Drug utilization pattern of antihypertensive drugs in chronic kidney disease stage 5 patients in a tertiary care hospital of central India

Background: India is experiencing a rapid health transition and is projected to become a major reservoir of chronic diseases like Diabetes and Hypertension and 25 to 40% of these subjects may develop chronic kidney disease and end stage renal disease. Aim and objective of the study was to analyze utilization pattern of antihypertensive drugs in chronic kidney disease patients in a tertiary care hospital.Methods: The present observational cross-sectional study was conducted in Sri Aurobindo Institute of Medical Sciences, Indore (M.P.) from 01.01.2018 to 31.03.2018 on patients with chronic kidney disease stage 5. The drug utilization pattern was studied with respect to age, sex, basic disease, duration of dialysis, type of antihypertensive used, etc. Comparison of mean between gender and dialysis / not on dialysis was done using unpaired ‘t’ test. A p value of < 0.05 was taken as statistically significant.Results: Of 198 patients, 63 (31.8%) were females and 135 (68.2%) were males, showing a male preponderance. Majority of the patients (54%) belonged to the age group 41-60 years. Majority of the patients were having diabetic nephropathy (40.9%), followed by CGN-CKD 5d (18.7%) and CIN-CKD 5d (17.2%). 11.6% patients were not on dialysis, while 88.4% were on dialysis with a mean duration of dialysis of 31.45±34.57 months. Calcium channel blockers were given in 87.4% patients, followed by centrally acting drugs in 56.1% patients, beta blockers in 51.0% and alpha blockers in 39.9%. 93.9% patients were on multidrug antihypertensive therapy. Mean number of antihypertensives required in patients on dialysis was lower than those not on dialysis (2.69±1.44 vs. 3.48±1.16, p <0.05), similarly mean number of antihypertensives use in males was higher than females (2.99±1.41 vs. 2.32±1.37, p <0.05).Conclusions: In order to treat CKD, it is important to treat hypertension as hypertension and CKD are related to each other. Treatment of hypertension will help in controlling future development of comorbidities. Calcium channel blockers and centrally acting drugs are the treatment of choice in patients with CKD stage 5D with hypertension. Multi-drug antihypertensive therapy is a better choice than mono/single-drug antihypertensive therapy

A Study of Cerebrospinal Fluid Flow Dynamics in patients with Cerebral Venous Thrombosis

INTRODUCTION: Thrombosis of cerebral veins is a distinct cerebrovascular disorder that most often affects young adults and children. Cerebral venous thrombosis is far more common than previously assumed. The spectrum of its clinical presentation is extremely wide and course is highly variable. There are three intracranial compartments namely the brain tissue, blood and CSF that if any pathology involves these will result in intracranial hypertension. Thrombosis of a cerebral venous sinus results in impediment of the sinus blood outflow. This causes increase in CSF pressure and increase in intracerebral venous blood pressure causing brain edema. With time, probably due to establishment of collateral venous circulation there is resolution of brain edema, cerebral sinus compression and resolution of CSF pressure. An occlusion of superior saggital sinus may to some degree, obstruct resorption of CSF by the arachnoid villi, leading to increased CSF pressure. But studies done so far find only small disturbance in CSF absorption process with only a minor contribution to intracranial pressure elevation. Hence we propose to study the CSF flow dynamics by bolus saline infusion method and analyse its relation to the various sites of venous sinus thrombosis proven radiologically by MRV. AIMS AND OBJECTIVES: 1. To study the cerebrospinal fluid opening pressure and outflow resistance in patients with cerebral venous sinus thrombosis. 2. To analyse the correlation between Intra Cerebral Pressure and the site of venous sinus thrombosis. 3. To analyse the correlation between clinical symptoms and outcome with the site of sinus thrombosis. MATERIALS AND METHODS: The study was done at Institute of Neurology, Government General Hospital and Madras Medical College, Chennai during the period of September 2010 to January 2013. Patients admitted in the hospital with the clinical suspicion of cerebral venous sinus thrombosis were included in the study after confirming the diagnosis by MRI with MRV. Detailed clinical history and examination were recorded. Among this group those patients with general contraindications for lumbar puncture procedure such as bleeding disorders, thrombocytopenia(platelet count < 100,000), unequal supratentorial pressure, skin infection at puncture site etc. were excluded. All those included in the study were subjected to lumbar puncture and CSF flow dynamics study by modified bolus injection method, the MIN method using bedside saline manometer. RESULTS: Our study is a cross sectional study including 30 patients diagnosed as CVST confirmed with MRI/MRV, for whom we have measured the CSF flow dynamics. The mean age of the study group is 31 yrs. Among the total 30 cases, 16 were male and 14 were female. 86.7% did complain of headache and 60% had papilledema. 56.7% of the study group had SSS thrombosis, transverse sinus thrombosis in 56.7%, 30% had sigmoid sinus thrombosis and 10% had straight sinus thrombosis. Of the total 53.3% had persistent headache even after treatment. Among those who complained of persistent headache, 75% had SSS thrombosis (P=0.035). The mean Rout is 41.83 mm Hg/ml/min and higher range of Rout was present in patients with SSS thrombosis (P=0.001). The mean Rout in those with persistent headache was in a higher range (49.81mm Hg/ml/min) with P=0.027. 72.2% with SSS thrombosis had papilledema ( P=0.035). CONCLUSION: 1. The cerebrospinal fluid opening pressure Po and the outflow resistance Rout were in a higher range in patients with cerebral venous sinus thrombosis. 2. The opening pressure Po and outflow resistance Rout were higher in patients with superior sagittal sinus thrombosis when compared to other sites of sinus involvement. 3. The patients with superior sagittal sinus thrombosis had the higher incidence of headache ,papilledema and also did complain of persistent headache even after medical treatment. 4. The increase in Rout suggests that the raised ICP due to reduced compliance will take longer time to normalise inspite of recanalisation secondary to anticoagulant therapy. 5. In view of persistent headache, these patients will require long term medical treatment for raised ICP. 6. For unexplained reasons, these group of patients do not develop hydrocephalus inspite of raised ICP

Type of antihypertensive medications in CKD-stage V patients on hemodialysis and its relationship with demographic variables: an observational study

Background: The majority of the patients with chronic kidney disease stage V on hemodialysis have been found to have hypertension and many studies have recommended that hypertension should be essentially controlled in these patients for better clinical outcome. But till now no study analyzing the relationship between antihypertensive medication and the demographics of the patient has been done, so with this objective in mind the present study was carried out. Aim and objectives were to analyse the types of antihypertensive being used in CKD stage V patients on hemodialysis and their relationship with the demographic variables.Methods: The present observational cross-sectional study was conducted in Sri Aurobindo Institute of Medical Sciences, Indore (M.P.) from 01 January 2018 to 31 March 2018 on patients with chronic kidney disease stage V on hemodialysis. The demographic variables evaluated were age, sex, basic disease and duration of dialysis. The relationship with type of antihypertensive being used and these demographic variables was calculated using Pearson Chi-square test. A p value of<0.05 was taken as statistically significant.Results: Diabetic nephropathy, CIN-CKD 5d, CGN-CKD 5d and hypertensive nephropathy were the commonest basic diseases in our study. Calcium channel blockers, beta blockers, ATRB, centrally acting antihypertensive, ACE inhibitors were the commonest antihypertensive used. Statistically significant relationship was seen between antihypertensive and basic disease (p<0.05).Conclusions: The study revealed that all the antihypertensive medications are prescribed on the basis of basic disease while other demographic variables do not play a vital role prescribing antihypertensive in patients with CKD stage V on haemodialysis. And the prescription of antihypertensive medications also matches with the actual clinical practice

A supply chain collaboration solution using XQuery

Enterprises in a collaborative supply chain share information for quick and intelligent decision making. Collaborative Planning, Forecasting and Replenishment (CPFR), a business model developed by an organization called Voluntary Inter-industry Commerce Standards, defines a set of business processes to collaborate on planning, forecasting and replenishment activities to arrive at a common order. This involves sharing sales forecast, order forecast and promotion information among business partners. The Internet has paved the way for using Web Services to share this information as XML data in real time and to make it available across enterprises. Enterprises need to access this information and integrate it with the information available in their databases, Excel sheets and XML applications. This thesis discusses the development of an information architecture using XQuery (a declarative query language by W3C) for aggregating data from disparate data, and evaluates XQuery as a tool to enable information integration for supply chain collaboration. For this purpose, several CPFR scenarios are identified where two retailers share their sales forecast, order forecast and promotion forecast information with the manufacturer. A prototype application is developed which can fetch data from disparate data sources such as Web Service, XML databases and CSV files, aggregate it, and use it to identify exceptions in forecasts and calculate the key performance indicators (KPI). These KPIs are then presented as an executive dashboard using Visual FoxPro. This Dashboard presents information graphically and enables executives to track the performance of the supply chain, and hence enables them to make quick and intelligent decisions

Personality in Alam and Katralai Novel

Alaam and Katralai are two novels written by S. Tamilchelvi.&nbsp; A person's personality is formed by the influence of experiences, environment, education, society, culture, etc. which can be acquired from the birth till death. So personality itself is subject to change. Sundarampal and Manimegala are the heroines of the novels. After heroine’s husband leaves, they becomes the one who carries the burden of the family and brings up the girl children in a good manner. The purpose of this article is to examine the nature and behavioral characteristics of these heroine's in a detailed way

Brain-Derived Neurotrophic Factor as a Biomarker for Aging and Dementia

The number of people with dementia due to Alzheimer’s disease (AD) is increasing worldwide. Although AD pathology begins well before clinical symptoms are apparent, identifying individuals at risk of developing AD to provide early interventions is still a challenge. Brain-derived neurotrophic factor (BDNF) is produced by neurons and glial cells and has complex interactions with AD pathology. BDNF also crosses the blood-brain barrier and can be measured in serum or plasma. In this dissertation, I investigated the biomarker potential of serum BDNF for AD using post mortem human samples, an aged rat model of cognitive impairment, and blood samples from cognitively healthy older adults. In the first part of my dissertation, I investigated the relationship between CSF, serum, and brain tissue levels of BDNF and AD-related pathology using post mortem human brain tissue samples. In these studies, I demonstrated, for the first time, that serum proBDNF levels reflect brain BDNF levels and that low brain BDNF levels are associated with increased accumulation of pTau and amyloid in the hippocampus. In the next part of my dissertation, I investigated whether serum BDNF levels were altered in an aged rat model exposed to a combination of the locus coeruleus selective neurotoxin and inflammation caused by lipopolysaccharides (LPS). I found that serum BDNF levels have an inverse relationship with inflammatory markers, and BDNF levels increase at two weeks post LPS injection, suggesting a compensatory increase. Finally, in the last part of my dissertation, I investigated whether serum BDNF levels can predict early changes in neuropsychological performance and neuroimaging measures associated with AD in cognitively healthy older adults. In this cohort of older adults, we found significant differences between women and men. Women had higher serum BDNF levels than men, the changes of neuropsychological performance over time were different in women and men, and higher baseline BDNF levels were associated with greater declines in hippocampal volume and limbic FA in men but not in women. Overall, results from this dissertation indicate that serum BDNF levels correlate with brain BDNF levels, are reduced by neurodegeneration and inflammation, and may reflect clinically-relevant changes in older adults and, therefore, should be considered for inclusion in routine blood workup in a clinical setting

Prescription of antihypertensive agents in the treatment of hypertension in diabetic nephropathy patients on hemodialysis

Background: All the patients with diabetic nephropathy have inherent hypertension and uncontrolled hypertension leads to deterioration in the kidney disease speedily. Aims and objectives were to analyze the prescription of antihypertensive agents in the treatment of hypertension in diabetic nephropathy patients on hemodialysis.Methods: The study was conducted on diabetic nephropathy patients on maintenance hemodialysis, in Sri Aurobindo Institute of Medical Sciences, Indore (M.P.). We had included 73 diabetic nephropathy patients on maintenance hemodialysis, who provided their consent for participation in the study. Pearson coefficient of correlation was used for finding the correlation. Unpaired ‘t’ test was applied for intergroup mean comparison. A p value of0.05). An inverse and statistically not significant correlation was seen between duration of dialysis; age and use of multiple antihypertensive medications (p>0.05).Conclusions: A strong association has been reported by many between hypertension and diabetic nephropathy. It is imperative that hypertension is well controlled in all the patients of diabetic nephropathy. This will slow down the progression of kidney disease and improve the quality of life in patients with diabetic nephropathy

Coronary Vasospasm after Giving Adenosine for Supraventricular Tachycardia

Palpitations due to supra-ventricular tachycardia are a common mode of presentation to the emergency department. A 12 lead electrocardiography usually leads to immediate diagnosis and prompt management of this condition. Adenosine injection is the treatment of choice for rapid termination of supra-ventricular tachycardia which is widely used. It is generally considered safe and serious side effects are rare. We presented a rare case of a post-menopausal female admitted with supra-ventricular tachycardia and after injection of Adenosine, chest pain with a transient elevation of ST segment occurred. The ST segment changes reverted back to normal after a few minutes spontaneously without any therapy. This phenomenon could be explained due to coronary vasospasm produced by Adenosine. A review of literature revealed anecdotal cases of adenosine induced possible coronary vasospasm

ANTIBACTERIAL AND SYNERGISTIC ACTIVITY OF TERMINALIA CHEBULA AND TERMINALIA BELLERICA FRUIT EXTRACTS AGAINST ESBL PRODUCERS

Objective: Bacterial infections and the resistance related to indiscriminate antibiotic use have led to an alarming situation in the clinics. The rapid spread of Extended Spectrum Beta Lactamases (ESBLs) and carbapenemase producing Gram negative bacteria has initiated the need for development of a new drug or an alternative choice by using the combination of drugs with medicinal plant extracts. This study was aimed at examining the antibacterial potential and synergistic activity of ethanolic extracts of Terminalia chebula and Terminalia bellerica fruits against clinically important reference bacterial strains.Methods: The crude ethanolic extracts of T. chebula and T. bellerica fruits were prepared and reconstituted with 5% dimethylsulfoxide (DMSO). The fruit extracts (~25 mg/well) were added into the wells in the plates inoculated with various ESBL and AmpC producers and they were incubated at 37 °C for 24 h. The antibiotics ceftazidime (30 µg) and cefotaxime (30 µg) were added to the wells alone and in combination with the fruit extracts to determine their own antibacterial and synergistic activity respectively.Results: The ethanolic fruit extracts combination improved the activity of ceftazidime and cefotaxime against the tested ESBL and AmpC producers. Though both the extracts showed activity, T. chebula was found to show better synergistic antibacterial activity.Conclusion: The synergistic activity of these fruit extracts with ceftazidime and cefotaxime against the ESBL and AmpC producers shows the efficiency of the combination therapy, which can be considered in therapeutic point of view to prevent the misuse of antibiotics and minimise the increasing resistance in bacteria

Cultural Records on Shiva Parvati’s Marriage through Kandhapuranam

Culture is a reflection of society’s history. Culture cannot be narrowed down to specific boundaries. The literature of the people is very helpful to know the culture of the people. Thus, the Kandhapuranam composed by KachiyappaSivachariyar is a storehouse of Culture. Kachiyappar has told not only mythological stories but also the culture of the Tamils of his time. Kachiyappar describes the marriage of Shiva and Parvathi in great detail. KachiyappaSivachariyar explains the marriage rituals of the Andhanars in the marriage of Shiva and Parvathi. Based on his notes, this article examines the marriage ceremony of the Andhanars of medieval time