial coronary trunks will be analyzed by taking transverse sections at 3-mm intervals. Representative sections will be taken for histopathological examination after fixing in 10% Formalin solution. Then after subjecting the tissue sections to routine tissue processing, staining with haematoxylin & eosin will be done. Finally, the gross findings and the histopathological findings will be correlated. After the analysis, in case of any inheritable cardiac pathology, counselling of close family members of the deceased about requirement of essential investigations and preventive measures will be done to prevent sudden cardiac death in family members due to inheritable cardiac diseases in future. 7.10 Methodology for data analysis: Data will be analyzed using descriptive statistics and chi-square test. Suitable statistical software will be utilized for analysis and will be presented in the form of tables, figures, graphs, diagrams wherever necessary. 7.11 Does the study require any investigation or intervention to be conducted on patients or other humans or animals? If so please describe briefly. Yes. Human cadaver is subjected to post mortem examination and heart is studied in detail. 7.12 Has ethical clearance has been obtained from your institution in case of 7.11? Yes. 8. List of references: 1. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J. Harrison's principles of internal medicine.18th ed. USA; Mc Graw-Hill Companies Inc: 2012. vol 2 p.1811. 2. Zheng ZJ, Croft JB, Giles WH, Mensah A. Out-of-hospital cardiac deaths in adolescents and young adults in the United States, 1989 to 1998. Am J Prev Med 2005;29(5 suppl 1):36-41. 3. Saukko P, Knight B. Knight’s forensic pathology. 3rd ed. UK: Hodder Arnold (publishers)Ltd; 2004. p. 493,507. 4. Report on medical certification of cause of death 2011. Government of Karnataka. Office of the chief registrar of births & deaths and directorate of economics & statistics, Bangalore; 2013. p.13,21,100-102. 5. Chugh SS, Chung K, Zheng ZJ, John B, Titus JL. Cardiac pathologic findings reveal a high rate of sudden cardiac death of undetermined etiology in younger women. Am Heart J 2003 Oct ;146(4):635-639. 6. Ogeng’o JA, Gatonga P, Olabu BO. Cardiovascular causes of death in an east African country: an autopsy study. Cardiol J. 2011;18(1):67-72. 7. Nibhoria S, Jhajj KK, Nibhoria VK, Sandhu SK, Bamra NS, Padda P. A case studyRole of heart autopsy in evaluating the cause of death. Indian J FMT 2013 Jan-Jun ;7(1):72-75. 8. Doolan A, Semsarian C, Langlois N. Causes of sudden cardiac death in young Australians. Med J Aust 2004;180(3):110-112. 9. Signature of the candidate This study has not been conducted in the recent past hence the outcome will be useful to the doctors and 10. Remarks of the Guide 11.1 Name and designation of Guide 11.2 11.3 patients. Dr. P.K. Devadass Professor and Head Department of Forensic Medicine Bangalore Medical College and Research Institute, Bangalore. Signature Name and designation of Co-Guide 11.4 Signature 11.5 Head of the Department Dr. Dayananda. S. Biligi Professor Department of Pathology Bangalore Medical College and Research Institute, Bangalore. Dr. P.K. Devadass Professor and Head Department of Forensic Medicine Bangalore Medical College and Research Institute, Bangalore. 11.6 Signature Remarks of the, 12.1 Director cum Dean 12.2 Signature