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

Prevalence of migraine in patients of allergic rhinitis

Background: Migraine and allergic rhinitis are common disorders. Studies have shown increased frequency of migraine headaches in patients with allergic rhinitis. The aim of this study is to identify how age, sex and degree of allergic sensitization influences the occurrence, severity and treatment outcome of migraine headaches in patients with allergic rhinitis.Methods: The study was conducted between 2014 and 2018 in a tertiary care hospital. 150 patients diagnosed with allergic rhinitis clinically were selected and total serum IgE levels were estimated. These patients were subjected to a detailed history taking to determine the characteristics of headache. All classifiable headache diagnoses had met criteria of the International Classification of Headache Disorders-II-2004. Severity of headache was assessed based on MIDAS score. The data was accessed based on age, sex, serum IgE levels, frequency and severity of migraine attacks and the treatment outcome using statistical methods.Results: The prevalence of migraine in this study was 68% among those who had allergic rhinitis. In this study out 150 patients 111 were females and 39 were males. Comparatively females’ patients 84 (75.7%) were found to be more prone for migraine. Majority patients were in the age group of 20 to 40 years (cumulative percentage of 67.3%). There was a negative correlation between age and IgE levels with r= -0.092. In comparison patients with higher levels of IgE (mean 3633) had more severe headaches. Patients with higher levels of IgE required a longer duration of treatment.Conclusions: This study shows that allergic rhinitis is a risk factor for development of migraine. Apart from high prevalence of migraine in patients with allergic rhinitis it is evident from the study that female sex, younger age group and high degree of allergic sensitization also play an important role as the severity of migraine and treatment course depend on these parameters. Hence the treatment for migraine in patients should aim at reducing the allergic sensitization in addition to concurrent treatment for migraine

Osteochondral Avulsion Fracture of the Femoral Origin of the Anterior Cruciate Ligament in an 11-Year-Old Child

Although tibial end avulsions of the anterior cruciate ligament are relatively common in clinical practice, avulsions of the femoral end of this ligament are by comparison rare. We present the case of an 11-year-old boy with a bony avulsion injury, which was presumed to have arisen from the tibial insertion of the anterior cruciate ligament but turned out instead to be an osteochondral avulsion fracture of the femoral origin. This unexpected finding that was not detected during preoperative workup resulted in the first attempt at surgical fixation being aborted. The need for a second planned definitive fixation procedure emphasises the importance of combining a thorough history and examination in association with appropriate imaging in the patient workup. The patient's definitive operative treatment and outcome are described. Although rare, surgeons (and emergency room doctors) treating such patients should include femoral end avulsion injuries of the anterior cruciate ligament in the differential diagnosis of a child presenting with an acute haemarthrosis of the knee. Furthermore, once diagnosed, early onward referral to an experienced knee surgeon is advocated

Efficacy, safety and cost effectiveness of levocetrizine and ebastine in allergic rhinitis: a comparative study

Background: Allergic rhinitis is a ubiquitous aliment affecting a large population of individuals. The mainstay of treatment includes antihistamines and topical steroids. With a large assortment available, the choice of the drugs needs to be non-random and evidenced based. Hence this study was undertaken to compare Levocetrezine and Ebastine in terms of efficacy, safety and cost effectiveness in treatment of allergic rhinitis.Methods: Newly diagnosed patients with allergic rhinitis were categorized into two groups and treated with Levocetrizine 5mg and Ebastine 20mg per day respectively. Severity of the symptoms at the commencement and at the end of second and the fourth weeks of therapy were assessed using a four-point Likert scale and assigning a Total Nasal Symptoms Score (TNSS). The primary efficacy measure was mean change from baseline TNSS at each follow up visit. Change in TNSS was compared using Independent sample test. Adverse effects in both the groups were compared using Chi square test. Cost effectiveness was inferred by calculation of the Average Cost Effectiveness Ratio.Results: A total of 159 patients 84 from Levocetrizine group (L group) and 75 from the Ebastine group (E group) were available for study. At the end of second week, the E group showed a better reduction in TNSS(p-0.04). However, both the groups showed similar reduction in TNSS at the concluding visit (p-value of 0.09). The incidence of adverse effects was significantly higher in the L than in E. Levocetrezine was found to be more cost effective than Ebastine.Conclusions: Levocterezine and Ebastine are equally efficacious in treatment of allergic rhinitis. Hence treatment will have to be personalized to the individual patients based on other factors such as adverse drug effects and cost effectiveness

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

Emergence of Severe Acute Respiratory Syndrome (SARS) COVID-19 and approach of AYUSH systems of medicine towards its prevention and management

SARS-CoV-2/novel coronavirus is a fresh virus strain that was first detected in the city of Wuhan located at Hubei province of China in December, 2019. Within a couple of months the virus has spread rapidly to different geographical regions through human transmission leading to serious disease burden worldwide. Although research is under progress to develop effective vaccine and drugs for the disease, a unified approach between conventional and traditional medicine system may prove to be beneficial in early prevention and management of the disease. Joint efforts are being put up at global scientific community level to enhance the research on advancement of meticulous diagnostics, antiviral measures and finally leading to development of an effective vaccine against the novel coronavirus. Some basic and safe measures from AYUSH systems of medicine have also been advocated for prophylaxis and treatment of COVID-19 which can be used independently or with integrated approach. The rationale of this review paper is to provide the details regarding disease spectrum, modes of transmission, social & economic consequences, and role of AYUSH systems of medicine in prevention and management of COVID-19. Based on the signs and symptoms of COVID-19, list of herbs and drugs of AYUSH systems of medicine were also searched and are being reported here