Comparing Three Models of Community-Based Diabetic Retinopathy Screening, Treatment, and Awareness Creation Services in Southern India / South Kerala.

Background: The aim of the study was to evaluate the effectiveness of three models of diabetic retinopathy (DR) screening from an economic perspective and their effectiveness in awareness creation, screening, and ability to deliver treatment. Materials and Methods: Analysis of a prospective screening program for diabetes mellitus and DR in South Kerala was done. Three models were created: Model 1: blood screening camp, Model 2: comprehensive eye camp, and Model 3: institution-based screening camp. Results: Forty-seven camps were conducted in Model 1, 438 in Model 2, and 18 in Model 3. Of 94,993 people screened, the percentage of diabetes was 17.4. Of the diabetics screened, the percentage of retinopathy was 22.8. Model 1 was most economically viable to detect a large number of new diabetics. Model 2 was more economically challenging but had the best overall pickup rate for new DR patients. Model 3 had a lesser pickup of new DR patients. Conclusion: Model 1 is effective in picking up new diabetics but poor for DR screening. Model 3 is cost-efficient with very high DR detection rates. Cost-effective screening activities and service delivery are best achieved through a well-planned Model 2 camp which has the best overall detection rate for DR.

Retinal vasospastic phenomenon in a known case of systemic lupus erythematosus.

Retinal vasospasm was visualized in a young female; a known case of systemic lupus erythematosus (SLE) retinopathy with unaffected vision. The fundus fluorescein angiogram showed a cyclical filling and emptying of the retinal vessels which was suggestive of vasospasm and a retinal Raynaud's-like phenomenon with no obvious perfusion deficit. There was retinal thinning involving the superficial layers that was seen on optical coherence tomography (OCT), capillary fill voids on OCT angiography, and retinal surface undulations seen on multicolor imaging. All imaging was performed on Spectralis (Heidelberg, Germany).

Left anterior descending artery endarterectomy by hydrodissection.

Complete revascularisation of a diffusely diseased left anterior descending (LAD) coronary artery is best done by endarterectomy in conjunction with coronary artery bypass grafting. We describe a simple, effective, and safe technique of performing LAD endarterectomy by hydrodissection.

Medium-term results of surgical ventricular restoration with papillary muscle realignment: providing additional benefits in enlarged ischemic left ventricle.

In 2001, we described a new surgical technique of surgical ventricular restoration (SVR) in severe heart failure by papillary muscle re-alignment and volume reduction. This procedure has been offered in our institution to patients with severely impaired left ventricular function. Here we examine our mid-term results and also compare them with a similar cohort of patients who had coronary artery bypass grafting (CABG) only. Between 1998 and 2005, 30 patients underwent SVR by papillary muscle realignment with coronary artery revascularization at our institution. A subset of 20 patients had their left ventricular volume measured by echocardiogram and MRI scan, and a maximal cardiopulmonary exercise test was performed before and after the operation. An unselected consecutive cohort of patients with matching age, gender, and hemodynamic status who underwent CABG only without SVR was tested using the same protocol and the results were compared. We noticed that there was a significant advantage for patients who had additional SVR over patients who had CABG only. The observed improvement in those who had SVR may be due to reduced metabolic mismatch as a result of reduced wall tension and normalization of the apical twist of the left ventricle. We believe this would provide a form of surgical treatment for heart failure secondary to ischemic cardiomyopathy at a time of reduced donor organ availability for transplant.

Nitric oxide associated with iNOS expression inhibits acetylcholinesterase activity and induces memory impairment during acute hypobaric hypoxia.

The mechanisms responsible for cholinergic dysfunction associated learning and memory impairment during hypoxia are not well-understood. However it is known that inflammatory mediators like inducible nitric oxide synthase (iNOS) hamper the functions of cholinergic neurons. In this present experiment we made an effort to study the iNOS expression mediated retrograde and anterograde memory impairment in Balb/c mice following acute hypobaric hypoxia (at an altitude of 23,000ft for 6h) using elevated plus maze and passive avoidance step-through tasks. Our results demonstrated that hypoxia transiently impairs the retrograde memory without affecting the anterograde memory functions, accompanied with a substantial rise in iNOS expression and nitric oxide levels in cerebral cortex on days 2 and 3 post hypoxia. Treatment with aminoguanidine (iNOS inhibitor ), resulted in down-regulation of the iNOS expression, attenuation of the surge of nitric oxide (NO) in cerebral cortex and reversal of retrograde memory impairment due to hypoxia. Moreover the reduced AChE activity and elevated lipid peroxidation in cerebral cortex were evident during post hypoxia re-oxygenation period, which was not observed in the hippocampus. Additionally, NO donor spermine NONOate could inhibit the AChE activity in brain homogenates in a concentration-dependent manner, which further substantiate that nitric oxide produced during post hypoxia re-oxygenation, primarily contributes to the observed inhibition of cortical AChE activity. Based on these experiments we hypothesize that the NO burst as a result of iNOS upregulation during hypoxia interrupts the memory consolidation by altering the cholinergic functions.

Benzamide protects delayed neuronal death and behavioural impairment in a mouse model of global cerebral ischemia.

The present study is aimed at evaluating the functional and neuroprotective effect of benzamide, a poly-(ADP-ribose) polymerase (PARP) inhibitor on delayed neuronal death (DND) in hippocampus CA1 region and memory impairment following global cerebral ischemia (GCI) in a mouse model. GCI was induced by bilateral common carotid artery occlusion (BCAo) for 20 min followed by reperfusion for 9 days. Postischemic continuous treatment with benzamide (160 mg/kg b w i.p. for 9 days) significantly reversed the GCI-induced anterograde memory impairment in passive avoidance step through and elevated plus maze tasks. The observed memory impairment in vehicle treated ischemia group was found to be well correlated with DND and downregulation of cholinergic muscarinic receptor-1 expression, which was possibly mediated by inflammation and apoptosis, as revealed from inducible nitric oxide synthase (iNOS) expression and number of TUNEL positive neurons in hippocampus CA1 region. It is clear from the present experiment that benzamide treatment significantly decreases the iNOS expression and number of apoptotic neurons and thereby improves the neuronal survival and memory during GCI. Our present findings provide compelling evidence that multiple doses of benzamide treatment is a promising therapeutic approach for cerebrovascular and neurodegenerative diseases, which deserves further clinical evaluation.

Long term survival after coronary endarterectomy in patients undergoing combined coronary and valvular surgery--a fifteen year experience.

BACKGROUND: Coronary Endarterectomy (CE) in patients undergoing coronary artery bypass graft (CABG) surgery has been shown to be beneficial in those with diffuse coronary artery disease. There are no published data on its role and benefit in patients undergoing more complex operations. We present our experience with CE in patients undergoing valve surgery with concomitant CABG. MATERIALS AND METHODS: Between 1989 and 2003, 237 patients underwent CABG with valve surgery under a single surgeon at our institution. Of these, 41 patients needed CE. Data was retrospectively obtained from hospital records and database. Further follow-up was obtained by telephone interview. All variables were analyzed by univariate analysis for significant factors relating to hospital mortality. Morbidity and long term survival was also studied. There were 29 males and 12 females with a mean age of 67.4 +/- 8.1 and body mass index of 26.3 +/- 3.3. Their mean euroscore was 7.6 +/- 3.2 and the log euro score was 12.2 +/- 16.1. RESULTS: Thirty-two patients were discharged from the intensive therapy unit within 48 hours after surgery. Average hospital stay was 12.7 +/- 10.43 days. Thirty day mortality was 9.8%. Six late deaths occurred during the 14 year follow up. Ten year survival was 57.2% (95% CL 37.8%-86.6%). Three of the survivors had Class II symptoms, with one requiring nitrates. None required further percutaneous or surgical intervention. We compared the result with the available mortality figure from the SCTS database. CONCLUSION: Compared to the SCTS database for these patients, we have observed that CE does not increase the mortality in combined procedures. By accomplishing revascularization in areas deemed ungraftable, we have shown an added survival benefit in this group of patients.

Somatostatin receptor subtype expression in the human heart: differential expression by myocytes and fibroblasts.

In acromegaly, somatostatin receptor ligands (SRLs) can ameliorate left ventricular hypertrophy (LVH) and their use is associated with demonstrable improvements in various parameters of cardiac function. It remains unclear as to whether these beneficial effects are principally attributable to falling GH and IGF-I levels, or whether SRLs exert independent direct effects on the heart via somatostatin receptors. To help address this issue, we have sought to investigate somatostatin receptor expression in human heart. A human heart cDNA library was probed using PCR techniques to determine expression of somatostatin receptor subtypes. Subsequently, human heart biopsies and human cardiac fibroblasts and myocytes were analysed to determine whether expression differed between cardiac chambers or cell types. mRNAs for four of the five somatostatin receptor subtypes (sst1, sst2, sst4 and sst5) were shown to be co-expressed by the human heart. These receptors were present in both atrial and ventricular tissue. Human cardiac myocytes expressed mRNA for only sst1 and sst2, while human cardiac fibroblasts expressed all four subtypes found in whole heart tissue. The expression of functional somatostatin receptors on human cardiac fibroblasts was confirmed by mobilisation of intracellular calcium in response to somatostatin. The presence of cardiac somatostatin receptors raises the possibility of a direct effect of somatostatin analogues on the heart. Furthermore, the differential expression of somatostatin receptor subtypes by human cardiac myocytes and fibroblasts opens up the possibility of differential modulation of the cell types in the heart by subtype-specific somatostatin analogues.

Mitral Valve Surgery Using a Modified Superior Left Atrial Approach.

Most surgeons use a longitudinal right lateral left atrial incision behind the inter-atrial groove for the exposure of the mitral valve, even though several other surgical techniques have been described. The shortest route to the mitral valve is, however, through the roof of the left atrium, where the incision is closest to the mitral annulus. This was first described by Meyer et al., but the approach became unpopular because of its technical difficulties and inadequacies. We have modified this technique, making it safer, easier and adaptable to any type of mitral surgery. We describe our experience with 53 patients who had mitral valve surgery using this modified approach. All of the operations were performed by the same surgeon over an 18 month period with consistently satisfactory results.

Total Coronary Artery Revascularization Through a Mini-Sternotomy.

Revascularization of all significantly stenosed vessels remains the goal of coronary artery bypass surgery. Recent improvements in endoscopic instruments have resulted in the evolution of selective left anterior descending artery bypass grafting through a limited anterior small thoracotomy (LAST) incision. A major limitation of this technique is the inaccessibility for complete surgical revascularization in multivessel disease. In this article, we describe a minimally invasive technique for total coronary artery revascularization that combines conventional surgical techniques with the advantages of minimally invasive surgery. We have performed total coronary revascularization in 52 patients over a period of 16 months with consistently good results.