Predictive value of the PRAETORIAN score for defibrillation test success in patients with subcutaneous ICD: A subanalysis of the PRAETORIAN-DFT trial

BACKGROUND

The PRAETORIAN score estimates the risk of failure of subcutaneous implantable cardioverter-defibrillator (S-ICD) therapy by using generator and lead positioning on bidirectional chest radiographs. The PRospective randomized compArative trial of subcutanEous implanTable cardiOverter-defibrillatoR ImplANtation with and without DeFibrillation Testing (PRAETORIAN-DFT) investigates whether PRAETORIAN score calculation is noninferior to defibrillation testing (DFT) with regard to first shock efficacy in spontaneous events.

OBJECTIVE

This prespecified subanalysis assessed the predictive value of the PRAETORIAN score for defibrillation success in induced ventricular arrhythmias.

METHODS

This multicenter investigator-initiated trial randomized 965 patients between DFT and PRAETORIAN score calculation after de novo S-ICD implantation. Successful DFT was defined as conversion of induced ventricular arrhythmia in <5 seconds from shock delivery within 2 attempts. Bidirectional chest radiographs were obtained after implantation. The predictive value of the PRAETORIAN score for DFT success was calculated for patients in the DFT arm.

RESULTS

In total, 482 patients were randomized to undergo DFT. Of these patients, 457 (95%) underwent DFT according to protocol, of whom 445 (97%) had successful DFT and 12 (3%) had failed DFT. A PRAETORIAN score of ≥90 had a positive predictive value of 25% for failed DFT, and a PRAETORIAN score of <90 had a negative predictive value of 99% for successful DFT. A PRAETORIAN score of ≥90 was the strongest independent predictor for failed DFT (odds ratio 33.77; confidence interval 6.13-279.95; P < .001).

CONCLUSION

A PRAETORIAN score of <90 serves as a reliable indicator for DFT success in patients with S-ICD, and a PRAETORIAN score of ≥90 is a strong predictor for DFT failure.

The Zwolle experience with left bundle branch area pacing using stylet-driven active fixation leads

AIMS

Left bundle branch area pacing (LBBAP) is a novel physiological pacing modality and is regarded as a viable alternative to His bundle pacing. LBBAP has mostly been performed with the lumen-less permanent pacing lead (SelectSecure™ Model 3830, Medtronic, Inc.) with a fixed helix. The aim of this study was to compare the non-stylet driven lumen-less lead (LLL) (Medtronic 3830) with a standard stylet-driven active fixation lead (SDL) (Tendril™ STS Model 2088TC-38, Abbott Laboratories) in terms of lead parameters, procedural success and complication rates.

METHODS

Patients receiving a LBBA pacemaker in the Isala Hospital, The Netherlands, were prospectively enrolled. The majority received a standard right ventricular (RV) lead as backup, the implanter chose between LLL and SDL for the LBBAP lead.

RESULTS

The study included 94 patients with a mean follow-up of 30 weeks. 30/31 LLL procedures were successful, compared with 62/63 in the SDL group. Including the participants that lost LBBAP during follow-up resulted in success rates of 90.3% for LLL versus 96.8% for SDL, P = 0.199. Mean number of deployments was significantly lower in the SDL group compared with the LLL group (2 ± 2.3 versus 4 ± 3.4, P = 0.005), implantation and procedural times were comparable. Pacing thresholds were low and remained low in both groups (at last follow-up 0.8 ± 0.30 V for LLL versus 0.6 ± 0.20 V for SDL). Complication rates did not differ significantly between both groups, P = 0.805.

CONCLUSION

LBBAP using SDL is feasible and has comparable success rates with lower number of deployments of the active fixation screw.

Production, purification, and characterization of p-diphenol oxidase (PDO) enzyme from lignolytic fungal isolate Schizophyllum commune MF-O5

Fungi are producers of lignolytic extracellular enzymes which are used in industries like textile, detergents, biorefineries, and paper pulping. This study assessed for the production, purification, and characterization of novel p-diphenol oxidase (PDO; laccase) enzyme from lignolytic white-rot fungal isolate. Fungi samples collected from different areas of Pakistan were initially screened using guaiacol plate method. The maximum PDO producing fungal isolate was identified on the basis of ITS (internal transcribed spacer sequence of DNA of ribosomal RNA) sequencing. To get optimum enzyme yield, various growth and fermentation conditions were optimized. Later PDO was purified using ammonium sulfate precipitation, size exclusion, and anion exchange chromatography and characterized. It was observed that the maximum PDO producing fungal isolate was Schizophyllum commune (MF-O5). Characterization results showed that the purified PDO was a monomeric protein with a molecular mass of 68 kDa and showed stability at lower temperature (30 °C) for 1 h. The Km and Vmax values of the purified PDO recorded were 2.48 mM and 6.20 U/min. Thermal stability results showed that at 30 °C PDO had 119.17 kJ/K/mol Ea value and 33.64 min half-life. The PDO activity was stimulated by Cu2+ ion at 1.0 mM showing enhanced activity up to 111.04%. Strong inhibition effect was noted for Fe2+ ions at 1 mM showing 12.04% activity. The enzyme showed stability against 10 mM concentration oxidizing reducing agents like DMSO, EDTA, H2O2, NaOCl, and urea and retained more than 75% of relative activity. The characterization of purified PDO enzyme confirmed its tolerance against salt, metal ions, organic solvents, and surfactants indicating its ability to be used in the versatile commercial applications.

Role of Calcitonin and Strontium Ranelate in Osteoporosis

Background

Both Strontium Ranelate (SR) and Calcitonin (CT) can be used to treat osteoporosis. Calcitonin was actually one of the very initial medicines used to treat osteoporosis, especially in postmenopausal cases. However, the fracture prevention effect of Calcitonin is only proven to be in vertebrae and that too with nasal route only. When comparing Calcitonin with other conventional medications in treating osteoporosis, Calcitonin has got no additional advantages. Strontium Ranelate has got double effect, i.e., less bone resorption and more bone formation. Therefore, it can lead to an increase in bone mass significantly. Strontium Ranelate has been proven to decrease the risk of non-vertebral fractures as well as vertebral fractures.

Conclusion

Both Calcitonin and Strontium Ranelate are used only as a second-line therapy for the treatment of osteoporosis and not as first-line therapy, mainly because of their safety concern and also because they do not provide any advantages compared to other therapy for the treatment of osteoporosis.

Enhancement effect of AgO nanoparticles on fermentative cellulase activity from thermophilic Bacillus subtilis Ag-PQ

BACKGROUND

Cellulase is an important bioprocessing enzyme used in various industries. This study was conducted with the aim of improving the biodegradation activity of cellulase obtained from the Bacillus subtilis AG-PQ strain. For this purpose, AgO and FeO NPs were fabricated using AgNO3 and FeSO4·7H2O salt respectively through a hydro-thermal method based on five major steps; selection of research-grade materials, optimization of temperature, pH, centrifuge, sample washed with distilled water, dry completely in the oven at the optimized temperature and finally ground for characterization. The synthesized NPs were characterized by scanning electron microscope (SEM), energy dispersive X-ray (EDX), and X-ray diffraction (XRD) to confirm the morphology, elemental composition, and structure of the sample respectively. The diameter of the NPs was recorded through SEM which lay in the range of 70-95 nm.

RESULTS

Cultural parameters were optimized to achieve better cellulase production, where incubation time of 56 h, inoculum size of 5%, 1% coconut cake, 0.43% ammonium nitrate, pH 8, and 37 °C temperature were found optimal. The enhancing effect of AgO NPs was observed on cellulase activity (57.804 U/ml/min) at 50 ppm concentration while FeO NPs exhibited an inhibitory effect on cellulase activity at all concentrations. Molecular docking analysis was also performed to understand the underlying mechanism of improved enzymatic activity by nanocatalysts.

CONCLUSION

This study authenticates AgO NPs as better nanocatalysts for improved thermostable cellulase biodegradation activity with the extraordinary capability to be potentially utilized in bioethanol production.

Effects of Poultry Manure on the Growth, Physiology, Yield, and Yield-Related Traits of Maize Varieties

Industries play a significant role in the improvement of lifestyle and in the development of a country. However, the byproducts from these industries are a source of environmental pollution. The proper use of the byproducts of these industries can help to cope with environmental pollution. Some byproducts have high nutritional content and are good for crop plants. The purpose of this research was to investigate the effect of different rates of poultry manure on the soil chemical properties, growth, and yield of maize. A pot experiment was conducted in the botanical garden of the Department of Botany, University of Sargodha, Pakistan to investigate the effect of various treatments of poultry manure (0, 25, 50, 75, and 100 g/pot) on the morphological, physiological, and yield attributes of two maize varieties, Pearl and MMRI. Treatment T₁ was a mixture of soil and 75 g/pot poultry manure, T₂ was a mixture of soil and 50 g/pot poultry manure, T₃ was a mixture of soil and 25 g/pot poultry manure, and T₄ was 100 g/pot poultry manure. Soil without any industrial byproduct (100% soil only) was used as the control (T₀). The results revealed that the use of poultry manure enhanced the physical properties of the soil. Available P and soil organic matter were improved in soil amended with poultry manure. It is evident from the results that the vegetative growth of both maize varieties was significantly enhanced by growing in soil amended with poultry manure as compared to their respective control. Similar responses were also recorded for the physiological attributes of leaf area, photosynthetic rate, transpiration rate, stomatal conductance, and water use efficiency of both varieties. Yield and yield-contributing traits of both maize varieties were significantly improved by growing plants in soil amended with 50 and 75 g/pot of poultry manure. It is also inferred that the use of 50 g/pot poultry manure in soil amendment is an eco-friendly and economically effective option for maize growers of arid and semiarid regions to enhance the kernel yield and profit per annum. Poultry manure could be useful to ameliorate the adverse effects of salinity stress on all parameters, particularly the grain yield. Furthermore, this would be a useful and economical method for the safe disposal of byproducts.

School Health Education Program in Pakistan (SHEPP): findings from a feasibility trial in pre-adolescent school children from a lower middle-income country

BACKGROUND

The school environment plays an essential role in promoting health education and physical activity for children and adolescents. We aim to assess the feasibility of threefold health education program in children and its potential efficacy on physical activity and diet and cardiometabolic risk factors including blood pressure, body mass index (BMI), and waist circumference.

METHODS

The SHEPP was a parallel group feasibility intervention trial conducted in two schools over 23 months. All children aged 9-11 years enrolled in the schools were included. The SHEPP intervention comprised of health education on healthy lifestyle and physical activity sessions for children, training of teachers, and awareness sessions for parents conducted over 10 months. One school received the intervention of SHEPP while the other school continued routine activity. The primary outcome was the feasibility of SHEPP in terms of recruitment, retention, and treatment fidelity. Secondary outcomes were physical activity levels, dietary intake (of fruits and vegetables), and cardiometabolic risk factors (blood pressure, BMI, and waist circumference (WC)).

RESULTS

A total of 1280 preadolescent children were assessed for eligibility and 1191 were found eligible. The overall recruitment n (%) was 982/1191(82.5%) with 505(51.4) from SHEPP intervention school and 477(48.6) in routine activity school. The overall retention rate n (%) at 10-month follow-up was 912/982(92.8), with 465/505(92) in SHEPP intervention school and 447/477(93.7) in routine activity school. In treatment fidelity, 132/144(92) %). Physical activity sessions and all (100%) health education sessions were conducted for each of the twelve classes. Mean (SD) Seven-day Physical activity increased by 134 (196) min in the SHEPP intervention school v 29.8(177) in the routine activity school (P value < 0.001) from baseline to follow-up. Overall, there was an increase in vegetable intake (> 3 serving /day) in SHEPP intervention school of 5.5 to 21.4% from baseline to follow-up compared to 7.5 to 14.9% in routine activity school. The mean change (SD) in systolic blood pressure was 1.3(12) mmHg, 2.2(19.0) mm Hg in in diastolic blood pressure, - 0.09(5.4) kg/m² in BMI and 6.2 cm in waist circumference in the intervention arm versus - 3.4(11.1) mm Hg in SBP, - 4.3(9.9) mm Hg in DBP, - 0.04((4.6) kg/m² in BMI, and 3.8 cm in WC in the control arm.

CONCLUSION

We found that intervention using SHEPP is feasible in schools and may help children to adopt a healthy lifestyle as they age by increasing physical activity. However, the potentially beneficial effect on diet, MI, and BP needs further exploration and a longer follow-up, more specifically at the juncture of teenage and adulthood.

TRIAL REGISTRATION

NCT03303287.

Outcomes after primary intramedullary nail fixation of open tibial and femoral fractures in low resource settings

INTRODUCTION

Open fractures are unique in the urgency they impart to the injury and the therapeutic challenge they pose. Non-union and infection are among the major concerns. Open tibial and femoral shaft fractures are among the commonest orthopaedic urgencies. Primary intramedullary (IM) nailing requires a skillset and knowledge of the principles of open fracture management and also a well-equipped operating room with the necessary implants and instruments. In a low resource setting, one or more of these prerequisites may not be met, and the outcome may thus be affected similarly. The objective of this study was to study these outcomes.

METHODS

We prospectively studied primary IM nailing of open 1, 2 and 3A tibial and femoral fractures done in our hospital, in a simple non-modular operating room without an image intensifier.

RESULTS

There were 106 fractures in 104 patients: 93 tibial and 13 femoral. The mean time from injury to surgical debridement was 19.6 h. Mean duration of antibiotics therapy was 4.3 days, and the mean duration of hospital stay was 4.1 days. All patients were followed up to union. Mean time to radiographic union was 6.1 months for the tibia and 5.7 months for the femur. Non-union was seen in 4 tibial and 1 femoral fractures. There were 3 superficial infections but no deep infection.

CONCLUSION

The outcomes were comparable to, and in some cases better than, those found in existing literature. We conclude that primary IM nailing in open long bone fractures can be performed in austere environments with good success, in expert hands if the principles are adhered to.

Time to Reconsider the Inhaled Drugs for<br /> Tuberculosis

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Study of impacts of brickkiln emanations on soil quality of agriculture lands in selected areas of District Bhimber, Azad Jammu and Kashmir, Pakistan

The pollution is hot issue of current era in world and the current study was carried to explore impacts of brickkilns' emanations on physiochemical properties of agricultural lands from District Bhimber of Azad Jammu and Kashmir (AJK) Pakistan. In this research, various edaphic characteristics: pH, soil organic matter, organic carbon, water holding capacity, cation exchange capacity and heavy metal contamination in soils nearby of brickkilns were determined. The pH of soil ranged from 5.55 to 7.50, soil organic matter was 0.35-0.90% and organic carbon content was 0.65-1.40%. The water holding capacity ranged from 2.10 to 3.20 mgL-1 and carbon exchange capacity was 1250 to 4202 meq/100g. The contamination profile of heavy metal depicted that Pb showed highest conc. 0.065 mg/g followed by Co (0.053 mg/g) and Ni with 0.52 mg/g in the soil. Pb and Cr had high conc. in soil samples around brickkilns due to burning of coal and rubber tyres as fuel. The conc. of sulphate and nitrate ranged from 0.90±0.50 mol L-1 to 4.25±0.65 mol L-1 and 2.30±0.50 mol L-1 to 6.55±0.25 mol L-1, respectively. The fertility of agriculture lands was depicted that edaphic properties were directly related while nutritive features were inversely commensurate to distance from brickkilns. The research proved that emanations of brickkilns causes severe impact on quality of agriculture land, plant growth and its yield. Hence, reclamation measures should be taken to mitigate and/or eradicate nuisance of brickkilns emanations by using environmental friendly strategies.

An Investigation of Selected Socio-Demographic Factors with Aplastic Anemia in Pakistan: A Case-Control Study

Introduction

In Pakistan, the incidence rate of aplastic anemia is 3.5 cases/million. The associated risk factors are exposure to pesticides, chemicals, and some drugs. The link between aplastic anemia and socio-demographic factors is debatable.

Purpose

We conducted this study to investigate the role of socio-economic and -demographic factors with aplastic anemia.

Methodology

A total of 191 lab-confirmed incident cases of aplastic anemia were identified from the tertiary hospital of Karachi-Pakistan in between 2015 and 2018. Age and gender-matched 694 controls were randomly selected from the same institute admitted or visited for other non-neoplastic conditions. Socio-demographic and exposure information was gathered using a data collection form. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were computed for selected socio-demographic factors.

Results

Among socio-demographic factors, significant associations of aplastic anemia risk emerged for illiteracy (aOR: 2.3; 1.5; 3.5) occupation (any type) (aOR: 2.1; 1.7; 2.5), living in rural environments (aOR: 2.9; 1.9; 4.2). The odds of aplastic anemia increased with the age group 31–50 years (aOR: 1.8; 1.7; 3.5) and >50 years (aOR: 2.5; 2.1; 4.2). We observed no association of income with the risk of aplastic anemia.

Conclusion

This study highlights the importance of socio-demographic factors as a risk factor for the development of aplastic anemia in the population of Pakistan. In order to reduce disease incidence, health education program and use of personal protective equipment and organization of screening camps in high-risk population is warranted.

Lead extractions: dissecting adhesions up to the lead-tip of the right ventricle: safety and success-rates

AIMS

Goal of Transvenous Lead Extraction (TLE) is complete removal of all targeted leads, without complications. Despite counter traction manoeuvres, efficacy rates are often hampered by broken right ventricle lead (RV-lead) tips. Mechanically powered lead extraction (Evolution sheath) is effective, however safety of dissection up to the lead tip is unclear. Therefore, we examined the feasibility and safety of RV-lead extraction requiring dissection up to the myocardium.

METHODS AND RESULTS

From 2009 to 2018, all TLE in the Isala Heart Centre (Zwolle, The Netherlands) requiring the hand-powered mechanical Evolution system to extract RV-leads (n = 185) were examined from a prospective registry. We assessed 4 groups: TLE with the first generation Evolution (n = 43) with (A1,n = 18) and without (A2,n = 25) adhesions up to the myocardium and TLE with the Novel R/L type (n = 142) of sheath with (B1, n = 59) and without (B2, n = 83) adhesions up to the myocardium. Complete success rate in Group B was significantly higher than group A (96.5 vs 76.7%, p = 0.0354). When comparing the patients with adhesions up to the myocardium, total complete success is higher in the R/L group (61.1% vs 90.5%, p = 0.0067). There were no deaths. Overall major complication rates were low (2/185; 1.1%) and there was no statistically significant difference in major and minor complications between the two groups.

CONCLUSION

Extraction strategy with the bidirectional Evolution R/L sheath for right ventricular leads with adhesions up to the myocardium is safe and feasible.

Assessment of macronutrients consumption in the diet of adolescent school children in four seasons: a longitudinal study from an urban city in Pakistan

BACKGROUND

A healthy diet in the adolescence period is essential for physical, mental, and immunological development. We aimed to assess macronutrient consumption in the diet of adolescent school children using 24 h recalls in four seasons of the year.

METHOD

This was a longitudinal study conducted from February 2014 to June 2015. The study population included 155 school children aged 7-14 years from an urban school in Karachi. 24HR recall was conducted on 4 random days of the 4 main seasons. A food composition table was developed where the weight, calories, carbohydrate, fat, and protein content of the food items were listed. Macronutrients quantification was calculated by using proportional weight from the food composition table. Food groups were also assigned to each food item including vegetables, fruits, grains, protein foods, dairy products, and oils.

RESULTS

A total of 155 adolescent children aged between 7 and 14 years were approached. Out of the 155 preadolescents and adolescents, 150 (96.7%) agreed to participate. The mean (SD) age of the children was 11.31 (1.6) years, and 59% of all the children were males. Overall mean (SD) daily intake for all seasons was 195.31 (86.87) grams of carbohydrates, 94.77 (71.87) grams of proteins, and 55.87 (30.79) grams of fats. Carbohydrates formed 48.16%, protein 21.92%, and fat 29.93% of the total caloric intake. The mean (SD) daily caloric intake was 1517 (644) grams. Overall, the highest source of calories was from carbohydrate 781 (347) Kilocalories (Kcal), followed by fat 502 (277) Kcal and protein 379 (287). The Carbohydrate intake in 24 h was highest in the autumn; 212.81 (85.37), and there was a significant difference in carbohydrate intake in all seasons (p value 0.003). Consumption of discretionary food group was high (31.3%), and consumption of fruits and vegetables was low (29%).

CONCLUSION

The study reports a suboptimal caloric intake of fewer than 2000 cal/day among the adolescents from school. The highest source of calories was from carbohydrates.The highest consumption of food was in autumn and the least in summer. Fruits and vegetable intake was low, and discretionary food intake was high.

Lead In Food And Its Correlation With Blood Lead Levels Among Pregnant Women Of Sindh, Pakistan

BACKGROUND

With increasing control of lead (Pb) in gasoline, food has emerged as an important secondary pathway for Pb exposure globally. This study assessed Pb levels in food duplicates and blood. Furthermore, it assessed the correlation of Pb in food duplicates and blood Pb levels with common food items taken by pregnant women of Sindh, Pakistan.

METHODS

A cross-sectional study was conducted from August 2014 to November 2015, in urban (Karachi) and rural (Gambat, Khairpur) area of Sindh-Pakistan. A total of 103 venous blood samples (Karachi = 63 and Gambat = 40) of pregnant women were measured for blood Pb levels at the time of delivery. One month post-delivery, food frequency questionnaire (FFQ) was administered and three-day food duplicates (same number of cooked portions of food eaten by women) were collected. Food duplicates were analysed for Pb levels. Multivariable linear regression was conducted to identify the frequency of food items which contribute to blood and food Pb levels of pregnant women, separately.

RESULTS

With 90% confidence interval, chapati (local flat bread) (β=0.20, p<0.001), boiled rice (β=0.35, p<0.001), cooked root vegetables (β= 0.16, p=0.03), fried savory items (β=0.15, p=0.03), sweet snacks (β=0.13, p=0.08) were positively associated with elevated mother blood Pb levels. While cream biscuits (β =-0.14, p=0.04), lassi (blend of yogurt, water and spices) (β= -0.31, p<0.01), market milk desserts (β=-0.22, p<0.001), fish (β= -0.16, p=0.02), soft drinks (β= -0.19, p=0.01) and supari/gutka (betel-nut) (β=-0.13, p= 0.06) were negatively associated with mother Pb levels. Tetra-pak market juices (β= 0.30, p<0.001) and cooked root vegetables (β=0.19, p=0.05) were positively associated with mother food Pb levels, at 90% CI.

CONCLUSIONS

Bread, boiled rice, fried savoury items, sweet snacks and cooked root vegetables were contributing to blood Pb levels of pregnant women in Pakistan. These food items may be contaminated with Pb during processing, packaging and storage. Inverse relation of Supari/gutka and soft drinks with blood Pb levels may be due its overall reduction in absorption capacity of the gut for nutrients. Objective individual food item analysis for Pb is warranted for further intervention.

Significantly less inappropriate shocks in ischemic patients compared to non-ischemic patients: The S-ICD experience of a high volume single-center

BACKGROUND

The subcutaneous cardioverter-defibrillator (S-ICD) continues to be preferentially used in relatively young patients, with less advanced heart disease.

OBJECTIVE

We, therefore, studied the short and long-term efficacy and safety of the S-ICD in subgroups of patients, which are underreported at present.

METHODS

A total of 218 patients between November 2010 and February 2019 undergoing S-ICD with a follow up of at least 6 months implantation were included in a prospective registry. Mean follow up was 38 months.

RESULTS

The most common indication for S-ICD implantation was ischemic cardiomyopathy (n = 106, 49%). Complication rate needing invasive intervention was 9% (n = 21). Appropriate shock rate in patients with an S-ICD was 3.5%/year. A total of 30 inappropriate shocks (IAS) occurred in 19 patients (8.7%; 2.7%/year). The proportion of appropriate and inappropriate shock rates in patients with different cardiomyopathies shows remarkable variances. There were significant more IAS (3.6%/year vs. 1.7%/year, p = .048) in patients with non-ischemic cardiomyopathy versus patients with ischemic cardiomyopathy. Multivariate analysis identified, besides type of cardiomyopathy, atrial fibrillation (AF) as predictor for IAS.

CONCLUSION

In this real-world prospective registry we analyzed S-ICD performance in the more traditional ICD patient. Patients with ischemic cardiomyopathy had significantly less inappropriate therapy compared to patients with non-ischemic cardiomyopathy and appear to be appropriate patients for this type of device.

Inventorization of traditional ethnobotanical uses of wild plants of Dawarian and Ratti Gali areas of District Neelum, Azad Jammu and Kashmir Pakistan

BACKGROUND

An ethnobotanical expedition was conducted to document the traditional ethnobotanical (TEB) uses of wild flora of Dawarian and Ratti Gali villages of District Neelam, Azad Jammu and Kashmir (AJK) Pakistan. District Neelam has rich plant diversity and is hub of many endemic plant species while the study areas are not yet explored. The research area: Dawarian and Rati Gali (DRG) area is mountaineous terrain and villages are located on far and farther distances. DRG area has rich biocultural and plant diversity comprising of different ethnic groups of Kashmir state. The current research was aimed to explore and document traditional medicines (TEMs) and other domestic and commercial uses of wild plants. This study will assist to evaluate conservation and commercial worth of wild flora which can be potential candidate for drug discovery through ethnopharmacological analysis.

METHODS

The current quantitative ethnobotanical research was carried out in 2018 by interviewing 150 indigenous informants (90 male and 60 female) of DRG area using questionnaire applying structured and semi structured interview methodology. Data analysis was analyzed by using quantitative ethnobotanical statistical tools such as fidelity level (FL), informant consensus factor (ICF), Spearman's rank correlation (SRC) and data matrix ranking (DMR).

RESULTS

The indigenous people of DRG area use wild plants in their daily life to cope life necessities i.e. food, vegetables, fodder, fuel, shelter, timber and herbal medicines. TEMs are primarily used to cure different infirmities like diabetics, asthma, dysentery, constipation, cold, fever, joint pain, wound healing, cancer, cardiovascular disorders, epilepsy, kidney infections and many types of skin diseases. Current study revealed the data of 103 wild plants species belonging to 46 plant families from selected areas of District Neelum, AJK. Results depicted that Asteraceae ranked 1st (12 plants spp). Among plant parts used leaf ranked 1st (18%), followed by seed (17%) and root (13%). While prevalent form recipe mode was decoction (20%), followed by powder (17%) and extract (14%) and fodder was highest (37%) EB use-form fodder, followed by food (32%) and fuel (17%). Quantitative ethnobotanical analysis (QEA) was carried to find the reliability and novelty of the study. Five plant species including Berberis lyceum (FL = 97.78%), Isodon rugosus (FL = 95.71%), Saussurea lappa (FL = 94.74%), Aconitum heterophyllum (FL = 92.71%) and Taxus baccata (91.58%) had shown high fidelity level which confirmed that these plants have high medicinal worth in study area. The highest value (0.94) of ICF was for diseases group "tuberculosis and leucorrhea", followed by stomachache and flatulence (0.93), diabetics and blood pressure (0.92) and asthma and chest infections (0.88). For other uses fuel with ICF (0.83) ranked first and second was hedging and thatching (ICF = 0.82) where people use plants or their parts for construction. Spearman's rank correlation (SRC) test indicated that number of TEB uses increases if number of species is increased. Jaccard index (JI) analysis depicted that 56.31% plants are being used as TEMs which are first time explored from the study area. While 26.21% plants are being used in different TEB uses which are different from past cited literature. These novel findings of research indicate that wild flora of the study area has great potential for novel drug discovery and provision of materialist services for the indigenous communities.

CONCLUSION

The present research revealed that TEMs uses of 58 plants are novel being first time reported from the study area (DRG) of District Neelam of AJK. The results showed that plants like Acer cappadocicum, Ajuga bracteosa and Swertia paniculata are used to cure diabetes, Viscum album, Viola canescens, Taxus baccata are used for cure of cancer, Isodon rugosus, Polygala chinensis are used in TEMs for treating cardiovascular disorders and Anaphalis triplinervis is used for epilepsy. Berberis lyceum, Ajuga bracteosa, Aconitum heterophyllum, Bistorta amplexicaule, Saussurea lapa and Jurinea dolomiaea are severely threatened and there is urgent need to do conservation measures for available of valuable MPs to the indigenous communities for life necessities and for future research. The current study will also be useful addition in ethnobotanical database, preservation of traditional culture and drug discovery and drug development through future ethnopharmacological research.

Ethnomedicinal and folklore inventory of wild plants used by rural communities of valley Samahni, District Bhimber Azad Jammu and Kashmir, Pakistan

The current study describes ethnobotanical (EB) and traditional ethnomedicinal (TEMs) uses of medicinal plants (MPs) of Tehsil Samahni area of Azad Jammu and Kashmir, Pakistan. Indigenous inhabitants of the area mostly reside in remote mountainous areas and depend on wild plants for life necessities and treatment of different diseases. This paper presents first quantitative ethnobotanical study describing the popularity level of MPs in indigenous communities by using relative popularity level (RPL) and rank order of priority (ROP) indices. The data of TEMs and EB uses were collected from 200 interviewees consisting of traditional herbal practioners (110) and farmers (90) from study area using structured and semi-structured interview methodology during year 2019. It was found that illiterate peasants have more knowledge and practice of TEMs than other people. A total of 150 plant species belonging to 58 families with botanical and local names, parts used, mode of recipes preparation, administration mechanism and TEMs uses were documented in systematic manner. It was explored that highest number (7.69%) of plants of Moraceae were used in TEMs and followed by species of Asteraceae (6.29%). The ethnobotanical data was analyzed by using quantitative ethnobotanical tools viz: informant consensus factor (ICF), fidelity level (FL), relative frequency of citation (RFC), use value index (UVI), relative importance of plants (RIP), relative populatiry level (RPL) and rank order of popularity (ROP). The leaf ranked first (36.49%) and fruit 2nd (12.07%) being used in TEMs while prevalent use-form was decoction (29.28%), followed by tea (23.05%) and preferably taken as oral (46.66%). ICF analysis proved that diabetes, hypertension, rabies, snake sting and joint pains were the most prevalent occurring infirmities. The highest RFC (0.95) was found for Acacia modesta, followed by Boerhavia procumbens (RFC:0.87) and Berberis lycium (RFC:0.85). The relative importance of MPs was calculated by using UVI and Moringa oleifera showed highest (1.38), followed by Zanthoxylum armatum (1.25) and Withania somnifera (1.24) use-values. High UVI of plants depicts that these species are predominantly used in local health care system. The plants Phyllanthus emblica, Morus macruora, Justicia adhatoda and Melia azedarach depicted high values (1.00) of FL and RPL proving that these taxa are commonly used in indigenous medicines by local inhabitants and have better potential for drug discovery by ethnopharmacological analysis. Out of total, 26 species had more than 50% ROP index and Phyllanthus emblica and Flacourtia indica (ROP = 100) followed by Morus macruora (ROP: 97) were used to cure 'hypertension and hyperlipidemia' and 'cough, chest infection', respectively. It was found that 30% of total species were previously reported as medicinal while 70% plants were first time reported to be used in TEMs and authenticated by using of quantitative ethnobotanical tools. Ethnopharmacological potential of indigenous plants was confirmed by RIP and RPL indices which had been used to cure one or more body systems and were promulgated in the local herbal medicine system. The research provides clues to screen these plant species by using latest phytochemical and pharmacological analysis for novel drug discovery. This study will also be useful for conservation of bioculture traditional knowledge of indigenous communities and the most important is to conserve medicinal plants of the study area for future generations.

War-Related Mental Health Issues and Need for Yoga Intervention Studies: A Scoping Review

Conflicts and humanitarian crises lead to serious mental health disorders, including depression, anxiety, stress, and cognitive decline. Exposure to these circumstances in early life can lead to the development of disorders such as mild cognitive impairment, dementia, and Alzheimer's disease (AD), for which no treatments are available. In this review, various research papers have been compiled to develop an understanding about mental health of population affected due to wars and conflicts and how stress and depression can accelerate the development of dementia and AD. Due to failure of drugs in the treatment of dementia and AD, yoga and mindfulness-based approach has been proposed for future investigations. Although studies have shown that yoga and mindfulness can be helpful in the management of stress, anxiety, depression, and posttraumatic stress disorder in the war-afflicted areas, limited mechanistic studies in yoga and mindfulness remain the chief cause precluding its clinical application in such warzones. The molecular studies in the field of yoga can be undertaken by targeting these warzones. This review provides a scientific evaluation of mind-body techniques as a justification for mental health rehabilitation in the war-afflicted zones in face of failed clinical trials for various drugs. This may help reduce the risk of developing dementia and AD in this susceptible population.

Alkaline lipase production by novel meso-tolerant psychrophilic Exiguobacterium sp. strain (AMBL-20) isolated from glacier of northeastern Pakistan

Lipase is an important commercial enzyme with unique and versatile biotechnological applications. This study was conducted to biosynthesize and characterizes alkaliphilic lipase by Exiguobacterium sp. strain AMBL-20^T isolated from the glacial water samples of the northeastern (Gilgit-Baltistan) region of Pakistan. The isolated bacterium was identified as Exiguobaterium sp. strain AMBL-20^T on the basis of morphological, biochemical, and phylogenetic analysis of 16S rRNA sequences with GenBank accession number MW229267. The bacterial strain was further screened for its lipolytic activity, biosynthesis, and characterization by different parameters with the aim of maximizing lipase activity. Results showed that 2% Olive oil, 0.2% peptone at 25 °C, pH 8, and 24 h of incubation time found optimal for maximum lipase production. The lipase enzyme was partially purified by ammonium sulphate precipitation and its activity was standardized at pH 8 under 30 °C temperature. The enzyme showed functional stability over a range of temperature and pH. Hence, extracellular alkaliphilic lipase from Exiguobacterium sp. is a potential candidate with extraordinary industrial applications, particularly in bio-detergent formulations.

School health education program in Pakistan (SHEPP)-a threefold health education feasibility trial in schoolchildren from a lower-middle-income country

Background

The school environment plays an essential role in promoting health education and physical activity for children and adolescence, and they are more likely to adapt it into their adulthood. School health education program has been endorsed and emphasized by the World Health Organization has not been implemented in true spirit in Pakistan yet. We aim to test feasibility of threefold health education program in children and its potential efficacy on physical activity and diet and cardiometabolic risk factors by including BP, BMI, and waist circumference.

Methods

It is a parallel-group feasibility intervention trial. It is being conducted in two schools from lower to middle-income areas, at different locations but having the same school curriculum under the Aga Khan Education Service, Pakistan (AKESP). All children aged 9-11 years enrolled from the schools mentioned above were included. Children with any physical disability were excluded. One school received threefold intervention (focused on children, parents, and teachers) of school health education program in Pakistan (SHEPP) while the other school continued routine activity. Intervention of SHEPP is directed towards educating children, parents, and teachers about healthy behaviors. Children will receive interactive educational sessions and specially designed physical activity sessions. A 3-h health education session focusing on same healthy behaviors as for children will be conducted for both parents and teachers. Primary outcome is feasibility of SHEPP in terms of recruitment, retention, and treatment fidelity. Secondary outcomes are physical activity levels, dietary intake (of fruits, vegetable), and cardiometabolic risk factors (blood pressure, BMI, and waist circumference (WC)). The total number of children recruited were 982 (82.5 %); 505 from school A and 477 from school B and 496 (50.5) were boys.

Conclusion

SHEPP is a unique health education program for children as it focuses on children while involving the parents and teachers in the behavior change process. If found feasible and demonstrating potential efficacy on physical activity, dietary behaviors, and cardiometabolic parameters, we will be able to replicate this on a larger scale in public sector schools also.

Trial registration

NCT03303287

Effectiveness of Yoga as the Public Health Intervention Module in the Management of Diabetes and Diabetes Associated Dementia in South East Asia: A Narrative Review

BACKGROUND

Diabetes mellitus (DM) is widely spread in South Asian (ASEAN) and Indian sub-continent. The increasing healthcare costs of DM can be prevented in the developing world by improved public healthcare interventions. Modifiable risk factors of DM like sedentary lifestyle, obesity, and stressful conditions are associated with its progression; however, the epidemiological data collected by Public Institutions are limited.

SUMMARY

A review of published literature describing geographic distribution of DM and associated dementia in South Asian region, particularly India, was conducted with the purpose of assessing the feasibility and challenges associated with the Yoga-based risk reduction. PubMed and Google Scholar databases were searched for DM and dementia-related articles by using a combination of keywords: Diabetes, Diabetes related Dementia Southeast Asia, Pre-diabetes, Yoga, lifestyle modification, Dementia and Exercise. The epidemiological data generated from these diseases have not prompted to any major public health policies. Yoga can be a cost-effective intervention for the prevention of Type 2 DM (T2DM) and its associated cognitive decline when detected early. If nationwide intervention of Yoga is brought about by the state, its integration in health care will become more meaningful and acceptable. Key Message: Studies suggest that Yoga and change in lifestyle can modify the health risks associated with T2DM and associated dementia if it is mainstreamed with the public health initiative of Ayushman Bharat scheme.

Effect of Endoxylanase and Iron Oxide Nanoparticles on Performance and Histopathological Features in Broilers

Endoxylanase enzyme is used as poultry feed additive to degrade anti-nutritional factors like non-starch polysaccharides. Moreover, iron is one of the most important trace elements, and its deficiency can lead to various pathological conditions and stunted growth. In the current study, a combination of xylanase and iron nanoparticles is used to assess the overall effect on poultry growth. Endoxylanase enzyme was obtained from Aspergillus awamori SAIB-17 (identified on the basis of internal transcribed spacer (ITS) sequence analysis). The characterization of purified endoxylanase revealed that the K_m and V_max were 0.25 g/ml and 833.33 nkat/ml/s, respectively. Effect of pH and temperature showed that pH 4.5 and temperature 45 °C was best for enzyme activity. Iron nanoparticles were synthesized by co-precipitation of ferric chloride and ferrous chloride. Characterization of nanoparticles using X-ray diffraction (XRD) and SEM revealed that the mean diameter of synthesized iron nanoparticles was around 50 nm. These nanoparticles have no inhibitory effect on endoxylanase up to concentration of 20 ppm. Iron oxide nanoparticles along with endoxylanase were used as additives in different concentrations and were fed to the groups of broiler chicks. It was observed that the group fed with 40 nkat of endoxylanase and 15 ppm of iron nanoparticles showed 54.5% (2010 ± 103.58) more weight gain by the fifth week as compared with the control group. The iron analysis in the muscles showed no increase in iron concentration while histopathology slides showed no morphological changes in liver cells. The combination of iron oxide nanoparticles and xylanase proved to have great potential to be used in poultry feed for large-scale meat production without any toxicological effects.

Probing into Therapeutic Anti-cancer Potential of Apigenin: Recent Trends and Future Directions

Background:

Natural products represent a therapeutic option for the treatment of inflammation- associated diseases. Flavonoids which are one of the special categories of such natural products, have previously shown promising therapeutic potential.

Objectives:

The current review discusses the synthetic preview and anti-inflammatory potential of apigenin along with the underlying molecular mechanism in chronic human diseases especially cancer. In addition, the relevant patents on the therapeutic potential of apigenin have also been mentioned.

Methods:

A literature search was carried out using PubMed/Science, Google Scholar, etc. which was further expended by the different combination of keywords: apigenin, inflammation, mechanism, therapeutic potential, cancer, etc. Patent information was retrieved by searching the key terms: apigenin, inflammation, therapeutic potential from various databanks including Espacenet, Google Patents, Free Patents Online and Mendeley of WIPO, USPTO, SIPO, JPO, KIPO and EPO databases.

Results:

A total of 76 references have been found relevant with the theme of the manuscript. These citations have described recent ongoing advances in the area of inflammation and cancer with respect to apigenin.

Conclusion:

Studies related to the anti-inflammatory and anticancer potential of apigenin have been explored through this review article. Moreover, the patent analysis of apigenin has further strengthened its therapeutic role. Probing into the therapeutic properties of apigenin, further adds value to this molecule in terms of its downregulation of major inflammatory and cancer-associated signaling pathways. The article would simultaneously assist the scientific community to precisely understand the role of apigenin and design novel anti-cancer therapies.

A fresh look at radial shaft fracture fixation: The lateral approach to the radius

INTRODUCTION

Open reduction and internal fixation using plates is the gold standard for the treatment of displaced forearm bone fractures in adults. The ulna being subcutaneous throughout has a constant approach. However, the radius is approached from either the dorsal or the volar side. Both the dorsal and the volar approaches to the radial shaft involve meticulous dissection and preservation of important neurovascular structures. The posterior interosseus nerve is at risk in the dorsal approach and the radial artery and its branches in the volar approach. Dissection of these structures also adds to the operative time. The possibility of a third alternate approach was perceived, which could decrease the potential risks of the conventional approaches.

PATIENTS AND METHODS

Sixteen patients with radial shaft fractures in the middle third were operated on using the lateral approach: 6 of them had isolated radius fracture and 10 had both-bone fractures. There were 13 males and three females with a mean age of 37.9 years. Limited contact dynamic compression plate or locking compression plate of 3.5 mm was used to fix all fractures. All patients were operated on within 36 h of injury and then followed up till union. Union was assessed using serial radiographs and functional outcome using Anderson et al.'s criteria. The final functional outcome was assessed at an average 6 months after surgery and the results compiled.

RESULTS

The mean operative time in isolated radius fractures was 37.5 min and that for plating of both bones was 80.7 min. Primary bone grafting of the radius was done in one case and secondary bone grafting in another patient with delayed union of the radius. Union was achieved in all cases at a mean time of 17.25 weeks. The functional outcome was excellent in 10 patients, satisfactory in 5 patients, and unsatisfactory in 1 patient.

CONCLUSION

The lateral approach is a simple approach with low operative complexity and complications. We found this approach to provide a reliably good exposure of the middle third of the radius, enabling lateral plating without complications.

Macromorphological and micromorphological seed features of selected taxa of Caesalpiniaceae using light and scanning electron microscopy

Seed micromorphological and macromorphological characteristics of 12 taxa of Caesalpiniaceae from Pakistan have been studied, using light and scanning electron microscopy, to investigate the importance of seed coat features as a taxonomic tool. Great variations have been observed in color, shape, dimension, and seed surface pattern among the different genera of the family. A taxonomic key was prepared for the studied taxa. Six types of seed shapes were observed; circular, elliptical, irregular, oblong, oval, and ovoid. All examined seeds were hard except fragile seeds of Haematoxylom campechianum. Eight types of surface ornamentation have been noticed that include levigate, lugose, papillate, reticulate, reticulate irregular, reticulate regular, rhombus, and rogues. Majority of the taxa has been observed with thick ornamentation wall but thin ornamentation wall has also been recorded in few species. Fracture line of the various patterns was present in all taxa except genus Bauhinia. Three types of texture crudeness; coarse, medium, and fine have been recorded. Both micromorphological and macromorphological characters of seed are very fruitful in identification and classification of Caesalpiniaceae.

Success and complication rates of lead extraction with the first- vs. the second-generation Evolution mechanical sheath

Aims

The Evolution sheath (Cook Medical, USA) is a power sheath frequently used for chronic lead extraction. In 2013, a novel type (bidirectional) of Evolution sheath (the RL type) was introduced. We evaluated differences in success and complication rates of the two types.

Methods and results

From 2009 to 2015, all lead extractions requiring the use of an Evolution sheath were prospectively examined. According to the current guidelines, complete procedural success was defined as the removal of all targeted lead materials. Clinical success was the retention of a small portion of the lead, and failure was the inability to achieve either complete procedural or clinical success or the development of any permanently disabling complication. The Evolution sheath was used to extract 149 leads in 103 patients. The first 56 leads were extracted with the original unidirectional sheath, and 93 leads were extracted with the novel bidirectional R/L type. The median age of the lead at the time of extraction was 6.8 vs. 9.1 years (P = 0.007). Complete procedural success was higher for the Evolution R/L (80.0 vs. 98%, P = 0.0004). Clinical success rate was 98 vs. 99%. There were no major complications and 6 (12.0%) vs. 2 (3.8%) minor complications (P = 0.153). We did not observe changes in success rates or complications over time, meaning that the difference cannot be explained by learning curve.

Conclusion

Use of the novel Evolution R/L sheath vs. the original Evolution sheath was associated with significant higher complete success rates, without major complications and with a trend towards the reduction of minor complications.

A de novo mosaic mutation in SPAST with two novel alternative alleles and chromosomal copy number variant in a boy with spastic paraplegia and autism spectrum disorder

Here we report a 12 year old male with an extreme presentation of spastic paraplegia along with autism and dysmorphisms. Whole exome sequencing identified a predicted pathogenic pair of missense variants in SPAST at the same chromosomal location, each with a different alternative allele, while a chromosome microarray identified a 1.73 Mb paternally inherited copy gain of 1q21.1q21.2 resulting in a blended phenotype of both Spastic paraplegia 4 and 1q21.1 microduplication syndrome. We believe that the extreme phenotype observed is likely caused by the presence of cells which contain only mutant SPAST, but that the viability of the patient is possible due mosaicism of mutant alleles observed in different proportions across tissues.

Predictors and long-term outcome of super-responders to cardiac resynchronization therapy

BACKGROUND

The level of improvement in left ventricular ejection fraction (LVEF) in super-responders to cardiac resynchronization therapy (CRT) is exceptional. However, the long-term prognosis remains unknown in a large population.

HYPOTHESIS

Whether super-responders haven good long-term outcomes.

METHODS

We registered 347 patients with primary CRT-D indication. Super-response was defined by LVEF >50% at follow-up echocardiogram. Best-subset regression analysis identified predictors of super-response. Endpoints were major adverse cardiac events (MACE; eg, all-cause mortality or heart failure hospitalization, cardiac death, and appropriate ICD therapy).

RESULTS

Fifty-six (16%) patients with LVEF >50% were classified as super-responders. Female sex (OR: 3.06, 95% CI: 1.54-6.05), nonischemic etiology (OR: 2.70, 95% CI: 1.29-5.68), higher LVEF at baseline (OR: 1.07, 95% CI: 1.02-1.13), and wider QRS duration (OR: 1.17, 95% CI: 1.04-1.32) were predictors of super-response. Cumulative incidence of MACE at a median of 5.3 years was 18% in super-responders, 22% in responders, and 51% in nonresponders (P < 0.001). None of super responders died from cardiac death, compared to 9% of responders and 25% of non-responders (P < 0.001). None of super-responders experienced appropriate ICD therapy, compared with 10% of responders and 21% of non-responders (P < 0.001). In super-responders, the adjusted hazard ratio was 0.37 (95% CI: 0.19-0.73) for MACE and 0.44 (95% CI: 0.20-0.95) for total mortality, compared with non-responders.

CONCLUSIONS

Female sex, non-ischemic etiology, higher baseline LVEF, and wider QRS duration were independently associated with super-response. Super-response was associated with persistent excellent prognosis regarding survival and appropriate ICD therapy during long-term follow-up.

Association of apical rocking with super-response to cardiac resynchronisation therapy

Background

Super-responders to cardiac resynchronisation therapy (CRT) show an exceptional improvement in left ventricular ejection fraction (LVEF). Previous studies showed that apical rocking was independently associated with echocardiographic response to CRT. However, little is known about the association between apical rocking and super-response to CRT.

Objectives

To determine the independent association of LV apical rocking with super-response to CRT in a large cohort.

Methods

A cohort of 297 consecutive heart failure patients treated with primary indication for CRT-D were included in an observational registry. Apical rocking was defined as motion of the left ventricular (LV) apical myocardium perpendicular to the LV long axis. ‘Super-response’ was defined by the top quartile of LVEF response based on change from baseline to follow-up echocardiogram. Best-subset regression analysis identified predictors of LVEF super-response to CRT.

Results

Apical rocking was present in 45 % of patients. Super-responders had an absolute mean LVEF increase of 27 % (LVEF 22.0 % ± 5.7 at baseline and 49.0 % ± 7.5 at follow-up). Apical rocking was significantly more common in super-responders compared with non-super-responders (76 and 34 %, P < 0.001). In univariate analysis, female gender (OR 2.39, 95 % CI 1.38–4.11), lower LVEF at baseline (OR 0.91 95 % CI 0.87–0.95), non-ischaemic aetiology (OR 4.15, 95 % CI 2.33–7.39) and apical rocking (OR 6.19, 95 % CI 3.40–11.25) were associated with super-response. In multivariate analysis, apical rocking was still strongly associated with super-response (OR 5.82, 95 % CI 2.68–12.61). Super-responders showed an excellent clinical prognosis with a very low incidence of heart failure admission, cardiac mortality and appropriate ICD therapy.

Conclusion

Apical rocking is independently associated with super-response to CRT.

Electronic supplementary material

The online version of this article (doi:10.1007/s12471-015-0768-4) contains supplementary material, which is available to authorized users.

Are changes in the extent of left ventricular dyssynchrony as assessed by speckle tracking associated with response to cardiac resynchronization therapy?

Echocardiographic assessment of left ventricular (LV) dyssynchrony is used to predict response to cardiac resynchronization therapy (CRT). However, the association between reduction in the extent of speckle tracking based LV-dyssynchrony and echocardiographic response to CRT has not been explored yet. The aim of this study was to assess the changes in the extent of LV dyssynchrony as a result of CRT and its association with echocardiographic response to CRT in a large consecutive series of patients. We studied 138 patients with standard CRT indication. Time-based speckle tracking longitudinal strain (maximal delay between 6-segments in 4-chamber view) was performed to assess LV-dyssynchrony at baseline and after a mean follow-up of 22 ± 8 months. Echocardiographic CRT response was defined as a reduction in LV end-systolic volume ≥15 %. Mean age was 68 ± 8 years (30 % female). Mean LV ejection fraction (LVEF) was 26 ± 7 %. Ninety six patients (70 %) were classified as echocardiographic responders. In the total study group, LV-dyssynchrony decreased from 196 ± 89 ms at baseline to 180 ± 105 ms during follow-up, P = 0.01. Of note, in responders there was a pronounced reduction in LV dyssynchrony (198 ± 88 ms at baseline vs 154 ± 50 ms after CRT, P < 0.001), whereas in non-responders there was a significant increase (191 ± 92 ms at baseline vs 243 ± 160 ms after CRT, P = 0.04). After multivariate analysis, decreased in LV-dyssynchrony, wider QRS duration and non-ischemic etiology were independently and significantly associated with CRT response. Changes in the extent of LV dyssynchrony as measured by speckle tracking after CRT are independently associated with response to CRT.

Association of apical rocking with long-term major adverse cardiac events in patients undergoing cardiac resynchronization therapy

AIMS

Correctly identifying patients who will benefit from cardiac resynchronization therapy (CRT) is still challenging. 'Apical rocking' is observed in asynchronously contracting ventricles and is associated with echocardiographic response to CRT. The association of apical rocking and long-term clinical outcome is however unknown at present. We assessed the predictive value of left ventricular (LV) apical rocking on a long-term clinical outcome in patients treated with CRT.

METHODS AND RESULTS

Consecutive heart failure patients treated with primary indication for CRT-D between 2005 and 2009 were included in a prospective registry. Echocardiography was performed prior to CRT to assess apical rocking, defined as motion of the LV apical myocardium perpendicular to the LV long axis. Major adverse cardiac event (MACE) was defined as combined end point of cardiac death and/or heart failure hospitalization and/or appropriate therapy (ATP and/or ICD shocks). All echocardiograms were assessed by independent cardiologists, blinded for clinical data. Multivariable analyses were performed to adjust for potential confounders. Two hundred and ninety-five patients with echocardiography prior to implantation were included in the final analyses. Apical rocking was present in 45% of the study patients. Apical rocking was significantly more common in younger patients, females, patients with sinus rhythm, non-ischaemic cardiomyopathy, and in patients with LBBB and wider QRS duration. During a mean clinical follow-up of 5.2 ± 1.6 years, 92 (31%) patients reached the end point of the study (MACE). Patients with MACE had shorter QRS duration, had more ischaemic cardiomyopathy, and were more often on Amiodarone. In univariate analyses, MACE was associated with shorter QRS duration, ischaemic aetiology, and the absence of apical rocking. After multivariable analyses, apical rocking was associated with less MACE (hazards ratio, HR 0.44, 95% confidence interval, CI 0.25-0.77).

CONCLUSION

Apical rocking is an independent predictor of a favourable long-term outcome in CRT-D patients.

Response to cardiac resynchronization therapy as assessed by time-based speckle tracking imaging

BACKGROUND

Response to cardiac resynchronization therapy (CRT) is still difficult to predict with previously investigated dyssynchrony indices. The predictive value of speckle tracking strain analysis has not been fully delineated yet. The objective of this study was to assess the predictive value of longitudinal strain (LS) and radial strain (RS) speckle tracking measurements on echocardiographic and clinical response to CRT.

METHODS

A total of 138 consecutive patients with functional class II-IV heart failure who underwent CRT were studied. Echocardiography was performed at baseline and during follow-up. Six different time-based left ventricular (LV)-dyssynchrony indices were measured with LS and RS. Echocardiographic response to CRT was defined as a reduction in LV end-systolic volume ≥15% and clinical response as survival without heart failure hospitalization. Multivariable analyses were performed to adjust for potential confounding factors.

RESULTS

Echocardiographic and clinical follow-up was 22 ± 8 and 42 ± 8 months, respectively. Ninety-six patients (70%) were classified as echocardiographic responders and 114 patients (83%) survived without heart failure hospitalization. QRS duration and nonischemic etiology predicted echocardiographic response to CRT. None of the speckle tracking indices was different between echocardiographic responders and nonresponders to CRT. Regarding clinical response, only maximal delay between six segments in four-chamber view measured with LS was different between responders and nonresponders, with 154-ms delay as the optimal cut-off value. Neither stratified analyses in patients with sinus rhythm nor multivariable analyses did change these findings.

CONCLUSION

Of all time-based measured speckle tracking indices, only maximal delay between six segments in four-chamber view as assessed with LS was associated with clinical response to CRT.

Report: nutrient evaluation and elemental analysis of four selected medicinal plants of soon valley Khushab, Punjab, Pakistan

To check the nutritional and mineral contents of four medicinal plants viz., Peganum hermla, Solanum nigrum, Mentha longifolia, Achryanthus aspera, which are used as medicine traditionally in Soon Valley Khushab, Pakistan. Proximate analysis of plant sample determined that protein (7.491%) and ash (22.79%) was highest in Mentha longifolia, carbohydrate (75.23%) in Peganum hermla, fats (12.595%) and moisture (6.82%) was highest in Achryanthus aspera. In comparative assessment of the various species, the results showed that Achryanthus aspera. is the most significant species having higher concentrations of fat, fibre values compared to the other species. Absorption Spectrometric method was used for the elemental analysis of essential elements such as Fe, Cd, Cu,Mn, Pb, Cr, Ni and Na in medicinal plants in different range.

Sex-Based Differences in Cardiac Arrhythmias, ICD Utilisation and Cardiac Resynchronisation Therapy

Many important differences in the presentation and clinical course of cardiac arrhythmias are present between men and women that should be accounted for in clinical practice. In this paper, we review published data on gender differences in cardiac excitable properties, supraventricular tachycardias, ventricular tachycardias, sudden cardiac death, and the utilisation of implantable defibrillators and cardiac resynchronisation therapy. Women have a higher heart rate at rest, and a longer QT interval than men. They further have a narrower QRS complex and lower QRS voltages on the 12-lead ECG with more often non-specific repolarisation abnormalities at rest. Supraventricular tachycardias, such as AV nodal reentrant tachycardia, are twice as frequent in women compared with men. Atrial fibrillation, however, has a 1.5-fold higher prevalence in men. The triggers for idiopathic right ventricular outflow tract tachycardia (VT) initiation are gender specific, i.e. hormonal changes play an important role in the occurrence of these VTs in women. There are clear-cut gender differences in acquired and congenital LQTS. Brugada syndrome affects men more commonly and severely than women. Sudden cardiac death is less prevalent in women at all ages and occurs 10 years later in women than in men. This may be related to the later onset of clinically manifest coronary heart disease in women. Among patients who receive ICDs and CRT devices, women appear to be under-represented, while they may benefit even more from these novel therapies.