Management protocols for chronic heart failure in India

Heart failure is a common clinical syndrome and a global health priority. The burden of heart failure is increasing at an alarming rate worldwide as well as in India. Heart failure not only increases the risk of mortality, morbidity and worsens the patient’s quality of life, but also puts a huge burden on the overall healthcare system. The management of heart failure has evolved over the years with the advent of new drugs and devices. This document has been developed with an objective to provide standard management guidance and simple heart failure algorithms to aid Indian clinicians in their daily practice. It would also inform the clinicians on the latest evidence in heart failure and provide guidance to recognize and diagnose chronic heart failure early and optimize management.

Pattern of adverse drug reactions to antibiotics commonly prescribed in department of medicine and pediatrics in a tertiary care teaching hospital, Ghaziabad.

Adverse Drug Reactions (ADRs) are an important cause of mortality and morbidity and constitute an enormous burden on the society. Many studies have implicated that the antibiotics are among the major group of drugs, which cause adverse drug reactions (ADRs). This Retrospective, non- interventional study was undertaken in Medicine and Pediatrics unit from November 2013 to April 2014 to monitor the adverse drug reactions of antibiotics prescribed by physicians and pediatricians in a tertiary care hospital, Ghaziabad, to establish ten most common antibiotics which caused ADRs, to determine most commonly affected organ system and assess their causality. A total of 126 ADRs were identified in 80 patients, out of which 42(52.5%) occurred in male patients and 38(47.5%) in female patients. The age wise distribution revealed that adult patients showed more incidence of ADRs 46(57.5%), followed by children 26(32.5%) and Geriatrics 8(10%). GIT 28(22.2%) was the most affected organ system by Adverse Drug Reactions due to antibiotics followed by the Respiratory system 26 (20.63%), Skin 23(18.25%), CVS 17 (13.5%), CNS 12(9.52%), Musculo-skeletal system 10(7.93%), Urinary System 8 (6.35%) and Haemopoietic Disorders 2 (1.58%). Maximum ADRs were reported with Beta-Lactams class 51 (40.4%) followed by Aminoglycosides 29(23.01%), Quinolones 20(15.8%), Others 16 (12.69%) and Macrolides 10(7.93%), . Antibiotics comprise the major volume of the drug family and inpatient prescriptions and thus are the most irrationally prescribed. So implementation of antibiotic guideline policy for the hospitals and strict adherence to it should be ensured to promote their rational and safe use. Also health system needs to promote spontaneous reporting of ADRs detected in clinical practice to Regional Pharmacovigilance centers.

To monitor the adverse drug reactions and safety of medicines commonly prescribed at obstetrics and gynaecology unit in a tertiary care hospital.

Adverse drug reactions are the recognized hazards of drug therapy and they can occur with any class of drugs. Any substance that is capable of producing a therapeutic effect can also produce unwanted or adverse effects. Adverse Drug Reactions result in increased healthcare cost due to the need of some interventions and increased hospital stay. The study was undertaken to monitor the adverse drug reactions to medicines commonly prescribed at obstetrics and gynaecology unit in a tertiary care hospital, to establish ten most commonly prescribed medicines in this unit that gave maximum adverse drug reactions and to determine the list of commonly affected organ systems and assess their causality. In this Retrospective, non-interventional study a total of 63 adverse drug reaction reports were collected from 249 patients. The most common medicine that caused maximum ADRs was Oxytocin 10 (15.87%). Other frequently used drugs were Amikacin, Methylergometrine, Mifepristone+Misoprostol, Levonorgestrel+Ethinylestradiol, Cefotaxim+sulbactam, Cefixime+Ofloxacin, Mifepristone alone, Clomifene citrate, Tramadol. The most commonly affected organ system was cardio-vascular system 12 (19.04%).The assessment by Naranjo’s scale showed that out of 63 ADRs, 41 (65.07%) ADRs were probably related to drugs, 21 (33.33%) ADRs were possibly related to drugs and 1 (1.58%) ADR was doubtful. WHO causality assessment scale revealed that out of 63 ADRs, 51(80.95%) ADRs were probable or likely, 12(19.04%) ADRs were possible. It was observed that safe medicines were prescribed in obstetrics and gynaecology department as per FDA category A with no banned drugs .However, there is a need to sensitize the doctors to prescribe rationally and emphasize this aspect in under and post graduate medical teaching as well. The health system needs to promote spontaneous reporting of Adverse Drug Reactions from all health care professionals and the public at large in a well structured programme to build synergies for monitoring ADR in the country. Also proper documentation and periodic reporting to regional pharmacovigilance centres should be encouraged to arrive at meaningful conclusion on safety issue of medicines and thereby reduce considerably social and economic consequences of ADRs.

Prescribing pattern of drugs in the outpatient department of a tertiary care teaching hospital in Ghaziabad, Uttar Pradesh.

The study was done to find out the current prescribing pattern in this tertiary care teaching hospital in Ghaziabad. The study was carried out at Santosh Medical College and Hospital over a period of 3 months. A total of 500 prescriptions were collected and analyzed. Total number of drugs prescribed was 1450 out of which 564 drugs were prescribed by generic names. Average number of drugs was 2.9. 327 drugs were fixed dose combinations while only 595 were from essential drug list. The mean number of drugs per prescription should be as low as possible otherwise there is increase risk of drug interaction, bacterial resistance, non-compliance and increase in cost The prescribing practices are more of irrational types like polypharmacy, use of vitamins and injections, less number of drugs by generic names and lesser drugs from Essential Drug List. There is an urgent need for some interventions to improve the situation.

A duplicated coxI gene is associated with cytoplasmic male sterility in an alloplasmic Brassica juncea line derived from somatic hybridization with Diplotaxis catholica.

A cytoplasmic male sterile (CMS) line of Brassica juncea was derived by repeated backcrossing of the somatic hybrid (Diplotaxis catholica + B. juncea) to B. juncea. The new CMS line is comparable to euplasmic lines for almost all characters, except for flowers which bear slender, needle-like anthers with aborted pollen. Detailed Southern analysis revealed two copies of coxI gene in the CMS line. One copy, coxI-1 is similar to the coxI gene of B. juncea, whereas the second copy, coxI-2 is present in a novel rearranged region. Northern analysis with eight mitochondrial gene probes showed altered transcript pattern only for the coxI gene. Two transcripts of 2.0 and 2.4 kb, respectively, were detected in the CMS line. The novel 2.4 kb transcript was present in floral bud tissue but absent in the leaf tissue. In plants where male sterility broke down under high temperature during the later part of the growing season, the 2.4 kb coxI transcript was absent, which suggested its association with the CMS. The two coxI genes from the CMS line showed two amino acid changes in the coding region. The novel coxI gene showed unique repeats in the 5' region suggesting recombination of mitochondrial genomes of the two species. The possible role of the duplicated coxI gene in causing male sterility is discussed.

Prescription Trends in Schizophrenia and Manic Depressive Psychosis

The prospective study was carried out by collecting and evaluating prescriptions trends in schizophrenia and manic depressive psychosis in Outpatient in Government Psychiatry Hospital, Jammu. The present study indicated nitrazepam & parkinforte (Trifluperazine + chlorpromazine + Trihexphenidyl ) to be the most preferred drug for treatment of schizophrenia whereas nitrazepam and lithium for manic depressive psychosis. The present study suggests that prescriptions of our hospital are rational and includes drug therapy as per standard treatment guidelines (2002) of WHO.

Drug Utilization Study in Outpatient Ophthalmology Department of Government Medical College Jammu

The present study was undertaken to assess the patterns of prescription and drug utilization by measuring WHO delineated drug use indicators. This study was conducted in the Postgraduate Department of Pharmacology and Therapeutics in collaboration with the Postgraduate Department of Ophthalmology Govt. Medical College Hospital, Jammu. Total number of prescriptions analyzed were 440 , in which total of 822 drugs were prescribed. Analysis of the prescriptions showed that average number of drugs per prescription was 1.87. The maximum number of drugs prescribed were in the form of eye drops (66.18%), followed by ointments (16%), capsules (9.5%), tablet (6.57%), syrup (0.73%), injection (0.73%) and lotion (0.24%). The dosage form was indicated for 94%, frequency of drug administration for 98% drugs and duration of treatment for only 75% of the drugs prescribed. The number of antibiotics prescribed was 266 (32.26%), out of these 160 (60.15%) antibiotics prescribed in the form of drops, 100 (37.59%) as ointment and 6 (2.26%) orally. Number of encounters with anti-inflammatory and antiallergic drugs was 92 (11.2%), mydriatics and cycloplegics 64(7.9%), miotics 20 (2.4%), multivitamins 58 (7.05%) andothers used were lubricant and miscellaneous eye drops 322 (40%). Common prescription writing errors were minimum and there was no evidence of polypharmacy. However, duration of treatment and prescribing by generic name was very low.

Lipoprotein(a) as a marker of coronary artery disease and its association with dietary fat.

OBJECTIVE: The main objectives of the study were to evaluate the effect of dietary fat on plasma lipoprotein(a) [Lp(a)] levels and to study the potential of Lp(a) as a more reliable marker for CAD compared to other lipids and lipoproteins. METHODS: Twenty CAD patients and 20 healthy controls were recruited for the study. Their fasting plasma Lp(a) levels and complete lipid profile were assayed. The fat intake was calculated using 24 hours dietary recall method. The patients and controls were each divided into two subgroups: Group A consuming dietary fat > 30% and Group B consuming dietary fat < or = 30% of the total kilo-calories/day. RESULTS: Results indicated that plasma Lp(a), total serum cholesterol (TC), tryglyceride (TG), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) and LDL-C/HDL-C ratio of CAD patients were significantly higher than the controls. High fat intake was found to be associated with higher plasma Lp(a) levels (p<0.05) in patients only. No significant correlation was found between Lp(a) levels and other conventional lipoproteins. CONCLUSION: The lack of correlation between Lp(a) and other lipoproteins indicates its potential as an independent risk factor for CAD. High fat intake led to higher plasma Lp(a) levels in patients; hence it would be worthwhile to evaluate the effect of quality and quantity of fat intake on plasma Lp(a) levels in a larger sample size.

Agrobacterium-mediated transformation of cauliflower: optimization of protocol and development of Bt-transgenic cauliflower.

A number of factors that are known to influence genetic transformation were evaluated to optimize Agrobacterium-mediated transformation of hypocotyl explants of cauliflower variety Pusa Snowball K-1. The binary vector p35SGUSINT mobilized into Agrobacterium strain GV2260 was used for transformation and transient GUS expression was used as the basis for identifying the most appropriate conditions for transformation. Explant age, preculture period, bacterial strain and density were found to be critical determinants of transformation efficiency. Using the optimized protocol, the synthetic cryIA(b) gene was mobilized into cauliflower. Molecular analyses of transgenics established the integration and expression of the transgene. Insect bioassays indicated the effectiveness of the transgene against infestation by diamondback moth (Plutella xylostella) larvae

Formulation, evaluation and comparison of gels containing different COX-2 inhibitors.

PG synthesis plays major role in inflammation. The enzymes responsible for PG synthesis are cox-1 and cox-2. Cox-1 regulates physiological functions in gut and kidney while cox-2 induces inflammation. Selective cox-2 inhibitors have little effect on cox-1 and thus showed better GI tolerability. The efficacy of new drugs is not greater than that of NSAID's by oral route of administration. In the present study new selective cox-2 inhibitors also showed less efficacy than NSAID'S by topical route of administration. However if current studies confirm the reduced GI toxicity this can be the only advantage of these drugs because these drugs showed less efficacy than NSAID'S by oral and topical routes of administration.

I-cell disease (Mucolipidosis II).

I-cell disease (Mucolipidosis II) is one of the lysosomal storage diseases which presents in the neonatal period, and within six months will phenotypically resemble the severe forms of the group of disorders called the "mucopolysaccharidoses" but without mucopolysacchariduria. In Mucolipidosis II, fibrocytes exhibit "abnormal lysosomes". Activities of several lysosomal enzymes are low in fibroblast cultures but high in mucolipidosis II serum. We present a patient with I-cell disease diagnosed on the basis of clinical, radiological and biochemical features. The mother of this child was pregnant and the fetus was also found to be affected.

Isolated congenital coronary arteriovenous fistula.

During the last eight years a total of nine cases of isolated congenital coronary arteriovenous fistula (CAVF) have been diagnosed at our centre. Age of these patients ranged from 11 days to 22 years (mean 6.4 +/- 4.2 years). There were seven male and two female patients. Right and left coronary arteries were the sites of origin in seven and three cases respectively. One patient had two fistulae, one each originating from right coronary artery and obtuse marginal artery. The drainage sites were right ventricle in seven cases and right atrium in two. The pulmonary artery pressure was normal in eight cases and elevated in one case. The pulmonary artery to systemic flow ratio ranged from 1.1:1-2.4:1 in all except the 11 day-old-baby in whom it was 4:1. Pulmonary vascular resistance (PVRI) was below 3.5 in all cases (range 1.0-3.5 units). Surgical ligation of fistula was done in four cases and two patients underwent coil embolisation of fistula. Follow-up is available in five out of eight patients including three cases in whom CAVF was closed. Two other young patients are being followed-up conservatively and all the patients are asymptomatic. CAVF can present at any age; majority of the cases have small left to right shunts and more commonly CAVF arise from right coronary artery. Surgical ligation of fistula is safe in older patients, non-surgical embolisation using coils may be an alternative to surgery in selected cases.

Serum levels of lipoprotein (a) and other lipids in angiographically defined coronary artery disease patients and healthy blood bank donors.

Lipoprotein (a) (Lp(a)) and other lipid values have been correlated with angiographically defined [table: see text] coronary artery disease. To study this relationship in Indian patients, plasma levels of Lipoprotein (a) and other lipids were assessed in 74 patients undergoing Coronary arteriography and also in 53 age and sex matched healthy male blood bank donors who served as controls. Total cholesterol (mg/dl) (211 +/- 56 vs 186 +/- 43; p < 0.001), low density lipoprotein Cholesterol (mg/dl) (117 +/- 40 vs 88 +/- 29; p > 0.001) and low density lipoprotein/high density lipoprotein cholesterol ratio (2.6 +/- 0.8 vs 2.2 +/- 0.9; p < .001) were significantly higher in patients than controls. High density lipoprotein-cholesterol (mg/dl) (43.5 +/- 6 vs 42.1 +/- 7; p-ns) very low density lipoprotein-cholesterol (mg/dl) (49.7 +/- 17 vs 56.1 +/- 25; p-ns) and triglycerides (mg/dl) (155 +/- 101 vs 167 +/- 88; p-ns) were not statistically different in two groups. Lipoprotein (a) levels showed highly skewed distribution. Patients (n = 74) showed almost five fold higher lipoprotein (a) levels (mg/dl) as compared to controls (n = 53) [105 +/- 565 vs 23 +/- 76]. Patients with very high lipoprotein (a) levels [values of more than 40 mg/dl] (n = 18) had high density lipoprotein cholesterol and total cholesterol significantly lower than rest of the patient group. [high density lipoprotein cholesterol (mg/dl) 41.00 +/- 3.7 vs 44 +/- 6.4; p < 0.01 and total cholesterol (mg/dl) 192 +/- 34 vs 217 +/- 53; p < 0.05].

Two-catheter approach for ablation of accessory pathways in different locations.

Radiofrequency ablation is the treatment of choice for patients with Wolff-Parkinson-White syndrome and symptomatic tachyarrhythmias. The technique involves localising the pathway with multiple catheters at various sites followed by radiofrequency energy application at that site. Single catheter approach has been described for ablation of manifest left-sided accessory pathways. In this article, we report the ablation of accessory pathways in different locations in patients with Wolff-Parkinson-White syndrome by using a two-catheter approach. Twenty-three consecutive patients with symptomatic Wolff-Parkinson-White syndrome were taken up for radiofrequency ablation with this approach. Pathways could be successfully ablated in 11 out of 13 patients with left free wall, 5 out of 7 with right posteroseptal, one patient of left posteroseptal and each of the 2 patients of right mid septal locations giving an overall success in 19/23 (82.6%) patients. Hence, two-catheter approach can be used safely to ablate accessory pathways in different locations with high success rate, thus minimising the procedure time associated with conventional approach.

Apolipoprotein(a) polymorphism and its association with plasma lipoprotein(a) levels: a north Indian study.

Elevated levels of lipoprotein(a) has been regarded as an independent risk factor for coronary, peripheral and cerebral atherosclerosis. The enormous intra-personal variation in the plasma concentration of lipoprotein(a) is almost entirely controlled by the apolipoprotein(a) i.e. gene locus on the chromosome 6q 26-27. The apolipoprotein(a) molecule is highly polymorphic and is known to exist in multiple, genetically determined isoforms. These polymorphisms may be responsible for difference in promoter activity, variable size of apolipoprotein(a) and thereby variation in plasma lipoprotein(a) concentration. We studied the effect of two types of polymorphisms, (i) variation in length of the pentanucleotide repeat in the 5' flanking region starting -1373 bp upstream of AUG codon, and (ii) the Kringle-4 type 2 size polymorphism, on plasma lipoprotein(a) levels in North Indian population. The study group consisted of 88 angiographically assessed male coronary artery disease patients (age range 30-70 years) and 83 age- and sex-matched healthy controls. The pentanucleotide repeat polymorphism was analysed using polymerase chain reaction. In all, 8/11 pentanucleotide repeat isoforms were observed. Using SDS-agarose gel electrophoresis and immunoblotting isoforms having 12-50 Kringle-4 type 2 repeats were detected. Our study indicates a strong association of elevated plasma lipoprotein(a) concentration with coronary artery disease. An inverse correlation was seen between lipoprotein concentration and isoform size for both the pentanucleotide repeat polymorphism and the Kringle-4 type 2 polymorphisms; statistically significant difference (p = 0.001) was, however, observed only for the later.

Interrelationship between angiographically defined coronary artery disease, plasma insulin levels and lipids in Indian patients.

We investigated the interrelationship between plasma insulin levels, various lipoproteins and coronary artery disease. No significant differences were observed on comparing patients with controls for plasma insulin, high density lipoprotein cholesterol, fasting blood sugar levels and triglyceride levels. However patients showed significantly higher levels of total cholesterol and low density lipoprotein cholesterol compared with controls. No significant differences were observed on comparing patients of multivessel disease with single vessel disease in serum insulin or various lipid subfractions. In addition, there was no correlation between serum insulin quartiles and various biochemical parameters. In conclusion, in this cross-sectional study plasma insulin levels failed to show any significant association with severity and extent of coronary artery disease. Further there was no correlation of various lipid parameters with insulin quartiles.