SACUBITRIL/VALSARTAN: A NEW PARADIGM IN HEART FAILURE

ABSTRACTHeart failure (HF) is a syndrome whose cardinal symptoms are dyspnea and fatigue leading to a progressive decrease in exercise capacity. Drugscurrently used include angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers (ARB), diuretics, alone or in combination, and inthe cases where indicated, digoxin. Sacubitril/valsartan represents a new approach to treatment since the drug complex is made up of moietiesof sacubitril, a neprilysin inhibitor and valsartan, an ARB. Since sacubitril and valsartan, inhibit neprilysin and block the angiotensin receptor,respectively, the drug molecule can be considered to play a central role by causing a dual inhibition of both the pathways that play an importantrole in the pathogenesis of HF. It was approved in July 2015 by the US Food and Drug Administration to reduce the risk of cardiovascular death andhospitalization for HF in patients with chronic HF (NYHA Class II-IV) and reduced ejection fraction. Symptomatic hypotension and angioedema werethe major side effects reported from clinical trials. The trials are currently being done to study its effects in HF preserved ejection fraction, chronickidney disease, and aortic stiffness; the results of which are awaited.Keywords: Sacubitril/valsartan, Neprilysin inhibitor, Dual neutral endopeptidaseneprilysin renin-angiotensin system Inhibition

DOES HYPERCHOLESTOLEMIA PREDISPOSE TO ROTATOR CUFF PATHOLOGIES?

Background:  Rotator cuff tear are one of most common orthopedic musculoskeletal problem gaining importance due to large health scale expenditure. Causes of rotator cuff tears are multifactorial and unclear.  Previous studies have suggested relation between elevated serum lipid profile and rotator cuff tear in western population. We therefore undertook study in our Indian population to correlate association of hypercholesterolemia with rotator cuff tear.Objective: To find association of rotator cuff pathology with hypercholesterolemia in Indian patients.Materials and methods: After obtaining clearance from institutional ethics committee. We prospectively collected fasting lipid samples of population who came to our hospitals with complaints of shoulder pain during our study period. 50 patients had rupture of rotator cuff which was confirmed by ultrasound of involved shoulder. 50 were seen for non-cuff related complaints.  We followed strict inclusion and exclusion criteria.Results: Total cholesterol, Triglycerides and low density lipoprotein concentration of patients with rotator cuff tendon tear were on higher side than control group. High density lipoprotein trend showed being lower than control group.  21 of 50 (42%) had high cholesterol (total cholesterol greater than 240mg/dl) than compared to 18 of 50 (36%) in control group. however P value=0.539 and showed no statistical significance between groups.Conclusion: In Indian population there was no correlation between hypercholesterolemia and rotator cuff tear which is statistically significant.Key words Rotator cuff tear, Hypercholesterolemia, Indian population.  Â

Case report of aplastic anaemia detected in third trimester of pregnancy: dilemmas faced

Aplastic anaemia with pregnancy is rarely encountered. Management of aplastic anaemia in pregnancy primarily involves a multidisciplinary approach offering supportive care. Our case was challenging as she developed aplastic anaemia during the third trimester and had refractory thrombocytopenia. She required platelet transfusions on a daily basis for few weeks as well as packed red blood cells frequently. Her leucocyte count was low initially but improved quickly unlike the platelet counts. Initiation of immunosuppressive therapy turned out to be beneficial and culminated in a good outcome. After starting immunosuppressive therapy with eltrombopag and cyclosporine she drifted through term and achieved a normal vaginal delivery

Effect of Oral and Maxillofacial Injuries on the Development of Post-Traumatic Stress Disorder: A Cross-Sectional Study

Objective: To assess the influence of oral and maxillofacial trauma on the development of Post-Traumatic Stress Disorder (PTSD) and to determine the efficiency of the Impact of Event Scale-Revised (IES-R) as a diagnostic tool for detecting PTSD in patients with Oral and Maxillofacial injuries. Material and Methods: PTSD was assessed one month postoperatively by the diagnostic instrument, IES-R, to arrive at a provisional diagnosis. A structured clinician-administered PTSD Scale then assessed the patients for the Diagnostic and Statistical Manual of Mental Disorders-5th edition (CAPS-5) to establish a final diagnosis. The assessment of the severity of PTSD was done based on various types of oral and maxillofacial injuries. Results: The IES-R scale provisionally diagnosed 54 subjects with PTSD, out of which 42 were diagnosed to have PTSD by the CAPS-5 scale. Subjects with injuries involving the ‘orbital complex,’ those presenting with a perceptible scar in the maxillofacial region and with multiple avulsed/ luxated anterior teeth, showed a higher affinity to develop PTSD, and this was statistically significant. Conclusion: Higher levels of PTSD in patients with injuries to the maxillofacial region warrants correct diagnosis and detection, and hence the maxillofacial surgeon plays a vital role in this regard. The IES-R is a useful diagnostic tool to detect PTSD early

An isolated palmar scaphoid dislocation with undisplaced fracture: A case report and review of literature

Isolated carpal scaphoid dislocation is an extremely uncommon injury. Various methods have been used to treat the scaphoiddislocations, which involves open reduction and K-wire fixation with or without ligament repair or just closed reduction andcast application. The rarity of this injury has led to the proposal of vague and sometimes conflicting treatment strategies. In thisarticle, we report a case of isolated palmar dislocation of scaphoid with an undisplaced fracture. Even though isolated dislocationsof scaphoid have been reported before, this particular injury pattern of isolated dislocation with a fracture through the waist ofscaphoid has not been reported before to the best of our knowledge. This case was managed by closed reduction, percutaneousHerbert screw fixation, and cast immobilization for 6 weeks, which produced a satisfactory short-term outcome

RECURRENT TEMPOROMANDIBULAR JOINT DISLOCATIONS IN GERIATRIC PATIENT ON ANTIPSYCHOTIC DRUGS AND ITS CONSERVATIVE MANAGEMENT

  Recurrent temporomandibular joint (TMJ) dislocation can cause difficulty in swallowing and speech hence can be distressing for the patient. A 79-year-old male patient reported with recurrent dislocation of TMJ since 2 months. He was on antipsychotic medication for schizophrenia which predisposes to recurrent TMJ dislocation due to oromandibular dystonia. Since the patient had undergone tracheostomy, his systemic condition was not suitable for surgical management. Thus a conservative option of chin cup was planned. The chin cup limits the movement of the mandible hence prevents dislaocation of the TMJ. The patient was successfully rehabilitated with no new episodes of TMJ dislocation for the last 4 months. It focuses on conservative management of recurrent TMJ dislocations induced by antipsychotic drugs

The Role of Positive Affect in Asthma Control and Symptom Severity in Adolescents

Introduction We test the effects of positive affect and its arousal subscale components of calm, wellbeing, and vigor on asthma control and symptom severity in adolescents with moderate to severe asthma. Additionally, we test whether positive affect (and its arousal components) moderate how stress impacts asthma control and symptom severity. Methods Adolescents with asthma (N = 66, ages 12–17) completed brief surveys 4 times a day for 7 days reporting on their positive affect, stress, and asthma symptom severity and conducted a morning peak expiratory flow assessment each day. Asthma control and psychological asthma triggers were assessed at the end of the 7 days. Results Positive affect moderated the association between stress and asthma control (b = −0.33, p = 0.009) as well as the association between psychological triggers and asthma control (b = −0.74, p = 0.007). When assessing the positive affect arousal components, calm and wellbeing seemed to be driving these effects. Additionally, calm moderated the association between stress and asthma symptom severity (b = −0.33, p = 0.036) as well as the association between psychological triggers and asthma symptom severity (b = −0.75, p = 0.021). Conclusions When considering patient stress (e.g., general stress, psychological asthma triggers), positive affect and its arousal components of calm and wellbeing may be helpful for patients with higher levels of stress and/or for patients experiencing greater numbers of psychological triggers

ADARRI:a novel method to detect spurious R-peaks in the electrocardiogram for heart rate variability analysis in the intensive care unit

We developed a simple and fully automated method for detecting artifacts in the R-R interval (RRI) time series of the ECG that is tailored to the intensive care unit (ICU) setting. From ECG recordings of 50 adult ICU-subjects we selected 60 epochs with valid R-peak detections and 60 epochs containing artifacts leading to missed or false positive R-peak detections. Next, we calculated the absolute value of the difference between two adjacent RRIs (adRRI), and obtained the empirical probability distributions of adRRI values for valid R-peaks and artifacts. From these, we calculated an optimal threshold for separating adRRI values arising from artifact versus non-artefactual data. We compared the performance of our method with the methods of Berntson and Clifford on the same data. We identified 257,458 R-peak detections, of which 235,644 (91.5%) were true detections and 21,814 (8.5%) arose from artifacts. Our method showed superior performance for detecting artifacts with sensitivity 100%, specificity 99%, precision 99%, positive likelihood ratio of 100 and negative likelihood ratio <0.001 compared to Berntson’s and Clifford’s method with a sensitivity, specificity, precision and positive and negative likelihood ratio of 99%, 78%, 82%, 4.5, 0.013 for Berntson’s method and 55%, 98%, 96%, 27.5, 0.460 for Clifford’s method, respectively. A novel algorithm using a patient-independent threshold derived from the distribution of adRRI values in ICU ECG data identifies artifacts accurately, and outperforms two other methods in common use. Furthermore, the threshold was calculated based on real data from critically ill patients and the algorithm is easy to implement

Global, regional, and national burden of disorders affecting the nervous system, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND: Disorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021. METHODS: We estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined. FINDINGS: Globally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378–521), affecting 3·40 billion (3·20–3·62) individuals (43·1%, 40·5–45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7–26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6–38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5–32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7–2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer. INTERPRETATION: As the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed