Carcinogenic herbs: a review

Herbal toxicity is a field that has rapidly grown over the last few years along with increased use of herbal products worldwide. People prefer using herbal medicines rather than allopathic because herbals are considered safe. Use of herbal medicines from ancient times does not ensure their complete safety. With the growing awareness regarding pharmacovigilance worldwide, there has been an increase in the number of reported adverse events occurring with the use of herbal products. The objective of the study is to aware the researchers about most commonly used Indian medicinal herbs inducing carcinogenicity like Aloe vera, Ginkgo biloba, Kava kava, etc.

ADVERSE DRUG REACTIONS OF ANTI-EPILEPTIC DRUGS IN PEDIATRIC AGE GROUP IN A TERTIARY CARE TEACHING HOSPITAL; A CROSS-SECTIONAL STUDY

Objectives: In this cross-sectional study, the aims were to analyze the incidence and pattern of adverse drug reactions (ADRs) of antiepileptic drugs in pediatric patient. Most common adverse effect and most common drug causing adverse effect were evaluated. Methods: Study was conducted over 60 Patients for 6 months in out-patient basis pediatric department in Rajindra Hospital associated with GMC, Patiala, a tertiary care teaching hospital in Punjab. The patient diagnosed by the Pediatrician with epilepsy who fulfilling inclusion and exclusion criteria was enrolled after taking informed consent. ADRs were noted using Pediatric Epilepsy Side Effect Questionnaire at clinic visit and any other adverse effects reported by patients. Results: In this study, a total of 60 children were enrolled. The mean age was 10.26±3.70, median were 11.00. 41 (68.33%) patients were boys and 19 (31.67%) were girls. In Cognitive ADRs with anti-epileptic drugs, there were total 17 ADRs reported. Valproate was causing most cognitive ADRs (32.43%). Among all cognitive ADRs, attention difficulty was the commonest complains. There were no motor and behavioral ADRs reported. Total 27 general neurological ADRs reported, which was highest reported ADRs. Among general neurological, Clobazam was causing highest ADRs (55.56%). 10 patients also reported tremor as another ADR and Clobazam causing most (22.22%). Conclusion: In the present study, boys were developing more epilepsy than girls. Valproate was causing most ADRs. Among all cognitive ADRs, attention difficulty was the most common ADR. General neurological ADRs were highest reported ADRs

Amiodarone Toxicity: A Case Report

Amiodarone is one of the commonly used drug in arrhythmias. It is first line of treatment for ventricular tachycardia particularly in treatment of supraventicular tachycardia like atrial fibrillation. Amiodarone has a wide range of adverse effects ranging from endocrine to cardiac system. A case of raised thyroid stimulating Hormone (TSH)  with amiodarone was reported in our Adverse drug  monitoring centre (AMC), in which several other adverse events such as raised raised billirubin and hyponatremia were present. Patient was treated with thyroxine while amiodarone along with atorvastatin and metoprolol were withdrawn. We present a case who developed subclinical hypothyroidism, electrolyte imbalance and liver dysfunction with amiodarone therapy

Analysis of cost of medical therapy in patients of metabolic syndrome: an observational study

Background: The objective of the study was to analyze cost of medical therapy in patients of Metabolic syndrome.Methods: This was an observational study. The study was conducted by enrolling patients of the outpatient department of Medicine of Rajindra Hospital, Government Medical College, Patiala, Punjab. A total of 100 patients diagnosed with Metabolic syndrome were enrolled in the study. The total daily cost of the therapy was calculated by adding the direct cost of individual drugs taking in consideration the frequency of the drug. The daily cost of therapy was then extrapolated to calculate the monthly as well as annual cost of therapy.Results: The mean age of patients was 58.27±10.32 years. Out of a total of 100 patients, there were 57 female and 43 male patients, indicating a female preponderance of the disease. The average individual daily cost of medical therapy is INR 44.56 which upon extrapolation gives monthly and annual cost of INR 1336.90 and INR 16264.40 respectively. The cost of treatment in males is costlier than females (INR 50.09 in males versus INR 40.22 in females). The cost of treatment of age 31-40 years is INR 27.90 while it INR 36.97, 48.16 and 50.75 for age groups 41-50, 51-60 and 61-70 years. The various components of metabolic syndrome viz. diabetes mellitus, hypertension and dyslipidemia contribute differently to the cost of therapy. Daily cost of medical therapy for diabetes mellitus is INR 18.57 while for hypertension and dyslipidemia are INR 10.25 and INR 6.13 respectively.Conclusions: Chronic diseases like metabolic syndrome have a huge share of the healthcare budget. Given the fact that it is a lifestyle disease, its prevalence is likely to swell in the coming decades. Hence, formulation of preventive and innovative treatment guidelines is of utmost importance

Communicable behavior of non-communicable diseases

Communicability of non- communicable diseases can be explained using the prototype of non- communicable diseases. The concept can be further extended to other non- communicable diseases. Diabetes mellitus (DM) is regarded as the prototype of non-communicable diseases. Its subtype, type 2 DM is usually associated with obesity. Obesity, in turn, can be attributed to deranged eating habits and lack of physical activity. Eating habits of a person bears a close resemblance to the parental eating habits. Other factors contributing to obesity like alcoholism can also be transmitted from parents to child. Smoking, another factor implicated in DM, can be picked as a habit from peer group as well as family. All these factors implicated directly or indirectly in the pathogenesis of DM are actually components of lifestyle. These lifestyle components can be transmitted both in an inter-generation and intra-generation fashion. And so the chances of transmission of DM (a lifestyle disease) in the same fashion cannot be ruled out

A study to evaluate compliance in patients of diabetes mellitus in a North-Indian tertiary care hospital

Background: The objective of the study was to determine level of adherence and recognize various causative factors which can affect the compliance in the diabetic patients.Methods: This was an observational study. The study was conducted by enrolling patients of the outpatient department of Medicine of Rajindra Hospital, Government Medical College, Patiala, Punjab. To assess adherence, a questionnaire was administered to the patients - Morisky Medication Adherence Scale (MMAS) -8 item questionnaire. The various factors affecting compliance was determined by a researcher made questionnaire.Results: Out of a total of 100 subjects, age range extended from 18 years to 80 years. The mean age was 57.52±12.33years. 51% of patients were females and 49% was males. Analysis of MMAS- 8 item scores of patients showed that 52% of patients had low adherence, 29% had medium while 19% had high adherence to the treatment. Only 30% patients were compliant i.e. with HbA1C value of 7 or less while 70% patients were non-compliant i.e. with HbA1C value of more than 7.Conclusions: Compliance to medical treatment is influenced by a myriad of factors. In order to promote compliance, it is necessary to increase awareness about the disease, possible complications and treatment guidelines among patients as well as their family members.

Impact on quality-of-life: before and after topical combinational treatment in patients of acne vulgaris

Background: The objective was to study quality-of-life in patients of acne vulgaris before and after treatment by benzoyl peroxide 2.5% gel and clindamycin 1% gel or benzoyl peroxide 2.5% gel and nadifloxacin 1% cream or tretinoin 0.025% and clindamycin 1% gel.Methods: This was a prospective, open, randomized, parallel comparative study of 60 patients of acne vulgaris attending the Department of Dermatology and Venereal Diseases, Government Medical College, Rajindra Hospital, Patiala. Three groups were made 20 in each group, one group received benzoyl peroxide 2.5% gel and clindamycin 1% gel, the second group received benzoyl peroxide 2.5% gel, and nadifloxacin 1% cream and the third group received tretinoin 0.025% and clindamycin 1% gel. Cardiff acne disability index questionnaire was filled before starting and after the treatment.Results: In these three groups, it was found that the group on benzoyl peroxide 2.5% gel and clindamycin 1% gel, mean score, before starting treatment was 8.35±3.48 and after treatment was 2.95±2.09 (p<0.001), group on benzoyl peroxide 2.5% gel and nadifloxacin 1% cream, mean score, before starting treatment was 7.60±3.75 and after treatment was 5.80±2.98 (p<0.001) and group on tretinoin 0.025% and clindamycin 1% gel mean score is 8.00±3.06 and after treatment was 5.40±2.93 (p<0.001).Conclusion: Quality-of-life improves more in patients taking benzoyl peroxide 2.5% gel and clindamycin 1% gel, and then, tretinoin 0.025% and clindamycin 1% gel and then benzoyl peroxide 2.5% gel and nadifloxacin 1% cream

Comprehensive, Evidence-Based, Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain from the American Society of Interventional Pain Physicians (ASIPP).

BACKGROUND: Opioid prescribing in the United States is decreasing, however, the opioid epidemic is continuing at an uncontrollable rate. Available data show a significant number of opioid deaths, primarily associated with illicit fentanyl use. It is interesting to also note that the data show no clear correlation between opioid prescribing (either number of prescriptions or morphine milligram equivalent [MME] per capita), opioid hospitalizations, and deaths. Furthermore, the data suggest that the 2016 guidelines from the Centers for Disease Control and Prevention (CDC) have resulted in notable problems including increased hospitalizations and mental health disorders due to the lack of appropriate opioid prescribing as well as inaptly rapid tapering or weaning processes. Consequently, when examined in light of other policies and complications caused by COVID-19, a fourth wave of the opioid epidemic has been emerging. OBJECTIVES: In light of this, we herein seek to provide guidance for the prescription of opioids for the management of chronic non-cancer pain. These clinical practice guidelines are based upon a systematic review of both clinical and epidemiological evidence and have been developed by a panel of multidisciplinary experts assessing the quality of the evidence and the strength of recommendations and offer a clear explanation of logical relationships between various care options and health outcomes. METHODS: The methods utilized included the development of objectives and key questions for the various facets of opioid prescribing practice. Also utilized were employment of trustworthy standards, and appropriate disclosures of conflicts of interest(s). The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed. The recommendations were developed after the appropriate review of text and questions by a panel of multidisciplinary subject matter experts, who tabulated comments, incorporated changes, and developed focal responses to questions posed. The multidisciplinary panel finalized 20 guideline recommendations for prescription of opioids for chronic non-cancer pain. Summary of the results showed over 90% agreement for the final 20 recommendations with strong consensus. The consensus guidelines included 4 sections specific to opioid therapy with 1) ten recommendations particular to initial steps of opioid therapy; 2) five recommendations for assessment of effectiveness of opioid therapy; 3) three recommendations regarding monitoring adherence and side effects; and 4) two general, final phase recommendations. LIMITATIONS: There is a continued paucity of literature of long-term opioid therapy addressing chronic non-cancer pain. Further, significant biases exist in the preparation of guidelines, which has led to highly variable rules and regulations across various states. CONCLUSION: These guidelines were developed based upon a comprehensive review of the literature, consensus among expert panelists, and in alignment with patient preferences, and shared decision-making so as to improve the long-term pain relief and function in patients with chronic non-cancer pain. Consequently, it was concluded - and herein recommended - that chronic opioid therapy should be provided in low doses with appropriate adherence monitoring and understanding of adverse events only to those patients with a proven medical necessity, and who exhibit stable improvement in both pain relief and activities of daily function, either independently or in conjunction with other modalities of treatments

Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines.

BACKGROUND: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives.The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness.The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations

Shifting the limits in wheat research and breeding using a fully annotated reference genome

Introduction: Wheat (Triticum aestivum L.) is the most widely cultivated crop on Earth, contributing about a fifth of the total calories consumed by humans. Consequently, wheat yields and production affect the global economy, and failed harvests can lead to social unrest. Breeders continuously strive to develop improved varieties by fine-tuning genetically complex yield and end-use quality parameters while maintaining stable yields and adapting the crop to regionally specific biotic and abiotic stresses. Rationale: Breeding efforts are limited by insufficient knowledge and understanding of wheat biology and the molecular basis of central agronomic traits. To meet the demands of human population growth, there is an urgent need for wheat research and breeding to accelerate genetic gain as well as to increase and protect wheat yield and quality traits. In other plant and animal species, access to a fully annotated and ordered genome sequence, including regulatory sequences and genome-diversity information, has promoted the development of systematic and more time-efficient approaches for the selection and understanding of important traits. Wheat has lagged behind, primarily owing to the challenges of assembling a genome that is more than five times as large as the human genome, polyploid, and complex, containing more than 85% repetitive DNA. To provide a foundation for improvement through molecular breeding, in 2005, the International Wheat Genome Sequencing Consortium set out to deliver a high-quality annotated reference genome sequence of bread wheat. Results: An annotated reference sequence representing the hexaploid bread wheat genome in the form of 21 chromosome-like sequence assemblies has now been delivered, giving access to 107,891 high-confidence genes, including their genomic context of regulatory sequences. This assembly enabled the discovery of tissue- and developmental stage–related gene coexpression networks using a transcriptome atlas representing all stages of wheat development. The dynamics of change in complex gene families involved in environmental adaptation and end-use quality were revealed at subgenome resolution and contextualized to known agronomic single-gene or quantitative trait loci. Aspects of the future value of the annotated assembly for molecular breeding and research were exemplarily illustrated by resolving the genetic basis of a quantitative trait locus conferring resistance to abiotic stress and insect damage as well as by serving as the basis for genome editing of the flowering-time trait. Conclusion: This annotated reference sequence of wheat is a resource that can now drive disruptive innovation in wheat improvement, as this community resource establishes the foundation for accelerating wheat research and application through improved understanding of wheat biology and genomics-assisted breeding. Importantly, the bioinformatics capacity developed for model-organism genomes will facilitate a better understanding of the wheat genome as a result of the high-quality chromosome-based genome assembly. By necessity, breeders work with the genome at the whole chromosome level, as each new cross involves the modification of genome-wide gene networks that control the expression of complex traits such as yield. With the annotated and ordered reference genome sequence in place, researchers and breeders can now easily access sequence-level information to precisely define the necessary changes in the genomes for breeding programs. This will be realized through the implementation of new DNA marker platforms and targeted breeding technologies, including genome editing