Himalayan Microbiomes for Agro-environmental Sustainability: Current Perspectives and Future Challenges.

The Himalayas are one of the most mystical, yet least studied terrains of the world. One of Earth's greatest multifaceted and diverse montane ecosystems is also one of the thirty-four global biodiversity hotspots of the world. These are supposed to have been uplifted about 60-70 million years ago and support, distinct environments, physiography, a variety of orogeny, and great biological diversity (plants, animals, and microbes). Microbes are the pioneer colonizer of the Himalayas that are involved in various bio-geological cycles and play various significant roles. The applications of Himalayan microbiomes inhabiting in lesser to greater Himalayas have been recognized. The researchers explored the applications of indigenous microbiomes in both agricultural and environmental sectors. In agriculture, microbiomes from Himalayan regions have been suggested as better biofertilizers and biopesticides for the crops growing at low temperature and mountainous areas as they help in the alleviation of cold stress and other biotic stresses. Along with alleviation of low temperature, Himalayan microbes also have the capability to enhance plant growth by availing the soluble form of nutrients like nitrogen, phosphorus, potassium, zinc, and iron. These microbes have been recognized for producing plant growth regulators (abscisic acid, auxin, cytokinin, ethylene, and gibberellins). These microbes have been reported for bioremediating the diverse pollutants (pesticides, heavy metals, and xenobiotics) for environmental sustainability. In the current perspectives, present review provides a detailed discussion on the ecology, biodiversity, and adaptive features of the native Himalayan microbiomes in view to achieve agro-environmental sustainability.

Duration of Inducible Ventricular Tachycardia Early After ST-Segment-Elevation Myocardial Infarction and Its Impact on Mortality and Ventricular Tachycardia Recurrence.

Background The clinical significance of the duration of inducible ventricular tachycardia (VT) at electrophysiology study (EPS) in patients soon after ST-segment-elevation myocardial infarction and its predictive utility for VT recurrence are not known. Methods and Results Consecutive ST-segment-elevation myocardial infarction patients with day 3 to 5 left ventricular ejection fraction ≤40% underwent EPS. A positive EPS was defined as sustained monomorphic VT with cycle length ≥200 ms. The induced VT was terminated by overdrive pacing or direct current shock at 30 s or earlier if hemodynamic decompensation occurred. Patients with inducible VT duration 2 to 10 s were compared with patients with inducible VT >10 s. The primary end point was survival free of VT or cardiac mortality. From 384 consecutive ST-segment-elevation myocardial infarction patients who underwent EPS, 29% had inducible VT (n=112, 87% men). After mean follow-up of 5.9±3.9 years, primary end point occurred in 35% of patients with induced VT 2 to 10 s duration (n=68) and in 22% of patients with induced VT >10 s (n=41) (P=0.61). This was significantly different from the noninducible VT group, in which primary end point occurred in 3% of patients (n=272) (P=0.001). Conclusions This study is the first to show that in patients who undergo EPS early after myocardial infarction, inducible VT of short duration (2-10 s) has similar predictive utility for ventricular tachyarrhythmia as longer duration (>10 s) inducible VT, which was significantly different to those without inducible VT. It is possible that immediate cardioversion of rapid VT might have contributed to some of the short durations of inducible VT.

Influence of Body Mass Index on Recurrence of Ventricular Arrhythmia, Mortality in Defibrillator Recipients With Ischaemic Cardiomyopathy.

BACKGROUND: Obesity is associated with increased risk of cardiovascular disease. There is little known, however, about the influence of body mass index (BMI) on spontaneously occurring ventricular arrhythmias in patients with ischaemic heart disease. We sought to examine the effect of BMI on the ventricular arrhythmia (VA) recurrence and mortality in defibrillator recipients with ischaemic cardiomyopathy. METHODS: Consecutive patients (n = 123) with ischaemic cardiomyopathy (left ventricular ejection fraction (LVEF) ≤ 40%) and a primary or secondary prevention defibrillator were included. Patients were classified according to their BMI as being normal (18.5-24.99, n = 54/ 43.9%), overweight (2 -29.99, n = 43/ 35%) or obese (>30, n = 26/20.3%). RESULTS: The primary combined endpoint of VA recurrence and mortality occurred in 36%, 5.4% and 11.5% of patients with normal, overweight and obese BMI (p = 0.001). When adjusting for risk factors such as ejection fraction, age and triple vessel disease, on multivariable analysis, normal BMI remained a significant predictor for the primary outcome (Hazard Ratio, Normal vs Overweight = 7.1, 95% CI 1.8-25, p = 0.002: Hazard Ratio, Normal vs Obese = 5.5, 95% CI 1.11-25, p = 0.033). There was a non-significant trend towards reduced survival in patients with normal weight in comparison to overweight and obese patients (p = 0.08). CONCLUSION: In defibrillator recipients with ischaemic cardiomyopathy, BMI appears to be a significant predictor for the combined primary outcome of spontaneously occurring ventricular arrhythmias and mortality. Normal BMI, compared to overweight and obese patients had worse outcomes, suggesting the presence of the obesity paradox in ventricular arrhythmogenesis late post infarction.

Influence of BMI on Short and Long-Term Outcomes in Patients With STEMI and LV Dysfunction.

BACKGROUND: Recent studies suggest an obesity paradox in individuals with myocardial infarction with better outcomes in obese relative to normal weight patients. We assessed the influence of body mass index (BMI) on early and long-term outcomes in patients with ST elevation myocardial infarction (STEMI) and left ventricular (LV) dysfunction. METHODS: Outcomes were assessed according to BMI status in 478 consecutive patients with STEMI and LV dysfunction (ejection fraction [EF]<40%) admitted to Westmead Hospital between 1 January 2004 and 16 April 2014. Normal weight, overweight and obesity were defined as BMI < 25, 25-29.9, and ≥30 kg/m2, respectively. RESULTS: Obese patients were significantly younger (p = 0.01) and were more likely to have hypertension and diabetes (p = 0.04 and 0.001 respectively). In hospital outcomes and 30-day major adverse cardiac events (MACE) were similar in all three groups. There was no difference in recurrent myocardial infarction (MI) and target vessel revascularisation (TVR) during long-term follow-up (mean follow-up 809 days). Overall mortality following hospital discharge was significantly lower in overweight and obese patients. Adjusted hazard ratio for all-cause mortality in normal weight patients compared to overweight patients was 2.4 (95% C.I 1.1-5.3, p= -0.03). The adjusted hazard ratio for all-cause mortality in normal weight patients in comparison to obese patients was 2.7 (95% C.I, 1 -7.4, p = 0.05). Left ventricular ejection fraction (LVEF) and age were other predictors of all-cause mortality. CONCLUSIONS: Normal weight, overweight and obese patients with STEMI and LV dysfunction had similar in hospital outcomes and 30-day outcomes. Long-term all-cause mortality was, however, higher in normal weight patients suggesting the presence of an obesity paradox in this cohort.

Immunogenicity and safety of an intramuscular split-virion quadrivalent inactivated influenza vaccine in individuals aged ≥ 6 months in India.

A quadrivalent split-virion inactivated influenza vaccine (IIV4; Fluzone® Quadrivalent, Sanofi Pasteur) has been available in the US since 2013 for individuals aged ≥ 6 months. Here, we describe the results of an open-label, multicenter trial (WHO Universal Trial Number U1111-1143-8370) evaluating the immunogenicity and safety of IIV4 in Indian children aged 6-35 months and 3-8 years, adolescents aged 9-17 years, and adults aged ≥ 18 years (n = 100 per group). Post-vaccination hemagglutination inhibition titers for all strains in all age groups were ≥ 8 fold higher than at baseline (range, 8-51). At least 70% of participants in all age groups seroconverted or had a significant increase in titer for each strain. The most common solicited reactions were injection-site pain and tenderness, plus fever in participants 6-23 months and myalgia in older children and adolescents. All injection-site reactions and most systemic reactions were grade 1 or 2 and resolved within 3 days. Only three vaccine-related unsolicited adverse events were reported, all of which were grade 1 or 2 and transient. No immediate adverse events, adverse events leading to study discontinuation, adverse events of special interest, or serious adverse events were reported. This study showed that IIV4 was well tolerated and highly immunogenic in all age groups. This adds important data on the safety, tolerability, and immunogenicity of influenza vaccines in India.

Long-term survival in patients presenting with STEMI complicated by out of hospital cardiac arrest.

BACKGROUND: There is limited data regarding long-term survival in patients who present with STEMI and out of hospital cardiac arrest (OHCA). METHODS: We prospectively analysed outcomes in 3521 consecutive patients who were diagnosed with STEMI and underwent primary percutaneous coronary intervention (PPCI) or coronary artery bypass surgery from 2004 to 2017. They were divided into two groups according to the presence of cardiac arrest (group I, patients with cardiac arrest; n = 156 group II, patients without cardiac arrest; n = 3365). RESULTS: Patients with OHCA had higher in hospital mortality (27.7% vs 2.9%, p < 0.01), sustained VT or VF (44.6% vs 4.3%, p < 0.01) and cardiogenic shock (22.9% vs 6.8%, p < 0.01). 30-day mortality (excluding death within first 24 h) was also higher in the OHCA group (24.6% vs 3.3%, p < 0.01). There was no significant difference in recurrent AMI, TVR, stroke, major bleeds or new onset heart failure. After a mean follow-up of 18.6 months, mortality was higher in patients with OHCA (7.9% vs 3.8%, p 0.04). This was driven mainly by an increase in cardiac mortality (5% vs 1.1%, p < 0.01). OHCA was a significant predictor of mortality beyond 30 days (HR - 2.5, 95% CI 0.99-6.3). Kaplan-Meier curves and the log-rank test revealed that patients with OHCA had significantly lower survival (p < 0.01). CONCLUSIONS: Patients with STEMI complicated by OHCA remain a high-risk group associated with high in hospital mortality. Beyond 30 days the occurrence of cardiac arrest was a significant predictor of all-cause and cardiac mortality.

ST-elevation myocardial infarction in a migrant population: a registry-based study of patient treatment and outcomes.

BACKGROUND: Internationally, a growing number of studies has identified race-related disparities in the presentation, treatment and outcomes of patients with ST-elevation myocardial infarction (STEMI). With a large migrant population, Australia presents a unique microcosm in which to study the impact of migrant status and ethnicity in STEMI patients. AIM: To investigate if first-generation migrants differed in presentation, treatment or outcomes following STEMI compared with the Australian-born population. METHODS: We conducted a retrospective observational study using data from a clinician-initiated registry. The study involved 2154 patients who presented to 12 hospitals between 2004 and 2012. Our main outcome measures included time to reperfusion, 30-day mortality and complications. RESULTS: Migrants (n = 1035, 48.8%) were more likely to be older (61 vs 58 years, P < 0.001), diabetic (29.3 vs 21.5%, P < 0.001) and have a prolonged symptom to door time (102 vs 91 min, P = 0.04). Despite lower rates of previous known ischaemic heart disease (22.5 vs 26.6%, P = 0.03), migrants had more diffuse disease (triple vessel or left main (3VD/LM): 29.8 vs 22.0%, P < 0.001) and higher troponin values (3.77 vs 3.22 µg/L, P = 0.01). We found no significant differences in hospital treatment times, intervention types or rates. Multivariate regression identified age, diabetes, female gender and multi-vessel disease as predictors of complications and death at 30 days. CONCLUSIONS: Migrants had longer pre-hospital delays and exhibited different cardiovascular risk profiles than Australian-born patients but received comparable treatment in the acute hospital setting. Higher rates of diabetes and multi-vessel coronary artery disease were seen among migrant patients, indicating a relatively higher risk population.

Influence of BMI on inducible ventricular tachycardia and mortality in patients with myocardial infarction and left ventricular dysfunction: The obesity paradox.

BACKGROUND: There is little known about the influence of obesity on ventricular electrical remodelling after myocardial infarction. The aim of our study was to assess the relationship between body mass index (BMI) and the primary outcome of inducible-VT and the secondary outcome of all-cause mortality in consecutive patients who presented with ST elevation myocardial infarction (STEMI) and LV-dysfunction (LVEF ≤ 40%). METHODS AND RESULTS: Consecutive patients (n = 380) with STEMI and LV-dysfunction (LVEF ≤ 40%) underwent electrophysiological (EP) studies for risk-stratification. Inducible-VT ≥200 ms cycle-length (CL) with one to four extra-stimuli (ES) was considered abnormal. Patients were classified according their body mass index (BMI) to be normal (18.5-24.9), overweight (25-29.9) or obese (>30). The primary outcome of inducible-VT occurred in 42.7%, 21.5% and 21% of normal weight, overweight and obese patients respectively (p < 0.001). When adjusting for ejection-fraction, hypertension and triple-vessel-disease, normal BMI remained a significant predictor for inducible-VT. All-cause mortality was higher in patients with normal weight (12.8%) when compared to overweight (3.2%) and obese (3.8%) patients (p = 0.002) and was mainly driven by increased cardiac-death (6.8%, 1.9% and 1.9% in normal, overweight and obese patients respectively, p = 0.05). After adjusting for age, EF, and hypertension, normal BMI remained a significant predictor of mortality. CONCLUSION: In patients presenting with STEMI and LV-dysfunction, BMI appears to be a significant predictor of inducible-VT and all-cause mortality, with worse outcomes for those with normal weight, when compared to overweight or obese individuals. These findings are consistent with the obesity-paradox.

Immunogenicity and safety of a tetravalent dengue vaccine in healthy adults in India: A randomized, observer-blind, placebo-controlled phase II trial.

Dengue is a mosquito-borne viral disease that is endemic in India. We evaluated the immunogenicity and safety of recombinant, live-attenuated, tetravalent dengue vaccine (CYD-TDV) in Indian adults. In this observer-blind, randomized, placebo-controlled, Phase II study, adults aged 18-45 years were randomized 2:1 to receive CYD-TDV or placebo at 0, 6 and 12 months in sub-cutaneous administration. Immunogenicity was assessed using a 50% plaque reduction neutralization test (PRNT50) at baseline and 28 days after each study injection. 189 participants were enrolled (CYD-TDV [n = 128]; placebo, [n = 61]). At baseline, seropositivity rates for dengue serotypes 1, 2, 3 and 4 ranged from 77.0% to 86.9%. Seropositivity rates for each serotype increased after each CYD-TDV injection with a more pronounced increase after the first injection. In the CYD-TDV group, geometric mean titres (GMTs) were 2.38 to 6.11-fold higher after the third injection compared with baseline but remained similar to baseline in the placebo group. In the CYD-TDV group, the GMTs were 1.66 to 4.95-fold higher and 9.23 to 24.6-fold higher after the third injection compared with baseline in those who were dengue seropositive and dengue seronegative, respectively. Pain was the most commonly reported solicited injection site reaction after the first injection in both the CYD-TDV (6.3%) and placebo groups (4.9%), but occurred less frequently after subsequent injections. No serious adverse events were vaccine-related, no immediate unsolicited adverse events, and no virologically-confirmed cases of dengue, were reported during the study. The immunogenicity and safety of CYD-TDV was satisfactory in both dengue seropositive and seronegative Indian adults.

Right ventricular dysfunction predisposes to inducible ventricular tachycardia at electrophysiology studies in patients with acute ST-segment-elevation myocardial infarction and reduced left ventricular ejection fraction.

BACKGROUND: Inducible ventricular tachycardia (VT) is a strong predictor of spontaneous ventricular tachyarrhythmia following ST-segment-elevation myocardial infarction. Reduced left ventricular ejection fraction (EF) predisposes patients to inducible VT after ST-segment-elevation myocardial infarction. However, the role of right ventricular (RV) dysfunction in predisposing to inducible VT has not been described previously. METHODS AND RESULTS: Consecutive patients with ST-segment-elevation myocardial infarction treated with primary percutaneous coronary intervention underwent predischarge radionuclide gated heart pool scan to assess ventricular EF. The study cohort included patients with reduced left ventricular EF (left ventricular EF ≤40%) who underwent electrophysiology study (n=220) in an attempt to induce VT. We defined RV dysfunction as RVEF ≤35%. The end point was sustained monomorphic VT (cycle length ≥200 ms). This was considered a positive study. No inducible arrhythmia, ventricular fibrillation, or flutter (cycle length <200 ms) was considered a negative study. Infarct region, infarct-related artery, male sex, and RVEF ≤35% were univariable predictors of positive test. After multivariable analysis, RVEF ≤35% had the strongest association as an independent predictor of inducible VT at electrophysiology study (P<0.001; odds ratio, 5.8; 95% confidence interval, 3.005-11.262). CONCLUSIONS: RV dysfunction (RVEF ≤35%) predisposed to inducible VT at electrophysiology study in patients with impaired left ventricular EF (≤40%) after acute ST-segment-elevation myocardial infarction treated with primary percutaneous coronary intervention.

What is the optimal left ventricular ejection fraction cut-off for risk stratification for primary prevention of sudden cardiac death early after myocardial infarction?

AIMS: The optimal left ventricular ejection fraction (LVEF) to select patients early post myocardial infarction (MI) for risk stratification for prevention of sudden cardiac death (SCD) in the era of primary percutaneous coronary intervention (PPCI) is unknown. METHODS AND RESULTS: Consecutive patients (n = 1722) treated with PPCI for ST-elevation MI underwent early (median 4 days) LVEF assessment. An electrophysiological study (EPS) was performed if LVEF ≤40% and a prophylactic implantable-cardioverter defibrillator (ICD) implanted for a positive [inducible monomorphic ventricular tachycardia (VT)], but not a negative, result. According to an early LVEF, a primary endpoint of inducible VT at EPS and a secondary endpoint of death or arrhythmia (SCD, resuscitated cardiac arrest or ECG-documented VT/ventricular fibrillation) were determined. The proportion of patients with early LVEF >40, 36-40, 31-35, and ≤30% were 75% (n = 1286), 7% (n = 128), 8% (n = 136), and 10% (n = 172), respectively. Inducible VT occurred in 22, 25, and 40% of patients with LVEF 36-40, 31-35, and ≤30%, respectively (P = 0.014). Three-year death or arrhythmia occurred in 6.6 ± 0.8, 8.1 ± 2.6, 18.0 ± 3.4, and 37.4 ± 3.9% of patients with LVEF >40, 36-40, 31-35, and ≤30%, respectively (overall P<0.001; LVEF 36-40% vs. LVEF > 40% P = 0.265). The number of EPS-positive patients implanted with an ICD to treat one or more arrhythmic event (95% confidence interval) was 18.3 ± 2.4, 11.5 ± 3.0, and 4.2 ± 5.6 if LVEF is 36-40, 31-35, and ≤30%, respectively. CONCLUSION: A cut-off LVEF of ≤40% selects patients with a high incidence of inducible VT post-PPCI. Patients with LVEF ≤35% and inducible VT appear to derive a greater benefit from prophylactic ICD implantation due to their higher risk of death or arrhythmia.

Significance of repeat programmed ventricular stimulation at electrophysiology study for arrhythmia prediction after acute myocardial infarction.

BACKGROUND: The prognostic significance of a second programmed ventricular stimulation (PVS) at electrophysiology study (EPS), when the first PVS is negative for inducible ventricular tachycardia (VT), in patients following myocardial infarction (MI) is unknown. METHODS: Consecutive ST-elevation MI patients with left ventricular ejection fraction ≤ 40% following revascularization underwent early EPS. An implantable cardioverter defibrillator (ICD) was implanted for a positive (inducible monomorphic VT) but not a negative (no arrhythmia or inducible ventricular fibrillation [VF]/flutter) EPS. The combined primary end point of death or arrhythmia (sudden death, resuscitated cardiac arrest, and spontaneous VT/VF) was assessed in EPS-positive patients grouped according to if VT was induced on the first PVS application, or the second PVS application, when the first was negative. RESULTS: EPS performed a median 8 days post-MI in 290 patients was negative in 70% (n = 203) and positive in 30% (n = 87). In patients with a positive EPS, VT was induced on the first PVS in 67% (n = 58) and the second PVS, after the first was negative, in 33% (n = 29). Predischarge ICD was implanted in 79 of 87 patients with a positive EPS. Three-year primary end point occurred in 20.9 ± 5.6% and 38.3 ± 9.7% of patients with VT induced by the first and second PVS, respectively (P = 0.042) and in 6.3 ± 1.9% of electrophysiology-negative patients (P < 0.001). CONCLUSIONS: In patients with post-MI left ventricular dysfunction, VT can be induced in a significant proportion with a second PVS when negative on the first. These patients have a similar higher risk of death or arrhythmia compared to patients with VT induced on the first PVS.

Long-term arrhythmia-free survival in patients with severe left ventricular dysfunction and no inducible ventricular tachycardia after myocardial infarction.

BACKGROUND: A negative electrophysiology study (EPS) may delineate a subgroup of patients with severely impaired left ventricular ejection fraction (LVEF) whose care can be safely managed long-term without an implantable cardioverter-defibrillator. METHODS AND RESULTS: Consecutive patients treated with primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction underwent early (median 4 days) LVEF assessment. Patients with LVEF ≤40% underwent EPS. A prophylactic implantable cardioverter-defibrillator was implanted for a positive (inducible monomorphic ventricular tachycardia) but not a negative (no inducible ventricular tachycardia or inducible ventricular fibrillation/flutter) EPS result. Patients who would have become eligible for a late primary prevention implantable cardioverter-defibrillator with LVEF ≤30% or ≤35% with New York Heart Association class II/III heart failure were included and analyzed according to EPS result. Patients with LVEF >40%, ineligible for EPS, were followed up as control subjects (n=1286). The primary end point was survival free of death or arrhythmia (resuscitated cardiac arrest or sustained ventricular tachycardia/ventricular fibrillation). EPS performed in 128 patients with LVEF ≤30% or with LVEF ≤35% and heart failure was negative in 63% (n=80) and positive in 37% (n=48). Implantable-cardioverter defibrillators were implanted in <0.1%, 4%, and 90% of control, EPS-negative, and EPS-positive patients, respectively. The distribution of time to death or arrhythmia was comparable in control patients and EPS-negative patients with LVEF ≤30% or with LVEF ≤35% and heart failure (P=0.738), who both differed significantly from EPS-positive patients (P<0.001). At 3 years, 91.8 ± 3.2%, 93.4 ± 1.0%, and 62.7 ± 7.5% of control, EPS-negative, and EPS-positive patients were free of death or arrhythmia, respectively. CONCLUSIONS: Revascularized patients with ST-segment-elevation myocardial infarction with severely impaired left ventricular function but no inducible ventricular tachycardia have a favorable long-term prognosis without the protection of an implantable cardioverter-defibrillator.

Coronary artery reperfusion for ST elevation myocardial infarction is associated with shorter cycle length ventricular tachycardia and fewer spontaneous arrhythmias.

AIMS: Ventricular tachycardia (VT) induction at electrophysiological (EP) study early after ST elevation myocardial infarction (STEMI) has been a predictor of spontaneous ventricular arrhythmia. Reperfusion therapy for STEMI may have resulted in altered VT character. We attempted to determine differences in VT cycle length (CL) and VT recurrence rates, in patients who received early and late reperfusion treatment for STEMI. METHODS AND RESULTS: Of 180 consecutive patients with left ventricular ejection fraction < 40%, 77 patients had positive EP studies. Forty-nine patients receiving early reperfusion treatment (group 1, n = 49) were compared with 28 patients who received late reperfusion (group 2; n = 28). Seventy-five patients had defibrillators implanted for primary prevention of sudden death. Patients were followed for up to 6 years to assess long-term rates of spontaneous ventricular tachyarrhythmia. Patients who received early reperfusion demonstrated shorter CL inducible VT (231 ± 43 ms vs. 252 ± 56 ms; P = 0.016). They also had fewer spontaneous arrhythmias (adjusted hazard ratio of 2.94, 95% confidence interval: 1.07-8.13; P = 0.03) with shorter CL spontaneous VT (266 ± 54 ms vs. 320 ± 80 ms; P = 0.02) at 53 ± 33 months. Ventricular tachycardia CL was the only independent predictor of spontaneous arrhythmia or sudden cardiac death (1.22, 1.07-1.47; P = 0.016). CONCLUSIONS: Patients receiving early reperfusion for STEMI had faster inducible and spontaneous VT and fewer spontaneous recurrences. This may be due to changes in the myocardial substrate as a result of early coronary artery reperfusion.

Significance of inducible very fast ventricular tachycardia (cycle length 200-230 ms) after early reperfusion for ST-segment-elevation myocardial infarction.

BACKGROUND: Electrophysiological study (EPS) after myocardial infarction may have a role in identifying patients at risk of sudden cardiac death. It has been shown previously that inducible very fast ventricular tachycardia (VT; cycle length [CL], 200-230 ms) is predictive of arrhythmia recurrence; however, its significance early after reperfusion in ST-segment-elevation myocardial infarction is unknown. METHODS AND RESULTS: Consecutive patients with ST-segment-elevation myocardial infarction treated with primary percutaneous coronary intervention with a left ventricular ejection fraction ≤40% underwent early EPS with an implantable-cardioverter defibrillator implanted for inducible VT, but not for a negative EPS. The end point was the cumulative incidence of death or first arrhythmic event (defined as resuscitated cardiac arrest or spontaneous ventricular tachyarrhythmia). A total of 1721 patients with ST-segment-elevation myocardial infarction underwent early left ventricular ejection fraction assessment (median, 4 days after myocardial infarction) with a left ventricular ejection fraction≤40% in 24%. EPS was performed in 290 eligible patients with no arrhythmia or ventricular fibrillation/flutter (CL<200 ms) induced in 203 patients (EPS negative, group 1), monomorphic VT induced in 87 patients, consisting of very fast VT in 67% (group 2; n=58), and standard VT (CL>230 ms) in 33% (group 3; n=29). Kaplan-Meier 4-year cumulative incidence of death or arrhythmia was 8.2±2.3%, 33.1±7.1%, and 37.0±10.2% in groups 1, 2, and 3, respectively (P<0.001). CONCLUSIONS: The majority of inducible VT in patients who have been reperfused early after ST-segment-elevation myocardial infarction is very fast VT (CL, 200-230 ms). This very fast VT incurs at least a similar risk of arrhythmia or death as inducible standard VT (CL>230 ms) and a significantly higher risk than patients with a negative EPS.

Hemoperitoneum in dengue Fever with normal coagulation profile.

A 43-year-old male living in Bengaluru sought emergency services due to high-grade fever, headache, myalgia, abdominal pain and distension. Platelet count (except the first-96,000/mm(3)) and coagulation profile was in normal limits. The dengue serology was positive for IgM and Ig G (immunoglobulin M and G) antibodies. Ultrasound abdomen showed gross ascites, mild bilateral pleural effusion and hepatosplenomegaly. The patient continued to have abdominal pain and progressive distention Ascitic tap was hemorrhagic. Later laparoscopy showed 1.5 liters peritoneal fluid with blood clots and mild diffuse congestion of the peritoneum. Liver, spleen and blood vessels were normal. Then what would be the possible mechanism to explain hemoperitoneum, is it the increased vascular permeability caused by the virus? India being endemic for dengue illness, it is an interesting and rare case presentation.

Comparing the effect of different mouthrinses on de novo plaque formation.

PURPOSE: Several antiplaque agents are being available in the market in spite of vast development of modern medical science, satisfactory treatment of 'oral diseases' by newer drugs is not fully achieved, rather the chemical compounds has exposed the patients to it is different ill effects, therefore, there is interest to find out effective remedy of any disease by harmless herbal drugs thus the aim of this study was to compare plaque formation at 24 hours after the use of Triphala, Hi ora, Chlorhexidine and Colgate Plax mouth washes. METHODS: A controlled, randomized, double-blind, crossover clinical trial was designed. Thirty subjects underwent four consecutive experimental phases with four treatments: Triphala, Hi Ora, Chlorhexidine and Colgate Plax. On the day of study, the subjects discontinued all other oral hygiene habits and were randomly assigned for treatment with the experimental mouthwash. Each experimental phase was preceded by a 28-day washout period. Plaque formation was recorded after one undisturbed day. RESULTS: Triphala, Hi Ora and Chlorhexidine reduced de novo plaque formation to a greater extent than the colgate plax mouthwash (p < 0.05). CONCLUSION: Triphala and Hi Ora presents an anti-plaque efficacy similar to that of chlorhexdine, and was more effective at inhibiting plaque formation than the Colgate Plax mouth wash.

Induction of ventricular tachycardia with the fourth extrastimulus and its relationship to risk of arrhythmic events in patients with post-myocardial infarct left ventricular dysfunction.

AIMS: The prognostic significance of ventricular tachycardia (VT) induced by three extrastimuli (ES) is similar to that of VT induced by one or two ES in patients with coronary disease and abnormal left ventricular (LV) function. The significance of VT inducible with four ES is unclear. To examine the prognostic significance of VT inducible with the fourth ES in patients with post-myocardial infarct (MI) LV dysfunction. METHODS AND RESULTS: Consecutive patients (n= 432) with post-MI LV ejection fraction ≤40% underwent electrophysiological (EP) studies for risk stratification. Inducible VT ≥ 200 ms cycle length (CL) with one to four ES was considered inducible. The primary endpoint of arrhythmia (sudden death or spontaneous VT/ventricular fibrillation) was compared among patients with VT inducible with less than or equal to two, three, and four ES. The incidence of inducible VT was 37.9% (n= 164). In patients with inducible VT, inducibility was with less than or equal to two, three, and four ES in 24% (n= 39), 46% (n= 75), and 30% (n= 50). Compared to VT induced with less than or equal to three ES, VT induced with the fourth ES was of shorter CL (218 vs. 256 ms, P = 0.01) and more likely to be haemodynamically unstable requiring cardioversion (77 vs. 55%, P = 0.05). After 3 years the primary endpoint occurred in 28 ± 8, 28 ± 6, and 18 ± 6% in patients with VT induced with less than or equal to two, three, and four ES, respectively (P= 0.31) and in 5 ± 2% of EP-negative patients (P< 0.01). CONCLUSION: In patients with post-MI LV dysfunction, VT can be induced in a significant proportion of patients with the fourth ES. These patients are at comparable risk of arrhythmia to patients with inducible VT with less than or equal to three ES.

Impact of duration of ischemia on left ventricular diastolic properties following reperfusion for acute myocardial infarction.

We sought the correlation between duration of myocardial ischemia and severe left ventricular (LV) diastolic dysfunction (restrictive filling pattern [RFP]) in patients with acute ST-elevation myocardial infarction (STEMI). Duration of ischemia determines infarct size and survival after STEMI. However, the impact of duration of ischemia on LV diastolic function has not been previously studied. Ninety-five consecutive patients with first-ever STEMI underwent transthoracic echocardiography 3 days after primary percutaneous coronary intervention (PCI). RFP was defined as a mitral inflow E/A ratio >2.0 and/or E-wave deceleration time <140 ms. Composite major adverse cardiovascular events (death, reinfarction, heart failure, revascularization) were determined at 12 months. Twenty patients (21%) had RFP on day 3. Symptom-to-reperfusion time in the RFP group was 413 ± 287 versus 252 ± 138 minutes in the non-RFP group (p = 0.014). Peak troponin T levels were higher in the RFP group (12.2 ± 8.4 vs 5.7 ± 3.6 ng/ml, p = 0.002). Logistic regression identified symptom-to-reperfusion time (hazard ratio 1.02, 95% confidence interval 1.01 to 1.03, p = 0.010) and infarct size by peak troponin T levels (hazard ratio 1.54, 95% confidence interval 1.14 to 2.10, p = 0.005) as independent predictors of RFP. Major adverse cardiovascular events occurred in 10 patients (50%) in the RFP group and 6 patients (8%) in the non-RFP group. On multivariate Cox proportional hazards analysis, RFP was an independent predictor of major adverse cardiovascular events at 12 months (hazard ratio 5.43, 95% confidence interval 1.52 to 19.39, p = 0.001). In conclusion, delayed reperfusion after STEMI was associated with severe LV diastolic dysfunction, which in turn independently predicted adverse long-term outcomes. LV diastolic dysfunction represents a significant pathophysiologic link among duration of myocardial ischemia, infarct size, and outcomes.