Statins Ticagrelor and Rhabdomyolysis: A Coincidence or a Drug Interaction?

Objective: Statins play a key role in the management of atherosclerotic cardiovascular disease for both primary and secondary prevention. However, their increasing usage has correspondingly led to a higher incidence of adverse effects, with muscle symptoms being the most common. An intriguing drug interaction exists between ticagrelor and high-intensity statins, which may exacerbate the adverse effects of statin-induced rhabdomyolysis, leading to significant consequences. This study was conducted to examine the profile of patients who have experienced statin-induced rhabdomyolysis while undergoing percutaneous transluminal coronary angioplasty (PTCA). Methods: This was an observational study that included 1,862 patients who underwent PTCA at our institute over the course of 1 year. Results: Over a 1-year period, we encountered four patients who were being treated with high-intensity statin therapy following acute coronary syndrome. These patients presented with muscle weakness and kidney injury. A notable commonality among all patients was the co-prescription of ticagrelor. Two patients died, while the other 2 were successfully managed through hydration, electrolyte balance, dialysis, and alternative lipid management drugs. Conclusion: The concomitant use of ticagrelor and high-intensity statins should be carefully considered due to the additional risk of rhabdomyolysis and kidney injury. Future pharmacokinetic studies are needed to establish a causal relationship and predict potential drug interactions, which, if not avoided, could be fatal.

Molecular identification and genetic characterization of Theileria and Anaplasma infection in sheep and goat of North Gujarat, India.

Hemoprotozoal diseases are significant health concerns in small ruminants. The present study was conducted to identify and characterize the species of Theileria and Anaplasma in sheep and goats located in different districts of North Gujarat, India. A total of 226 (Banaskantha = 175, Patan = 26, and Bhuj = 25) blood samples were collected from sheep (n = 78) and goats (n = 148), and 46 ticks were collected and identified from sheep and goats. PCR assays were carried out using genus and species-specific primers for Theileria targeting 18S rRNA locus and for Anaplasma targeting the msp5 gene. Overall, 37.2% sheep (29/78) and 10.8% of goats (16/148) were positive for Theileria by PCR, whereas 15.4% of sheep (12/78) and 25.7% goats (38/148) were positive for Anaplasma infection. Moreover, mixed infection was found in 4.4% (10/226) of sheep and goats by PCR. Sanger sequencing of Theileria and Anaplasma positives revealed a high similarity to T. ovis and A. ovis using NCBI blast, respectively. Phylogenetic analyses revealed that the Anaplasma spp. DNA sequences belonged to the A. ovis group and closely associated with the A. ovis nucleotide sequence strain Haibei isolated in China from sheep (GQ483471). The phylogenetic analysis based on the SSU rRNA locus revealed that the Theileria ovis DNA sequences belonged to the T. ovis group and closely related to MW440586 isolated in Kerala, India, from a goat. The majority of ticks (91.3%) were identified as Hyalomma. In conclusion, Theileria ovis and Anaplasma ovis were commonly identified species in sheep and goats and transmitted mainly by Hyalomma ticks in North Gujarat, India, which is important baseline data for future research and control strategies. This is the first report on Theileria and Anaplasma co-infections in sheep and goats from North Gujarat, India.

Successful completion of Senning surgery in a patient with dextro-transposition of the great arteries (DTGA) with presentation in the fourth decade.

Transposition of great arteries (TGA) is a common congenital heart disease presenting in newborns. Nearly 90% of patients with TGA with intact interventricular septum die by one year of age if not treated. We present an interesting case of The Senning procedure , which was successfully performed on a 40-year-old lady.

Recombinant Human Granulocyte-Macrophage Colony-Stimulating Factor (rhu GM-CSF) as Adjuvant Therapy for Invasive Fungal Diseases.

Background: Sargramostim (yeast-derived, glycosylated recombinant human granulocyte-macrophage colony-stimulating factor [rhu GM-CSF]) augments innate and adaptive immune responses and accelerates hematopoietic recovery of chemotherapy-induced neutropenia. However, considerably less is known about its efficacy as adjunctive immunotherapy against invasive fungal diseases (IFDs). Methods: The clinical courses of 15 patients with pediatric malignancies and IFDs treated adjunctively with sargramostim at a single institution were analyzed in a retrospective cohort review. Further, a systematic review of published reports of rhu GM-CSF for IFDs was also conducted. Results: Among 65 cases, 15 were newly described pediatric patients and 50 were previously published cases of IFDs treated with rhu GM-CSF. Among the newly reported pediatric patients, IFDs were caused by Candida spp., Trichosporon sp., and molds (Aspergillus spp., Rhizopus sp., Lichtheimia sp., and Scedosporium sp). Twelve (80%) were neutropenic at baseline, and 12 (80%) were refractory to antifungal therapy. Among 12 evaluable patients, the overall response rate was 92% (8 [67%] complete responses, 3 [25%] partial responses, and 1 [8%] stable). Treatment is ongoing in the remaining 3 patients. Among 50 published cases (15 Candida spp., 13 Mucorales, 11 Aspergillus spp., 11 other organisms), 20 (40%) had baseline neutropenia and 36 (72%) were refractory to standard therapy before rhu GM-CSF administration. Consistent with responses in the newly reported patients, the overall response rate in the literature review was 82% (40 [80%] complete responses, 1 [2%] partial response, and 9 [18%] no response). Conclusions: Sargramostim may be a potential adjunctive immunomodulator for selected patients with hematological malignancies and refractory IFDs.

Reverse Myocardial Remodeling Following Valve Repair in Patients With Chronic Severe Primary Degenerative Mitral Regurgitation.

OBJECTIVES: The aims of this study were to quantify preoperative myocardial fibrosis using late gadolinium enhancement (LGE), extracellular volume fraction (ECV%), and indexed extracellular volume (iECV) on cardiac magnetic resonance; determine whether this varies following surgery; and examine the impact on postoperative outcomes. BACKGROUND: Myocardial fibrosis complicates chronic severe primary mitral regurgitation and is associated with left ventricular dilatation and dysfunction. It is not known if this nonischemic fibrosis is reversible following surgery or if it affects ventricular remodeling and patient outcomes. METHODS: A multicenter prospective study was conducted among 104 subjects with primary mitral regurgitation undergoing mitral valve repair. Cardiac magnetic resonance and cardiopulmonary exercise stress testing were performed preoperatively and ≥6 months after surgery. Symptoms were assessed using the Minnesota Living With Heart Failure Questionnaire. RESULTS: Mitral valve repair was performed for Class 2a indications in 65 patients and Class 1 indications in 39 patients. Ninety-three patients were followed up at 8.8 months (IQR: 7.4 months-10.6 months). Following surgery, there were significant reductions in both ECV% (from 27.4% to 26.6%; P = 0.027) and iECV (from 17.9 to 15.4 mL/m2; P < 0.001), but the incidence of LGE was unchanged. Neither preoperative ECV% nor LGE affected postoperative function, but iECV predicted left ventricular end-systolic volume index (ß = 1.04; 95% CI: 0.49 to 1.58; P < 0.001) and left ventricular ejection fraction (ß = -0.61; 95% CI: -1.05 to -0.18; P = 0.006). Patients with above-median iECV of ≥17.6 mL/m2 had significantly larger postoperative values of left ventricular end-systolic volume index (30.5 ± 12.7 mL/m2 vs 23.9 ± 8.0 mL/m2; P = 0.003), an association that remained significant in subcohort analyses of patients in New York Heart Association functional class I. CONCLUSIONS: Mitral valve surgery results in reductions in ECV% and iECV, which are surrogates of diffuse myocardial fibrosis, and preoperative iECV predicts the degree of postoperative remodeling irrespective of symptoms. (The Role of Myocardial Fibrosis in Degenerative Mitral Regurgitation; NCT02355418).

Long QT-Syndrome With Torsades de Pointes Managed Considering Financial Constraints Faced by the Patient.

Long QT syndrome (LQTS) is a rare arrhythmogenic condition characterized by abnormally long QT intervals on an electrocardiogram. The prevalence varies between 1 in 3000 and 1 in 10,000 but often remains undiagnosed. It is responsible for 3000 to 4000 sudden deaths among children and adults in the United States alone. LQTS can lead to torsades de pointes which is seen as twisting of QRS complex on electrocardiogram. We report a case of a 35-year-old patient with LQTS who presented with syncope and was found to have torsades de pointes. After acute management the patient was advised for automatic implantable cardioverter defibrillator (AICD) but because of financial constraints, she was placed on beta-blockers and permanent pacemaker.

A rare constellation of eventration of right diaphragm, severe right lung hypoplasia, and LPA sling.

Left pulmonary artery sling (LPAS) is a rare congenital cardiac anomaly and is commonly associated with complete tracheal rings and various degrees of tracheobronchial compression. We present a very rare association of LPAS and congenital eventration of right hemidiaphragm in this case report.

Myocardial fibrosis in asymptomatic and symptomatic chronic severe primary mitral regurgitation and relationship to tissue characterisation and left ventricular function on cardiovascular magnetic resonance.

BACKGROUND: Myocardial fibrosis occurs in end-stage heart failure secondary to mitral regurgitation (MR), but it is not known whether this is present before onset of symptoms or myocardial dysfunction. This study aimed to characterise myocardial fibrosis in chronic severe primary MR on histology, compare this to tissue characterisation on cardiovascular magnetic resonance (CMR) imaging, and investigate associations with symptoms, left ventricular (LV) function, and exercise capacity. METHODS: Patients with class I or IIa indications for surgery underwent CMR and cardiopulmonary exercise testing. LV biopsies were taken at surgery and the extent of fibrosis was quantified on histology using collagen volume fraction (CVFmean) compared to autopsy controls without cardiac pathology. RESULTS: 120 consecutive patients (64 ± 13 years; 71% male) were recruited; 105 patients underwent MV repair while 15 chose conservative management. LV biopsies were obtained in 86 patients (234 biopsy samples in total). MR patients had more fibrosis compared to 8 autopsy controls (median: 14.6% [interquartile range 7.4-20.3] vs. 3.3% [2.6-6.1], P < 0.001); this difference persisted in the asymptomatic patients (CVFmean 13.6% [6.3-18.8], P < 0.001), but severity of fibrosis was not significantly higher in NYHA II-III symptomatic MR (CVFmean 15.7% [9.9-23.1] (P = 0.083). Fibrosis was patchy across biopsy sites (intraclass correlation 0.23, 95% CI 0.08-0.39, P = 0.001). No significant relationships were identified between CVFmean and CMR tissue characterisation [native T1, extracellular volume (ECV) or late gadolinium enhancement] or measures of LV function [LV ejection fraction (LVEF), global longitudinal strain (GLS)]. Although the range of ECV was small (27.3 ± 3.2%), ECV correlated with multiple measures of LV function (LVEF: Rho = - 0.22, P = 0.029, GLS: Rho = 0.29, P = 0.003), as well as NTproBNP (Rho = 0.54, P < 0.001) and exercise capacity (%PredVO2max: R = - 0.22, P = 0.030). CONCLUSIONS: Patients with chronic primary MR have increased fibrosis before the onset of symptoms. Due to the patchy nature of fibrosis, CMR derived ECV may be a better marker of global myocardial status. Clinical trial registration Mitral FINDER study; Clinical Trials NCT02355418, Registered 4 February 2015, https://clinicaltrials.gov/ct2/show/NCT02355418.

Twelve-month clinical outcomes of sirolimus-eluting stent in coronary artery disease: An experience in real-world Indian patients.

OBJECTIVE: Supraflex (Sahajanand Medical Technologies Pvt. Ltd, Surat, India) is the latest generation of biodegradable polymer-coated sirolimus-eluting coronary stent designed on ultra-thin (60 µm) cobalt-chromium platform with flexible 'S-link.' The present study was designed to establish the safety and clinical performance of Supraflex in real-world Indian patients with coronary artery disease. METHODS: The study included 839 consecutive patients with coronary artery disease who were implanted with Supraflex from January 2014 to August 2017 at six different tertiary care centers in India. Follow-up was performed at 30 days, 6 months, and 12 months after the index procedure. The primary end-point of the study was the incidence of major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction (MI), and target lesion revascularization (TLR) at the 12-month follow-up. The occurrence of stent thrombosis was analyzed as safety end-point. RESULTS: A total of 1025 lesions were treated by implantation of 1098 Supraflex stents. At the 12-month follow-up, MACE was 4.92%, including 7 (0.86%) cardiac deaths, 16 (1.97%) MI, and 17 (2.09%) TLR. Only three incidences of stent thrombosis were found at the 12-month follow-up. CONCLUSION: The study results showed excellent safety and clinical effectiveness of Supraflex in a high proportion of high-risk real-world Indian patients with coronary artery disease.

Effect of Goal-directed Hemodynamic Therapy in Postcardiac Surgery Patients.

BACKGROUND AND AIMS: Early goal-directed therapy (EGDT) provides preset goals to be achieved by intravenous fluid therapy and inotropic therapy with earliest detection of change in the hemodynamic profile. Improved outcome in cardiac surgery patients has been shown by perioperative volume optimization, while postoperative intensive care unit (ICU) stay can be decreased by improving oxygen delivery. Our aim of this study was to study the outcome of EGDT in patients undergoing elective cardiac surgery. MATERIALS AND METHODS: This is a prospective single institute study involving a total of 478 patients. Patients were divided into group I, who received standard hospital care, and group II, who received EGDT. Postoperatively, patients were observed in ICU for 72 hours. Hemodynamics, laboratory data, fluid bolus, inotrope score, complication, ventilatory time, and mortality data were collected. RESULTS: Postoperative ventilatory period (11.12 ± 10.11 vs 9.45 ± 8.87, p = 0.0719) and frequency of change in inotropes (1.900 ± 0.9 vs 1.19 ± 0.61, p = 0.0717) were lower in group II. Frequency of crystalloid boluses (1.33 ± 0.65 vs 1.75 ± 1.09, p = 0.0126), and quantity of packed cell volume (PCV) used (1.63 ± 1.03 vs 2.04 ± 1.42, p = 0.0364) were highly significant in group II. Use of colloids was higher in group II and was statistically significant (1.98 ± 1.99 vs 3.05 ± 2.17, p = 0.0012). The acute kidney injury (AKI) rate was (58 (23.10%) vs 30 (13.21%), p = 0.007) lower and statistically significant (p = 0.007) in group II. CONCLUSION: Early goal-directed therapy reduces the postoperative ventilatory period, frequency of changes in inotropes, and incidence of AKI, and decreases ventilation hours, number of times inotropes changed, and AKI. HOW TO CITE THIS ARTICLE: Patel H, Parikh N, Shah R, Patel R, Thosani R, Shah P, et al. Effect of Goal-directed Hemodynamic Therapy in Postcardiac Surgery Patients. Indian J Crit Care Med 2020;24(5):321-326.

Idiopathic Constrictive Pericarditis and Eggshell Calcification of the Heart.

Extensive pericardial calcification is rare in patients with chronic constrictive pericarditis (CCP). We report the case of a young man who had CCP with "eggshell" calcification of the pericardium and the classic features of CCP on echocardiography and cardiac catheterization. The patient had an uneventful recovery following surgical pericardiectomy. (Level of Difficulty: Intermediate.).

Elucidation of genotype-environment interactions and genetic stability parameters for yield, quality and agromorphological traits in ashwagandha (Withania somnifera (L.) Dunal).

The present study was undertaken to delineate genotype-environment interactions and stability status of 16 genotypes of ashwagandha (Withania somnifera (L.) Dunal) in context to the 12 characters, namely plant height, number of primary branches, number of secondary branches, days to flowering, days to maturity, number of berries, number of seeds/berry, root length, root diameter, root branches, dry root yield and total alkaloid content (%). Experiment was carried out in a randomized complete block design with three replicationsover three different locations (S. K. Nagar, Jagudan and Bhiloda) in north Gujarat for three years (2016-17, 2017-18 and 2018-19). Pooled analysis of variance revealed that the mean squares due to genotypes and genotype 9 environment interaction along with linear and nonlinear components were highly significant (P<0.01) for most of the traits under study. Stability parameters for component traits through Eberhart and Russell model showed that genotypes that can be used directly in breeding programme are SKA-4 for early flowering, SKA-21 for early maturity and SKA-1, SKA-4, SKA-6 and SKA-17 for shorter plant height. Further, SKA-21 could be used for improving number of primary branches per plant, SKA-11 and SKA-17 for number of secondary branches per plant, SKA-19 for number of berries per plant, SKA-6, SKA-21, SKA-27 and AWS-1 for root branches and SKA-17 for root length as these genotypes were found to be moststable across the environments for mentioned traits. The result revealed that some reliable predictions about genotype 9 environment interaction and its unpredictable components were involved significantly in determining the stability of genotypes. Hence, the present investigation can be exploited for the identification of more productive genotypes in specific environments, leading to significant increase in root productivity of ashwagandha.

Improvising livestock service in hilly regions through indigenous wisdom towards control of tick infestation: Institutional relationships.

AIM: This study was conducted to demonstrate the acaricide efficacy of novel indigenous veterinary medication shared by an outstanding knowledge holder against naturally infested cattle and efforts in mainstreaming such wisdom. MATERIALS AND METHODS: An indigenous herbal medication in control of tick infestation was documented, and experimentation was held against naturally affected cattle. Eighteen clinically infested cattle population comprising 16 crossbred and 2 non-descript cattle were purposively selected. Majority of them were adult females, reported with a higher incidence of tick at Veterinary institution. The average pre-treatment tick count at 24 sites of observations among these animals was 18.91±2.04 (Mean [x̄]±standard error [SE]). The medication was topically applied once daily for 2 days and post-treatment observations were recorded for an experimental period of 14 days' duration. RESULTS: During 24-h post-treatment observation, the medication had shown 92.95% acaricidal property with clinically irrelevant rate of tick infestation of 1.33±0.39 (x̄ ±SE) was noticed before application of subsequent (second) dosage. This practice was found significantly effective at 5% level of significance (t0.05, 23=9.08) illustrating faster relief to livestock. Animals were treated with herbal medication as per dosage on the second day and no reinfestation was noticed up to 14 days of experimental observation. CONCLUSION: The study strengthens the belief that indigenous herbal acaricide can facilitate quality livestock service at geographically distant locations. These medications can provide quicker relief, minimize tick resistance and are favorable to the environment.

Biocatalysis for synthesis of pharmaceuticals.

Chirality is a key factor in the safety and efficacy of many drug products and thus the production of single enantiomers of drug intermediates and drugs has become important and state of the art in the pharmaceutical industry. There has been an increasing awareness of the enormous potential of microorganisms and enzymes (biocatalysts) for the transformation of synthetic chemicals with high chemo-, regio- and enatioselectivities providing products in high yields and purity. In this article, biocatalytic processes are described for the synthesis of key chiral intermediates for development pharmaceuticals.

Hydrocortisone, Vitamin C and thiamine for the treatment of sepsis and septic shock following cardiac surgery.

BACKGROUND AND AIMS: The effect of vitamin C on vasopressor requirement in critically ill patients have been evaluated previously. We aimed to evaluate the effect of vitamin C, hydrocortisone and thiamine on vasopressor requirement and mortality in post-operative adult cardiac surgical patients with septic shock. METHODS: About 24 patients with septic shock were randomised into Group 1 (receiving matching placebo per day for 4 days) and Group 2 (receiving 6 g vitamin C, 400 mg thiamine and 200 mg hydrocortisone per day for 4 days). Vasopressor dose over 4 days of therapy was the primary endpoint, whereas in-hospital mortality was the secondary endpoint. RESULTS: APACHE IV and EUROSCORE II scores were similar between both the groups. Significant reductions in the requirement of vasopressin (difference from day 1 - 0.0008 ± 0.00289 vs 0.0033 ± 0.00492 units/kg/min; P = 0.019) and noradrenaline (difference from day 1 - 0.0283 ± 0.040 vs 0.023 ± 0.035 µg/kg/min; P = 0.006) were observed with vitamin C treatment as compared to control group. PCT levels on Day 3 (68.11 ± 33.64 vs 33.2 ± 27.55 ng/mL; P = 0.0161) and Day 4 (70.03 ± 29.74 vs 26.3 ± 23.08 ng/mL; P = 0.0009) were significantly lower in treatment group as compared to control. However, there was no difference in the Sepsis-Related Organ Failure Assessment (SOFA) score and mortality between the studied groups. CONCLUSION: Combination of vitamin C, thiamine and hydrocortisone reduces vasopressor requirement in adult cardiac surgical patients with septic shock.

A prospective study examining the role of myocardial Fibrosis in outcome following mitral valve repair IN DEgenerative mitral Regurgitation: rationale and design of the mitral FINDER study.

BACKGROUND: The optimal management of chronic severe primary degenerative mitral regurgitation (MR) is to repair the valve but identification of the optimal timing of surgery remains challenging. Current guidelines suggest 'watchful waiting' until the onset of symptoms or left ventricular (LV) dysfunction but these have been challenged as promoting 'rescue surgery'. Better predictors are required to inform decision-making in relation to the necessity and timing of surgery. Chronic volume overload is a stimulus for adverse adaptive LV remodelling. Subclinical reduction in LV strain before mitral repair predicts a fall in LV ejection fraction following surgery and is thought to reflect the development of myocardial fibrosis in response to chronic volume overload. Myocardial fibrosis can be detected non-invasively using cardiac magnetic resonance (CMR) imaging techniques as an expansion of the extracellular volume (ECV). METHODS/DESIGN: This study investigates whether: 1) patients with above median ECV will have smaller reduction in end-systolic volume index (as a measure of the degree of reverse LV remodelling) on CMR following mitral valve repair, compared to those with below median ECV; and 2) higher ECV on CMR, validated through histology, adversely impacts upon post-operative complications and symptomatic improvement following surgery. This is a multi-centre, prospective, cross-sectional comparison of patients prior to and 9 months following surgery for chronic severe primary degenerative MR. To establish the natural history of ECV in MR, an additional cohort of patients with asymptomatic MR who do not wish to consider early repair will be followed. Investigations include CMR, cardiopulmonary exercise test, stress echocardiography, signal-averaged electrocardiogram, 24-h electrocardiogram monitoring, laboratory tests and patient-reported outcome measures. Patients undergoing surgery will have cardiac biopsies performed at the time of mitral valve repair for histological quantification of fibrosis. DISCUSSION: This study will advance our understanding of ventricular remodelling in MR, its impact on patient symptoms and ventricular response following surgery. Establishing the link between myocardial fibrosis (measured on CMR and validated through histology), with early ventricular dysfunction, will offer physicians a novel non-invasive biomarker that can further inform the timing of surgery. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov ( NCT02355418 ) on 30th November 2015.

Monitoring Microcirculatory Blood Flow during Cardiopulmonary Bypass in Paediatric Cardiac Surgery Patients as a Predictor for Anaerobic Metabolism.

INTRODUCTION: Improving tissue oxygenation is one of most important tasks in management of low cardiac output. Central venous oxygen saturation (ScvO2) and lactate are established criteria for monitoring the adequacy of tissue oxygenation. The venous-to-arterial carbon dioxide difference [P(v-a)CO2] is inversely associated with cardiac output. AIM: To study the use of P(v-a)CO2/C(a-v)O2 ratio as a marker of low cardiac output during Cardiopulmonary Bypass (CPB) in paediatric cardiac surgical patients. MATERIALS AND METHODS: The present study was a prospective observational study conducted over a period of nine months from 1st August 2015 to 30th April 2016. A total of 110 children were enrolled, who underwent CPB during cardiac surgery. The CPB time, Mean Arterial Pressure (MAP), flow rate, cross clamp time, were recorded for all the patients as well as Arterial Blood Gas (ABG) and Venous Blood Gas (VBG) were checked at four different points of time: 1) Before CPB, 2) 10 minutes after initiation of CPB, 3) 30 minutes on CPB and 4) off CPB. RESULTS: The results indicated that Receiver Operating Characteristic curve (ROC curve) at 30 minute of CPB time P(v-a)CO2/C(a-v)O2 was more specific and sensitive than lactate to detect anaerobic metabolism. Decrease platelet count was significant on second postoperative day. CONCLUSION: The present study suggests the use of P(v-a)CO2/C(a-v)O2 ratio as a marker to detect low flow on CPB. Our study was single centric and with a small size, studies involving large population and multiple centers are required to support the recent findings.

Zinner syndrome: an unusual cause of bladder outflow obstruction.

Zinner syndrome is a rare condition comprising a triad of unilateral renal agenesis, ipsilateral seminal vesicle obstruction and ipsilateral ejaculatory duct obstruction. The mutual embryological origins of the seminal vesicle and the ureteral bud result in both anomalous genital and urinary tracts. We present the case of a 39-year-old patient where the initial presentation of this condition was bladder outflow obstruction. In this paper, we discuss the embryological origin of this condition, the range of imaging tools used to diagnose Zinner syndrome and the inherent benefits and shortcomings of each modality.

Green Synthetic Approach for Synthesis of Fluorescent Carbon Dots for Lisinopril Drug Delivery System and their Confirmations in the Cells.

In this work, highly luminescent carbon dots (CDs) were synthesized by the hydrothermal method at 170 °C for 12 h using pasteurized milk as a carbon source. The prepared CDs exhibited bright blue fluorescence under UV light illumination at 365 nm. The CDs show fluorescence life time of ~4.89 ns at excitation wavelength of 370 nm. The effect of different solvents on the fluorescence property of CDs was also investigated. The lisinopril (Lis)-loaded CDs were fabricated by self-assembly of lisinopril on the surfaces of CDs, which were characterized by UV-visible and FT-IR spectroscopic techniques. The controlled release of lisinopril from the Lis-CDs was realized at pH values of 5.2, 6.2 and 7.4, respectively. The results of the cytotoxicity and confocal laser scanning microscopic images indicate that the Lis-CDs were successfully uptaken by HeLa cells without apparent cytotoxicity. The synthesized CDs show great potential as drug vehicles with good biocompatibility, sustained release of lisinopril from CDs, indicating that the CDs can act as a promising drug delivery system for therapeutic delivery and/or bioimaging applications.