Expert Opinion: Use of sodium glucose co-transporter type-2 inhibitors in South Asian population -The Pakistan perspective.

Sodium-glucose co-transporter type 2 inhibitors (SGLT 2- i)are increasingly being used in the management of type 2 diabetes mellitus (T2DM). With the novel insulinindependent glycosuric action, these agents help to attain glycaemic goals by lowering HbA1c and fasting blood glucose. In addition, these agents improve metabolic control in diabetes and ameliorate comorbidities like obesity and hyper tension. Beneficial effec ts on cardiovascular outcomes have been a key attraction for physicians. These agents are used alone or in combination with oral antidiabetic agents and insulin to attain glycaemic and metabolic targets. A major disadvantagewith these agents is the increased risk for genital andurinary infections. When used in appropriate settings, there is no additional increased risk of hypoglycaemia or volume depletion with these agents. Available evidence suggests good efficacy and safety of these agents in diabetes management. The easy and convenient oncedaily dosing should be customized according to patient needs and glycaemic profiles.

Comparison of nebulised 3% hypertonic saline with ipratropium bromide in treatment of children with bronchiolitis: a randomized control trial.

Introduction: Several drugs are in use for nebulization in children with acute bronchiolitis and no study has yet been conducted to compare the treatment outcome of nebulized ipratropium bromide and nebulized 3% hypertonic saline in Pakistan. Objective: The objective was to compare the treatment outcome of nebulized hypertonic saline and ipratropium bromide in children with acute bronchiolitis. Setting: Department of Pediatrics. Study duration: October 2019 to March 2020. Subjects and methods: A total of one hundred (n=100) children of either sex diagnosed with acute bronchiolitis were enrolled and randomized either to be nebulized with 3% hypertonic saline or ipratropium bromide. Outcomes were assessed in terms of respiratory rate, heart rate, and SpO2 and respiratory distress assessment instrument score at different time intervals, length of hospital stay, and need of admission. Results: Respiratory rate and SPO2 improved significantly at 60 min and 24 h, respiratory distress assessment instrument improved significantly at 30 min, 60 min, and 24 h after the treatment in patients who were nebulized with hypertonic saline when compared to those nebulized with ipratropium bromide. The length of hospital stay was significantly shorter (2.63 vs. 3.82 days, P=0.008) and a lesser number of patients needed hospital admission (22% vs. 44%, P=0.019) in patients who were nebulized with hypertonic saline when compared to those nebulized with ipratropium bromide. Conclusions: Nebulization with 3% hypertonic saline resulted in significant improvement in symptoms, a shorter duration of hospital stay, and a lesser number of hospital admissions as compared to nebulization with ipratropium bromide in children with acute bronchiolitis.

Optimize PLA/EVA Polymers Blend Compositional Coating for Next Generation Biodegradable Drug-Eluting Stents.

In this research work, polymer blends of poly-lactic acid (PLA)/ethylene vinyl acetate (EVA) were prepared as the drug carrier materials for a bi-layer drug-loaded coating film for coronary stents. Different optimum compositions of blends were prepared by using an intense mixer. Then, the blends were hot-pressed and later cold-pressed to prepare for films of different thickness. The changes in weight, surface analysis and biodegradability with increasing time were studied using Scanning electron microscopy (SEM), weight loss and biodegradability tests. The mechanical and thermal properties of drug-loaded films were studied through universal testing machine (UTM) and thermo-gravimetric analysis (TGA). The effects of PLA, EVA and drug contents on in-vitro drug contents were investigated through the Ultraviolet-Visible Spectroscopy (UV-VIS) chemical analysis technique. The results obtained clearly showed that the addition of PLA promoted the unleashing of the drug whereas the addition of EVA nearly did not have the same affect. The mechanical properties of these various films can be tuned by adjusting the contents of blend parts. The factors affecting the unleashing of the drug became a serious matter of concern in evaluating the performance of bio-resorbable drug eluting stents. As a result, today's chemical blends may be useful drug carrier materials for drug-loaded tube coatings capable delivering purgative drug in an incredibly tunable and regulated manner.

Aminodextran Coated CoFe2O4 Nanoparticles for Combined Magnetic Resonance Imaging and Hyperthermia.

Aminodextran (AMD) coated magnetic cobalt ferrite nanoparticles are synthesized via electrostatic adsorption of aminodextran onto magnetic nanoparticles and their potential theranostic application is evaluated. The uncoated and aminodextran-coated nanoparticles are characterized to determine their hydrodynamic size, morphology, chemical composition, zeta potential and magnetization. The aminodextran containing cobalt ferrite nanoparticles of nanometer size are positively charged in the pH range from 3 to 9 and exhibit saturation magnetization of 50 emu/g. The magnetic resonance imaging (MRI) indicates capability for diagnostics and a reduction in intensity with an increase in nanoparticle amount. The hyperthermia capability of the prepared particles shows their potential to generate suitable local heat for therapeutic purposes. There is a rise of 7 °C and 9 °C at 327 kHz and 981 kHz respectively and specific absorption rates (SAR) of aminodextran-coated nanoparticles are calculated to be 259 W/g and 518 W/g at the given frequencies larger than uncoated nanoparticles (0.02 W/g). The development of novel aminodextran coated magnetic cobalt ferrite nanoparticles has significant potential to enable and improve personalized therapy regimens, targeted cancer therapies and ultimately to overcome the prevalence of nonessential and overdosing of healthy tissues and organs.

Percutaneous transcatheter closure of patent foramen ovale with the Amplatzer Cribriform septal occluder.

OBJECTIVES: We tested the feasibility of percutaneous patent foramen ovale (PFO) closure utilizing the Amplatzer multifenestrated Cribriform atrial septal occluder device. BACKGROUND: This device recently became available and may offer unique advantages for closure of PFO. METHODS: Nineteen consecutive patients who underwent closure of PFO with the Cribriform device for a variety of indications under intracardiac echocardiographic and fluoroscopic guidance were studied. The degree of shunting was quantified pre- and postprocedure by echocardiography using both Doppler and agitated saline administration. The results with this device were compared to the prior 19 patients who underwent closure with a CardioSeal device. RESULTS: The mean age of patients was 52 years and 47% were female. Indications for closure were paradoxical embolism in 17 patients, and hypoxemia due to right to left shunt in 2 patients. The postprocedure bubble contrast study showed a marked improvement in right to left shunting with 13 patients (68%) demonstrating no shunt flow, 4 (21%) having trace shunting, and 2 (11%) mild shunting. There were no device-related complications. The mean procedure time was 28 +/- 10 min. In comparison to the CardioSeal device, a trend was apparent in terms of a greater percentage of patients with immediate closure with the Cribriform device, although a similar percentage of defect closure was seen at 6 months with both devices. Procedure time was shorter with the Cribriform device, related in part to the reduced need for balloon sizing. CONCLUSIONS: This initial experience suggests a number of favorable characteristics of the Amplatzer Cribriform device for PFO closure.

Pseudoaneurysm with thrombus and left ventricular inflow obstruction after left circumflex stenting.

A 61-year-old woman had stenting of the left circumflex coronary artery. She had a repeat coronary angiogram the day after stenting because of hypotension and orthopnea. The left circumflex stent was patent. A transesophageal echocardiogram showed a 2.5 cm x 3.0-cm mass in the atrioventricular groove compressing the left atrium. A pseudoaneurysm with thrombus and left ventricular inflow obstruction was diagnosed. The patient was observed for 48 hours to allow the pseudoaneurysm to seal and coagulate. She then had surgical evacuation of the thrombus, which had caused her hypotension and orthopnea by compression of the left atrium.

Long-term follow-up of high-dose mitoxantrone-based induction therapy for patients with newly-diagnosed acute myelogenous leukemia. Twelve year results from a single institution.

This report provides long-term results of the treatment of patients with newly-diagnosed AML with a single high dose of mitoxantrone combined with once daily cytarabine. One-hundred and sixty-five patients treated on four studies of high-dose mitoxantrone-based induction therapy are included. Patients with a prior antecedent hematologic disorder were eligible. The median follow-up time is 65.9 months (95% CI: 55.7-86.2 months). The overall complete remission rate was 64%, with responses in 78% of patients less than 60 years of age and 51% of patients 60 years of age or older. The median duration of response is 21.2 months and 8.0 months and overall survival is 15.4 months and 7.6 months, respectively. For a sub-set of patients who would be eligible for most US trials, the complete remission rate was 84% in younger patients and 60% in older patients. The median duration of response was 39.0 and 8.2 months and the median overall survival was 19.4 and 7.6 months, respectively. The efficacy of these regimens compared favorably to results reported with standard '3 + 7' regimens. Use of a once-daily cytarabine regimen resulted in almost no neurotoxicity and allowed for administration of consolidation in the outpatient setting.

Sauna as a therapeutic option for cardiovascular disease.

The physiologic effect of the sauna in human beings has been studied extensively, but only recently have there been studies to suggest sauna can be an effective therapeutic modality for patients with cardiovascular disease, especially for those with congestive heart failure. The data reported to date have been promising, but definitive studies are not possible because sauna treatment would be difficult to evaluate in a double-blind, placebo-controlled study.

Diagnosis and management of viral myocarditis.

Myocarditis has been shown to be a common cause of cardiomyopathy; it is believed to account for 25% of all cases of heart failure in humans. Unfortunately, the disease is difficult to detect clinically before a myopathic process ensues. Treatment of myocarditis-induced heart failure includes the standard regimen of diuretics, digoxin, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and beta-adrenergic blockers. Treatment of myocarditis itself is dependent on the etiology of the illness. Additional treatments under investigation for viral and autoimmune myocarditis include immunosuppressants, nonsteroidal anti-inflammatory agents, immunoglobulins, immunomodulators, and antivirals, with no specific therapy having a real advantage over standard treatment for heart failure. Despite advances in treatment, more work needs to be done in the early detection of myocarditis. In addition, better means need to be established for distinguishing between viral and noninfectious autoimmune forms of the disease so that appropriate treatment can be instituted.

One-year mean follow-up of 41 patients treated with bifurcation stenting.

Forty-one patients, mean age 61 +/- 13 years, had stenting of bifurcation coronary artery lesions. Of the 41 patients, a crushing stent was used in 33 patients (80%), a T stent in 6 patients (15%), a kissing stent in 1 patient (2%), and side branch angioplasty in 1 patient (2%). Mean follow-up was 12 months (range 7-17 months). At follow-up, of the 41 patients, none (0%) died, 1 (2%) had a myocardial infarction, 3 (7%) had thrombotic stent occlusion, 3 (7%) had restenosis, 4 (10%) had target lesion revascularization, and 6 (15%) had myocardial infarction or target lesion revascularization or had died.

Two patients with heparin-induced thrombocytopenia followed by idiopathic (immune) thrombocytopenic purpura: case report.

Heparin-induced thrombocytopenia (HIT) and idiopathic thrombocytopenic purpura (ITP) are separate and well-recognized clinical syndromes, 10both having potential for disastrous outcomes. Sequential occurrence of these two diseases has not been reported in the literature. We report herein two patients who were initially diagnosed as having HIT but whose later clinical course was similar to ITP. Although dysfunction of immune system seems to play a role, the precise mechanisms for the development of these diseases are unclear. As both conditions have different natural histories and require different treatment modalities, it is important to recognize that these two diseases may be seen sequentially.

Innovative drug treatments for viral and autoimmune myocarditis.

Myocarditis is a common cause of cardiomyopathy and is thought to account for 25% of all cases in humans. Unfortunately, the disease is difficult to detect clinically before a myopathic process ensues. Management of myocarditis-induced heart failure includes the standard regimen of diuretics, digoxin, angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, and beta-adrenergic blockers. The management of myocarditis itself is dependent on the etiology of the illness. Treatments that are currently under investigation include immunosuppressants, nonsteroidal antiinflammatory agents, immunoglobulins, immunomodulation, antiadrenergics, calcium-channel blockers, angiotensin-converting enzyme inhibitors, nitric oxide inhibitors (e.g., aminoguanidine), and antivirals. Despite advances in treatment, more work needs to be done in the early detection of myocarditis. Additionally, better means need to be established for distinguishing between viral and noninfectious autoimmune forms of the disease, so that appropriate treatment can be instituted.

Circumflex coronary artery occlusion after blunt chest trauma.

A 32-year-old white male police officer suffered blunt trauma to the anterior chest wall during a routine training session. This was accompanied by the precipitous onset of chest discomfort. There was no previous history of any cardiac risk factors. The diagnosis of an inferior wall myocardial infarction was made based on the electrocardiogram findings, at his local community hospital. The total creatine kinase, creatine kinase-MB, and troponin I were normal. The transesophageal echocardiogram performed at that time demonstrated no aortic or coronary dissection. He was transferred to our tertiary care center. Emergency cardiac catheterization demonstrated lateral wall hypokinesis with a left ventricular ejection fraction of 45% and a total occlusion of the left circumflex coronary artery in its proximal portion. This was successfully recannulized with angioplasty and stenting techniques. We believe this to be only the second reported case of circumflex coronary artery obstruction after blunt chest trauma.