Mucormycosis is an emergent and threatening invasive fungal invasion underdiagnosed by clinicians due to lack of awareness and aspecific clinical picture. The authors describe a clinical case of a diabetic and cirrhotic patient who developed rhino-orbital-cerebral and pulmonary mucormycosis, non-responsive to treatment. Typical gaps in the management of this deadly disease are addressed. There is a strong need for novel therapies and an expectation that sponsors will recognize the critical need for randomized clinical trials.
Mucormycosis; Diabetes; High mortality; Delays; Hyperbaric medicine; Randomized clinical trials
Some women complain of low back pain that they believe is due to wearing high-heeled shoes, and some clinicians seem to think the reason is that high-heeled shoes cause increased lumbar lordosis. This article examines Internet information aimed at the general public and presents a literature review of available research in this area.
The keywords high heels and high-heeled shoes, combined with the words lumbar, lordosis, and pelvic tilt, were used in an Internet search of Ask.com; in published literature searches of PubMed, MANTIS, CINAHL, Scopus, and ProceedingsFirst; and in searches for theses and dissertations of PapersFirst through June 2010.
There are many Internet sites that support the belief that high-heeled shoes cause increased lordosis. However, published research for this topic mostly does not support this belief; but some mixed results, small subject groups, and questionable methods have left the issue unclear.
It appears that some health care providers are offering advice about the effect of high-heeled shoes on lumbar lordosis that conflicts with most published research. However, the prevalence of such advice is unknown; and the published research is equivocal. Considering that both low back pain and the wearing of high heeled-shoes are common, clinicians could use some clearer guidance; this is an area that deserves further investigation.
Lordosis; Lumbar; Shoes; Posture; Low back pain; Chiropractic
Several classes of antihypertensive agents have been in clinical use, including diuretics, α-blockers, β-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin II type 1 receptor blockers (ARB), and organic calcium channel blockers (CCBs). All these drugs are being currently used in the treatment of Hypertension & various disease conditions of the heart either alone or in combination. Cilnidipine is a new antihypertensive drug distinguished from other L-type Ca2+ channel blockers or even other antihypertensives, which will be useful for selection of antihypertensive drugs according to the pathophysiological condition of a patient.
Despite recent advances, the diagnosis and management of heart failure evades the clinicians. The etiology of congestive heart failure (CHF) in the Indian scenario comprises of coronary artery disease, diabetes mellitus and hypertension. With better insights into the pathophysiology of CHF, biomarkers have evolved rapidly and received diagnostic and prognostic value. In CHF biomarkers prove as measures of the extent of pathophysiological derangement; examples include biomarkers of myocyte necrosis, myocardial remodeling, neurohormonal activation, etc. In CHF biomarkers act as indicators for the presence, degree of severity and prognosis of the disease, they may be employed in combination with the present conventional clinical assessments. These make the biomarkers feasible options against the present expensive measurements and may provide clinical benefits.
Biomarkers; Heart failure; Brain natriuretic peptide; NT-proBNP; BNP, B-type natriuretic peptide; HF, heart failure
New generation DES are effectively used in all spectrum of coronary artery diseases (CAD) and are replacing earlier DES and BMS. Biolimus A9™-eluting stent is a new generation DES containing the anti-proliferative drug biolimus A9™ incorporating a biodegradable abluminal coating that leaves a polymer-free stent after drug release enhancing strut coverage while preventing neointimal hyperplasia. A retrospective data analysis was done in patients treated with DES, with a major share of Biolimus A9™ (BA9™) drug-eluting stents (DES) at Bombay Hospital, Mumbai. A total of 158 patients with 219 lesions were treated with DES, comprising Biolimus A9-eluting stent and others and the major adverse cardiac events (MACE) rate and stent thrombosis (ST) at 1, 6, 12 months and 24 months were analyzed. Mace rate was 3.16 % for average follow-up of 19 months. There were 3 cases of ST (2 of acute and 1 of subacute onset) and one non-cardiac death reported during this time. This retrospective data demonstrates good one- and two-year clinical safety and efficacy of DES, especially of BioMatrix stents in real world setting.
BioMatrix; Biodegradable polymer; Biolimus A9; Abluminal; Major adverse cardiac events
Diabetes mellitus (DM) is a pandemic disease and an important cardiovascular (CV) risk factor. The atherogenic dyslipidemia in diabetes (ADD) is characterized by high serum triglycerides, high small dense LDL levels, low HDL levels and postprandial lipemia. Insulin resistance is a primary cause for ADD. Though statins are highly effective for CVD prevention in DM but a significant residual CV risk remains even after optimal statin therapy. Fibrates, niacin and omega-3 fatty acids are used in addition to statin for treatment of ADD (specifically hypertriglyceridemia). All these drugs have some limitations and they are far from being ideal companions of statins. Many newer drugs are in pipeline for management of ADD. Dual PPAR α/γ agonists are in most advanced stage of clinical development and they have a rational approach as they control blood glucose levels (by reducing insulin resistance, a primary factor for ADD) in addition to modulating ADD. Availability of dual PPAR α/γ agnosits and other drugs for ADD management may improve CV outcomes and decrease morbidity and mortality in diabetic patients in future.
Hypertriglyceridemia; Saroglitazar; Atherogenic dyslipidemia in diabetes; Dual PPAR alpha and gamma agonists
The e-BioMatrix is a post marketing multicenter registry with an objective to evaluate the 2 year clinical safety and efficacy outcomes in patients treated with BioMatrix™ - Biolimus A9™ (BA9™) drug eluting stents (DES).
Drug-eluting stents still have late-stage disadvantages that might be attributable to the permanent polymer. BioMatrix a new generation DES containing anti-proliferative drug Biolimus A9™ incorporating a biodegradable abluminal coating that leaves a polymer-free stent after drug release enhancing strut coverage while preventing neointimal hyperplasia.
This interim analysis consists of a total of 1189 patients with 1418 lesions treated with BioMatrix stent who entered this multicenter registry in India. We analyzed the incidence of major adverse cardiac events (MACE) and stent thrombosis (ST) at 1, 6, and 12 months with an extended follow-up of 2 years. Recommended antiplatelet regimen included clopidogrel and aspirin for 12 months.
The mean age was 57.6 ± 10.9 years, 81.8% were males, comorbidity index was 1.20 ± 1.33, 68% presented with acute coronary syndrome, 49% had hypertension and 40.8% had diabetes mellitus. One-year clinical follow-up was completed in 987 patients at the time of interim analysis. The incidence of MACE is 0.45 for 1544 person-year follow-up. There were only 03 cases of ST (01 late ST) reported during this time.
This registry demonstrates excellent one-year clinical safety and efficacy of BioMatrix stents. The 1-year result shows that BioMatrix stent may be a suitable alternative as compared to contemporary DESs which are currently available in the market for simple as well complex disease.
BioMatrix; BES; Biodegradable; MACE; Stent thrombosis
CAD; AMI; STEMI; Thrombolytics in AMI
The objective of this registry is to establish safety and efficacy of BioMatrix, BioMatrix™-Biolimus A9™ eluting stent in diabetic population in India.
Diabetes mellitus is a major predisposing factor for coronary artery disease. Prognosis for diabetic population patients presenting with coronary artery disease who undergo coronary revascularization is inferior to non diabetics and remains an independent risk factor of restenosis, need for revascularization, and overall mortality. Stent thrombosis is a potential complication of first generation, permanent polymer drug-eluting stents. Biodegradable polymer is a good relief in this era and its utility in diabetic patients will be a major advantage for them.
334 patients with diabetes mellitus and requiring angioplasty, implanted with BioMatrix stent were followed at 1, 6, 12 and 24 months who entered in a multicenter registry in India. We analyzed the incidence of major adverse cardiac events (MACE) and stent thrombosis (ST) at 1, 6, 12 and 24 months.
The mean age was 58.71 ± 9.2 years, 81% were males, comorbidity index was 1.6 ± 1.02, and 59.1% presented with acute coronary syndrome. The incidence of adverse event rates was: MACE 1.27%. There were no incidences of myocardial infarction (MI) and target vessel revascularization (TVR). Definite stent thrombosis occurred only in 2 patients.
In this registry of diabetic population treated with BioMatrixTM-Biolimus A9TM eluting stent (BioMatrix), the reported incidence of MACE and ST were much lower than previously published results. The 1- and 2-year follow-up result supports favorable clinical outcomes of using BioMatrix stents as a suitable alternative to contemporary DES available during PCI in diabetic patients.
BioMatrix; BES; Diabetes; MACE; Stent thrombosis
To study the efficacy and safety of single intravenous bolus administration of indigenously developed tenecteplase (TNK-tPA) in the management of patients with ST-elevation myocardial infarction (STEMI) in clinical practice.
Observational, prescription-event monitoring study.
Data of 15,222 patients who had STEMI and received weight adjusted TNK injection was analyzed. Overall 95.43% patients had clinically successful thrombolysis (CST). In the different subgroups, hypertensives, diabetics, smokers and hyperlipidemic patients had CST rates comparable to the general patient data. CST rates were significantly lower in the elderly patients (>70 years; 92.11%; p < 0.0001), in patients with history of Ischemic Heart Disease (IHD, 93.86%; p = 0.0004) and in patients receiving delayed treatment (>6 h after onset of chest pain; 85.38%; p < 0.0001). CST was significantly higher in patients who received an early thrombolysis (<3 h after onset of chest pain; 96.54%; p = 0.006). Overall mortality was 1.69%, while it was significantly higher in the elderly (4.42%), patients with history of IHD (2.67%), females (2.93%) and in those who received delayed treatment (4.98%). The overall incidences of intracranial hemorrhage (ICH), bleeding excluding ICH, stroke and ventricular tachyarrhythmia were 0.39%, 2.01%, 0.16% and 2.35% respectively. Age >70 years, diabetes, hyperlipidemia and history of IHD were associated with a higher incidence of heart failure, myocardial re-infarction or ventricular tachyarrhythmias. However, incidence of ICH and bleeding other than ICH was comparable amongst all patient subgroups.
This study confirms the safety and efficacy of indigenous tenecteplase in Indian patients with STEMI, including high risk subgroups. It also highlights the fact that delayed treatment denotes denial of benefits of pharmacologic reperfusion therapy.
Tenecteplase; STEMI; Prescription-event monitoring
Some doctors and therapists believe that wearing high-heeled shoes causes increased lumbar lordosis and that this may be a cause of low back pain. The purpose of this study was to evaluate whether high-heeled shoes increase lumbar lordosis and to do so with more reliable methods and a larger sample size than used in previous studies.
Fifty participants from a chiropractic university were included in a test group (32 female and 18 male) and 9 in a control group (3 female and 6 male). A Spinal Mouse was used to measure lumbar lordosis in test participants barefoot and then again with 3- or 4-in high-heeled shoes after a 10-minute adaptation period of walking and sitting and standing while wearing the shoes. Reliability of the testing conditions was evaluated with 9 barefoot control participants before and after an identical adaptation period, and intra- and interexaminer reliability of Spinal Mouse measurements was tested by use of a wooden model built to mimic the proportions of a human spine.
Both groups showed non-significant decreases in lordosis between the first and second scans (high heels: 23.4° to 22.8°, P = .17; control: 18.8° to 17.6°, P = .16). Scans of the wooden spine model were highly reliable (intra- and interexaminer intraclass correlation coefficients > .999).
Consistent with most previous studies, high-heeled shoes did not affect lumbar lordosis in most people while standing. Future research could investigate the effect of shoes during dynamic conditions or identify affected subgroups.
Spine; Lordosis; Shoes; Low back pain; Chiropractic
Sudden cardiac death (SCD) is the most lethal manifestation of heart disease. In an Indian study the SCDs contribute about 10% of the total mortality and SCD post ST elevation myocardial infarction (MI) constitutes for about half of total deaths.
Given the limitations of existing therapy there is a need for an effective, easy to use, broadly applicable and affordable intervention to prevent SCD post MI. Leading cardiologists from all over India came together to discuss the potential role of n-3 acid ethyl esters (90%) of eicosapentaenoic acid (EPA) 460 mg & docosahexaenoic acid (DHA) 380 mg in the management of post MI patients and those with hypertriglyceridemia.
Highly purified & concentrated omega-3 ethyl esters (90%) of EPA (460 mg) & DHA (380 mg) has clinically proven benefits in improving post MI outcomes (significant 15% risk reduction for all-cause mortality, 20% risk reduction for CVD and 45% risk reduction in SCD in GISSI-Prevenzione trial) and in reducing hypertriglyceridemia, and hence, represent an interesting option adding to the treatment armamentarium in the secondary prevention after MI based on its anti-arrhythmogenic effects and also in reducing hypertriglyceridemia.
Sudden cardiac death; Myocardial infarction; Hypertriglyceridemia; Omega-3-acid ethyl esters; Eicosapentaenoic acid & docosahexaenoic acid
Parasitic encoded proteases are essential to regulating interactions between parasites and their hosts and thus they represent attractive anti-parasitic druggable and/or vaccine target. We have utilized annotations of Ixodes scapularis proteases in gene bank and version 9.3 MEROPS database to compile an index of at least 233 putatively active and 150 putatively inactive protease enzymes that are encoded by the Ixodes scapularis genome. The 233 putatively active protease homologs hereafter referred to as the degradome (the full repertoire of proteases encoded by the I. scapularis genome) represents ~1.14% of the 20485 putative I. scapularis protein content. Consistent with observations in other animals, the content of the I. scapularis degradome is ~6.0% (14/233) aspartic, ~19% (44/233) cysteine, ~40% (93/233) Metallo, ~28.3% (66/233) serine and ~6.4% (15/233) threonine proteases. When scanned against other tick sequences, ~11% (25/233) of I. scapularis putatively active proteases are conserved in other tick species with ≥60% amino acid identity levels. The I. scapularis genome does not apparently encode for putatively inactive aspartic proteases. Of the 150 putative inactive protease homologs none are from the aspartic protease class, ~8% (12/150) are cysteine, ~58.7% (88/150) metallo, 30% (45/150) serine and ~3.3% (5/150) are threonine proteases. The I. scapularis tick genome appears to have evolutionarily lost proteolytic activity of at least 6 protease families, C56 and C64 (cysteine), M20 and M23 (metallo), S24 and S28 (serine) as revealed by a lack of the putatively active proteases in these families. The overall protease content is comparable to other organisms. However, the paucity of the S1 chymotrypsin/trypsin-like serine protease family in the I. scapularis genome where it is ~12.7% (28/233) of the degradome as opposed to ~22–48% content in other blood feeding arthropods, Pediculus humanus humanus, Anopheles gambiae, Aedes Aegypti and Culex pipiens quinquenfasciatus is notable. The data is presented as a one-stop index of proteases encoded by the I. scapularis genome.
Ixodes scapularis degradome; aspartic; serine; metallo; cysteine; threonine
Older patients with combination of aortic coarctation and large patent ductus arteriosus can be managed with transcatheter interventions. The strategies depend on anatomy of coarctation and size of ductus arteriosus.
We present three different patients with this combination. The anatomic factors like isthmic hypoplasia, dilatation of post coarctation descending aorta and size of ductus arteriosus were noted.
Patients with isthmic hypoplasia needed stent angioplasty of the coarctation. If there is no dilatation of post coarctation aorta, a single covered stent excluded the ductus arteriosus and relieved the coarctation gradients. Dilated post coarctation aorta precluded a covered stent and warranted closure of duct with occluder device and stent angioplasty of coarctation. When there is a good sized aortic isthmus in a discrete membranous coarctation, device closure of the duct and balloon aortoplasty was successful.
In coarctation with patent ductus arteriosus associated with good sized aortic isthmus, closure of duct with duct occluder device and balloon aortoplasty would correct the lesions. If there is isthmic hypoplasia, device closure of the duct and stenting of the coarctation is needed. Covered stent is a reasonable alternative only in presence of non dilated descending aorta.
Coarctation of aorta; Patent ductus arteriosus; Transcatheter treatment