The association between blood pressure and long-term outcomes of patients with ischaemic cardiomyopathy with and without surgical revascularization: an analysis of the STICH trial.

Aims: Hypertension (HTN) is a well-known contributor to cardiovascular disease, including heart failure (HF) and coronary artery disease, and is the leading risk factor for premature death world-wide. A J- or U-shaped relationship has been suggested between blood pressure (BP) and clinical outcomes in different studies. However, there is little information about the significance of BP on the outcomes of patients with coronary artery disease and left ventricular dysfunction. This study aimed to determine the relationship between BP and mortality outcomes in patients with ischaemic cardiomyopathy. Methods and results: The influence of BP during a median follow-up of 9.8 years was studied in a total of 1212 patients with ejection fraction ≤35% and coronary disease amenable to coronary artery bypass grafting (CABG) who were randomized to CABG or medical therapy alone (MED) in the STICH (Surgical Treatment for Ischaemic Heart Failure) trial. Landmark analyses were performed starting at 1, 2, 3, 4, and 5 years after randomization, in which previous systolic BP values were averaged and related to subsequent mortality through the end of follow-up with a median of 9.8 years. Neither a previous history of HTN nor baseline BP had any significant influence on long-term mortality outcomes, nor did they have a significant interaction with MED or CABG treatment. The landmark analyses showed a progressive U-shaped relationship that became strongest at 5 years (χ2 and P-values: 7.08, P = 0.069; 8.72, P = 0.033; 9.86; P = 0.020; 8.31, P = 0.040; 14.52, P = 0.002; at 1, 2, 3, 4, and 5-year landmark analyses, respectively). The relationship between diastolic BP (DBP) and outcomes was similar. The most favourable outcomes were observed in the SBP range 120-130, and DBP 75-85 mmHg, whereas lower and higher BP were associated with worse outcomes. There were no differences in BP-lowering medications between groups. Conclusion: A strong U-shaped relationship between BP and mortality outcomes was evident in ischaemic HF patients. The results imply that the optimal SBP might be in the range 120-130 mmHg after intervention, and possibly be subject to pharmacologic action regarding high BP. Further, low BP was a marker of poor outcomes that might require other interactions and treatment strategies. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.

White collar rhabdomyolysis with acute kidney injury.

Rhabdomyolysis is a clinical syndrome resulting from the disintegration of muscle cell and spillage of toxic intracellular contents into circulation. Strenuous, unaccustomed exercise leads to exertional rhabdomyolysis and cause AKI. We report a 26-year-old female who developed white collar rhabdomyolysis with AKI after performing sit-ups (Super Yoga Brain) for 108 times in temple. She was managed with hemodialysis and supporting therapy. She made a full recovery after 4 weeks. Awareness of this condition and early diagnosis is highlighted.

Oral Hygiene Levels in Children of Tribal Population of Eastern Ghats: An Epidemiological Study.

BACKGROUND: Oral hygiene has been given due importance since ages. Different cultures have been using different methods for the maintenance of good oral hygiene. The study was done to find out the oral hygiene levels in children of tribal population and to correlate the brushing methods used and the oral hygiene levels. METHODOLOGY: A total of 5129 children of 5-12 years age (boys 2778, girls 2351) were checked for the simplified oral hygiene index in the study. RESULTS: The overall oral hygiene status of 1267 girls and 1348 boys was fair, whereas 821 girls and 937 boys was good and 263 girls and 493 boys was poor. It has been shown that fair oral hygiene practices were being followed by the children. CONCLUSION: Children using twigs and other materials for oral hygiene had nearly equally good oral hygiene when compared to the tooth brush and tooth paste, though children using toothbrush and tooth paste had slightly better oral hygiene.

Prevalence of gingival enlargement in Karnataka school going children.

BACKGROUND: Periodontal diseases affect more people all over the world than dental caries. Increase in size of gingiva is known as gingival hyperplasia or gingival enlargement. Gingival swelling is almost universally the result of Fluid accumulation within the tissues. Enlargement and even aesthetically disfiguring over growth of the gingival tissue, is also a common finding of leukemia, scurvy and subjects undergoing the hormonal changes of puberty, pregnancy, menopause and drugs. MATERIALS & METHODS: A sample size of 1500 was taken. All children who were between the chronological age of 5-12 years from selected schools were included in the study.Three age groups were selected for the study, Group I: 5-7yrs, Group II: 7-9 yrs, Group III 9-12yrs. Each group comprised of 500 students. The examination of gingival enlargement was made according to Gingival Enlargement Index. The oral hygiene status of the child was examined using Oral Hygiene Index-Simplified. RESULTS: The prevalence of Gingival Enlargement increased with the increase of age. Though the Prevalence of GE in female children (15.1%) was more than male children (13.4%), it was not statistically significant. Female children (1.6%) had a higher prevalence of epilepsy than male children (0.29%) in this present study. CONCLUSION: The prevalence of gingival enlargement was predominantly inflammatory, showing that the oral hygiene status of the oral Children in Karnataka was far from satisfactory. Further studies need to be undertaken regarding the prevalence if GE in School going children. How to cite the article: Krishna KB, Raju PK, Chitturi RR, Smitha G, Vijai S, Srinivas BV. Prevalence of gingival enlargement in Karnataka school going children. J Int Oral Health 2014;6(1):106-10.

Tobacco use, smoking quit rates, and socioeconomic patterning among men and women: a cross-sectional survey in rural Andhra Pradesh, India.

BACKGROUND: Tobacco use is common in India and a majority of users are in rural areas. We examine tobacco use and smoking quit rates along gender and socioeconomic dimensions in rural Andhra Pradesh. DESIGN AND METHODS: Data come from a cross-sectional survey. Markers of socioeconomic status (SES) were education, occupation, and income. Regression analyses were undertaken to examine determinants of current smoking, smoking quit rates, tobacco use by type (cigarettes, bidis, and chewing), and quantity consumed (number per day, pack-years). RESULTS: The weighted prevalence of current smoking and tobacco chewing was higher in men (50.3%, 95% confidence interval, CI, 48.1-52.6 and 5.0%, 95% CI 4.1-5.9, respectively) compared with women (4.8%, 95% CI 3.9-5.7 and 1.0%, 95% CI 0.6-1.4, respectively) and higher among older age groups. The quit rate was higher in women (45.5%, 95% CI 38.7-52.2) compared to men (18.8%, 95% CI 16.7-20.9). Illiterate individuals were more likely to be current smokers of any type compared to those with secondary/higher education (odds ratio, OR, 3.25, 95% CI 2.54-4.16), although cigarette smoking was higher in men of high SES. Smoking quit rates were positively associated with SES (OR 2.56, 95% CI 1.76-3.71) for secondary/higher education vs. illiterates. Level of consumption increased with SES and those with secondary/higher education smoked an additional 1.93 (95% CI 1.08-2.77) cigarettes or bidis per day and had an additional 1.87 (95% CI 0.57-3.17) pack-years vs. illiterates. CONCLUSIONS: The social gradients in cigarette smoking and level of consumption contrasted those for indigenous forms of tobacco (bidi smoking and chewing). International prevention and cessation initiatives designed at modifying Western-style cigarette usage will need to be tailored to the social context of rural Andhra Pradesh to effectively influence the use of cigarettes and equally harmful indigenous forms of tobacco.

Comparative analysis of colony counts of different species of oral streptococci in saliva of dentulous, edentulous and in those wearing partial and complete dentures.

OBJECTIVES: To study and compare the number of colony forming units of Streptococcus mutans, Streptococcus sanguis, Streptococcus salivarius, Streptococcus mitis and Streptococcus milleri in dentulous, edentulous and in those wearing partial and complete dentures by using semi-quantitative culture method of saliva samples with calibrated standard loop. MATERIALS: Sterile specimen collection bottles, Mitis salivarius agar plates, Standard loop, Candle jar, Incubator, Colony counter. METHODOLOGY: Study population consisted of 100 subjects with 25 in each group, with an age range of 40 to 80 years, who were attending the Department of Community Dentistry and Prosthodontics at MNR Dental College, Sangareddy, Hyderabad. Unstimulated saliva samples were collected from patients and inoculated on to Mitis salivarius agar plates using calibrated standard loop. The plates were then incubated anaerobically at 37°C for 24 hours and left at room temperature for further 24 hours. Using a colony counter, the number of colonies of each species was counted. RESULTS: Streptococcus mutans and Streptococcus mitis predominates in the dentulous group, Streptococcus sanguis in complete denture group, Streptococcus salivarius in edentulous group and Streptococcus milleri in removable partial denture group. CONCLUSION: The results of our study are in accordance with the previous studies, which have sought to differentiate different groups of mutans streptococci using a simple calibrated standard loop.

Socio-economic distribution of cardiovascular risk factors and knowledge in rural India.

BACKGROUND: To investigate the prevalence, screening and knowledge of cardiovascular risk factors (CVRFs) by socio-economic position (SEP) in rural India. METHODS: An age- and sex-stratified random sample of 4535 adults was recruited from rural Andhra Pradesh and a questionnaire was administered to assess prevalence, screening and knowledge of CVRFs and record recent attempts to modify behaviour. Education, income and occupation were used to measure SEP. RESULTS: Lower fruit intake and higher tobacco and alcohol use were found in those with lower SEP. Overweight, physical inactivity, diabetes, hypertension, family history of cardiovascular disease (CVD) and previous CVD (men only) were greater in higher SEP participants. Lower SEP participants had less blood pressure, glucose or cholesterol screening and less knowledge of nine CVRFs. Regardless of SEP, participants knowledgeable of the harms of a CVRF were more likely to have attempted to modify behaviour. For example, knowledge of benefits of smoking cessation was associated with an increased odds ratio (OR) for attempting to quit: in educated participants-OR 3.67, 95% confidence interval (CI) 2.10-6.42; in participants with no education-OR 3.98, 95% CI 2.27-6.97. CONCLUSIONS: Some biological CVRFs were worse in higher SEP participants while some behavioural risk factors were worse in lower SEP participants. Lower SEP participants had less CVRF screening and knowledge of CVRFs. Those with knowledge of CVRFs were more likely to make healthy behavioural changes. Our findings suggest equipping rural Indians with knowledge about CVRFs may ameliorate projected future increases in CVD.

Contribution of sudden cardiac death to total mortality in India - a population based study.

INTRODUCTION: Epidemiology of sudden cardiac death (SCD) in India is understudied. METHODS: We assessed proportion of SCD among total mortality in a population in Southern India using a staged, questionnaire-based kindred-wide approach. Detailed questionnaires (DQs) were completed by medical trainees from 8 medical colleges. Preliminary questionnaires evaluated total deaths in the kindred of a respondent. Deaths due to obvious non-cardiac causes were excluded. DQs were completed for the remaining deaths and categorized using a three-member adjudication system. RESULTS: A total population of 22,724 was evaluated by 478 respondents, (278 M and 200 F). Out of a total of 2185 deaths, 1691 (77.4%) were recallable. A total of 173 (10.3%; 128 M and 45 F; mean age - 60.8 ± 14 years) deaths were adjudicated as SCD. Of these, 82 (47.3%) were ≤ 60 years of age. Prior MI, LV dysfunction and prior aborted SCD were found in 33.5%, 22.5% and 5.7% respectively. Coronary artery disease (CAD) was observed in 66 (38%) and acute myocardial infarction documented in 30 (17%). At least 1 of 3 CAD risk factors - hypertension, diabetes, or smoking was observed in 80.6%. Proportion of subjects with at least one risk factor for CAD were similar in the age groups above and below 50 years (67.6% vs. 81.7%, p=0.065). CONCLUSIONS: SCD contributed to 10.3% of overall mortality in this population from Southern India. On an average, SCD cases were 5-8 years younger compared to populations reported in the western hemisphere, with a high prevalence of major risk factors for CAD.

Prevention of cardiovascular disease in a rural region of India and strategies to address the unmet need.

OBJECTIVES: To determine levels of cardiovascular disease (CVD) prevention and to model the potential impact of improved prevention strategies for a large rural Indian region. DESIGN: A cross-sectional study with modelling of coronary heart disease (CHD) events over 10 years. SETTING: Rural Andhra Pradesh, India. PARTICIPANTS: A stratified random sample of 1,079 adults 30 years and older. MAIN OUTCOME MEASURES: Proportion on medical and behavioural treatments for prevention of CVD; estimated number of CHD events using a locally recalibrated Framingham risk equation. RESULTS: Among the 3.5% (95% CI 2.1% to 4.9%) with existing CVD, 49.3% (95% CI 28.8% to 69.8%) were on blood pressure (BP)-lowering medication, 4.7% (95% CI 0 to 10.4%) were on cholesterol-lowering medication, 24.6% (95% CI 9% to 40.3%) had increased exercise and 26.9% (95% CI 2.6% to 51.1%) attempted to quit smoking. Among the 7.6% (95% CI 6.2% to 8.9%) with a high global CHD risk (>20% over 10 years), 29.5% (95% CI 19.5 to 39.5%) were on BP-lowering medication, 2.8% (95% CI 0 to 6.7%) were on cholesterol-lowering medication, 19.4% (95% CI 10.9% to 28%) had increased exercise and 24.8% (95% CI 15.8% to 33.8%) attempted to quit smoking. If confirmed drug therapies were provided to all individuals at high risk there would be a 28% reduction in cardiovascular events over 10 years at an approximate annual treatment cost of US$533 per event avoided. CONCLUSIONS: There are serious deficiencies in CVD prevention in rural areas of India. Addressing these with simple confirmed drug treatments could produce a large reduction in the future cardiovascular burden in India.

An international randomised placebo-controlled trial of a four-component combination pill ("polypill") in people with raised cardiovascular risk.

BACKGROUND: There has been widespread interest in the potential of combination cardiovascular medications containing aspirin and agents to lower blood pressure and cholesterol ('polypills') to reduce cardiovascular disease. However, no reliable placebo-controlled data are available on both efficacy and tolerability. METHODS: We conducted a randomised, double-blind placebo-controlled trial of a polypill (containing aspirin 75 mg, lisinopril 10 mg, hydrochlorothiazide 12.5 mg and simvastatin 20 mg) in 378 individuals without an indication for any component of the polypill, but who had an estimated 5-year cardiovascular disease risk over 7.5%. The primary outcomes were systolic blood pressure (SBP), LDL-cholesterol and tolerability (proportion discontinued randomised therapy) at 12 weeks follow-up. FINDINGS: At baseline, mean BP was 134/81 mmHg and mean LDL-cholesterol was 3.7 mmol/L. Over 12 weeks, polypill treatment reduced SBP by 9.9 (95% CI: 7.7 to 12.1) mmHg and LDL-cholesterol by 0.8 (95% CI 0.6 to 0.9) mmol/L. The discontinuation rates in the polypill group compared to placebo were 23% vs 18% (RR 1.33, 95% CI 0.89 to 2.00, p = 0.2). There was an excess of side effects known to the component medicines (58% vs 42%, p = 0.001), which was mostly apparent within a few weeks, and usually did not warrant cessation of trial treatment. CONCLUSIONS: This polypill achieved sizeable reductions in SBP and LDL-cholesterol but caused side effects in about 1 in 6 people. The halving in predicted cardiovascular risk is moderately lower than previous estimates and the side effect rate is moderately higher. Nonetheless, substantial net benefits would be expected among patients at high risk. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12607000099426.

Fatal and nonfatal cardiovascular disease and the use of therapies for secondary prevention in a rural region of India.

BACKGROUND: The rate of cardiovascular disease is widely considered to be increasing throughout India. Precise and reliable data on fatal and nonfatal cardiovascular disease, however, are few, and little is known about the use of preventive therapies. This is particularly true for rural regions. METHODS AND RESULTS: Data were collected from 53 villages in the Godavari region of Andhra Pradesh. Mortality data were obtained from a verbal autopsy-based mortality surveillance system during a 12-month period in 2003 to 2004. The prevalence of nonfatal cardiovascular disease and the use of preventive therapies were estimated from a stratified random sample of 4535 adults (> or =30 years of age) in 2005. Cardiovascular disease was the leading cause of mortality, accounting for at least 32% of all deaths. The average age at cardiovascular death was 65 years, and 51% of all cardiovascular deaths occurred in patients <70 years of age. Among adults, the prevalence of coronary heart disease was estimated to be 4.8% (95% CI, 4.1 to 5.5), and the prevalence of cerebrovascular disease was estimated at 2.0% (95% CI, 1.5 to 2.4). Among individuals with either diagnosis, 14% (95% CI, 10 to 18) reported taking aspirin, 41% (95% CI, 36 to 47) took a blood pressure-lowering medication, and 5% (95% CI, 3 to 7) reported using a cholesterol-lowering medication. CONCLUSIONS: This region has a large disease burden attributable to cardiovascular disease with significant underuse of proven, low-cost preventive medications.

Greater adverse effects of cholesterol and diabetes on carotid intima-media thickness in South Asian Indians: comparison of risk factor-IMT associations in two population-based surveys.

Asian Indians appear particularly susceptible to coronary heart disease compared with other ethnic groups. We compared the effects of vascular risk factors on carotid intima-media thickness (IMT) in a population of South Asians from Andhra Pradesh, India with a population of Caucasians from Perth, Australia. Cardiovascular risk factors and ultrasound-assessed carotid IMT were measured in randomly selected adults from two villages in rural India (n=303) and compared to those for randomly sampled adults from Australia (n=1111). Regression models with interaction terms were used to compare the strengths of associations between risk factors and carotid IMT, in these two populations. There were stronger associations of cholesterol (p for interaction=0.009) and diabetes (p=0.04) with carotid IMT in the Indian compared to the Australian population. Also, while increasing HDL-cholesterol was associated with decreasing carotid IMT in the Australian population the reverse was true for the Indian population (p<0.001). The associations with IMT of blood pressure, triglycerides, age, HDL to total cholesterol ratio, glucose, BMI, waist, waist to hip ratio and smoking were not different between the populations. Greater adverse effects of total cholesterol and diabetes on atherosclerosis and no protective effect of HDL-cholesterol amongst Asian Indians provide a novel possible explanation for observed excess rates of cardiovascular disease amongst these populations.

Effect of antiasthmatic medication on dental disease: dental caries and periodontal disease.

The prevalence of asthma has been increasing since the 1980s. Asthma and tooth decay are the two major causes of school absenteeism. There are few studies present in the literature. The objectives of the present study were to know the severity of dental caries and periodontal problems in children before and after taking antiasthmatic medication. The present study was conducted on 105, six- to fourteen-year-old asthmatic children to determine the condition of their dental caries and their periodontal status before and after taking antiasthmatic medication, for a period of 1 year and these were matched with their controls. The results showed that salbutamol inhaler shows increased caries rate with high significance over other groups, which was followed by salbutamol tablets and beclamethasone inhaler respectively. It has been concluded that antiasthmatic medication has its effects on dental caries and periodontal disease and asthmatic patients are recommended to adopt more precautionary oral hygiene practices and keep their caries activity and periodontal health under constant check.

Cardiovascular disease and risk factors among 345 adults in rural India--the Andhra Pradesh Rural Health Initiative.

BACKGROUND: Heart attack and stroke are problems already faced by some urban populations of India, but less is known about cardiovascular disease and risk factors in rural areas. The aim of the study was to investigate the levels and management of major cardiovascular risk factors and the prevalence of cardiovascular disease in two villages in rural Andhra Pradesh, India. METHODS: A cross-sectional survey was done by selecting a random sample stratified by age and gender from each village using census lists compiled in 2002. For each individual, trained study staff administered a Telugu-translation of a structured questionnaire, performed a brief physical examination and collected a fasting venous blood sample. Weighted estimates of mean (or percentages with) risk factor levels in the population were calculated and are reported with confidence intervals unless otherwise specified. RESULTS: Data was collected from 345 adults aged 20 to 90. The average household size was 4.2 and the mean combined household income was about Indian Rupees 25,454 (580 US dollars) per year. The mean systolic blood pressure was 116 (114-117) mm Hg, diastolic blood pressure 73 (114-120) mm Hg, total cholesterol 4.6 (4.5-4.7) mmol/L, HDL-cholesterol 0.8 (0.8-0.9) mmol/L, LDL-cholesterol 3.2 (3.1-3.3) mmol/L and triglyceride 1.3 (1.2-1.4) mmol/L. The prevalence of current smoking was 19.9% (15.4-24.4%), hypertension 20.3% (16.2-24.4%), diabetes 3.7% (1.8-5.5%), overweight 16.9% (12.3-21.5%) and obesity 4.4% (1.9-6.8%). A medical diagnosis of cardiovascular disease (previous heart attack, stroke or angina) was reported by 2.5% (1.1-3.9%) and a further 1.1% (0.1-2.1%) had angina by the 'Rose' classification. CONCLUSIONS: The possibility of increasing cardiovascular risk factors and prevalence of vascular disease in areas of rural India represent a public health concern. Larger and repeated epidemiological studies focusing on chronic diseases are required to inform treatment and prevention strategies suitable for use in these areas and other resource poor settings.