Selective Imidazoline Receptor Agonists: redefining the role of centrally acting agents in management of hypertension

Hypertension, often referred to as ‘The silent killer’, is christened so, as it is seldom preceded by any warning signs or symptoms. With the new ACC/AHA guidelines lowering the Blood Pressure (BP) threshold values, it has resulted in a 140% relative increase in the hypertension prevalence in India, which is 3 times higher than that of in United States. Imidazoline receptor agonists control BP effectively with minimal adverse effects of sedation and mental depression that are usually associated with centrally acting antihypertensives. While having a low affinity to the α2-adrenergic receptors, these new generation centrally acting antihypertensive agents are highly selective for imidazoline receptor. Moxonidine, a second-generation centrally acting antihypertensive drug having selective agonist activity on imidazoline I1 receptors and minor activity on imidazoline α2 adrenoceptors, reduces the activity of Sympathetic Nervous System (SNS) by activating I1 imidazoline receptors in Rostral Ventrolateral Medulla (RVLM). Studies of moxonidine have shown equal effectiveness in lowering BP like other well-established antihypertensive drugs such as nifedipine, atenolol or angiotensin-converting enzyme inhibitors, with minimal adverse events. At doses of 0.2-0.6 mg, moxonidine induces satisfactory BP reduction in patients with mild-to-moderate essential hypertension. In patients with mild-to-moderate hypertension, moxonidine (0.2-0.4 mg o.d.) significantly decreased Systolic Blood Pressure/Diastolic Blood Pressure (SBP/DBP), respectively, by 19.5/11.6 mmHg. In obese, non-controlled hypertensive patients, there is a 14% and 13.5% reduction in the mean SBP and DBP, respectively, from the baseline value after moxonidine treatment and during the follow-up with an additional reduction in body weight, plasma leptin levels and Body Mass Index (BMI) (p<0.01). Thus, moxonidine could be considered as a therapeutic option in obese patients with metabolic syndrome.

A Study on Prevalence of Overweight and Obesity among Adolescent children in an Urban Field Practice area of a Teaching Medical College in South India

Background: Obesity is a major public health problem, causing a significant morbidity and mortality. Aim: The aim of the study was to assess the prevalence of overweight and obesity among adolescents aged (10-19 years) and to describe certain socio-economic, demographic characteristics related to overweight and obesity among adolescents. Material & Methods: A Community Based Cross Sectional Study conducted at the Field Practice Area of Urban Health Training Centre. A total of 900 adolescents between 10-19 years were enrolled. Parameters of height, weight and waist circumference and hip circumference were measured and recorded. Following the completion of the questionnaire, the results were compared against the body mass index (BMI). Questions from the GSHS (Global School- based student health survey) Questionnaire were also applied. Results: The prevalence of overweight and obesity was 18.7% and 5.8% among adolescents aged (10-19 years). It was found that the prevalence of overweight and obesity was more in boys compared to girls. The present study found a positive association of overweight and obesity with age, SES. Conclusion: The prevalence of overweight and obesity were high among boys and need to be addressed by primary and secondary methods of prevention.

Reconstruction Of Plantar Foot Defects Using Medial Plantar Artery Flap: Our Experience

Background: Reconstruction of full-thickness plantar foot defects present a challenge to surgeons. These defects ideally should be reconstructed with durable sensate tissue. Despite the numerous procedures that have been described for resurfacing these plantar, to achieve a sensate foot with normal function still remains an intricate task. We present our clinical experience of plantar foot defects reconstructed using medial plantar artery flap. Methods: 18 patients with defects of the plantar surface of the foot were reconstructed using medial plantar artery flap.All the flaps were raised as sensate fasciocutaneouspedicled flaps based on the medial plantar artery. The donor site was closed using a split thickness graft. Results: In 13 patients the defect healed with good results and no complications within 4 weeks, 3 patients presented with superficial epidermolysis in the periphery and 1 patient had a flap loss. 2 patients had partial graft loss in the secondary defect. Conclusion: In our experience medial plantar artery flap cover is a durable option for sole defects with acceptable aesthetic and functional outcomes. Donor site morbidity is minimal. This flap is a safe reliable and technically easy alternative flap coverage for plantar defects especially around the heel.

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.

Reduction of vitrification in in vitro raised shoots of Chlorophytum borivilianum Sant. & Fernand., a rare potent medicinal herb.

Reduction of vitrification in in vitro raised shoots derived from shoot bases and immature floral buds along with inflorescence axis used as explants of C. borivilianum, a rare medicinal herb is described. Shoot multiplication was obtained on MS medium with 2 mg l(-1) benzylaminopurine (BAP) + 0.1 mg l(-1) indole-3-butyric acid (IBA) and MS medium with 2 mg l(-1) kinetin (Kin) + 0.1 mg l(-1) 2,4-dichlorophenoxy acetic acid (2,4-D) from shoot bases and inflorescence axis respectively. Best multiplication rates were obtained from both the explants on MS medium with 2 mg l(-1) BAP. Vitrification of shoots in cultures appeared during the multiplication stage. Culture bottles with aerated caps reduced the vitrification to 80%. Reduction of BAP concentration from 2 mg l(-1) to zero during subsequent subcultures also minimized vitrification. Use of 0.5-2 mg l(-1) Kin produced healthy shoots when compared to BAP. In vitro raised shoots rooted on Knop salts containing iron and vitamins of MS medium, 2 mg l(-1) IBA and 0.1% activated charcoal. About 80% plantlets survived upon soil transfer. Scanning electron microscopic and image analyzer studies reveal the morphological structural differences between the leaves of normal and vitrified plantlets.

In vitro clonal propagation of Chlorophytum borivilianum Sant. et Fernand., a rare medicinal herb from immature floral buds along with inflorescence axis.

A novel method of shoot regeneration from immature floral buds along with inflorescence axis in C. borivilianum, a rare medicinal herb is described. Using this explant, axenic cultures were established with very less contamination (10%). MS medium with 2 mg l(-1) kinetin and 0.1 mg l(-1) 2, 4-dichlorophenoxyacetic acid proved to be the best for multiple shoot induction. Maximum number (35) of shoot production was achieved in MS medium with 2 mg l(-1) benzylaminopurine. Rooting of shoots (86.7%) with maximum fasciculated roots (5) occurred on Knops medium containing iron and vitamins of MS medium with 2 mg l(-1) indole-3-butyric acid and 0.1% activated charcoal. Plant survival was 80% in four weeks after their removal from in vitro conditions. Per explant 34 hardened plants generated within 50 weeks. This protocol can be useful for large-scale clonal multiplication from immature floral buds with inflorescence axis and successfully used for germplasm conservation of this rare medicinal herb without destroying the mother plant.

Cataract surgeries by phaco-sandwich technique through sclerocorneal tunnel, a cohort study in Oman

To evaluate the changes in Preoperative and Postoperative keratometry results and rapid visual rehabilitation in Cataract surgery by our phaco-sandwich technique through the self sealing sclero-corneal tunnel incision without phacoemulsification. 96 eyes of 88 patients with age-related cataracts underwent small incision suture less cataract surgery without phacoemulsification. All eyes were operated by the phaco-sandwich technique through sclerocorneal tunnel with 6 mm frown-shaped external scleral incision. 6 mm single piece PMMA lens was implanted in the capsular bag. Patients were evaluated at 1week, 4 weeks and 12 weeks post-operatively. Ninety six eyes of eighty eight patients were our cohort. During the first post-operative week 8 eyes [8.3%] had uncorrected visual acuity [UCVA] of 6/6. By the end of 12 post-operative weeks, 33 eyes[34.5%] had UCVA of 6/6. 64 [66.7%], 72[75%] and 80[83.3%] eyes had best correctable visual acuity [BCVA] of 6/6 after 4 weeks, 8 weeks and 12 weeks respectively. 64 [66.7%] eyes after 4 weeks, 72 [75%] after 8 weeks and 80 [83%] after 12 weeks had best correctable visual acuity [BCVA] of 6/6. Suture less, small-incision cataract surgery is an economical, safe and effective method of managing cataract cases. This technique also ensures satisfactory and rapid rehabilitation for patients. This procedure can be effectively applied to clear the backlog of cataract-related blindness in places wherein the resources for phaco facilities are not available

M-shaped doppler signal across ventricular septal defect: potential implications for estimation of right ventricuilar systolic pressure.

An 8-year-old child suffering from ventricular septal defect and severe valvular pulmonary stenosis was evaluated by echo-Doppler technique and cardiac catheterization. A peak instantaneous transventricular systolic gradient of 64 mmHg was recorded across the ventricular septal defect with an interesting M-shaped spectral pattern. However, cardiac catheterization revealed a peak-to-peak non-simultaneous gradient between the right and the left ventricle of only 14 mmHg. This discrepancy along with its implications are discussed in this report.

Plant defense induced in in vitro propagated banana (Musa paradisiaca) plantlets by Fusarium derived elicitors.

Perception of microbial signal molecules is part of the strategy evolved by plants to survive attacks by potential pathogens. To gain a more complete understanding of the early signaling events involved in these responses, we used fungal components of Fusarium under in vitro condition and checked the rise in signal molecule, salicylic acid (SA), and marker enzymes in defense reactions against the pathogen. SA level increased by 21 folds in elicitor treated plantlets as compared to that of control plantlets and there was marked increase in phenylalanine ammonia-lyase(PAL), peroxidase(POX), polyphenol oxidase(PPO) along with higher total phenolic content. Present results indicated that use of fungal components had successfully induced systemic resistance in in vitro cultured banana plantlets.

Noncompaction of left ventricular myocardium in the presence of calcific aortic stenosis in an adult.

We describe an adult patient with a hitherto unreported association of severe aortic stenosis with extensive noncompaction of the left ventricular myocardium without any hypertrophy; however, there was severe left ventricular systolic dysfunction in the presence of a normal-sized left ventricular cavity on two-dimensional echocardiography. This condition was differentiated from persistence of embryonic intramyocardial sinusoids by selective coronary angiography.

Congenitally unguarded tricuspid valve orifice with a giant right atrium and a massive clot in an asymptomatic adult.

Congenitally unguarded tricuspid valve orifice, a variant of tricuspid valve dysplasia, is a rare malformation with protean manifestations. This report describes an asymptomatic adult who, on echocardiographic examination ordered in view of an abnormal 12-lead surface electrocardiogram and plain chest X-ray, was found to have an unguarded tricuspid valve orifice with a giant right atrium (12 x 10 cm), intense spontaneous echo contrast and a large right atrial clot.

Recording of double atrial potentials as a marker for isthmus block during ablation of atrial flutter.

Radiofrequency ablation is an established method for treatment of type I atrial flutter. The assessment of creation of complete bidirectional isthmus block following linear ablation of the isthmus is an integral part of ablation procedure. Conventionally, bidirectional isthmus block is tested by pacing on either side of ablation line and looking for reversal of activation sequence in the right atrium. We looked at the feasibility of recording double potentials, separated by an isoelectric interval along the ablation line as an alternative method to demonstrate bidirectional isthmus block. An attempt was made to record the double potentials following linear ablation of the cavotricuspid isthmus. Following ablation, bidirectional isthmus block was also tested by pacing from the coronary sinus os and the low-lateral right atrium. We could demonstrate double potentials in 9 of the 11 patients in whom we attempted to record them following linear ablation of flutter. The presence of bidirectional block by pacing from coronary sinus os and low lateral right atrium could be demonstrated in 10 (91%) patients. Thus, double atrial potentials, separated by an isoelectric interval can be demonstrated following ablation of atrial flutter. Double potentials, if demonstrable on coronary sinus os and low lateral right atrium pacing, could serve as an alternative marker of isthmus block.

Radiofrequency catheter ablation of common atrial flutter--acute and follow-up results.

Atrial flutter with a structurally well-defined macro-reentrant circuit in the right atrium has recently become amenable to radiofrequency ablation with the recognition of isthmus as a narrow zone of slow conduction. This study describes 20 consecutive and symptomatic patients with atrial flutter (15 males, 5 females; mean age 38.5 +/- 10.2 years) who underwent radiofrequency ablation in our institute in the last 18 months. Fourteen patients had structurally normal hearts, while the remaining six patients had specific disorders (prior surgery for closure of atrial septal defect-2, idiopathic restrictive cardiomyopathy-1, primary sinus node dysfunction-2, tachycardiomyopathy-1). The endpoints of a complete isthmus block and conversion to sinus rhythm were achieved in 19 of the 20 patients. Total number of pulses needed to attain the endpoints was a mean of 4.2 (range 1-5), each pulse being delivered for 90 seconds. At a mean follow up of 9.4 +/- 3.2 months (range 6-12 months), recurrence of atrial flutter was seen in one patient, atrial fibrillation in two and sinus node reentrant tachycardia in one. These results are comparable to those reported in the literature. Achievement of a complete isthmus block appears to be an important endpoint in obtaining optimal results. The issues of alternative sites of ablation, long-term results and advantages of an 8 mm tip catheter need to be examined further. In conclusion, radiofrequency ablation appears to be the preferred mode of treatment for patients with atrial flutter with excellent short-term and mid-term results.