Real-world clinical experience of ticagrelor in Indian patients with acute coronary syndrome after discharge from a tertiary setting

Background: To understand the usage pattern of ticagrelor in real-life clinical experience in Indian patients with the acute coronary syndrome (ACS) after discharge from a tertiary care setting. Methods: A retrospective multicentric observational study conducted across Indian healthcare centers having medical records of adult patients with ACS. Patients prescribed with ticagrelor post-discharge for at least 1 month were included. The study endpoints were to determine the clinical effectiveness of ticagrelor in post-ACS patients and adverse events reported during the study period. Results: A total of 1910 patients with ACS with a mean (SD) age of 58.2 (11.3) years were enrolled in this study. The median (IQR) duration of treatment was 30.0 (30.0-90.0) days. More than half of the patients (n=1115, 58.4%) were managed with interventional therapy. The most common comorbid conditions were type-2 diabetes mellitus (46.9%), followed by hypertension (36.8%). A total of 9.7% of patients reported complaints after treatment with ticagrelor. Among them, weakness, giddiness, and body pain were the most common (3.2%). Conclusions: This real-world study revealed that ticagrelor had been used widely in patients who underwent different management strategies. History of diabetes and hypertension were the most common risk factors. There were no major adverse events reported during the follow-up, indicating ticagrelor is well-tolerated in Indian patients with ACS.

Effect of stretching exercises on blood gluocse levels in patients with type 2 diabetes mellitus: a brief review

Diabetes has become worldwide pandemic. Among the diabetic population 90-95% patients have type 2 diabetes mellitus (T2DM). The development of T2DM can be slowed down by modification in lifestyle through physical activities such as brisk walking, physical body movement and adopting proper balanced diet. Various physical exercises such as aerobic exercises, resistance exercises, high intensity interval training performed regularly can help with management of blood glucose level, lipid profile, blood pressure, quality of life and cardiovascular complications. Geriatric patients with type 2 diabetes are either extremely frail, wheelchair bound, or bed bound and do not have sufficient physical work capacity to exercise aerobically and with high resistance. Static stretching of the skeletal muscles accrues the benefits of exercise without its accompanying physical stress as in case of aerobic exercise and resisted exercises. Several studies have shown that stretching helps in lowering the blood glucose level in patients with T2DM immediately after the intervention. Till date there are no definitive guidelines are present for stretching exercises as treatment protocol for reduction of blood glucose level and HbA1c level in patients with T2DM. In order to establish a definitive stretching protocol in patients with T2DM and for individual based exercise to be decided further research needs to be conducted.

Effect of stretching exercises on blood gluocse levels in patients with type 2 diabetes mellitus: a brief review

Diabetes has become worldwide pandemic. Among the diabetic population 90-95% patients have type 2 diabetes mellitus (T2DM). The development of T2DM can be slowed down by modification in lifestyle through physical activities such as brisk walking, physical body movement and adopting proper balanced diet. Various physical exercises such as aerobic exercises, resistance exercises, high intensity interval training performed regularly can help with management of blood glucose level, lipid profile, blood pressure, quality of life and cardiovascular complications. Geriatric patients with type 2 diabetes are either extremely frail, wheelchair bound, or bed bound and do not have sufficient physical work capacity to exercise aerobically and with high resistance. Static stretching of the skeletal muscles accrues the benefits of exercise without its accompanying physical stress as in case of aerobic exercise and resisted exercises. Several studies have shown that stretching helps in lowering the blood glucose level in patients with T2DM immediately after the intervention. Till date there are no definitive guidelines are present for stretching exercises as treatment protocol for reduction of blood glucose level and HbA1c level in patients with T2DM. In order to establish a definitive stretching protocol in patients with T2DM and for individual based exercise to be decided further research needs to be conducted.

Study of knowledge, attitude, and practice regarding hepatitis B infection in first-degree relatives of patients suffering with hepatitis B infection

Background: Hepatitis B virus (HBV) infection is a significant public health problem in third-world countries, including India. The risk of infection among close family members of patients infected with chronic HBV infection is four to six times higher than in the general population. However, literature is scarce regarding the Knowledge, attitude, and practice toward HBV infection among the first-degree relatives of patients suffering from chronic hepatitis B. Hence, this study aimed to assess the knowledge, attitude, and practice regarding hepatitis B virus infection among first-degree relatives of hepatitis B patients. Methods: A cross-sectional, observational study was conducted amongst the 354 first-degree relatives of HBsAg-positive patients. A validated questionnaire consisted of twenty questions of knowledge, seven questions of attitude, and ten practice questions were employed to gather information. Results: The mean knowledge, attitude, and practice (KAP) were significantly better amongst participants aged 55-65 years and those who were educated. There was a positive correlation between knowledge and attitude (r=0.58, p value<0.05) and knowledge and practice (r=0.64, p value<0.05). Conclusions: There is insufficient knowledge regarding hepatitis B, its common symptoms, modes of transmission, and preventive tools among close relatives of patients suffering from chronic hepatitis B.

Topical corticosteroid therapy: clobetasol propionate 0.025%

Topical corticosteroids have been the cornerstone of treatment over the last six decades for various dermatoses characterized by dry, scaly, crusted, or erythematous skin as well as those associated with inflammation and pruritus. The potency of a topical steroid depends on the specific molecule, the amount of drug reaching the target, absorption through the skin (0.25%–3%), and the formulation. Clobetasol propionate (CP) 0.025% cream formulation is a potent, fifth-generation topical corticosteroid. It is approved by the United States Food and Drug Administration to be applied twice daily for the treatment of moderate-to–severe psoriasis in adults. This case series covers the clinical experience of various dermatologists, including their expert opinion on the safety and efficacy of ImpoyzTM (CP) cream 0.025% in different skin disorders.

A Study on Prevalence of Trigger Factors and Associated Disorders in Tension-type Headache

Objective: To study the prevalence of trigger factors and associated disorders in tension-type headache (TTH). Trigger factors have been widely studied in the context of migraine, but very few studies have investigated trigger factors in the context of TTH. Materials and methods: A total of 400 patients above the age of 15 years fulfilling the third edition of the International Classification of Headache Disorders (ICHD 3) criteria of frequent episodic tension-type headache (FETTH) and chronic tension-type headache (CTTH) were enrolled and evaluated using a questionnaire. Details regarding demographics, headache characteristics, triggers, and associated symptoms were obtained. Associated psychiatric disorders were also recorded. Data were analyzed using Microsoft Excel and statistical analysis was done using SPSS 22 trial version. Chi-square test and Fischer’s exact test were used for statistical analysis and subgroup comparison. Results: Out of 400 patients, 360 (90%) were found to have triggers. The mean headache intensity on visual analog scale (VAS) was 6.7. The most common trigger factor was emotional stress among both males and females. There was a statistically significant difference in the frequency of trigger factors between men and women for emotional stress, sunlight, sleep deprivation/insomnia, noise, weather change, studying, fried food, and hypersomnia. Psychiatric comorbidity was found in 29% of individuals, with sleep disorder being the most common. Conclusions: TTH has been an underrated diagnosis despite being an extremely common disorder. The trigger factors are less studied and their interactions are lesser known. The diagnostic criteria as per ICHD 3 make TTH a diagnosis of exclusion, rather than a positive diagnosis of inclusion. The trigger factors must be included in the diagnostic criteria in future versions of ICHD and associated psychiatric disorders should be sought for and treated simultaneously for better management and quality of life.

Comparison of laboratory-developed test & validated assay of programmed death ligand-1 immunohistochemistry in non-small-cell lung carcinoma

Background & objectives: Inhibitors of immune checkpoint regulators, programmed death-1 (PD-1) and programmed death ligand-1 (PD-L1), improve outcome in advanced non-small-cell lung carcinoma (NSCLC). Tumours expressing PD-L1 protein are more likely to benefit from this targeted therapy. Multiple concurrent clinical trials evaluating different anti-PD-1/PD-L1 therapies have validated five different immunohistochemistry (IHC) assays using varied antibody clones and staining conditions. This study was aimed at identification of a single harmonized PD-L1 assay for tumour tissue conservation and cost-effectiveness in patients with NSCLC. Methods: The performance of low-cost, manual, laboratory-developed technique (LDT) PD-L1 IHC assay using the easily available SP142 clone was compared with trial validated Ventana SP263 IHC performed on automated Ventana staining platform on tumour sections of NSCLCs. Results: Eighty cases of NSCLC were included. SP263 and SP142 stained both tumour cells and immune cells. The concordance rate of tumour cell staining was about 76 per cent, with SP263 detecting more tumour cells in 16 per cent of cases. The concordance rate of immune cell staining was only 61 per cent, with SP142 detecting more immune cells in 24 per cent of cases. The sensitivity, specificity, positive and negative predictive values of manual SP142 LDT assay against gold standard SP263 Ventana assay were 70, 94, 86 and 86 per cent, respectively, at positivity thresholds of ?1 per cent tumour cell staining. Interpretation & conclusions: The study findings suggested that LDT using SP142 clone showed only moderate concordance with SP263 Ventana assay, and the two assays were not interchangeable. More such validation studies need to be done to generate information that can complement patient therapy in cases of NSCLC.

Histotyping of Indian thymomas: A clinicopathologic study from north India

Background & objectives: Thymomas are rare, but most common anterior mediastinal lesions. The histomorphologic spectrum of thymic epithelial tumours (TETs) in Indian population has not been explored in depth. This study was aimed to assess the histomorphology of TETs in the Indian patients and correlate clinical parameters with pathological features. Methods: It was a retrospective study conducted in a tertiary referral hospital in north India. All morphologically confirmed cases of TETs since 2009 were included. Clinical details and histology slides were reviewed using the Modified Masaoka-Koga staging system and WHO 2015 classification. Clinicopathological correlation and survival analysis were done. A comparative review from other published Indian studies was performed. Results: A total of 219 cases of TETs (138 resections and 81 biopsies) were identified. The most common histomorphologic type was B2, and the most frequent stage was I. Types A/AB were common in older age (P<0.01). Clinically, higher stage tumours were found mostly in men (P<0.01), and these were Type B thymomas (P<0.01). Myasthenia gravis was more common in women (P<0.02) and in lower stages (P<0.05). Survival analysis revealed significant association between recurrence and tumour stage. Although thymic carcinoma was diagnosed on biopsy, no resectable case was identified. Interpretation & conclusions: Our findings showed that the thymomas in Indian patients were most commonly Stage I tumours of B2 and AB histotypes. Resected thymic carcinomas were conspicuously absent in our study. More studies need to be done to establish the frequency and biology of TETs from India.

A practical diagnostic approach to hepatic masses

The differential diagnosis of hepatic mass lesions is broad and arriving at the right diagnosis can be challenging, especially on needle biopsies. The differential diagnosis of liver tumors in children is different from adults and is beyond the scope of this review. In adults, the approach varies depending on the age, gender, and presence of background liver disease. The lesions can be divided broadly into primary and metastatic (secondary), and the primary lesions can be further divided into those of hepatocellular origin and nonhepatocellular origin. The first category consists of benign and malignant lesions arising from hepatocytes, while the second category includes biliary, mesenchymal, hematopoietic, and vascular tumors. Discussion of nonepithelial neoplasms is beyond the scope of this review. The hepatocytic lesions comprise dysplastic nodules, focal nodular hyperplasia, hepatic adenoma, and hepatocellular carcinoma, and the differential diagnosis can be challenging requiring clinicopathological correlation and application of immunohistochemical (IHC) markers. Liver is a common site for metastasis, sometimes presenting with an unknown primary site, and proper workup is the key to arriving at the correct diagnosis. The correct diagnosis in this setting requires a systematic approach with attention to histologic features, imaging findings, clinical presentation, and judicious use of IHC markers. The list of antibodies that can be used for this purpose keeps on growing continually. It is important for pathologists to be up to date with the sensitivity and specificity of these markers and their diagnostic role and clinical implications. The purpose of this review is to outline the differential diagnosis of hepatic masses in adults and discuss an algorithmic approach to make a right diagnosis.

Design and development of transdermal drug delivery system.

In the course of development of microspheres preparation techniques, the encapsulation of hydrophilic drugs with high entrapment efficiency has been a problem, as the commonly used technique like single emulsification technique and w/o/w double emulsification technique show low entrapment of the hydrophilic drugs. The problem is overcome by using by using w/o/o double emulsification technique, several modifications have been done in this technique one of most widely and effective technique in w/o/o double emulsification is the solvent diffusion technique. In this brief review comparison of w/o/o double emulsification technique with other methods and details about the w/o/o double emulsification technique and the drugs encapsulated using this technique will be discussed.

Cupriavidus pauculus (Ralstonia paucula) concomitant meningitis and septicemia in a neonate: First case report from India.

Ralstonia paucula (formerly classifi ed as CDC (Centre for Disease Control) group IVc-2, Wautersia paucula; recently renamed as Cupriavidus pauculus) is an environmental Gram-negative bacillus isolated from water sources and can cause serious human infections. Patients recover bacteriologically indicating low virulence. A total of 32 cases have been reported world-wide, but no isolation has ever been reported from cerebrospinal fl uid or in India. The fi rst case of R. paucula meningitis and septicemia is being reported here along with the brief summary of cases reported world-wide.

Use of John Cunningham virus polymerase chain reaction in the diagnosis of progressive multifocal leucoencephalopathy - A rare presenting manifestation in an HIV-positive patient.

John Cunningham virus infection is an important cause of progressive multifocal leucoencephalopathy (PML) in the context of advanced human immunodeficiency virus infection. Limited data are available regarding the true incidence of PML as a presenting manifestation of HIV. We report one such case and also highlight the effective use of polymerase chain reaction in confirming its diagnosis.

A comparative solubility enhancement study of rosuvastatin using solubilization techniques.

Solid dispersion of Rosuvastatin was prepared by solvent evaporation method; PEG (Polyethylene glycol) 4000, mannitol and urea were used as carriers. Hydrotropic studies were carried out using different hydrotropic agents (sodium acetate, sodium benzoate and salicylate) and Micellar solubilization was carried out using different surfactant solutions (sodium lauryl sulphate, tween 80 and cetrimide).The solubility enhancement of Rosuvastatin by different solubilization technique was observed in decreasing order as hydrotropic solubilization > solid dispersion > micellar solubilization. It was observed that the solubility increased with the increase in the concentration of hydrotropic agents and amongst the various hydrotropic agents used the solubility was Rosuvastatin was enhanced greatest to 55 folds with sodium salicylate. This increase may be attributed due to aggregation of the hydrotropic molecules and inclusion of one of these aggregates at high concentration probably by reacting to form an associated product as a result of hydrogen bonding.

Tobacco Control Policies in India: Implementation and Challenges.

Tobacco use is a major public health challenge in India with 275 million adults consuming different tobacco products. Government of India has taken various initiatives for tobacco control in the country. Besides enacting comprehensive tobacco control legislation (COTPA, 2003), India was among the first few countries to ratify WHO the Framework Convention on Tobacco Control (WHO FCTC) in 2004. The National Tobacco Control Programme was piloted during the 11 th Five Year Plan which is under implementation in 42 districts of 21 states in the country. The advocacy for tobacco control by the civil society and community led initiatives has acted in synergy with tobacco control policies of the Government. Although different levels of success have been achieved by the states, non prioritization of tobacco control at the sub national level still exists and effective implementation of tobacco control policies remains largely a challenge.

Antidiabetic activity of aqueous extract and non polysaccharide fraction of Cynodon dactylon Pers.

Petroleum ether (60 degrees-80 degrees C), chloroform, acetone, ethanol, aqueous and crude hot water extracts of the whole plant of C. dactylon and the two fractions of aqueous extract were tested for antihyperglycaemic activity in glucose overloaded hyperglycemic rats and in alloxan induced diabetic model at two-dose levels, 200 and 400 mg/kg (po) respectively. The aqueous extract of C. dactylon and the non polysaccharide fraction of aqueous extract were found to exhibit significant antihyperglycaemic activity and only the non polysaccharide fraction was found to produce hypoglycemia in fasted normal rats. Treatment of diabetic rats with aqueous extract and non polysaccharide fraction of the plant decreased the elevated biochemical parameters, glucose, urea, creatinine, serum cholesterol, serum triglyceride, high density lipoprotein, low density lipoprotein, haemoglobin and glycosylated haemoglobin significantly. Comparatively, the non polysaccharide fraction of aqueous extract was found to be more effective than the aqueous extract.

Levels of malondialdehyde and antioxidants in the blood of patients with vitiligo of age group 11–20 years.

The aetiopathogenesis of vitiligo has not been fully understood. To investigate the role of oxidative stress in pathogenesis of vitiligo, we examined the blood level of antioxidants and malondialdehyde in 40 patients with generalized vitiligo and 40 healthy volunteers belonging to same age group. Our results revealed that the level of malondialdehyde was significantly raised while those of vitamin E, uric acid and ceruloplasmin were significantly lowered (P<0.05) in patients with generalized vitiligo as compared to controls. This demonstrates the presence of an imbalance in the oxidant-antioxidant system in the blood of vitiligo patients and thus provides support for a free radical mediated damage as a pathogenic event in vitiligo.

Iron deficiency anaemia in sickle cell disorders in India.

BACKGROUND & OBJECTIVE: Iron deficiency anaemia (IDA) is uncommon in individuals with sickle cell disease (SCD) because of availability of an adequate iron source potentially from increased red cell turnover and from blood transfusions. Also, iron deficiency anaemia can often go unnoticed because the sickle cell disease patients are already anaemic. Iron deficiency in sickle cell patients may result in lowering the intracellular haemoglobin concentration and this may ameliorate sickling. The present study was undertaken to determine the prevalence of iron deficiency anaemia and the response of iron supplementation in sickle cell disorders in tribal population of the four States viz. Maharashtra, Gujarat, Orissa and Tamil Nadu. METHODS: A total of 8434 individuals (7105 AA, 1267 AS and 62 SS) were tested for zinc protoporphyrin/haem (ZPP/H) ratio and haemoglobin levels. Twenty two sickle cell anaemia (SS), 47 sickle cell trait (AS) and 150 normal control (AA) individuals who were iron deficient, were given iron therapy for a period of 12 wk and the laboratory investigations were repeated at the 13th wk. RESULTS: Sixty seven per cent of subjects with sickle cell anaemia and 26 per cent with sickle cell trait had elevated ZPP/H ratios (>80 micromol/mol) as against 22.8 per cent of normal individuals. The elevated ZPP/H ratios is an indicator of microcytic anaemia of iron deficiency. Following iron therapy, an improvement in the Hb levels and ZPP/H ratios was observed in both sickle cell disorders and normal individual cases. INTERPRETATION & CONCLUSION: This study suggests that iron deficiency anaemia is an important problem in Indian sickle cell anaemia patients and iron supplementation should be given only in proven cases of iron deficiency anaemia.

Increased yield of smear positive pulmonary TB cases by screening patients with > or =2 weeks cough, compared to > or =3 weeks and adequacy of 2 sputum smear examinations for diagnosis.

BACKGROUND: RNTCP recommends examining three sputum smears for AFB from Chest Symptomatics (CSs) with cough of > or =3 weeks for diagnosis of Pulmonary TB (PTB). A previous multi-centric study from Tuberculosis Research centre (TRC) has shown that the yield of sputum positive cases can be increased if duration of cough for screening was reduced to > or =2 weeks. Other studies have shown that two smear examinations are adequate for diagnosis of smear positive PTB . To validate the above findings, a cross sectional multi-centric study was repeated in different settings in five geographical areas in India. METHODS: Three primary and secondary level health facilities with high out-patient attendance were selected from two Tuberculosis Units (TU) in each of the 15 selected districts to screen about 10,000 new adult outpatients from each state. For patients who did not volunteer history of cough, symptoms were elicited using a structured simple questionnaire. All the CSs were referred for sputum examination. RESULTS: A total of 96,787 out-patients were registered. Among them 69,209 (72%) were new adult out-patients. Using > or =2 weeks of cough instead of 3 weeks as the criterion for screening, there was an overall increase of 58% in CS and 23% increase in the detection of smear-positive cases. Among 211 patients, 210 were positive at least by one smear from the initial two specimens. Increase in the work-load if 2 smears were done for patients with cough of > or =2 weeks cough were 2 specimens (i.e. 13 to 15) per day for an adult OPD of 150. CONCLUSION: The yield of sputum positive PTB cases can be improved by screening patients with > or =2 weeks cough and two specimens are adequate for diagnosis.