Malaysian parental attitudes toward medicine use in children.

INTRODUCTION: Parental attitudes can have a significant impact on the use of medicines in children. This study aimed to investigate parental attitudes towards medicines used in children in Malaysia and the sociodemographic factors associated with it. MATERIALS AND METHODS: A cross-sectional study using convenience sampling was conducted among 230 parents with children aged 12 years and below in Malaysia. Data were collected between November 2020 and January 2021 through online platforms. RESULTS: The majority of respondents were mothers (67.8%) and aged between 40-49 years (43.0%). The results showed that antipyretics were the most commonly used medicines followed by cough and cold medicines, antibiotics, and analgesics. The results further revealed that parents have neutral attitudes toward the use of medicines in children (69.90 ± 12.12 from a total score of 105), and mothers and younger parents having a significantly more positive attitude than fathers and older parents, respectively (p < 0.05). CONCLUSION: This study provided insights into the types of medicines commonly used in children and parental attitudes towards medicines used in children in Malaysia.

A New Discrete Analog of the Continuous Lindley Distribution, with Reliability Applications.

In this paper, we propose and study a new probability mass function by creating a natural discrete analog to the continuous Lindley distribution as a mixture of geometric and negative binomial distributions. The new distribution has many interesting properties that make it superior to many other discrete distributions, particularly in analyzing over-dispersed count data. Several statistical properties of the introduced distribution have been established including moments and moment generating function, residual moments, characterization, entropy, estimation of the parameter by the maximum likelihood method. A bias reduction method is applied to the derived estimator; its existence and uniqueness are discussed. Applications of the goodness of fit of the proposed distribution have been examined and compared with other discrete distributions using three real data sets from biological sciences.

Antibacterial activity and mechanism of action of chitosan nanofibers against toxigenic Clostridioides (Clostridium) difficile Isolates.

BACKGROUND: Clostridioides difficile a Gram-positive, obliged anaerobic, rod-shaped spore-former bacterium, causes a wide spectrum of diseases, ranging from mild, self-limiting diarrhoea to serious diarrhea. Chitosan, a natural polysaccharide, is largely known for its activity against a wide range of microorganisms. Chitosan, in the form of nanofibrils (nanofibrilated chitosan), consists of separated fibers which can be suspended easily in aqueous media. STUDY DESIGN: This paper, for the first time, aims to evaluate the antimicrobial activity of chitosan nanofibers against C. difficile isolates. METHODS: Chitosan nanofibers were characterized through scanning electron microscopy and atomic force microscopy. Minimum inhibitory concentration and minimum bactericidal concentration of chitosan nanofibers against toxigenic C. difficile isolates (with resistance gene: ermB, tetM and tetW) was determined by the standard broth microdilution method. RESULTS: The Miniumum Inhibitory Concentration of chitosan nanofibers for two toxigenic isolates with resistance genes ermB, tetM and tetW, two toxigenic isolates ermB+ tetM+ and the standard strain ATCC 700057 was similar and equal to 0.25 mg/mL. The minimum bactericidal concentration for all isolates was 0.5 mg/mL. CONCLUSIONS: The results demonstrated that chitosan nanofibers exhibit potent antimicrobial activities against multiple toxigenic C. difficile isolates, and the antibacterial effect of chitosan nanofibers against C. difficile isolates with ermB, tetM and tetW resistance genes indicates that interfering with the synthesis of proteins is not the mechanism of action of chitosan nanofibers.

Cardioprotective effects of irbesartan in polymicrobial sepsis : The role of the p38MAPK/NF-κB signaling pathway.

BACKGROUND: Sepsis is a systemic inflammatory response usually correlated with multi-organ failure. Myocardial dysfunction is one of the adverse outcomes in septic patients and results in high mortality rates. The aim of this study was to investigate the impact of irbesartan in attenuation of cardiac depression during polymicrobial sepsis via decreased activation of the phospho-p38MAPK/nuclear factor (NF)-κB signaling pathway. MATERIALS AND METHODS: A model of polymicrobial sepsis induced via cecal ligation and puncture (CLP) with 8- to 12-week-old albino mice was used. Mice were treated with i.p. irbesartan (3 mg/kg) 1 h before CLP. Using a micro-tipped transducer catheter, the following hemodynamic parameters were evaluated after CLP: heart rate, ejection fraction, left ventricular (LV) end-diastolic pressure, LV systolic pressure, and cardiac output. Plasma levels of proinflammatory cytokines, including tumor necrosis factor (TNF)-alpha, interleukin (IL)-1 beta, IL-6, monocyte chemoattractant protein-1 (MCP-1), and cardiac troponin I (cTn-I), were measured via ELISA analysis. The degree of p38MAPK and NF-κB phosphorylation was assessed via Western blotting. RESULTS: Mice treated with irbesartan displayed improvement in LV function (ejection fraction: 42.4 ± 1.1% vs. 27.8 ± 3% in CLP mice). The attenuation of cardiac depression in irbesartan-treated mice was associated with lower levels of MCP-1 in plasma and a reduction in the levels of TNF-alpha, IL-1beta, and IL-6. Furthermore, irbesartan-treated mice displayed lower expression levels of p38-MAPK and NF-κB phosphorylation. CONCLUSION: Irbesartan can attenuate cardiac dysfunction during polymicrobial sepsis possibly via a reduction of proinflammatory cytokines through decreased activation of the p38MAPK/NF-κB pathways.

Bacterial etiology and antibiotic resistance pattern of septicemia in HIV and non-HIV patients admitted to tertiary care hospitals, Shiraz, South of Iran.

The present study aimed to determine the bacteriological etiology and antibiotic susceptibility pattern of sepsis in HIV infected and HIV uninfected patients, and related risk factors to introduce an appropriate therapy. This cross-sectional study was conducted from January 2014 to January of 2015 enrolling patients with sepsis associated with or without HIV infection admitted to Shiraz teaching hospitals, South of Iran. Blood and urine cultures were performed and standard microbiological methods were followed for isolation and identification of the bacteria. HIV antibody testing and CD4+ lymphocyte count were done for HIV-infected patients. Antimicrobial susceptibility tests were performed using the disk diffusion method in accordance with CLSI recommendations. Totally, 140 patients with sepsis including 30 HIV-positive, and 110 HIV-negative were enrolled. Our finding showed 26.7% and 20% blood and urine culture positivity in HIV-positive and 20.9% and 14.5% positivity in HIV-negative patients. Staphylococcus aureus, Salmonella spp. and coagulase-negative staphylococci (CoNS) each with frequency of 25% were detected as the most prevalent isolates in samples of HIV patients. In contrast, the main etiology for sepsis in HIV-negative patients was CoNS (47.8%), followed by Escherichia coli (17.4%). The median of CD4+ lymphocyte count and viral load in HIV patients were estimated 10.15 cells/mm3 and 68019.48 copies/mL, respectively. The results of the present study revealed that the main cause of sepsis in the studied hospitals was nosocomial pathogens. These findings highlighted the importance of infection control policies for preventing the emergence and spread of nosocomial infections.

Physicochemical and functional properties of short-chain fatty acid starch modified with different acyl groups and levels of modification.

Rice and quinoa starches are modified with short-chain fatty acids (SCFA) with different SCFA acyl chain lengths and levels of modification. This work is aimed to investigate the impact of modifying rice and quinoa starches with short-chain fatty acids (SCFAs) on various physicochemical properties, including particle size, protein and amylose content, thermal behavior, pasting characteristics, and in vitro digestibility. Both native and SCFA-starches showed comparable particle sizes, with rice starches ranging from 1.58 to 2.22 µm and quinoa starches from 5.18 to 5.72 µm. SCFA modification led to lower protein content in both rice (0.218-0.255 %) and quinoa starches (0.537-0.619 %) compared to their native counterparts. Esterification led to the reduction of gelatinization and pasting temperatures as well as the hardness of the paste of SCFA-starches were reduced while paste clarity increased. The highest level of modification in SCFA-starch was associated with the highest amount of resistant starch fraction. Principal component analysis revealed that modification levels exerted a greater influence on starch properties than the types of SCFA used (acetyl, propionyl, and butyryl). These findings is importance in considering the degree of substitution or level of modification when tailoring starch properties through SCFA modification, with implications for various applications in food applications.

Advanced heart failure therapies in the Eastern Mediterranean Region: current status, challenges, and future directions.

While there has been a global decrease in rates of heart failure (HF) prevalence between 1990 and 2019, the Eastern Mediterranean region (EMR) is experiencing an increase. In 2019, approximately 1,229,766 individuals lived with moderate to severe HF in the EMR. Despite the growth in the utilization of advanced heart failure (AHF) therapies in the EMR in the past two decades, current volumes are yet to meet the growing AHF burden in the region. Heart transplantation (HT) volumes in EMR have grown from 9 in the year 2000 to 179 HTs in 2019. However, only a few centers provide the full spectrum of AHF therapies, including durable mechanical circulatory support (MCS) and HT. Published data on the utilization of left ventricular assist devices (LVAD) in the EMR are scarce. Notably, patients undergoing LVAD implantation in the EMR are on average, 13 year younger, and more likely to present with critical cardiogenic shock, as compared to their counterparts in the Western world. Furthermore, AHF care in the region is hampered by the paucity of multidisciplinary HF programs, inherent costs of AHF therapies, limited access to short and long-term MCS, organ shortage, and lack of public awareness and acceptance of AHF therapeutics. All stakeholders in the EMR should work together to strategize tackling the challenging AHF burden in the region.

Expert Recommendations to Bridge Gaps in Heart Failure Patient Support in the Middle East and Africa Region.

Heart failure (HF) remains a serious health and socioeconomic problem in the Middle East and Africa (MEA). The age-standardized prevalence rate for HF in the MEA region is higher compared to countries in Eastern Europe, Latin America, and Southeast Asia. Also cardiovascular-related deaths remain high compared to their global counterparts. Moreover, in MEA, 66% of HF readmissions are elicited by potentially preventable factors, including delay in seeking medical attention, nonadherence to HF medication, suboptimal discharge planning, inadequate follow-up, and poor social support. Patient support in the form of activation, counseling, and caregiver education has been shown to improve outcomes in patients with HF. A multidisciplinary meeting with experts from different countries across the MEA region was convened to identify the current gaps and unmet needs for patient support for HF in the region. The panel provided insights into the real-world challenges in HF patient support and contributed strategic recommendations for optimizing HF care.

Optimal stiffness of a pedicle-screw-based motion preservation implant for the lumbar spine.

PURPOSE: Pedicle-screw-based dynamic implants are intended to preserve intervertebral mobility while releasing certain spinal structures. The aim of the study was to determine the as yet unknown optimal stiffness value of the longitudinal rods that fulfils best these opposing tasks. METHODS: A finite element model of the lumbar spine was used which includes the posterior implant at level L4/5. More than 250 variations of this model were generated by varying the diameter of the longitudinal rods between 6 and 12 mm and their elastic modulus between 10 MPa and 200 MPa. The loading cases flexion, extension, lateral bending and axial rotation were simulated. Evaluated optimization criteria were the ranges of motion, forces in the facet joints, posterior bulgings of the intervertebral disc and the intradiscal pressures. Various objective functions were evaluated. RESULTS: The results show that the objective values depend more on the axial stiffness of the rods than on bending and torsional stiffness, rod diameter and elastic modulus. The optimal stiffness value for most of the investigated objective functions is approximately 50 N/mm and is achieved, e.g. using a rod diameter of 6 mm and an elastic modulus of 50 MPa. The design with the least axial stiffness was the best one with regard to the mobility. The forces in the facet joints and the intradiscal pressures were reduced mostly by an implant with the highest axial stiffness. When minimal posterior disc bulging was the criterion, the optimal axial stiffness was also approximately 50 N/mm. CONCLUSIONS: The optimal axial stiffness of a pedicle-screw-based motion preservation implant for the lumbar spine is approximately 50 N/mm.

Strategic Recommendations to Bridge the Gaps in Awareness, Diagnosis and Prevention of Heart Failure in the Middle East Region and Africa.

Objective: With the increasing burden of heart failure (HF) in the Middle East Region and Africa (MEA), it is imperative to shift the focus to prevention and early detection of cardiovascular diseases. We present a broad consensus of the real-world challenges and strategic recommendations for optimising HF care in the MEA region. Method: To bridge the gaps in awareness, prevention, and diagnosis of HF, an assembly of experts from MEA shared their collective opinions on the urgent unmet needs. Results: Lack of awareness in the community, high prevalence of risk factors, poor accessibility and affordability of care and diagnostics are the major barriers for delayed or missed diagnosis of HF in MEA. Enhancing patient awareness, through digital or social media campaigns, alongside raising knowledge of healthcare providers and policymakers with training programmes, can pave the way for influencing policy decisions and implementation of robust HF programmes. Multicountry registries can foster development of guidelines factoring in local challenges and roadblocks for HF care. Region-specific guidelines including simplified diagnostic algorithms can provide a blueprint of care for early detection of at-risk patients and facilitate efficient referral, thus mitigating clinician "therapeutic inertia." Multidisciplinary care teams and HF clinics with expanded role of nurses can streamline lifestyle modification and optimum control of dyslipidaemia, blood pressure, and glycaemia through guideline-recommended prevention therapies such as sodiumglucose co-transporter-2 inhibitors-thus supporting pleiotropic effects in high-risk populations. Conclusion: Development of regional guidelines, enhancing awareness, leveraging digital technology, and commitment for adequate funding and reimbursement is pivotal for overcoming structural and health system-related barriers in the MEA region.

Quorum-quenching activity of some Iranian medicinal plants.

Anti-quorum sensing (QS) or quorum quenching (QQ) is known as a new anti-bacterial strategy to combat bacterial infection. One of the best candidates for this strategy is a natural plant or traditional herbal medicine. This review aimed to summarize and introduce Iranian medicinal plants with anti-QS properties. Biomedical databases (PubMed, Scopus, Google Scholar and Web of sciences) were investigated to retrieve all related manuscripts published in English and Persian. Out of 65 documents, 47 papers were published during 2010-2020. We categorized and summarized 19 papers that particularly presented the anti-QS activity of Iranian medicinal plants. Based on our results, different studies have been completed on the QQ effects of medicinal plants. We identified 106 plant species with different properties in medicine that have been evaluated for anti-QS activities in Iran. The QQ effects of herbal extracts were identified through different in vitro examinations on biosensor and clinical bacterial strains. Only 35 medicinal plants have shown these effects at sub-MICs. Our review summarizes Iranian medicinal plants with anti-QS properties. Some of these herbal extracts showed anti-QS activity against biosensors, standard and clinical bacterial strains. This result is very important because QS systems can be considered as a new target for the development of new remedial strategies and it is a good opportunity to perform QQ studies to effectively combat bacterial infections in the future.

Renoprotective Potential of the Ultra-Pure Lipopolysaccharide from Rhodobacter Sphaeroides on Acutely Injured Kidneys in an Animal Model.

One of the main causes of acute kidney injury is ischemic reperfusion injury (IRI). Inflammatory response, apoptotic damages, and oxidative stress-related injuries are all involved in the pathogenesis of IRI. Toll-like receptors (TLR) are strongly associated with IRIs, especially TLR4, which is markedly induced in response to IRI. Accordingly, the current study aimed to investigate the potential renoprotective effect of ultrapure lipopolysaccharide from Rhodobacter sphaeroides (ULPS-RS) at two doses in an animal model of bilateral IRI. A total of 30 adult male rats were divided randomly into five equal groups of control (laparotomy plus bilateral renal IRI), vehicle (same as the control group, but pretreated with the vehicle), sham (laparotomy only), ULPS-RS (same as the control group, but pretreated with 0.1 mg/kg of ULPS-RS), and ULPS-RSH (same as the control group, but pretreated with 0.2 mg/kg of ULPS-RS). Subsequent to 30 min of ischemia and 2 h of reperfusion, serum samples were collected for measuring urea, creatinine, and neutrophil gelatinase-associated lipocalin. Afterward, tissue samples were obtained from all animals to measure inflammatory mediators (interleukin 6, interleukin 1ß, and tumor necrosis factor α), oxidative stress marker (8-isoprostane), apoptosis mediators (B cell lymphoma 2 [Bcl2]), and Bcl2-associated X protein (Bax). In the control group, all of the measured parameters were significantly elevated in response to IRI, except for Bcl2, which decreased significantly. On the other hand, exactly opposite effects were observed in the ULPS-RS treated groups indicating the nephroprotective effect of this compound against IRI at both tested doses. The findings reveal for the first time that ULPS-RS has the therapeutic potential of attenuating the renal dysfunction induced by IRI.

Effect of Lipopolysaccharide from Rhodobacter sphaeroides on Inflammatory Pathway and Oxidative Stress in Renal Ischemia/Reperfusion Injury in Male Rats.

Ischemia/reperfusion injury (IRI) is caused by a sudden temporary impairment of the blood flow to the particular organ. The IRI of the kidneys is one of the main causes of acute kidney injury. A vigorous inflammatory and oxidative stress response to hypoxia and reperfusion usually happens as IRI consequences that disturb the organ function. The current study aimed to investigate the effect of antagonizing toll-like receptors (TLRs) effects by lipopolysaccharide obtained from Rhodobacter sphaeroides (LPS-RS) on this critical condition. In total, 28 adult male Wistar rats were divided into four groups (n=7) as follows: the sham group which underwent only laparotomy; control group that underwent laparotomy and IRI induction; vehicle group which was similar to the control group plus vehicle treatment, LPS-RS group that was similar to the control group but was pretreated with 0.5 mg/kg of LPS-RS. The results of the current research showed that LPS-RS reduced interleukin-1ß, interleukin-6, tumor necrosis factor α, and 8-isoprostane levels, compared to the control IRI group. However, LPS-RS did not ameliorate the kidney injury as manifested by the elevated levels of urea, creatinine, and neutrophil gelatinase-associated lipocalin. Taken together, the present study demonstrated that LPS-RS at the tested dose failed to offer a renoprotective effect against the IRI in rats.

Euphlyctis Cyanophlyctis Schneider, 1799 (Amphibia: Dicroglossidae) in district Lower Dir, Pakistan.

Euphlyctis cyanophlyctis (the skittering frog) is one of the most widespread species in Pakistan. Present study was aimed to know the presence of Euphlyctis cyanophlyctis in urban and rural areas of Lower Dir, the North-western Pakistan. A total of 33 frogs were collected, including 15 from rural and 18 from urban areas. The frogs were caught by hands covered with gloves instead of using nets. The collection was managed from August to October 2016 and from April to May 2018. Morphometric analysis, coloration as well as photographs of the frogs have been provided in detail. Skittering frogs were seen frequent in swampy areas near the water bodies. These frogs were mostly seen after sunset.

Evaluation of quorum-sensing inhibitory effects of extracts of three traditional medicine plants with known antibacterial properties.

Today an alternative approach to control bacterial infections is the use of natural and traditional plant compounds to interfere with their quorum-sensing (QS) systems. In this study, antibacterial and anti-QS sensing activity of Syzygium aromaticum, Dionysia revoluta Boiss. and Eucalyptus camaldulensis Dehnh. were evaluated. These plants are local to the Middle East region and have since ancient times been used for their antibacterial activity. Plant compounds were extracted with n-hexane, methanol and 96% ethanol mixed solvent. Antibacterial activity of this herbal extracts against five Gram-negative and Gram-positive bacteria were assessed. The effective sub-minimum inhibitory concentration (MIC) of this extract on bacterial QS systems were investigated by a violacein quantification assay in the Chromobacterium violaceum CV026 biosensor strain, inhibition of exogenously QS signal molecules in Aeromonas veronii bv. Sobria strain BC88 and Pseudomonas aeruginosa isolated from a patient with cystic fibrosis in vitro. Results found that Syzygium aromaticum 0.39 to 0.048 mg/mL, Dionysia revoluta Boiss. 3.1 to 0.39 mg/mL and E. camaldulensis 0.78 to 0.097 mg/mL showed anti-QS activities by reducing the violacein formation depletion of QS signals produced in A. veronii and P. aeruginosa at sub-MICs. Regarding the anti-QS effects of these herbal extracts, their effective components may be candidates for use in combating bacterial infections at sub-MICs.

Characterization and antibiotic resistance pattern of diffusely adherent Escherichia coli (DAEC), isolated from paediatric diarrhoea in Shiraz, southern Iran.

Diarrhoea is a major health concern, especially in developing countries. Research has implicated diffusely adherent Escherichia coli (DAEC) strains as a cause of diarrhoea. In this study, we investigated the prevalence, adherence assay, virulence gene profiles and antimicrobial resistance of DAEC at a hospital in southern Iran. In this cross-sectional study, 309 infants and children under the age of 13 years with diarrhoea who had been referred to Shahid Dastgheib Hospital, Shiraz between October 2018 and May 2019 were recruited. Microbiological methods, PCR, HEp-2 adherence assay and antimicrobial susceptibility test were used. Of the 309 stool samples, 207 (66.9%) were found to contain E. coli by biochemical tests and culture. Molecular analysis of Afa/Dr and AIDA-I adhesin-encoding genes showed that 14 (6.7%) out of 207 E. coli isolates were DAEC. All DAEC isolates in HEp-2 cells showed a diffusely adherent pattern. The virulence genes sat, pet, sigA, pic, astA and fimH were found in 50%, 0%, 14.2%, 14.2%, 21.4% and 100% of DAEC isolates, respectively. The most effective antibiotic against the DAEC isolates was imipenem (92.8%) and the least effective was ampicillin (0%). Our findings expand the knowledge on DAEC prevalence and its characteristics in Iran. It also explains the role of virulence genes in DAEC pathogenesis. The results showed that although the prevalence of DAEC is low, these strains exhibit a high rate of antimicrobial resistance as well as high frequency for carrying virulence genes.

Characterization and stability of short-chain fatty acids modified starch Pickering emulsions.

Acetylated, propionylated and butyrylated rice and quinoa starches at different levels of modification and starch concentrations, were used to stabilize oil-in-water starch Pickering emulsions at 10% oil fraction. Short-chain fatty acid modified starch Pickering emulsions (SPEs) were characterized after emulsification and after 50 days of storage. The particle size distribution, microstructure, emulsion index, and stability were evaluated. An increase in starch concentration led to a decrease of emulsion droplet sizes. Quinoa starch has shown the capability of stabilizing Pickering emulsions in both the native and modified forms. The emulsifying capacity of SPEs was improved by increasing the chain length of SCFA. Modified quinoa starch with higher chain lengths (i.e. propionylated and butyrylated), at higher levels of modification, showed higher emulsion index (>71%) and stability over the entire 50 days storage. At optimized formulation, SCFA-starch particles have the potential in stabilizing emulsions for functional foods, pharmaceutical formulations, or industrial food applications.

Impact of anemia on the survival of patients undergoing radical cystectomy for bladder cancer. / Impacto de la anemia sobre la supervivencia de los pacientes intervenidos de cistectomía radical por tumor vesical.

OBJECTIVE: To evaluate the prevalence of preoperative anemia and its effect on oncological outcomes in patients undergoing radical cystectomy (RC) due to bladder cancer. MATERIAL AND METHODS: Retrospective single-center study with 176 RCs between May 2008 and July 2018. Anemia was defined according to the WHO classification (male<130mg/dL, female<120mg/dL). Kaplan-Meier test was used to estimate recurrence-free, cancer-specific and overall survival rates. Multivariate logistic regression was used to identify factors associated with overall mortality rates. RESULTS: Overall, 89 (50.6%) patients had preoperative anemia, and 44 of them (49.4%) received neoadjuvant chemotherapy. Anemic patients resulted in higher rates of ASA (ASA>2: 54.6 vs. 27.5%; P=.003), ectasia rate previous to RC (41.6 vs. 19.5%; P=.002), treatment with neoadjuvant chemotherapy (49.4 vs. 19.5%; P<.001), blood transfusion rate (25.8 vs. 11.5%; P=.015) and pathological stage (pT>2: 49.4 vs. 33.3%; P=.03) compared to non-anemic patients. Median follow-up was 27.2 months (IQR 11.12-72.28). Median overall survival (105 vs. 34 months, log-rank; P=.001), cancer-specific survival (89 vs. 61 months; P=.004) and recurrence-free survival (85 vs. 57 months; P=.002) were significantly lower in anemic patients compared to the non-anemic group. In multivariable Cox analysis, preoperative anemia, pT>2 and N≥1 were independently associated with overall mortality. CONCLUSION: Preoperative anemia was common in patients undergoing RC for bladder cancer, and it is related with a worse cancer prognosis. Anemia is a preoperative modifiable factor; we believe that the implementation of Patient Blood Management programs during prehabilitation may have a relevant role in improving the oncological outcomes in these patients.

Chronic systolic heart failure, guideline-directed medical therapy, and systemic hypotension-less pressure but maybe more risk (does this clinical scenario need more discussion?).

Many clinical trials have demonstrated the survival benefit of medication regimens that modulate the neurohormonal activation that occurs with chronic heart failure (HF). These medications, however, also commonly lower systemic blood pressure (BP). Low arterial BP in patients with chronic HF has been shown to be an independent predictor of increased mortality. Given this apparent paradox in therapeutic goals (treat aggressively but keep BP from going too low), how low should we allow systemic BP to go as a result of our medication regimens before we compromise the proven benefits of such drug therapy? Or is the association between the BP-lowering effects of standard therapy and outcomes in HF even meaningful clinically? It is from this perspective that the merits, potential clinical implications, and the relevant published literature pertaining to this patient and practice management issue will be discussed.

Comparison of the systemic levels of inflammatory markers after percutaneous coronary intervention with bare metal versus sirolimus-eluting stents.

BACKGROUND: Percutaneous coronary intervention (PCI) with bare metal stent (BMS) deployment causes plaque disruption and a rise in systemic levels of C-reactive protein (CRP), interleukin (IL)-6, and monocyte chemoattractant protein (MCP)-1. Our aim is to study whether PCI with sirolimus-eluting stent (SES) use attenuates this response. METHODS: Patients with stable angina undergoing single-vessel PCI were enrolled in a randomized, open-label fashion into a BMS group or an SES group. Blood samples were drawn pre-PCI, 24 hours post-PCI, and 30 days post-PCI. Systemic concentrations of CRP, IL-6, and MCP-1 were measured at all time points. RESULTS: In total, 41 patients were enrolled (21 in the BMS group and 20 in the SES group). The baseline plasma concentrations of all markers were comparable between groups. At 24 hours, the mean plasma CRP concentration in the SES group was 20.21 mg/dL versus 8.95 mg/dL in the BMS group (P = 0.15). The mean plasma IL-6 concentration at 24 hours was 25.41 pg/mL in the SES group versus 17.44 pg/mL in the BMS group (P = 0.17). The mean plasma MCP-1 concentration at 24 hours was 382.38 pg/mL in the SES group versus 329.04 pg/mL in the BMS group (P = 0.2). At 30 days, plasma concentrations of all three markers decreased to similar values between groups. CONCLUSIONS: The use of SES did not inhibit the rise in systemic concentrations of CRP, IL-6, and MCP-1 at 24 hours or 30 days post-PCI, compared with BMS. Moreover, at 24 hours, there was a trend for higher systemic levels of all proinflammatory markers in the SES group compared with the BMS cohort.