The Pathophysiology and New Advancements in the Pharmacologic and Exercise-Based Management of Heart Failure With Reduced Ejection Fraction: A Narrative Review

Heart failure with reduced ejection fraction (HFrEF) is a clinical syndrome whose management has significantly evolved based on the pathophysiology and disease process. It is widely prevalent, has a relatively high mortality rate, and is comparatively more common in men than women. In HFrEF, the series of maladaptive processes that occur lead to an inability of the muscle of the left ventricle to pump blood efficiently and effectively, causing cardiac dysfunction. The neurohormonal and hemodynamic adaptations play a significant role in the advancement of the disease and are critical to guiding the treatment and management of HFrEF. The first-line therapy, which includes loop diuretics, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, hydralazine/isosorbide-dinitrate, and mineralocorticoid receptor antagonists (MRAs), has been proven to provide symptomatic relief and decrease mortality and complications. The newly recommended drugs for guideline-based therapy, angiotensin receptor/neprilysin inhibitor (ARNI), sodium-glucose cotransporter 2 inhibitors, soluble guanylate cyclase, and myosin activators and modulators have also been shown to improve cardiac function, reverse cardiac remodeling, and reduce mortality rates. Recent studies have demonstrated that exercise-based therapy has resulted in an improved quality of life, exercise capacity, cardiac function, and decreased hospital readmission rates, but it has not had a considerable reduction in mortality rates. Combining multiple therapies alongside holistic advances such as exercise therapy may provide synergistic benefits, ultimately leading to improved outcomes for patients with HFrEF. Although first-line treatment, novel pharmacologic management, and exercise-based therapy have been shown to improve prognosis, the existing literature suggests a need for further studies evaluating the long-term effects of MRA and ARNI.

Apical force distribution due to orthodontic forces: a finite element study

AIM

This finite element study was conducted to calculate the distribution of stresses in the periodontal ligament when various orthodontic forces were applied, with emphasis on the effect on root apex.

MATERIALS AND METHODS

An in vitro finite element method was used to construct a three-dimensional finite element model of a maxillary central incisor, its periodontal ligament and alveolar bone was constructed on the basis of average anatomic morphology. To this model, five types of orthodontic forces namely tipping, bodily movement, intrusion, extrusion and rotations were applied at various points on the crown of the tooth model. After the application of the forces, initial stress and initial displacements of the periodontal ligament were evaluated. The principal stress obtained on the periodontal ligament due to various orthodontic loadings on the maxillary central incisor was analyzed using ANSYS 10 finite element software.

RESULTS

It showed that the greatest amount of relative stress at the apex of maxillary central incisor occurred with intrusion, extrusion and rotation. Bodily movement and tipping forces produce stress concentrated at the alveolar crest and not at the root apex.

CONCLUSION

Clinical implications of this study suggest that if the clinician is concerned about placing heavy stresses on the root apex, then vertical and rotational forces must be applied with caution.

CLINICAL SIGNIFICANCE

If heavy stresses are to be placed on the root apex, then vertical and rotational forces must be applied with caution during orthodontic therapy.

Gonioscopy

Gonioscopy forms part of a complete ophthalmic examination and is mandatory for the diagnosis and management of glaucoma. Gonioscopy permits identification of eyes at risk for closure and detects angle abnormalities that could have diagnostic and therapeutic implications. The technique of gonioscopy, its value in management, and guidelines for routine use are discussed in this paper.

Biodegradable injectable implant systems for long term drug delivery using poly (lactic-co-glycolic) acid copolymers

Poly (lactide-co-glycolide) (PLG), is one of the most widely employed biodegradable synthetic polymers for sustained-release preparations. In the present work, PLG (50:50) copolymer has been used to deliver diclofenac sodium in the form of microspheres and in situ gel-forming systems, both of which can be injected subcutaneously. The pharmacodynamic and pharmacokinetic studies in the adjuvant-induced arthritic rats showed that the microspheres offered steady therapeutic levels of the drug in the plasma for about 16 days following a single subcutaneous injection. However, the in situ gel-forming system provided a significantly higher maximum plasma concentration and increased inhibition of inflammation, maintained for about 10 days. Injectable microspheres and in situ gel-forming implant systems of PLG (50:50) copolymer may therefore be considered as prospective implantable controlled-release dosage forms to deliver drugs in long-term therapy of chronic ailments.

Recovery from paraplegia following aortic saddle embolism. Case report

An aortic saddle embolus causing paraplegia is rare and even rarer is a documentation of neurological recovery from this event. A 47 year old male presented with absent pulsations in the lower limbs and paraplegia, both of sudden onset. He underwent immediate bilateral transfemoral embolectomy. The postoperative period was stormy. The paraplegia recovered over a period of 2 months and he could walk to his place of work after 6 months. The rare combination of saddle embolus and paraplegia is discussed. An attempt has been made to verify the hypothesis of Dickson et al which states that a low origin of the great radicular artery (GRA) below T12 level may be responsible for paraplegia when obstructed by a saddle embolus. We found the GRA arising at L2 vertebral level in this patient. Postoperative selective spinal arteriogram and magnetic resonance imaging (MRI) of the spinal cord showed a patent GRA and normal spinal cord structure respectively. Early surgical intervention in restoring the blood flow into the GRA may prevent severe histological changes hitherto responsible for nonrecovery from paraplegia in the earlier reports.