Amitesh Aggarwal

Indigenous Drugs in Ischemic Heart Disease in Patients with Diabetes

BACKGROUND India is currently facing the silent epidemic of ischemic heart disease, type 2 diabetes mellitus (T2DM), hypertension, and stroke. Both diabetes and ischemic heart disease appear in Indian people a decade earlier compared to whites. The recent evidence that certain medicinal plants possess hypoglycemic, lipid-lowering, and immunomodulating properties on account of their rich flavonoid and/or other glucose-lowering active constituents merits scientific scrutiny in this regard. OBJECTIVES The present communication aims to give a brief review of those plants that could be useful in T2DM associated with hypertension, ischemic heart disease, and/or dyslipidemia. METHODS Aegle marmelos (bael), Allium sativum (garlic), Curcuma domestica (turmeric), Eugenia jambolana (jamun), Murraya koenigii (curry leaves), Trigonella foenum graecum (fenugreek), and Terminalia arjuna (arjun) have been found to be useful in diabetes associated with ischemic heart disease. Their active biomolecules have been identified. They have also been demonstrated to be safe in long-term use. CONCLUSIONS Further clinical research regarding their potency and efficacy vis-à-vis oral hypoglycemics needs to done.

A retrospective case-control study of modifiable risk factors and cutaneous markers in Indian patients with young coronary artery disease.

Objective Indians have the highest risk rates for coronary artery disease (CAD) among all ethnic groups. There is a paucity of data on the risk factors and clinical markers associated with premature CAD. We aimed to determine whether young CAD is due to preventable lifestyle-related factors and cutaneous clinical markers are useful in identifying at-risk patients. Design Single-centre retrospective study. Setting Tertiary care center. Participants A total of 292 patients (age ≤40 years) who presented with acute CAD between January 2005 and June 2009 and 92 age, and gender-matched controls. Major outcome measures Details of smoking, family history of premature CAD, waist size, blood sugar and lipid profile. Clinical evidence of arcus juvenilis, premature greying of hair and premature baldness sought. Results Dyslipidaemia (91%), smoking (74.3%), low high-density lipoprotein cholesterol (HDL-C) (68.9%), central obesity (47.7%) and greying of hair (34.9%) were the most commonly associated factors. Compared with male patients, females had greater prevalence of dyslipidaemia, low HDL-C, central obesity, hypertension, diabetes and family history of premature CAD. The presence of cutaneous markers was significantly associated with premature CAD. Conclusions CAD in young Indian people is multifactorial; dyslipidaemia, low HDL-C, smoking, hypertension, central obesity and family history of premature CAD are the most common risk factors. Smoking in men and central obesity in women are the most prevalent factors. Clinicians should be highly suspicious of patients with presence of cutaneous markers, and they should be followed intensively for lifestyle modifications.

Evaluation of Geno Type MTBDRplus Line Probe Assay for Early Detection of Drug Resistance in Tuberculous Meningitis Patients in India

Background: Molecular methods which allow for rapid and reliable detection of drug resistance have yet not been sufficiently evaluated for timely management of patients with tuberculous meningitis. Aims: We aimed to evaluate Geno Type MTBDRplus line probe assay for early detection of drug resistance in Mycobacterium tuberculosis isolates and CSF samples of confirmed tuberculous meningitis patients. Settings and Design: This was a multicentric prospective study carried out from July 2011 to December 2013 in tertiary care hospitals of Delhi. Materials and Methods: The assay was performed on 89 M. tuberculosis isolates and 31 direct CSF samples from microbiologically confirmed tuberculous meningitis patients. The sensitivity and specificity of this assay was calculated in comparison to drug susceptibility testing by BACTEC MGIT 960 system. Results: The sensitivity, specificity for detection of resistance to Isoniazid was 93%, 97% and to Rifampicin was 80%, 98.8%, respectively by this assay in comparison with the phenotypic drug susceptibility testing. The line probe assay could detect M. tuberculosis in 55% of CSF samples from patients with microbiologically confirmed tuberculous meningitis. Only 5/89 isolates (5.6%) were resistant to both Isoniazid and Rifampicin while 9/89 (10%) isolates were additionally resistant to Isoniazid. Resistance to any of the drugs, namely Isoniazid, Rifampicin, Streptomycin or Ethambutol, was seen in 24.7% of strains. Conclusion: The line probe assay has a good sensitivity and specificity for detection of drug resistance to Isoniazid and Rifampicin in M. tuberculosis culture isolates. However, this assay has limited role in detection of M. tuberculosis and drug resistance from direct samples with confirmed diagnosis of tuberculous meningitis.

Helicobacter pylori: Does it add to risk of coronary artery disease

Helicobacter pylori (H. pylori) is a known pathogen implicated in genesis of gastritis, peptic ulcer disease, gastric carcinoma and gastric lymphoma. Beyond the stomach, the organism has also been implicated in the causation of immune thrombocytopenia and iron deficiency anemia. Although an area of active clinical research, the role of this gram negative organism in causation of atherosclerosis and coronary artery disease (CAD) remains enigmatic. CAD is a multifactorial disease which results from the atherosclerosis involving coronary arteries. The major risk factors include age, diabetes mellitus, smoking, hypertension and dyslipidemia. The risk of CAD is believed to increase with chronic inflammation. Various organisms like Chlamydia and Helicobacter have been suspected to have a role in genesis of atherosclerosis via causation of chronic inflammation. This paper focuses on available evidence to ascertain if the role of H. pylori in CAD causation has been proven beyond doubt and if eradication may reduce the risk of CAD or improve outcomes in these patients.

ASSOCIATION OF CAROTID INTIMA-MEDIA THICKNESS WITH LEPTIN AND APOLIPOPROTEIN B/APOLIPOPROTEIN A-I RATIO REVEALS IMMINENT PREDICTORS OF SUBCLINICAL ATHEROSCLEROSIS IN PSORIASIS PATIENTS

Psoriasis patients are often susceptible to cardiovascular diseases (CVD), including atherosclerosis. Traditional markers (biochemical and inflammatory) and diagnostic tools could detect occlusive but not subclinical atherosclerosis. Carotid intima-media thickness (CIMT), has recently been recognised as a non invasive diagnostic tool for identification of premature atherosclerosis. Therefore we evaluated 80 psoriasis patients and 80 age sex matched healthy controls for serum leptin levels and apolipoprotein B/apolipoprotein A-I ratio (apoB/apoA-I ratio) in relation with CIMT of carotid artery. Carotid intima-media thickness and carotid plaques were simultaneously measured by carotid sonography. Serum concentration of leptin and apolipoprotein were measured using enzyme-linked immuno sorbent assay (ELISA) and nephelometry respectively. Raised CIMT correlated to age of onset of the disease, serum leptin and apoB/apoA-I ratio in psoriasis patients. Taking into account, values that were above the 75 percentile of the three markers (leptin, apoB/apoA-I ratio and CIMT) the odds ratio was 4.26 (2.06-8.80 CI). Leptin and apoB/apoA-I ratio showed significant cumulative association with CIMT. Results of predictive analysis supports measurement of CIMT along with estimation of serum leptin and apoB/apoA-I ratio for prediction of premature atherosclerosis in psoriasis patients.

Cardiotoxicity from 'safe' herbomineral formulations.

Many herbomineral preparations are currently being used as therapeutic remedies for common ailments. Commonly known cardiotoxic herbs are Aconitum ferox (aconite), Areca catechu (betel nut), Thevetia peruviana (yellow oleander) and Cleistanus collinus (oduvan). Herbs mixed with lead, copper and/or mercury are known to be highly toxic. They produce cardiac arrhythmias, mainly ventricular ectopics, ventricular tachycardia and various degrees of arterioventricular (AV) blocks. We report 12 such successive cases where the patients developed vague feelings of discomfort, dizziness, chest discomfort and ventricular arrhythmias following herbal drug ingestion which warranted the immediate discontinuation of the drug. Three of the patients died. This paper emphasizes the risk of unsupervised use of herbomineral preparations by patients who believe that the remedies are always ‘safe’ and the urgent necessity for the pharmacognostic identification of the constituent herbs, their toxicological studies, uniform nomenclature, authenticity and standardization of plants and their parts before advocating them for therapeutic use.

Predisposing factors to premature coronary artery disease in young (age ≤ 45 years) smokers: a single center retrospective case control study from India.

Introduction: The role of the conventional risk factors in premature coronary artery disease (CAD) after eliminating the confounding variability of smoking has not been evaluated. This study was conducted to identify role of traditional risk factors in smokers with premature CAD. Methods: The case records of patients presenting acutely with premature CAD during the period 2007-2010 were analyzed retrospectively. Age, sex and smoking matched controls were selected from same time period. Data records were obtained for family history, alcohol, waist size, blood pressure, hypertension, blood sugar, lipid profile and presence of cutaneous markers for both groups and analyzed using statistical software. Results: 234 smokers with CAD and 122 smokers without CAD were included in groups 1 and 2, respectively. The patients in group 1 had significantly increased prevalence of hypertension, diabetes mellitus, metabolic syndrome, dyslipidemia and central obesity. There was no difference in prevalence of family history of CAD, arcus juvenilis and baldness. We found statistically significant association of hypertension, DM and metabolic syndrome in young smokers with premature acute CAD in Indian population as compared to young smokers without CAD. Conclusion: In young smokers, presence of hypertension, central obesity, diabetes mellitus and metabolic syndrome identifies a subset at increased risk for future acute CAD requiring more rigorous follow up and treatment.

Acute Pancreatitis in a Patient with Vivax Malaria

CONTEXT Acute pancreatitis is most commonly linked to gallstone disease or alcohol consumption. Occasionally it can follow infectious disease. Malaria, especially Plasmodium falciparum infection, has been associated with acute pancreatitis. CASE REPORT We present the case of a 17-year-old male who presented with a history of fever, abdominal pain and hypotension and revealing acute pancreatitis associated with infection by Plasmodium vivax. CONCLUSION Acute pancreatitis can accompany malaria, including Plasmodium vivax.

Newer perspectives of coronary artery disease in young

Coronary artery disease (CAD) occurring in less than 45 years of age is termed as young CAD. Recent studies show a prevalence of 1.2% of CAD cases in this age group. Ethnic wise south Asians especially Indians are more vulnerable to have CAD in young age group with a prevalence of 5% to 10%. Conventional risk factors such as smoking, diabetes, hypertension, obesity and family history seems to be as important as in older CAD subjects. But the prevalence of these risk factors seems to vary in younger subjects. By far the most commonly associated risk factor is smoking in young CAD. Several genes associated with lipoprotein metabolism are now found to be associated with young CAD like cholesterol ester transfer protein (CETP) gene, hepatic lipase gene, lipoprotein lipase gene, apo A1 gene, apo E gene and apo B. Biomarkers such as lipoprotein (a), fibrinogen, D-dimer, serum Wnt, gamma glutamyl transferase, vitamin D2 and osteocalcin are seems to be associated with premature CAD in some newer studies. In general CAD in young has better prognosis than older subjects. In terms of prognosis two risk factors obesity and current smoking are associated with poorer outcomes. Angiographic studies shows predominance of single vessel disease in young CAD patients. Like CAD in older person primary and secondary prevention plays an important role in prevention of new and further coronary events.

Acute viral hepatitis E presenting with haemolytic anaemia and acute renal failure in a patient with glucose-6-phosphate dehydrogenase deficiency.

The association of acute hepatitis E viral (HEV) infection with glucose-6-phosphate dehydrogenase (G6PD) deficiency leading to extensive intravascular haemolysis is a very rare clinical entity. Here we discuss such a patient, who presented with acute HEV illness, developed severe intravascular haemolysis and unusually high levels of bilirubin, complicated by acute renal failure (ARF), and was later on found to have a deficiency of G6PD. The patient recovered completely with haemodialysis and supportive management.