The Promise of Cilnidipine in Hypertension with Comorbidities: National Consensus Statement: National Consensus Group Comprises Cardiologists, Nephrologists, and Diabetologists from India in a National Meet at New Delhi held on 22nd May 2022

The rapidly increasing burden of hypertension is responsible for premature deaths from cardiovascular disease (CVD), renal disease, and stroke, with a tremendous public health and financial burden. Hypertension detection, treatment, and control vary worldwide; it is still low, particularly in low- and middle-income countries (LMICs). High blood pressure (BP) and CVD risk have a strong, linear, and independent association. They contribute to alarming numbers of all-cause and CVD deaths. A major culprit for increased hypertension is sympathetic activity, and further complications of hypertension are heart failure, ischemic heart disease (IHD), stroke, and renal failure. Now, antihypertensive interventions have emerged as a global public health priority to reduce BP-related morbidity and mortality. Calcium channel blockers (CCB) are highly effective vasodilators. and the most common drugs used for managing hypertension and CVD. Cilnidipine, with both L- and N-type calcium channel blocking activity, is a promising 4th generation CCB. It causes vasodilation via L-type calcium channel blockade and inhibits the sympathetic nervous system (SNS) via N-type calcium channel blockade. Cilnidipine, which acts as a dual L/N-type CCB, is linked to a reduced occurrence of pedal edema compared to amlodipine, which solely blocks L-type calcium channels. The antihypertensive properties of cilnidipine are very substantial, with low BP variability and long-acting properties. It is beneficial for hypertensive patients to deal with morning hypertension and for patients with abnormal nocturnal BP due to exaggerated sympathetic nerve activation. Besides its BP-lowering effect, it also exhibits organ protection via sympathetic nerve inhibition and renin-angiotensin-aldosterone system inhibition; it controls heart rate and proteinuria. Reno-protective, neuroprotective, and cardioprotective effects of cilnidipine have been well-documented and demonstrated.

Angiotensin Receptor-Neprilysin Inhibitor Therapy and Cardiac Remodeling in Heart Failure: Consensus Statement from India

Adverse cardiac remodeling refers to progressive structural and functional modifications in the heart because of increased wall stress in the myocardium, loss of viable myocardium, and neurohormonal stimulation. The guideline-directed medical therapy for Heart failure (HF) includes Angiotensin receptor-neprilysin inhibitor (ARNI) (sacubitril/valsartan), β-blockers, sodium-glucose co-transporter 2 (SGLT2) inhibitors, and mineralocorticoid receptor antagonists (MRA). ARNI is under-prescribed in India despite its attractive safety and efficacy profile. Therefore, the consensus discusses objectives and topics related to ARNI in the management of cardiac remodeling, and experts shared their views on the early timely intervention of effective dosage of ARNI to improve the diagnosis and enhance mortality and morbidity benefits in cardiac reverse remodeling (CRR).

Role of Iron Therapy in Heart Failure: A Consensus Statement from India

Iron deficiency (ID) with or without anemia is frequently observed in patients with heart failure (HF). Uncorrected ID is associated with higher hospitalization and mortality in patients with acute HF (AHF) and chronic HF (CHF). Hence, in addition to chronic renal insufficiency, anemia, and diabetes, ID appears as a novel comorbidity and a treatment target of CHF. Intravenous (IV) ferric carboxymaltose (FCM) reduces the hospitalization risk due to HF worsening and improves functional capacity and quality of life (QOL) in HF patients. The current consensus document provides criteria, an expert opinion on the diagnosis of ID in HF, patient profiles for IV FCM, and correct administration and monitoring of such patients.

The Power and Promise of Angiotensin Receptor Neprilysin Inhibitor (ARNI) in Heart Failure Management: National Consensus Statement

;Heart failure (HF) is a huge global public health task due to morbidity, mortality, disturbed quality of life, and major economic burden. It is an area of active research and newer treatment strategies are evolving. Recently angiotensin receptor-neprilysin inhibitor (ARNI), a class of drugs (the first agent in this class, Sacubitril-Valsartan), reduces cardiovascular mortality and morbidity in chronic HF patients with reduced left ventricular ejection fraction (LVEF). Positive therapeutic effects have led to a decrease in cardiovascular mortality and HF hospitalizations (HFH), with a favorable safety profile, and have been documented in several clinical studies with an unquestionable survival benefit with ARNI, Sacubitril-Valsartan. This consensus statement of the Indian group of experts in cardiology, nephrology, and diabetes provides a comprehensive review of the power and promise of ARNI in HF management and an evidence-based appraisal of the use of ARNI as an essential treatment strategy for HF patients in clinical practice. Consensus in this review favors an early utility of Sacubitril-Valsartan in patients with HF with reduced EF (HFrEF), regardless of the previous therapy being given. A lower rate of hospitalizations for HF with Sacubitril-Valsartan in HF patients with preserved EF who are phenotypically heterogeneous suggests possible benefits of ARNI in patients having 40-50% of LVEF, frequent subtle systolic dysfunction, and higher hospitalization risk.

Clinical outcomes of bronchiectasis in India: data from the EMBARC/Respiratory Research Network of India registry

BACKGROUND

Identifying risk factors for poor outcomes can help with risk stratification and targeting of treatment. Risk factors for mortality and exacerbations have been identified in bronchiectasis but have been almost exclusively studied in European and North American populations. This study investigated the risk factors for poor outcome in a large population of bronchiectasis patients enrolled in India.

METHODS

The European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) and Respiratory Research Network of India (EMBARC-India) registry is a prospective observational study of adults with computed tomography-confirmed bronchiectasis enrolled at 31 sites across India. Baseline characteristics of patients were used to investigate associations with key clinical outcomes: mortality, severe exacerbations requiring hospital admission, overall exacerbation frequency and decline in forced expiratory volume in 1 s.

RESULTS

1018 patients with at least 12-month follow-up data were enrolled in the follow-up study. Frequent exacerbations (≥3 per year) at baseline were associated with an increased risk of mortality (hazard ratio (HR) 3.23, 95% CI 1.39-7.50), severe exacerbations (HR 2.71, 95% CI 1.92-3.83), future exacerbations (incidence rate ratio (IRR) 3.08, 95% CI 2.36-4.01) and lung function decline. Coexisting COPD, dyspnoea and current cigarette smoking were similarly associated with a worse outcome across all end-points studied. Additional predictors of mortality and severe exacerbations were increasing age and cardiovascular comorbidity. Infection with Gram-negative pathogens (predominantly Klebsiella pneumoniae) was independently associated with increased mortality (HR 3.13, 95% CI 1.62-6.06), while Pseudomonas aeruginosa infection was associated with severe exacerbations (HR 1.41, 95% CI 1.01-1.97) and overall exacerbation rate (IRR 1.47, 95% CI 1.13-1.91).

CONCLUSIONS

This study identifies risk factors for morbidity and mortality among bronchiectasis patients in India. Identification of these risk factors may support treatment approaches optimised to an Asian setting.

Real-World Experience with Favipiravir for the Treatment of Mild-to-Moderate COVID-19 in India

Background

Favipiravir, an RNA-dependent RNA polymerase inhibitor (RdRp), is a broad-spectrum oral antiviral agent approved in India under emergency use authorization, for the treatment of mild-to-moderate coronavirus disease (COVID-19). The present study was planned to evaluate the effectiveness and safety of favipiravir in real-world clinical practice.

Materials and Methods

This was a multicentric, retrospective, single-arm study conducted across four centres in India, after obtaining permission from the independent ethics committee. Medical records were analysed to evaluate effectiveness and safety of patients who were prescribed favipiravir.

Results

The medical records of a total of 360 patients met the inclusion criteria, with 358 of them available for the final analysis. Males made up 58.46% of the study population. The average age of enrolled patients was 51.80 ± 16.45 years. The most common symptoms were fever, cough, and myalgia-fatigue. The median time to clinical cure and fever relief was five and four days, respectively. The average length of stay in the hospital was six days. In total, 8% of the patients experienced adverse events. Hepatic enzyme elevation, diarrhoea, decreased appetite, headache, fatigue, and giddiness were the common symptoms.

Conclusion

In our real-world study, favipiravir was found to have a clinical cure rate of more than 90% in mild-to-moderate COVID-19 patients. This supports the use of favipiravir in the treatment of COVID-19. Favipiravir was well tolerated, with only minimal side effects, which were transient in nature.

Pharmacogenetic variants influence vitamin K anticoagulant dosing in patients with mechanical prosthetic heart valves

Background: Vitamin K antagonists (VKAs) are class I oral anticoagulants that are widely prescribed following surgical heart valve implantation. The objective of this study was to quantify the relative effects of VKORC1, CYP2C9 and CYP4F2 genotypes in predicting VKA dosing. Materials & methods: A total of 506 South Indian patients with mechanical prosthetic heart valves who were prescribed oral VKAs, such as warfarin or acenocoumarol, were genotyped. The discriminatory ability of mutant genotypes to predict dose categories and bleeding events was assessed using regression analysis. Results: The VKORC1 rs9923231, CYP2C9*3 and CYP4F2*3 mutant genotypes significantly influenced VKA-dose requirements and explained 27.47% of the observed dose variation. Conclusion: These results support pharmacogenetic screening for initial VKA dosing among South Indian patients with mechanical prosthetic heart valves.

Hybrid Immunity in SARS-CoV-2: Are Antibody Responses Similar in all Infected and AZD1222 Vaccinated Persons?

Introduction: There is a diversity in population regarding the number and doses of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) vaccines and past infection status and the antibody titres may be different across various groups. The antibody titres determined in the same time-frame after the immune evoking event may give clues regarding the prioritisation for boosters and factors causing variability in titres. Aim: To compare and assess the Immunoglobulin G (IgG) antispike (S) antibody titres among the Healthcare Workers (HCWs) with history of Adenovirus vector based vaccine AZD1222 (Covishield) and infections, in different orders. Materials and Methods: An observational cross-sectional cohort study was conducted in a tertiary care centre during November 2021 to December 2021. The antibody titres of a healthy cohort of HCWs (n=178) who were either double-vaccinated with no history of SARS-CoV-2 infection or vaccinated but along with a history of SARS-CoV-2 infection were determined six weeks after the last event (infection/vaccination). They were grouped based on the order of vaccination (V) and infection (I). Results: The major groups were group 1 (V+V), group 2 (I+V+V), group 3 (V+ V+ I) and group 4 (V+I+V). The highest titres of Anti-S IgG antibody observed in vaccinated with breakthrough infection group 3-V+V+I (n=71) {20662(10853-34744)}. The group with double vaccination but with no history of infection {group 1-V+V (N=49)} had the lowest titres - {2395(844.4-7443)}. The hybrid immunity group (those who had infection which was followed by vaccination) group 2 (I+V+V) had titres 4241 (2220-7373) and group 4 (V+I+V) had titres 6542 (3772-11700) which were lower than those with breakthrough infection. Conclusion: Anti-S antibody titres are highest among vaccinated with breakthrough infections and lowest in those with two doses of vaccines but no history of previous confirmed infections and booster doses may be prioritised for the second group. The timing of previous infection can also be a criterion for further booster doses.

Pulmonary Hypertension Registry of Kerala, India (PRO-KERALA): One-year outcomes

BACKGROUND

Short term outcomes of patients with pulmonary hypertension are not available from low and middle-income countries including India.

METHODS

We conducted a prospective study of 2003 patients with pulmonary hypertension, from 50 centres (PROKERALA) in Kerala, who were followed up for one year. Pulmonary hypertension (PH) was mainly diagnosed on the basis of Doppler echocardiography. The primary outcome was a composite end-point of all-cause death and hospital admission for heart failure. All cause hospitalisation events constituted the secondary outcome.

RESULTS

Mean age of study population was 56 ± 16 years. Group 1 and Group 2 PH categories constituted 21.2% and 59% of the study population, respectively. Nearly two-thirds (65%) of the study participants had functional class II symptoms. 31% of Group 1 PH patients were on specific vasodilator drugs.In total, 83 patients (4.1%) died during the one-year follow-up period. Further, 1235 re-hospitalisation events (61.7%) were reported. In the multivariate model, baseline NYHA class III/IV (OR 1.87, 95% C.I. 1.35-2.56), use of calcium channel blockers (OR 0.18, 95% C.I. 0.04-0.77), vasodilator therapy (OR 0.5, 95% C.I. 0.28-0.87) and antiplatelet agents (OR 1.80, 95% C.I. 1.29-2.51) were associated with primary composite outcome at one-year (p < 0.05).

CONCLUSION

In the PROKERALA registry, annual mortality rate was 4%. More than half of the patients reported re-hospitalisation events on follow up. Uptake of guideline directed therapies were suboptimal in the study population. Quality improvement programmes to improve guideline directed therapy may improve clinical outcomes of PH patients in India.

Recent advances in valorization of organic municipal waste into energy using biorefinery approach, environment and economic analysis

Researcher's all around works on a copious technique to lessen waste production and superintend the waste management for long-term socio-economic and environmental benefits. Value-added products can be produced from municipal waste by using holistic and integrated approaches. In this review, a detail about the superiority of the different methods like anaerobic digestion, biofuel production, incineration, pyrolysis and gasification were used for the conversion of municipal waste to feedstock for alternate energy and its economic- environmental impacts were consolidated. Most conversion techniques were environmentally friendly to manage municipal waste. The biological process was more economically feasible compare to the thermal process, for the reason thermal process required a large amount of capital investment and energy utilization. In the thermal process, gasification shows low emission, and pyrolysis shows low capital investment and economically feasible compare to other thermal processes. Waste to energy technology significantly reduced the emission and energy demand.

Impact of the 2017 ACC/AHA guidelines on the prevalence of hypertension among Indian adults: Results from a cross-sectional survey

Background

The impact of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for diagnosis and management of hypertension on the prevalence of hypertension in India is unknown.

Methods

We analyzed data from the Cardiac Prevent 2015 survey to estimate the change in the prevalence of hypertension. The JNC8 guidelines defined hypertension as a systolic blood pressure of ≥140 ​mmHg or diastolic blood pressure of ≥90 ​mmHg. The 2017 ACC/AHA guidelines define hypertension as a systolic blood pressure of ≥130 ​mmHg or diastolic blood pressure of ≥80 ​mmHg. We standardized the prevalence as per the 2011 census population of India. We also calculated the prevalence as per the World Health Organization (WHO) World Standard Population (2000–2025).

Results

Among 180,335 participants (33.2% women), the mean age was 40.6 ​± ​14.9 years (41.1 ​± ​15.0 and 39.7 ​± ​14.7 years in men and women, respectively). Among them, 8,898 (4.9%), 99,791 (55.3%), 35,694 (11.9%), 23,084 (12.8%), 9,989 (5.5%) and 2,878 (1.6%) participants belonged to age group 18–19, 20–44, 45–54, 55–64, 65–74 and ​≥ ​75 years respectively. The prevalence of hypertension according to the JNC8 and 2017 ACC/AHA guidelines was 29.7% and 63.8%, respectively- an increase of 115%. With the 2011 census population of India, this suggests that currently, 486 million Indian adults have hypertension according to the 2017 ACC/AHA guidelines, an addition of 260 million as compared to the JNC8 guidelines.

Conclusion

According to the 2017 ACC/AHA guidelines, 3 in every 5 Indian adults have hypertension.

Serum Aminotransferase Levels as a Marker in Assessment of Severity of Dengue Fever in Adult Patients- A Cross-sectional Study

Introduction: Dengue Fever (DF) is the most common rapidly spreading mosquito-borne arboviral disease with a wide clinical spectrum that includes both severe and nonsevere clinical manifestations. Most patients with DF have liver involvement in the form of elevated serum Aminotransferase (AST). Severity of the disease is more in patients with elevated serum ASTs. Hence, this study was taken-up to assess the correlation with the elevated serum ASTs and severity of the disease. Aim: To measure and associate the serum AST levels as a marker in assessing severity of DF in adults. Materials and Methods: The cross-sectional study was conducted on 100 patients of DF admitted to General Medicine wards from May 2019 to April 2020 in Hassan Institute of Medical Sciences and hospital, Hassan, Karnataka, India. Serum AST levels were estimated at admission, on the day of discharge of the patient and correlated to prognosis of patient in DF. A pre-determined proforma was used to record the details of history, physical examination and investigation and results were recorded in a Microsoft excel master chart. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) software, version 20.0, ANOVA and student t-test were used for calculation of significance in all parameters within the groups while Fischer’s-exact test was used to compare the significance between the groups. The p-value <0.05 was to be considered level of significance. Results: In this study, 100 (mean age: 31.65±12.08 years) patients of dengue Nonstructural protein 1/Immunoglobulin M (NS1/IgM) positive patients were studied. Out of this 60% NS1 Antigen (Ag), 22% NS1 Ag and IgM Antibody (Ab) and 18% were IgM Ab positive. 63 were males and 37 were females. AST/SGOT values were on day 1 was 203.76±360.87 U/L and on day of discharge was 55.96±31.76 U/L (p-value<0.001). And ALT/SGPT on day 1 was 109.63±146.01 U/L and on day od discharge was 41.05±20.78 U/L (p-value <0.001). Indicating dengue patients had raised AST/SGOT values on day 1 as compared to day of discharge. There was a significant difference (p-value <0.001) found on day 1 and at the time of discharge. Conclusion: Hepatic involvement, characterised by elevation of liver enzymes, is very common finding in Dengue Fever. Serum Aminotranferase (AST) levels are elevated more as compared to serum Alanine aminotransferase (ALT) . The present study found significant association of serum AST levels with the hospital stay and prognosis of the patient. Hence, serum AST levels are mandatory in DF to look for complications and it is of prognostic value.

One-year clinical outcome of patients with nonvalvular atrial fibrillation: Insights from KERALA-AF registry

BACKGROUND

We report patient characteristics, treatment pattern and one-year clinical outcome of nonvalvular atrial fibrillation (NVAF) from Kerala, India. This cohort forms part of Kerala Atrial Fibrillation (KERALA-AF) registry which is an ongoing large prospective study.

METHODS

KERALA-AF registry collected data of adults with previously or newly diagnosed atrial fibrillation (AF) during April 2016 to April 2017. A total of 3421 patients were recruited from 53 hospitals across Kerala state. We analysed one-year follow-up outcome of 2507 patients with NVAF.

RESULTS

Mean age at recruitment was 67.2 years (range 18-98) and 54.8% were males. Main co-morbidities were hypertension (61.2%), hyperlipidaemia (46.2%) and diabetes mellitus (37.2%). Major co-existing diseases were chronic kidney disease (42.1%), coronary artery disease (41.6%), and chronic heart failure (26.4%). Mean CHA₂DS₂-VASc score was 3.18 (SD ± 1.7) and HAS-BLED score, 1.84 (SD ± 1.3). At baseline, use of oral anticoagulants (OAC) was 38.6% and antiplatelets 32.7%. On one-month follow-up use of OAC increased to 65.8% and antiplatelets to 48.3%. One-year all-cause mortality was 16.48 and hospitalization 20.65 per 100 person years. The main causes of death were cardiovascular (75.0%), stroke (13.1%) and others (11.9%). The major causes of hospitalizations were acute coronary syndrome (35.0%), followed by arrhythmia (29.5%) and heart failure (8.4%).

CONCLUSIONS

Despite high risk profile of patients in this registry, use of OAC was suboptimal, whereas antiplatelets were used in nearly half of patients. A relatively high rate of annual mortality and hospitalization was observed in patients with NVAF in Kerala AF Registry.

Enhanced Biosynthesis Synthesis of Copper Oxide Nanoparticles (CuO-NPs) for their Antifungal Activity Toxicity against Major Phyto-Pathogens of Apple Orchards

PURPOSE

The present study made an attempt to develop copper nanoparticles (Cu-NP) with antifungal property using green synthesis method. Copper oxide nanoparticles (CuO-NPs) botanically synthesized using Neem leaf extract (Azadirachta indica A. Juss) were characterized by using different techniques like; UV-visible spectrophotometry, FTIR, XRD, SEM and TEM.

METHODS

Materials were chosen the disease free and fresh Azadirachta indica A. Juss were collected and identified at Center of Biodiversity and Taxonomy. The plant samples were vigorously washed with distilled water then shade dried followed by sterilization with 0.1% mercuric chloride for 20 s and again it was washed with distilled water. 15 g powder form of plant material was added to 200 ml double distilled, CO₂ free and deionized water and kept in shaker at 80°C and 1500 rpm for six hours. After agitation, the extract was separated by regular centrifugation at 10,000 rpm followed by filtration by using whatmann filter paper. The final volume of 100 ml of supernatant was collected as pure extract and stored in cool place for further use.

RESULTS

The final results confirm a significant inhibition of CuO-NPs for the test fungi. Additionally, CuO-NPs demonstrated an enhanced effect when combined with Neem leaf extract. A total of 20-30% improvement in activity was noticed after combination, which correlates with commonly used synthetic fungicides. The toxicity results reveal that A. indica extract and their combined fractions with CuO-NP were less toxic to the test seeds of experimental plant while as bulk Cu followed by biosynthesized CuO-NPs influenced the germination rate as compared to control pots.

CONCLUSIONS

The study drops a concern of research and offers a promising route of developing Copper based green fungicides that can help to combat with modern issues of synthetic fungicides. An average size of 80 ± 15 nm monoclinic cupric oxide (CuO) and cubic cuprous oxides (Cu₂O) nanocrystals that existed in mixed form were successfully developed.

Cost Needed to Treat (CNT) and Number Needed to Treat (NNT) analysis of drugs for treatment of heart failure in India

Background

Only little attention has been paid to treatment strategies of chronic disease conditions that require long term treatment and repeated hospitalizations

Purpose

Our aim was to review cost-effectiveness of guideline directed medical therapy of heart failure in India and identify drugs that can be made available free of cost or at subsidized rates to the patient population.

Methods

Data extracted from ten landmark trials in heart failure was used to compute Number Needed to Treat (NNT) and Cost Needed to Treat (CNT) of drugs used in heart failure, to prevent cardiovascular mortality and heart failure re-hospitalization using HDS Plotter- Incremental Cost Effectiveness Calculator. Since various brands (i.e. trade names) with wide cost range are available in Indian market, the average retail price in Indian Rupees for year 2019 was considered and converted to US dollars and used for the analysis.NNT and CNT of each drug was computed and the cost-effectiveness was analyzed. WHO recommendation of three times per capita GDP was used as the cost effectiveness threshold.

Results

Medications that were labeled as class I for the treatment of heart failure, were included in our analysis. Ivabradine, Valsartan and Angiotensin Receptor Neprilysin inhibitor (ARNi) did not meet the cost effectiveness criteria for preventing cardio-vascular mortality. For prevention of heart failure re-hospitalization, all drugs except ARNi, met the cost effectiveness threshold.

Conclusion

Any future research would need to consider compliance factor along with Willingness to Pay (WTP) to understand the real acceptance of these drugs on the ground in India.

Log prices (in US$) of various HF drugs

Funding Acknowledgement

Type of funding source: None

Prevalence of metabolic syndrome and its risk factors in Kerala, South India: Analysis of a community based cross-sectional study

BACKGROUND

Coronary Artery Disease (CAD) is a leading cause of death and disability in Kerala, India. Metabolic syndrome (MS) is a constellation of established risk factors for CAD. We aimed to estimate the prevalence of MS and evaluate the association between MS and CAD using a community-based sample population.

METHODS

A cross-sectional community based survey was conducted in urban and rural areas of Kerala in 2011. We included 5063 individuals for analysis. Age standardized prevalence of MS, associated diagnoses (hypertension, diabetes and hypercholesterolemia) and other potential risk factors were assessed for men and women in both urban and rural locations. Univariate and multivariate logistic regression models were developed to identify participant characteristics that are associated with MS.

RESULTS

After standardization for age and adjustment for sex and urban-rural distribution, the prevalence of metabolic syndrome in Kerala was 24%, 29% and 33% for the NCEP ATP III, IDF and AHA/NHLBI Harmonization definitions, respectively. The mean (SD) age of the participants was 51 (14) years, and 60% were women. Women had a higher prevalence of MS than men (28% versus 20% for ATP III, p<0.001). Similarly, participants living in urban areas had higher prevalence of MS than their rural counterparts (26% versus 22%, p<0.001). Elevated body mass index, older age, and female sex were associated with MS in an adjusted multivariate model. The propensity for definite CAD was 1.7 times higher in individuals with MS defined based on ATP III criteria compared to those without MS (Adjusted OR = 1.69; 95% CI: 1.3-2.2, p<0.001).

CONCLUSIONS

One of four to one of three adult individuals in Kerala have MS based on different criteria. Higher propensity for CAD in individuals with MS in Kerala calls for urgent steps to prevent and control the burden of metabolic conditions.

The impact of anticancer activity upon Beta vulgaris extract mediated biosynthesized silver nanoparticles (ag-NPs) against human breast (MCF-7), lung (A549) and pharynx (Hep-2) cancer cell lines

The present study tried for a phyto-synthetic method of producing silver nanoparticles (Ag-NPs) with size controlled as and eco-friendly route that can lead to their advanced production with decorative tranquil morphology. By inducing temperature fluctuation of the reaction mixture from 25 to 80°C the plasmon resonance band raised slowly which had an ultimate effect on size and shape of Ag-NPs as shown by UV-visible spectroscopy and TEM results. The biosynthesized nanoparticles showed good cytotoxic impact against MCF-7, A549 and Hep2 cells compared to normal cell lines. Compared to control plates, the percentage of cell growth inhibition was found to be high with as concentrations of Ag-NPs becomes more as determined by MTT assay. The AO/EtBr staining observations demonstrated that the mechanism of cell death induced by Ag-NPs was due to apoptosis in cancer cells. These present results propose that the silver nanoparticles (Ag-NPs) may be utilized as anticancer agents for the treatment of various cancer types. However, there is a need for study of in vivo examination of these nanoparticles to find their role and mechanism inside human body. Further, studies we plan to do biomarker fabrication from the green synthesized plant extract nanoparticles like silver, gold and copper nanoparticles with optimized shape and sizes and their enhancement of these noble nanoparticles.

Synthesis of silver nanoparticles (Ag NPs) for anticancer activities (MCF 7 breast and A549 lung cell lines) of the crude extract of Syzygium aromaticum

In the present report, silver nanoparticles were synthesized using Piper nigrum extract for in vitro cytotoxicity efficacy against MCF-7 and HEP-2 cells. The silver nanoparticles (AgNPs) were formed within 20min and after preliminarily confirmation by UV-Visible spectroscopy (strong peak observed at ~441nm), they were characterized by using FT-IR and HR-TEM. The TEM images show spherical shape of biosynthesized AgNPs with particle size in the range 5-40nm while as compositional analysis were observed by EDAX. MTT assays were carried out for cytotoxicity of various concentrations of biosynthesized silver nanoparticles and Piper nigrum extract ranging from 10 to 100μg. The biosynthesized silver nanoparticles showed a significant anticancer activity against both MCF-7 and Hep-2 cells compared to Piper nigrum extract which was dose dependent. Our study thus revealed an excellent application of greenly synthesized silver nanoparticles using Piper nigrum. The study further suggested the potential therapeutic use of these nanoparticles in cancer study.

Glycogenic hepatopathy is an under-recognised cause of hepatomegaly and elevated liver transaminases in type 1 diabetes mellitus

Glycogenic hepatopathy (GH) is an under-recognised complication of type 1 diabetes mellitus (T1DM) not controlled to target resulting in hepatomegaly and elevated liver transaminases. We report the case of a 19-year-old man with T1DM not controlled to target who presented with abdominal pain, hepatomegaly and deranged liver transaminases. He was subsequently diagnosed with GH on liver biopsy, with the mainstay of treatment being reduction in caloric intake and insulin.

Tropism of subgroup J avian leukosis virus as detected by in situ hybridization

The HPRS-103 strain of avian retrovirus is the prototype of subgroup J avian leukosis virus (ALV-J) and causes myeloid leukosis in meat-type chickens. Using immunohistochemical detection of the viral groupspecific antigen (Gag) we have previously demonstrated that the induction of myeloid leukosis by ALV-J is associated with viral tropism for myelomonocytic cells. In this paper we describe an in situ hybridization (ISH) technique using digoxigenin (DIG)-labelled probes for detecting RNA transcripts in tissues from chickens infected with avian leukosis viruses (ALV) of subgroups J (HPRS-103 strain) and A (RAV-1 strain). Virus-specific RNA was detected mainly in the heart, kidney, proventriculus and adrenal in locations similar to those of the Gag protein. Viral gene expression could not be detected in the bone marrow or tumour tissues using this test. Higher levels of viral gene expression in the bursa of Fabricius infected with RAV-1, but not with HPRS-103, might help explain the inability of the latter virus to induce lymphoid leukosis.

Fipronil Compound Consumption Presenting as Status Epilepticus

Fipronil is a broadspectrum N-phenylpyrazole insecticide with gamma-aminobutyric acid type A receptor inhibitory action causing hyperexcitability of central nervous system. There is no literature reported in the past concerning its acute toxicity in human beings. A case report is useful for workers in medical and veterinary field. Hence, we are reporting a case in which young male intoxicated with fipronil compound was presented to the emergency department for having generalized tonic-clonic seizures and subsequently with the features of delirium for few days. This patient was treated with benzodiazepines which controlled the seizures and antipsychotics were given for few days for treating the psychosis.

Prevalence of coronary artery disease and its risk factors in Kerala, South India: a community-based cross-sectional study

BACKGROUND

There are no recent data on prevalence of coronary artery disease (CAD) in Indians. The last community based study from Kerala, the most advanced Indian state in epidemiological transition, was in 1993 that reported 1.4% definite CAD prevalence. We studied the prevalence of CAD and its risk factors among adults in Kerala.

METHODS

In a community-based cross sectional study, we selected 5167 adults (mean age 51 years, men 40.1%) using a multistage cluster sampling method. Information on socio-demographics, smoking, alcohol use, physical activity, dietary habits and personal history of hypertension, diabetes, and CAD was collected using a structured interview schedule. Anthropometry, blood pressure, electrocardiogram, and biochemical investigations were done using standard protocols. CAD and its risk factors were defined using standard criteria. Comparisons of age adjusted prevalence were done using two tailed proportion tests.

RESULTS

The overall age-adjusted prevalence of definite CAD was 3.5%: men 4.8%, women 2.6% (p < 0.001). Prevalence of any CAD was 12.5%: men 9.8%, women 14.3% (p < 0.001). There was no difference in definite CAD between urban and rural population. Physical inactivity was reported by 17.5 and 18% reported family history of CAD. Other CAD risk factors detected in the study were: overweight or obese 59%, abdominal obesity 57%, hypertension 28%, diabetes 15%, high total cholesterol 52% and low level of high density lipoprotein cholesterol 39%. Current smoking was reported only be men (28%).

CONCLUSION

The prevalence of definite CAD in Kerala increased nearly three times since 1993 without any difference in urban and rural areas. Most risk factors of CAD were highly prevalent in the state. Both population and individual level approaches are warranted to address the high level of CAD risk factors to reduce the increasing prevalence of CAD in this population.

Heart-type fatty acid-binding protein (H-FABP) as an early diagnostic biomarker in patients with acute chest pain

BACKGROUND

Heart-type fatty acid-binding protein (H-FABP) is an emerging biomarker, which was found to be sensitive for the early diagnosis of acute myocardial infarction (AMI). We prospectively investigated the usefulness of H-FABP determination for the evaluation of acute chest pain in patients arriving at the emergency department.

METHODS

Fifty-four patients presenting with acute ischemic chest pain were evaluated. H-FABP was estimated at admission using latex-enhanced immunoturbidimetric assay. Serial cardiac troponin I (cTnI), creatinine kinase-MB (CK-MB) determination, ischemia workup with stress testing, and/or coronary angiogram (CAG) were performed according to standard protocols.

RESULTS

The sensitivity and specificity of H-FABP was 89.7% and 68%, for cTnI it was 62.1% and 100%, and for CK-MB it was 44.8% and 92%, respectively for diagnosis of AMI. The sensitivity of H-FABP was found to be far superior to initial cTnI and CK-MB, for those seen within 6h (100% vs. 46.1%, 33% respectively). On further evaluation of patients with positive H-FABP and negative cTnI, 71.4% of the patients had significant lesion on CAG, indicating ischemic cause of H-FABP elevation. Six patients with normal cTnI and CK-MB with high H-FABP had ST elevation on subsequent ECGs and were taken for primary angioplasty.

CONCLUSION

H-FABP is a highly sensitive biomarker for the early diagnosis of AMI. H-FABP as early marker and cTnI as late marker would be the ideal combination to cover the complete diagnostic window for AMI. Detection of myocardial injury by H-FABP may also be applied in patients with unstable angina. H-FABP can also be used as a marker for early detection of STEMI before the ECG changes become apparent.

Framework for a National STEMI Program: consensus document developed by STEMI INDIA, Cardiological Society of India and Association Physicians of India

The health care burden of ST elevation myocardial infarction (STEMI) in India is enormous. Yet, many patients with STEMI can seldom avail timely and evidence based reperfusion treatments. This gap in care is a result of financial barriers, limited healthcare infrastructure, poor knowledge and accessibility of acute medical services for a majority of the population. Addressing some of these issues, STEMI India, a not-for-profit organization, Cardiological Society of India (CSI) and Association Physicians of India (API) have developed a protocol of "systems of care" for efficient management of STEMI, with integrated networks of facilities. Leveraging newly-developed ambulance and emergency medical services, incorporating recent state insurance schemes for vulnerable populations to broaden access, and combining innovative, "state-of-the-art" information technology platforms with existing hospital infrastructure, are the crucial aspects of this system. A pilot program was successfully employed in the state of Tamilnadu. The purpose of this article is to describe the framework and methods associated with this programme with an aim to improve delivery of reperfusion therapy for STEMI in India. This programme can serve as model STEMI systems of care for other low-and-middle income countries.

Effect of Tetracycline Hydrochloride and Spiramycin Sub Gingival Irrigation with Pulsated Jet Irrigator in Chronic Periodontitis Patients: A Clinical Study

BACKGROUND

The present study is designed to evaluate the clinical effects of pulsated subgingival irrigation with tetracycline and spiramycin.

MATERIALS AND METHODS

Ten patient diagnosed chronic periodontitis were included in the present study. Each patient is assigned to be irrigated with saline (placebo) (Group A), tetracycline HCl at 0.5% concentration (Group B), and 0.5% spiramycin (Group C). Scaling and root planing (SC/RP) was recorded as Group D. Plaque index, gingival index, gingival bleeding index, probing pocket depth were assessed on pre-irrigation (day 0), and at days 7, 14, 21, 28, and 35 day.

RESULTS

The results showed that subgingival irrigation with 0.5% tetracycline and spiramycin produced a significant reduction in clinical parameters compared to the control, while SC/RP was showed better improvement.

CONCLUSION

The result of this study suggested that subgingival irrigation of tetracycline and spiramycin play a beneficial role in the management of chronic periodontitis patients.

Lipodystrophy in Human Immunodeficiency Virus (HIV) Patients on Highly Active Antiretroviral Therapy (HAART)

BACKGROUND

In recent years, abnormal lipid deposition (both lipoatrophy and fat redistribution) and its related complications have changed from an anecdotal issue into a major problem for HIV (Human Immunodeficiency Virus) infected patients on HAART (Highly Active Anti-Retroviral Therapy). Lipoatrophy and fat redistribution are potentially stigmatizing complications of HAART and leads to poor adherence among patients. Hence we conducted this study to determine the pattern and to assess various risk factors for maldeposition of lipids in HIV patients.

MATERIALS AND METHODS

A cross-sectional case series study was conducted in ART PLUS centre, Bellary over a period of 8 months from January to August 2014 in HIV patients on ART to determine risk factors associated with and epidemiological pattern of fat redistribution or atrophy.

RESULTS

A total of 50 patients with LD {lipodystrophy} (26 with fat redestribution and 24 with lipoatrophy {LA} were diagnosed in this period. Most of them belonged to younger age and was commonly seen in females (76%). Patients with LA had a significantly lower BMI (18.73 ± 7.4), {the p-value being 0.19} compared to LH group (21.54 ± 7.62). The duration of disease was comparable among both groups (6.96 years in LH and 5.79 years in LA group) {p-value is 0.29}. There was a relatively good immunity among these patients with mean CD4 count was 509.23 in LH and 545.91 in LA group {single CD4 count was taken and the p-value was 0.001}. Most of the patients were in TLN (Tenofovir, Lamivudine, Nevirapine) regimen (58%).The duration that patient was on ART before commencement of study varied from patient to patient, but the mean duration was approximately five years in fat redistribution group and 4.5 years in LA group. There were no derangements in lipid and sugar levels among them.

CONCLUSION

This study shows the need to identify and impact of LD with respect to treatment adherence in young patients especially female patients. Early community based screening for LD by social workers and targeted annual screening might help early detection and awareness about LD. Also adopting the least toxic regimen is one of the main aspects of LD management.

Pheniramine Maleate-Induced Rhabdomyolysis and Aki: Is it Fatal?

Pheniramine maleate is an easily accessible, over-the-counterantihistaminic, which is frequently involved in overdoses. Pheniramine has antimuscarinic effect causing tachycardia, dilated pupils, urinary retention, and dry flushed skin, and decreased bowel sounds, confusion, mild increase in body temperature, cardiac arrhythmias, and seizures at lethal doses. It has not been implicated as an important cause of rhabdomyolysis and acute kidney injury (AKI). Rhabdomyolysis causing AKI is rarely reported in the literature. This case report emphasizes the occurrence of nontraumatic rhabdomyolysis in pheniramine maleate overdose which required hemodialysis. Since there is a lack of a specific antidote, treatment is mainly symptomatic and supportive. We report a fatal case of a young male with a very high dose of consumption of pheniramine maleate (4.077 g), which was complicated by seizures, respiratory depression, nontraumatic rhabdomyolysis, and AKI. Despite hemodialysis, ventilator support, and other intensive supportive care, patient could not survive and death ensued due to multiorgan dysfunction syndrome.