“A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE”

8/13/2019 A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE

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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


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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.


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.* SIGNATURE OF

HEAD OF

THE DEARTMENT

# #. REMARKS OF THE

CHAIRMAN

AND

PRINCIPAL

#.# SIGNATURE


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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


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*.# 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


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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.


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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


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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;:&;&


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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&;&


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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


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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&


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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

#. &ltered 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%


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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


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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


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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


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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


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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


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8ysdiadokinesia

g. E&ITH

h. %igns of &utonomic 8isturbances (resent&bsent

i. %igns of 6eningeal iriitation

Deck RigidityBernings signFrud'enski sign


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I8


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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


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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


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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


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SECTION A

A. T&:4 2 &4 %&6 A STUDY OF C-REACTIVE

PROTEIN IN ACUTE ISCHEMIC

STROKE

B. P1839;: 8


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D24% &4 %&6 8


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-4941=48&;: 6%4 8-9;&48&% ;8 4;:&


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21 &4 %&; 2 2%9&;:, 4%,

:: & 8&41414 & &41 6&4%

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“A STUDY OF C-REACTIVE PROTEIN IN ACUTE ISCHEMIC STROKE”

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