PGE-1 in addition to the standard care (statins) to prevent the renal injury after coronary angiography - is good ?

Can we give PGE-1 in addition to the standard care (statins) to prevent the renal injury after coronary angiography in mild to moderate CKD patients?

Prostaglandin E-1 is used to relieve the rest pain, heal ulcers in patients with non reconstructable critical ischemia. Prostaglandin E-1 is known to produce micro vasodilation and improve the metabolism of the tissues to relieve the symptoms and heal ulcers in ischemic patients. It has to be intravenously to get these benefits. Oral Prostaglandin E1 did not show similar benefits in these patients. Pulmonary hypertension in cardiac patients is also relieved by the PGE-1 in the perioperative periods. Contrast induced nephropathy (CIN) is a known complication after angiograms. We avoid this complication (CIN) - by properly hydrating the patients and giving N-acetyl cysteine. Coronary angiogram in mild to moderate CKD patients is associated with additional risk and there are no definite measures which can reduce the risk of worsening of renal failure. This has given opportunity for the Liu WJ et al from Shanghai to study benefits of adding PGE-1 to Statins to reduce the incidence of CIN in patients undergoing the coronary angiogram. They published their results recently and they are favourable.

In their study, a total of 156 consecutive patients with mild to moderate renal failure who underwent coronary angiography were enrolled in the study, and randomly categorized into two groups. In the statins group, 80 patients were treated with statins before and after coronary angiography. In the alprostadil plus statins group, 76 patients were treated with statins and alprostadil before and after coronary angiography. Serum creatinine (SCr), serum cystatin (CysC) and neutrophil gelatinase-associated lipocalin (NGAL) were detected after administration of contrast media, and adverse events were evaluated within six months. Inj. PGE-1 is given for 7 days (20mcg/day) started one day prior to coronary angiogram. In both groups, the SCr, CysC and NGAL significantly increased after coronary angiography and peaked at 48, 24 and 6 hours, respectively. SCr, CysC and NGAL were significantly lower in the alprostadil plus statins group than in the statins group (P < 0.05).

The incidence of CIN in the alprostadil plus statins group was slightly lower than in the statins group. The incidence of adverse events within six months in the alprostadil plus statins group was significantly lower than in the statins group (P = 0.034). They concluded by saying that Intravenous alprostadil in combination with oral statins is superior to statins alone for protecting renal function in patients with mild to moderate renal dysfunction who undergo coronary angiography, and can reduce the incidence of adverse events seen within six months.

Fig: Kaplan-Meier method was used to analyze the timing of adverse events during follow-up period. The incidence of adverse events was lower in the alprostadil plus statins group (group 2) than in the statins group (group 1) (P=0.034).

Chin Med J (Engl). 2013 Sep;126(18):3475-80. Renoprotective effect of alprostadil in combination with statins in patients with mild to moderate renal failure undergoing coronary angiography.Liu WJ, Zhang BC, Guo R, Wei YD, Li WM, Xu YW. Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China.

Atrial fibrillation and hypertension - increase the risk of Stroke

It is more important to recognize the atrial fibrillation and treat it  to prevent the stroke related morbidity.AF increases the risk of stroke. The degree of increase can be substantial, depending on the presence of additional risk factors (such as high blood pressure). Atrial fibrillation may be treated with medications to either slow the heart rate to a normal range ("rate control") or revert the heart rhythm to normal ("rhythm control"). Synchronized electrical cardioversion can be used to convert AF to a normal heart rhythm. Surgical and catheter-based ablation may be used to prevent recurrence of AF in certain individuals. Depending on the risk of stroke and systemic embolism, people with AF may use anticoagulants such as warfarin, which substantially reduces the risk but may increase the risk of major bleeding, mainly in geriatric patients. The prevalence of AF in a population increases with age, with 8% of people over 80 having AF. Chronic AF leads to a small increase in the risk of death.

Four types of Atrial fibrillations!!

All atrial fibrillation patients are initially in the category called first detected AF. These patients may or may not have had previous undetected episodes. If a first detected episode self-terminates in less than 7 days and then another episode begins later on, the case has moved into the category of paroxysmal AF. Although patients in this category have episodes lasting up to 7 days, in most cases of paroxysmal AF the episodes will self-terminate in less than 24 hours. If instead the episode lasts for more than 7 days, it is unlikely to self-terminate,^[2] and it is called persistent AF. In this case, the episode may be still terminated by cardioversion. If cardioversion is unsuccessful or it is not attempted, and the episode is ongoing for a long time (e.g., a year or more), the patient's AF is called permanent. Episodes that last less than 30 seconds are not considered in this classification system. Also, this system does not apply to cases where the AF is a secondary condition that occurs in the setting of a primary condition that may be the cause of the AF.

Can Gene modification occur with exercise to fight obesity and Type 2 diabetes? May be or may be not!

Exercise on daily basis seems to be helpful in many ways. But we still can’t find time to do the regular exercise or many of us take an excuse for not going for a walk or exercise or play a game to produce sweat. Exercise is advised to protect the heart, reduce weight, prevent and control diabetes, hypertension. Many people ask us for an alternative to 30 minute exercise because they feel that they are wasting another 1 hour they are needing prepare and get ready to go for work in the morning after exercises. Some say with a smiling face when will the doctors find a tablet which is equal to walking exercise and give the same benefits of walking? Some others feel that they can not walk because of their physical disabilities or leg pains and they are seriously looking for the alternatives to the regular walking exercise.

In the recent it was found that exercise actually works on methylation of the DNA and chemically changes the DNA of the fat tissues in the body and generates the benefits which we are noticing. The researchers found 24 sites located close to 18 of the candidate genes for obesity with a difference in DNA methylation in adipose tissue in response to the exercise intervention. Additionally, two of those genes (CPEB4 and SDCCAG8) showed significant changes in mRNA expression after exercise (meaning that the activity of these particular genes was significantly changed by exercise).

Among the T2D candidate genes, 45 sites in 21 different genes were differentially methylated in fat tissue before versus after exercise. Of note, 10 of these sites mapped to KCNQ1 and 6 sites mapped to TCF7L2-important since TCF7L2 is the gene showing the highest genetic association with type 2 diabetes. A simultaneous change in mRNA expression was seen for four of the T2D candidate genes where mRNA expression decreased while DNA methylation increased in adipose tissue in response to exercise, meaning that again, the activity of these particular genes was significantly changed by exercise. The study is by Dr Tina Rönn, Lund University, Malmö, Sweden. She adds: "Since we also observed DNA methylation changes in genes important for fat metabolism, which indicates increased fat uptake in response to exercise, these genes could potentially be a target for future drugs."

May be one day, there may be a pill for some one who can not do the exercise to get the benefits equal to that exercise. Very interesting too!! Let us hope so !  Let those also get the benefit of exercise without exercise.

The Beta3-Adrenergic Receptor Gene: The Beta3-adrenergic receptor gene makes a protein in fat cells that is involved in determining how much fuel your body burns when you are resting. A mutation in this gene slows down how quickly a person burns fat — increasing their tendency to be obese. One specific mutation in this gene, called TRP64ARG, is almost four times more common in Pima Indians than in people of European descent, and is one and a half times more common in people of African or Mexican descent. The prevalence of the TRP64ARG gene mutation in these populations probably accounts at least in part for why these ethnic groups have a higher rate of Type 2 diabetes. The genetics of Type 2 diabetes is complicated, with many different genes influencing a person's risk. Because of this array of genes, Type 2 diabetes is not inherited in a clearly dominant or recessive manner. Instead, a person may have one gene that increases their risk and other genes that decrease risk. Together, these genes, along with environmental factors, determine a person's overall risk for developing diabetes. With so many variables to consider, the medical community is a long way from a genetic test for Type 2 diabetes. Although there is no genetic test for Type 2 diabetes, the American Diabetes Association recommends screening for diabetes onset every three years if you have diabetes in the family. Doctors screen for diabetes onset using a fasting glucose test or glucose tolerance test, which tells doctors if your blood glucose levels are unusually high.

World heart day 2013 - September 29th

Researchers from the World Heart Federation say that in order to prevent the risk of heart disease and stroke, we need to raise awareness around risk factors, such as physical inactivity, unhealthy eating, obesity and tobacco use. They say that regular moderate exercise, including walking, has many heart benefits.  Walking, they note, is one of the most accessible and least expensive ways to achieve the recommended physical activity to prevent heart diseases.

By walking 30 minutes a day, 5 days a week, the World Heart Federation says people can increase their life expectancy by up to 3 years, reduce the risk of cardiovascular disorder by as much as 11%, and burn more fat than jogging.

As World Heart Federation President Dr. Srinath Reddy says, "Your feet can carry your heart very far in life." According to the organization, if people do not take action to live heart-healthy lives, cardiovascular disease will continue to be the leading cause of death worldwide, causing an estimated 23.6 million deaths each year by 2030.

The survey, conducted by the World Heart Federation, focused on walking because, according to the organization, it is one of the simplest things we can do to protect our heart health. Six countries - Brazil, China, India, Spain, UK and US - participated in the survey, which was conducted by YouGov and yielded a total of 7,367 respondents over 18 years of age in August 2013. The survey asked two questions: how much time do you spend walking at a slow pace each day and how much time at a fast pace?

Results from the study show that: In the US and UK, one in three adults do not know how much they walk each day, compared with only one in six adults in India. 


In the six countries surveyed, 55% of respondents who reported times walk briskly for less than 30 minutes each day. In the US and UK, only about 33% of adults do the recommended 30 minutes of brisk walking each day, compared with about 50% of adults in Brazil and India. Dr. Kathryn Taubert, chief science officer from the World Heart Federation, says: "Awareness is the first step to a healthy heart. Paying attention to how much we walk should be as simple as watching what we eat. On World Heart Day, we are urging people to take action to protect their hearts."

Comparison of coronary artery bypass surgery and percutaneous coronary intervention in patients with diabetes: a meta-analysis of randomised controlled trials

People with diabetes have a 30 per cent less chance of dying if they undergo coronary artery bypass surgery rather than opening the artery through angioplasty and inserting a stent, a new study has found.

Comparison of coronary artery bypass surgery and percutaneous coronary intervention in patients with diabetes: a meta-analysis of randomised controlled trials

Dr Subodh Verma MD a e g , Michael E Farkouh MD e f h, Bobby Yanagawa MD g, David H Fitchett MD b e h, Muhammad R Ahsan MD a, Prof Marc Ruel MD l, Sachin Sud MD h m, Milan Gupta MD a e h n, Shantanu Singh k, Nandini Gupta MD a l, Asim N Cheema MD b e h, Prof Lawrence A Leiter MD c e h i, Paul W M Fedak MD o, Hwee Teoh PhD a c e, David A Latter MD a e g, Prof Valentin Fuster MD p q, Dr Jan O Friedrich MD d e h j

The choice between coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) for revascularisation in patients with diabetes and multivessel coronary artery disease, who account for 25% of revascularisation procedures, is much debated. We aimed to assess whether all-cause mortality differed between patients with diabetes who had CABG or PCI by doing a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing CABG with PCI in the modern stent era.

We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials from Jan 1, 1980, to March 12, 2013, for studies reported in English. Eligible studies were those in which investigators enrolled adult patients with diabetes and multivessel coronary artery disease, randomised them to CABG (with arterial conduits in at least 80% of participants) or PCI (with stents in at least 80% of participants), and reported outcomes separately in patients with diabetes, with a minimum of 12 months of follow-up. We used random-effects models to calculate risk ratios (RR) and 95% CIs for pooled data. We assessed heterogeneity using I2. The primary outcome was all-cause mortality in patients with diabetes who had CABG compared with those who had PCI at 5-year (or longest) follow-up.

Findings

The initial search strategy identified 3414 citations, of which eight trials were eligible. These eight trials included 7468 participants, of whom 3612 had diabetes. Four of the RCTs used bare metal stents (BMS; ERACI II, ARTS, SoS, MASS II) and four used drug-eluting stents (DES; FREEDOM, SYNTAX, VA CARDS, CARDia). At mean or median 5-year (or longest) follow-up, individuals with diabetes allocated to CABG had lower all-cause mortality than did those allocated to PCI (RR 0·67, 95% CI 0·52—0·86; p=0·002; I2=25%; 3131 patients, eight trials). Treatment effects in individuals without diabetes showed no mortality benefit (1·03, 0·77—1·37; p=0·78; I2=46%; 3790 patients, five trials; pinteraction=0.03). We identified no differences in outcome whether PCI was done with BMS or DES. When present, we identified no clear causes of heterogeneity.

Interpretation

In the modern era of stenting and optimum medical therapy, revascularisation of patients with diabetes and multivessel disease by CABG decreases long-term mortality by about a third compared with PCI using either BMS or DES. CABG should be strongly considered for these patients.

Transparent nanocrystalline yttria-stabilized-zirconia calvarium prosthesis- This may have implications in other areas also!

Abstract 

Laser-based diagnostics and therapeutics show promise for many neurological disorders. However, the poor transparency of cranial bone (calvaria) limits the spatial resolution and interaction depth that can be achieved, thus constraining opportunity in this regard. Herein, we report preliminary results from efforts seeking to address this limitation through use of novel transparent cranial implants made from nanocrystalline yttria-stabilized zirconia (nc-YSZ). Using optical coherence tomography (OCT) imaging of underlying brain in an acute murine model, we show that signal strength is improved when imaging through nc-YSZ implants relative to native cranium. As such, this provides initial evidence supporting the feasibility of nc-YSZ as a transparent cranial implant material. Furthermore, it represents a crucial first step towards realization of an innovative new concept we are developing, which seeks to eventually provide a clinically-viable means for optically accessing the brain, on-demand, over large areas, and on a chronically-recurring basis, without need for repeated craniectomies.

Transparent cranial implants could serve as a critical enabler for laser-based diagnosis and treatment of many neurological disorders. However, the intrinsic brittleness of transparent implants reported thus far predisposes them to catastrophic fracture-based failure, thus limiting opportunity for clinical translation. Novel nanocrystalline transparent implants are reported herein that seek to address this limitation through use of zirconia, a tough ceramic with well-proven biocompatibility in other chronic implantation applications.

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