Dyslipidemia and heart failure: current evidence and perspectives of use of statins

Heart failure (HF) is a condition with growing morbidity and mortality. Dyslipidemia in HF is not concentrated around hypercholesterolemia as in coronary artery disease. As a corollary, the robust benefits seen with statins across the spectrum of CAD have not been replicated in HF. Multiple potential pleiotropic effects of statins include anti-inflammatory, antioxidant, endothelial stabilization, antiapoptotic, anti-thrombotic, and modulation of the autonomic system apart from lipid lowering. These benevolent actions need to be counterbalanced with the potential derangement of ubiquinone, selenoprotein and endotoxin pathways. While small randomized and non-randomized studies demonstrated a multitude of benefits in clinical and surrogate endpoints, two large RCTs failed to demonstrate unequivocal benefits. However, multiple large meta-analyses do demonstrate definite improvement in clinical endpoints including death and heart failure hospitalization. The clinical likelihood of benefit was higher in younger patients with less advanced HF and use of lipophilic statins.

Buprenorphine: two adolescent case reports of bridging the transmucosal form to the extended-release subcutaneous injectable form

According to the Centers for Disease Control and Prevention (CDC), 100,306 drug overdose deaths occurred in the US during a 12-month period ending in April 2021. Opioids were involved in 75% of these related deaths. Opioid Use Disorder (OUD) is a constantly evolving public health crisis with potentially lethal consequences. In 2017, 900 adolescents began to misuse opioids every day. Nearly 10% of high school seniors reported using opioids nonmedically. Additionally, the incidence for hospitalizations for adolescents among children 1-19 years of age increased nearly 2-fold from 1997 to 2012. This data emphasizes the dangers associated with the increasing accessibility of pharmaceutical and non-pharmaceutical opioids, particularly for adolescents. All three of the currently FDA approved medications for OUD have shown clear efficacy in decreasing all-cause mortality in adults. It is proposed that the same effects should be seen in adolescents but limited data is present. A recent study analyzed buprenorphine and naltrexone treatment amongst OUD in adolescents between 2001-2014; only 1 in 4 youth received any medication therapy within six months of diagnosis. Adolescents under 16 were the most likely to receive medications. However, even adolescents aged 17, for whom buprenorphine is FDA approved for, were less likely to receive therapy than adults over 18 years of age. The following case report aims to demonstrate how subcutaneous extended release buprenorphine treatment can be initiated effectively as an outpatient in an adolescent with OUD. It is critical that clinicians work to expand access to pharmacotherapy for adolescents struggling with OUD to ensure proper management and reduction of opioid-related overdoses.

Tianeptine as an opiate replacement in a patient on methadone treatment: A case report

Tianeptine, an antidepressant and full µ-opioid receptor agonist, has increased in popularity and has been used as an over-the-counter supplement over the past decade. Due to its well-documented euphoric effects, there exists elevated risk for potential abuse. Buprenorphine-naloxone has been successfully utilized to treat opioid use disorder (OUD) in patients concurrently using tianeptine, limiting withdrawal symptoms and abstinence. However, there is limited evidence on the management of tianeptine use disorder, specifically methadone or naltrexone. The current opioid epidemic, the emerging use of tianeptine, and the lack of physician awareness have emphasized the need for further research on the role of tianeptine in medication-assisted treatment for OUD. This case report aims to demonstrate how medication-assisted therapy can be successfully utilized in a patient with opioid and severe other (tianeptine) drug use disorder.

The Role of Non-Pharmaceutical Fentanyl-Contaminated Counterfeit Oxycodone in Increasing Opioid Overdoses: A Commentary Review

Importance: Opioid misuse/abuse is a pervasive problem in the United States, and the growing use of fentanyl-contaminated products is adding fuel to the opioid crisis.

Objective: To review the rising prevalence of nonprescription fentanyl in counterfeit oxycodone, paying specific attention to oxycodone for cost analysis.

Evidence Review: A literature search was performed using 3 databases (Google Scholar, PubMed, and Clinical Key) to identify English-language articles published from January 2010 to October 2022. Search terms were street oxycodone and prescription oxycodone, street oxycodone. An additional search of fentanyl was performed to gather more information about the pharmacology behind fentanyl overdoses. Studies and articles were selected based on information related to the presence of non-prescription fentanyl in illicit supplies of oxycodone. Additional articles were included to demonstrate the cost, manufacturing, and overdose rates of fentanyl-laced counterfeit opioids. A total of 13 articles were included in the final review.

Findings: The demand for illicit oxycodone provides an opportunity in which counterfeiters can thrive, using dangerous adulterating agents such as fentanyl to maximize their profits. Those purchasing oxycodone illicitly may or may not be aware of the presence of fentanyl in their tablets, which has clearly resulted in rising overdose numbers.

Conclusion: Clinicians should counsel patients at risk for opioid misuse on the risks of counterfeit oxycodone.

Prim Care Companion CNS Disord 2023;25(6):22nr03433.

Author affiliations are listed at the end of this article.

The Appearance of Xylazine in the United States as a Fentanyl Adulterant

Importance: Use of xylazine in the United States as an adulterant for drugs of abuse has increased in recent years, thus it is important for health care providers to understand the basic pharmacology and toxidrome of the drug, as well as management options for patients who have overdosed.

Observations: Data obtained from studies between 2006 and 2022 indicate a rapidly increasing incidence of xylazine overdose in the United States, with overdose cases now being seen in 25 states. Hallmark symptoms of xylazine overdose include respiratory depression, bradycardia, hyperglycemia, central nervous system depression, and initial hypertension turning to unstable blood pressure. Xylazine overdose is not reversible with naloxone and requires supportive measures.

Conclusions and Relevance: It is important for health care providers to be aware of presenting symptoms in xylazine overdose so that proper care can be provided. Facilities may consider adding xylazine to their routine toxicology report to aid in patient management and better assess the incidence of xylazine use as an adulterant in a given geographic area.

Prim Care Companion CNS Disord 2023;25(6):22nr03473.

Author affiliations are listed at the end of this article.

Xylazine Use in Pregnancy: The Effects of the Fentanyl Adulterant Xylazine on Pregnant Patients and the Developing Fetus

Objective

A literature review was completed to outline the effects of xylazine on the pregnant patient while raising awareness of the increasing prevalence of opioid use disorder in pregnancy and the increase in adulterants in non-prescribed controlled substances.

Data Sources

PubMed and Google Scholar were searched using the key words "xylazine, adulterant," "xylazine, humans," "xylazine, pregnancy," and "xylazine, placenta" to identify the studies evaluating xylazine's effects on humans and the pregnant patient.

Study Selection

Studies were included if they provided information on symptoms of xylazine exposure, the prevalence of xylazine in pregnant humans and the hemodynamic effects of xylazine on both human and animal pregnant populations. Animal studies were included given the limited data on xylazine in pregnant humans. Four studies were utilized for background data and five studies were included in the final review of the effects of xylazine on pregnancy.

Results

Studies involving humans show that xylazine toxicity can cause respiratory depression, bradycardia, and central nervous system depression. There is evidence of xylazine in human umbilical cord tissue, showing that the fetus is exposed to xylazine. Animal studies show decreased uterine blood flow, increased uterine vascular resistance, and decreased fetal growth in response to xylazine.

Conclusions

Due to the limited studies on the effects of xylazine on pregnant populations, providers rely on animal studies for knowledge on xylazine's effects throughout pregnancy. Animal studies suggest an increased risk of adverse effects during pregnancy in response to xylazine. Future studies should focus on the pregnancy outcomes in patients exposed to xylazine to create more robust recommendations for treatment and pregnancy surveillance.

Unraveling the invisible demon: a study of the oxidative stress markers, antioxidant activities and inflammatory markers in patients admitted with complete heart block

Funding Acknowledgements

Type of funding sources: None.

Introduction

Despite the recent advancements in the management of Complete Heart Block (CHB), the aetiology of CHB is still idiopathic in most of the cases. Our study explores this hitherto untouched aspect of complete heart block.

Purpose

We aimed to assess the aetiological profile of Complete Heart Block patients in our study.

Methods

The study population consisted of 60 patients with complete heart block aged between 30 to 80 years, attending as an inpatient in ER. Oxidative stress was measured by serum MDA, serum GSH, serum Catalase activity and serum SOD activity. Antioxidant activity was obtained by measuring the levels of serum total antioxidant capacity. Inflammatory stress was measured by IL-5 and TNF-alpha levels. These values were compared to 30 healthy controls with no prior history of smoking and diabetes mellitus.

Results

The mean age of the patient was 62.48 ± 7.98 years and the gender distribution was 37 males and 23 females out of 60 patients. The mean value of serum MDA (ng/mL) in cases is 1451.26 ± 206.32, and in controls, the mean value is 1197.98 ± 234.71 (p=<0.001). The mean value of serum GSH (mcg/mL) in cases is 46.982 ± 18.613, and in controls, the mean value is 54.155 ± 10.762 (p=0.027). The mean value of serum Catalase Activity (U/min/mg protein) in cases is 10.763 ± 4.038 and in controls, the mean value is 19.878 ± 7.787 (p=0.003). The mean value of serum SOD Activity (U/g) in cases is 24.950 ± 5.4565, and in controls, the mean value is 46.214 ± 14.6309 (p=0.891). The mean value of serum Total Antioxidant Capacity (U/mL) in cases is 5.546 ± 0.620 and in controls, the mean value is 8.346 ± 2.781 (p=0.025). The mean value of serum IL-5 (pg/mL) in cases is 481.442 ± 28.8995, and in controls, the mean value is 67.347 ± 20.445 (p<0.001). The mean value of serum TNF-ALFA (pg/mL) in cases is 196.741 ± 73.771, and in controls, the mean value is 144.530 ± 42.599 (p= 0.081).

Conclusions

During a complete heart block, SOD (p=0.891), CAT (p=0.003), GSH (p=0.027) and total antioxidant (TAOC) (p=0.025) were significantly decreased in cases, compared to healthy controls, thus suggesting that the elevated levels of oxidative free radicals causes endothelial dysfunctioning. The increase in ROS was observed by a highly significant increase of malondialdehyde (MDA) (p=<0.001) showing high ROS-mediated tissue damage. Besides damage by oxidative stress, our study suggests that there are certain inflammatory markers like TNF-α and IL-5 that actively participate in causing heart block. There was a significant increase in the concentration of IL-5 (p<0.001) in the cases as compared to the controls.

The surprises in optical coherence tomography (OCT) findings in patients presenting with in-stent restenosis: the road less travelled

Funding Acknowledgements

Type of funding sources: None.

Background

Morphological features of neointimal tissue play a pivotal role in the pathophysiology of In-Stent Restenosis (ISR) after percutaneous coronary intervention, hence understanding these features and patterns is crucial.

Purpose

The present study was designed to qualitatively and quantitatively assess neointimal characteristics of lesions using OCT in patients presenting with ISR.

Methods

This was a single-center, prospective, observational study performed between 1st August 2020 and 30th December 2021 at a tertiary-care center in India. Patients diagnosed with stable angina and acute coronary syndrome with post-procedural angiographically documented restenosis (>50%) were included. Qualitative and quantitative assessment of neointimal hyperplasia patterns was performed using OCT.

Results

A total of 34 patients with ISR were studied. Neointimal hyperplasia was classified as (i) homogenous group (n=18) and (ii) non-homogenous group (n=16). As many as 14 (77.8%) diabetics belonged to the homogenous group. Predominant plaque characteristics such as neoatherosclerosis, cholesterol crystals, and calcium were documented in 14 (77.8%), 12 (66.7%), and 11 (61.1%) patients in the homogenous group and in 10 (62.5%), 10 (62.5%), and 9 (56.2%) patients in the non-homogenous group, respectively. Unexpanded stent struts were identified in 11 (61.1%) and 11 (68.8%) patients in the homogenous and non-homogenous groups, respectively. Mean strut thickness was 93.73 ± 31.03 µm and 83.54 ± 18.0 µm, ISR was 72.50 ± 15.93% and 65.37 ± 21.69%, the neointimal thickness was 588.06 ± 167.82 mm and 666.25 ± 218.05 mm, and neointimal hyperplasia was 54.54 ± 11.23% and 59.26 ± 8.86% in the homogenous and non-homogenous groups, respectively.

Conclusion

Neoatherosclerosis and stent underexpansion was predominantly observed in our study, which was in contrast to most of the existing literature [1,2,3], and only diabetes was found to be significantly associated with homogenous neointimal hyperplasia, irrespective of the generation of the stent.

The Growing Epidemic of Opioid Use Disorder in the Elderly and Its Treatment: A Review of the Literature

Objective: US demographic trends show an increasing proportion of adults aged > 65 years old, approximately 1 million of whom are living with an opioid use disorder (OUD). OUD may be particularly problematic in this age group due to age-related pain syndromes and comorbidities that increase the risk of side effects, overdose, and death. The objective of this review was to assess the safety and efficacy of medications for OUD (MOUD) in the elderly.

Data Sources: A systematic search of the literature in PubMed, CINAHL, MEDLINE, Embase, and Cochrane Library databases was conducted from January 1992 through October 2021. The following terms were used: elderly, older adults, opioid use disorder, opioid dependence, buprenorphine, methadone, and medication-assisted treatment.

Study Selection: The search yielded 633 results. After following PRISMA guidelines and careful manual exclusion, 13 studies were selected for the review. No studies examining use of buprenorphine were identified for MOUD.

Results: The application of methadone for MOUD in the elderly shows that use is limited by preexisting conditions such as cardiac conduction abnormalities, which are more prevalent in the elderly than in the general population. Buprenorphine and naltrexone have been documented to have fewer interactions and potentially lethal adverse effects compared to methadone.

Conclusion: Future studies should focus on the application of buprenorphine or naltrexone for MOUD in the elderly.

Instantaneous wave-free ratio and fractional flow reserve: effect of variation in left ventricular end diastolic pressure

Funding Acknowledgements

Type of funding sources: None.

Introduction

Among patients with intermediate coronary artery stenosis (50-90%), assessment of functional significance of the lesion by instantaneous wave free ratio (iFR)/ fractional flow reserve (FFR) is recommended in latest guidelines. Though iFR is not much affected by change in hemodynamics compared to FFR, the change in iFR vs FFR due to various hemodynamic factors need a validation. Left ventricular end-diastolic pressure (LVEDP) is one of the hemodynamic factors whose variation and effect on FFR vs iFR is largely unknown. In the present study we evaluated the association of change in LVEDP on the changing pattern of iFR/FFR which may hold a clinical significance especially with percutaneous coronary intervention in heart failure patients.

Methods

This was a prospective, investigator-initiated, single-center study involving 20 patients with stable coronary artery disease and at least one intermediate coronary lesion (50-90%). The enrolled patients were subjected to both iFR and FFR along with baseline LVEDP measurement. Subsequently, intravenous nitroglycerine infusion was given to reduce LVEDP and corresponding iFR and FFR were re-evaluated. The dynamic changes in iFR and FFR were studied in relation to changes in LVEDP using Pearson’s correlation analysis and linear regression analysis.

Results

The mean LVEDP was lowered from 16.20 ± 1.54 mmHg to 9.50 ± 1.10 mmHg, the mean iFR and FFR got changed from 0.80 ± 0.12 to 0.76 ± 0.12 mmHg and 0.75 ± 0.09 to 0.72 ± 0.09 mmHg respectively. On Pearson’s correlation analysis, LVEDP change did not show statistically significant correlation (linear relationship) with iFR (p = 0.105, r2 = 0.373) and FFR (p = 0.227, r2 = 0.283) changes across the entire range of stenosis severity and in all vessels. Linear regression analysis did not state any independent correlation between LVEDP and iFR and FFR changes in the study group (p >0.05). The % R2 value for iFR and FFR (as a coefficient of determination) of the regression equation were 13.9% and 8%, which means only these percentages of the total variance in iFR and FFR change were explained by LVEDP changes respectively. There was no serious adverse event related to the procedure.

Conclusion

To the best of our knowledge, this is the first study comparing the effect of changes in LVEDP on both iFR and FFR simultaneously. In our study, 1 mmHg change in LVEDP was associated with a change in FFR by 0.004 and change in iFR by 0.004 which didn’t reveal any significant association (p = 0.227 and 0.105 respectively). This helps us to put FFR at par with iFR under variable hemodynamics.  So either of the variables may be used interchangeably with confidence in varied hemodynamic conditions including patients with heart failure. The correlation was non-significant across entire range of stenosis severity, irrespective of sex, age, diabetes and hypertension. This study sets platform for further research with larger number of heterogeneous patient population. Abstract Figure. Box whisker plot

Role of oral flecainide in assessement of atrio-ventricular conduction in symptomatic bifascicular block

Background

Intravenous flecainide is used to stress Atrio-ventricular (AV) conduction in patients (pts) with a history of syncope & bifascicular (Bi-Fasc) block. Role of oral flecainide is unclear.

Objective

To assess effect of oral Flecainide on infra-Hisian AV conduction in patients with symptomatic Bi-Fasc block.

Methods

Pts presenting with syncope & Bi-Fasc block without advanced AVCD on ECG, 24 hr holter or treadmill exercise test were taken. Those with history suggestive of reflex syncope & positive tilt test were excluded. Remaining underwent electro-physiological (EP) study. Pts with HV interval >100ms or intra/infra-Hisian block at rest or incremental pacing were subjected to PPI. Remaining received oral Flacanide 5 mg/kg (max 300 mg) & EP study was repeated after ½ hr, 1 hr, 2 hrs and 3 hrs. Primary end-point was HV ≥100ms or infra/intra-Hisian type IIB or III block.

Results

Of 41 pts enrolled for study, 28 patients (mean age 60.0 yrs, mean LVEF 60.7%) were eligible for EP Study. Basal PR interval was 185.8±47.4 ms & mean QRS width was 130.6±18.65 ms. On EP study, 4 (14.3%) with resting HV >100 ms & 6 (21.4%) with HV >100 ms on incremental pacing underwent PPI.

Out of remaining 18 pts who were given flecainide, 11 (66.1%) achieved primary endpoint (HV >100 ms in 6, infra-hisian IIB in 2 and 2:1 block in 3 patients). At mean follow up of 6.5 months, 13 (59.1%) out of 22 with PPI had mean 59.1% VP & none of 6 remaining patients had any symptom.

Conclusion

Oral Flecainide significantly increases the diagnostic yield of EP study in patients with symptomatic bi-fasc block.

Funding Acknowledgement

Type of funding sources: None.

Comparison of traditional versus artificial intelligence based coronary artery disease risk prediction scores in young patients with acute coronary syndrome

Background

Ever since the concept of preventive cardiology has come into vogue, several risk identification models have come up which combine several risk factors to create a risk prediction score for occurrence of cardiovascular (CV) event. While carrying a proven validation in Western population, none of the risk prediction model has been satisfactorily evaluated in Indians especially young <40 years old.

Objectives

To compare Artificial Intelligence based novel risk score with traditional risk scores in young (less than 40 years age) patients presenting with acute coronary syndrome (ACS) and to estimate the relative efficacy of different coronary artery disease (CAD) risk scores in young Indian Patients.

Design

Single center, Observational, Non-interventional study.

Participants

Cohort of Patients more than 20 but less than 40 years old with ACS in the department of Cardiology from 1st January 2019 to 31st October 2019.

Methods

314 young patients [mean age 36.14±4.17 years] presenting with acute coronary syndrome (ACS) were enrolled. The three clinically most pertinent risk assessment models [Framingham Risk score (FRS), World Health Organization risk prediction charts (WHO/ISH), and QRISK3 scores] and Artificial Intelligence based novel risk score (AICVD) were applied on day 1 of presentation, and tried to see whether one risk score versus other risk score could have predicted the event earlier had we applied it before the occurrence of ACS. Risk factors considered included those already in traditional scoring systems and new risk factors (diet, alcohol, tobacco, dyslipidemia, physical activity, family history of heart disease, history of heart disease, heart rate, respiratory rate, chronic heart symptoms and psychological stress).

Results

WHO/ISH provided the lowest high risk estimate with only 1 (0.9%) patient estimated to be having >20% 10-year risk. The FRS estimated high risk (>20% 10-year risk) in 3 (1%) patients. The QRISK3 estimated high risk (>10% 10-year risk) in 20 (6.5%) patient. In comparison, AICVD risk prediction model stood tall by identifying 73 (23.2%) patients as high risk and 62.74% patients as more than moderate risk for having CV events at 7 years (p<0.001).

Conclusion

Perhaps, this is the first study which has compared artificial intelligence based novel risk prediction model with the three most commonly applied models, in the young Indian patients. We found that a cohort of young Indian patients presenting with ACS, when studied retrospectively, was identified as “high risk” most likely by AICVD risk prediction model rather than the traditional counterparts. The WHO/ISH risk prediction charts and FRS were the poorest predictors. Performance of QRISK3 score also remained less than satisfactory. These findings suggested that AICVD risk prediction model is a promising tool to assess for CV risk in Indian population.

Funding Acknowledgement

Type of funding sources: None. Predictability of risk prediction models

Rapid microinduction of sublingual buprenorphine from methadone in an outpatient setting: "A case series"

Buprenorphine (BPN), FDA approved for opioid use disorder (OUD), requires an induction protocol for the patient in mild to moderate withdrawal. This can be problematic in outpatient practice due to complicated medical management. An emerging technique in literature uses a novel approach, called microinduction. In this method, escalating microdoses of BPN are administered, without requiring the patient to stop the opioid agonist. Our addiction treatment center used a microdosing technique to transit patients from methadone to BPN, without requiring opioid abstinence. Our case series is novel as it was outpatient microinduction from methadone to BPN in 7 days or less.

Covid19 impact screening of patients undergoing medication treatment for opioid use disorder

BACKGROUND

Populations with addiction are considered at-risk for both medical and financial effects of the COVID19 outbreak. Patients receiving medication treatment for opioid use disorder (MOUD) were screened to assess need, vulnerability factors and potential clinical impact of the pandemic for referral and allocation of resources. Methods: A 31-item quality improvement survey of COVID19-related factors (e.g. engagement in social distancing, food and financial security) and clinical benchmarks of anxiety, craving, and treatment response was administered between March 24 and April 29, 2020. Anonymized data were compiled for study. Frequencies and means were evaluated for gender, age and financial effects on anxiety and craving ratings. Results: A total of 200 (N = 117 male; N = 80 female; N = 1 transgender) patients (age 42 ± 13 years) were screened. Medical risk factors known to predict severe COVID19 reactions reported in 33% of patients did not contribute significantly to distress. While 95% of patients reported stable food and housing, personal financial and employment instability reported in 40% of patients was associated with significantly increased anxiety and craving rating, particularly for women. Conclusions: Financial ramifications of the COVID19 pandemic were the most salient concerns reported by patients engaged in MOUD in the early phases of the outbreak, particularly for women.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Secondary prevention of fragility fractures in Asia Pacific: an educational initiative

The Asia -Pacific Bone Academy (APBA) Fracture Liaison Service (FLS) Focus Group educational initiative has stimulated activity across the Asia -Pacific region with the intention of supporting widespread implementation of new FLS. In 2017, the APBA FLS Focus Group developed a suite of tools to support implementation of FLS across the Asia-Pacific region as a component of a multi-faceted educational initiative. This article puts this initiative into context with a narrative review describing the burden of fragility fractures in the region, the current secondary fracture prevention care gap and a summary of emerging best practice. The results of a survey to evaluate the impact of the APBA educational initiative is presented, in addition to commentary on recent activities intended to improve the care of individuals who sustain fragility fractures across the Asia -Pacific. A FLS Toolbox for Asia-Pacific was developed which included the following sections:1. The burden of fragility fractures in the Asia-Pacific region.2. A summary of evidence for FLS in the Asia-Pacific.3. A generic, fully referenced FLS business plan template.4. Potential cost savings accrued by each country, based on a country-specific FLS Benefits Calculator.5. How to start and expand FLS programmes in the Asia-Pacific context.6. A step-by-step guide to setting up FLS in countries in the Asia-Pacific region.7. Other practical tools to support FLS establishment.8. FLS online resources and publications.The FLS Toolbox was provided as a resource to support FLS workshops immediately following the 5th Scientific Meeting of the Asian Federation of Osteoporosis Societies (AFOS) held in Kuala Lumpur in October 2017. The FLS workshops addressed three key themes:• The FLS business case.• Planning the FLS patient pathway.• The role of the FLS coordinator in fragility fracture care management.A follow-up survey of 142 FLS workshop participants was conducted in August-September 2018. The survey included questions regarding how FLS were developed, funded, the scope of service provision and the support provided by the educational initiative. Almost one-third (30.3%) of FLS workshop participants completed the survey. Survey responses were reported for those who had established a FLS at the time the survey was conducted and, separately, for those who had not established a FLS. Findings for those who had established a FLS included:• 78.3% of respondents established a multidisciplinary team to develop the business case for their FLS.• 87.0% of respondents stated that a multidisciplinary team was established to design the patient pathway for their FLS.• 26.1% of respondents stated that their FLS has sustainable funding.• The primary source of funding for FLS was from public hospitals (83.3%) as compared with private hospitals (16.7%).Most hospitals that had not established a FLS at the time the survey was conducted were either in the process of setting-up a FLS (47%) or had plans in place to establish a FLS for which approval is being sought (29%). The primary barrier to establishing a new FLS was lack of sustainable funding. The APBA FLS Focus Group educational initiative has stimulated activity across the Asia-Pacific region with the intention of supporting widespread implementation of new FLS. A second edition of the FLS Toolbox is in development which is intended to complement ongoing efforts throughout the region to expedite widespread implementation of FLS.

Cardiovascular complications and its relationship with functional outcomes in Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome (GBS) is a monophasic disease characterized by acute polyradiculoneuropathy.

AIM

This study investigated cardiovascular complications in patients with GBS and their relationship with outcomes.

DESIGN AND METHODS

We included 96 patients, who were diagnosed with GBS according to Brighton case definitions. All enrolled patients were evaluated according to a predetermined algorithm, which included nerve conduction studies, cerebrospinal fluid analysis, electrocardiography, 2D echo, cardiac markers and autonomic function testing.

RESULTS

We enrolled a total of 96 patients. The mean age of patients was 35.75 ± 17.66 years. Furthermore, 54.2% of patients developed cardiovascular complications, of which changes in electrocardiography (ECG) findings (50%), hypertension (28.12%), labile hypertension (12.5), tachycardia (26.04), bradycardia (13.54%) and a fluctuating heart rate (HR) (11.46) were common. Other cardiovascular complications seen in GBS patients were increased pro-BNP (26.04%), raised troponin T levels (3.12%), acute coronary syndrome (2.08%), heart failure (2.08%) and abnormal 2D echo findings (8.33%). The results of the univariate analysis revealed that a history of preceding infection, a Medical Research Council sum score, neck muscle weakness, facial nerve involvement, bulbar involvement, respiratory failure, cardiovascular complications, autonomic dysfunction, acute motor sensory axonal neuropathy subtype and baseline Hughes score were significantly (P < 0.005) associated with poor outcomes. However, none of these factors were found to be independently associated with poor outcomes in the multivariate analysis.

CONCLUSION

A considerable number of patients with GBS developed cardiovascular complications and it needs attention.

Kratom (Mitragyna speciosa): Friend or Foe?

Increased use of the opioid-related plant kratom as an alternative treatment for opioid withdrawal symptoms has raised concerns regarding its potential for abuse and severe adverse effects. A review of the literature was performed to characterize kratom's pharmacology, clinical efficacy, and adverse effects to increase understanding and evaluate potential use as an alternative treatment for opioid dependence. Kratom use initiated as self-medication for an opioid use disorder or pain syndrome in the absence of effective alternatives is associated with a risk of kratom dependence, withdrawal, and life-threatening toxicity. The potential for a serious adverse reaction should discourage unregulated use of kratom products.

4300Strain parameters at rest and after exercise in symptomatically stable patients with improved heart failure - STRESS-HF

Background

Optimal medical therapy (OMT) results in improvement in left ventricular (LV) ejection fraction (EF) and reduction in LV size in approximately 40% of patients of heart failure with reduced ejection fraction (HFrEF). Recent studies have proposed to continue treatment in all patients of this subgroup as improvement in LVEF does not indicate actual myocardial recovery. Global Longitudinal strain (GLS) is more sensitive marker of LV systolic function and better predictor of mortality than LVEF. GLS may identify probable patients in whom the therapy can be minimized or stopped.

Aim

To determine global longitudinal strain at rest and after exercise in patients with idiopathic dilated cardiomyopathy (DCM) who have improved LVEF ≥50% on guideline directed medical therapy (GDMT) and compare with resting & exercising LVEF on 3-dimesional (3D).

Material and methods

This Observational study was conducted in a tertiary care referral hospital, from February 2018 to October 2018. All patients with idiopathic DCM who had a documented LVEF of ≤40% in the past and improved LVEF (LVEF ≥50%) on GDMT were included in the study. Patients with secondary causes of HFrEF, poor echocardiographic window and inability to exercise were excluded from the study. Strain parameters were calculated at rest and after atleast 5 METS of exercise. GLS value of ≥ minus 12.6% was considered as mildly reduced strain, ≤ minus 8% as severely reduced strain and the values in between as moderately reduced strain. Post exercise, drop of >5% in absolute LVEF value or decrease in GLS >15% from baseline was considered as poor myocardial recovery.

Results

A total of 44 patients [mean age of 46.8±13.1 years and 24 males (54.5%)] constituted the study group. At the time of diagnosis, 31 (70.5%) patients were in NYHA class II and the remaining were in class III. Duration of GDMT ranged from 4 to 38 (median 12) months. Following improvement on GDMT, 25 (56.8%) were in class I and rest were in class II. Mean LVEF at diagnosis and after recovery was 33.6±4.9% and 55.1±4.5%, respectively with a mean absolute change in LVEF of 21.3±6.1%. At rest, mean 3D LVEF was 53±3.5% and GLS was −12.3±3.1. Mild, moderate and severely reduced strain was seen in 24 (54.5%), 13 (29.6%) and 7 (15.9%), respectively. After exercise, mean 3D LVEF was 51.5.±4.5% (mean decrease 1.5±2.1%) and mean GLS was −7±4.2% (mean decrease −5.3±4.6%). After exercise, none had a fall of LVEF >5% however 32 (72.7%) had a decrease of >15% in GLS. Seven (15.9%) patients had improvement in GLS, 4 (9.1%) had <15% decrease and 1 (2.3%) showed no change in GLS on exercise. The change in GLS on exercise was significant (p=0.001), but change in 3D LVEF was not significant (p=0.956).

Conclusion

Global longitudinal strain is a better marker for assessing myocardial recovery than LVEF in patients of heart failure with improved ejection fraction.

Acknowledgement/Funding

None

Ecofriendly nanotechnologies and nanomaterials for environmental applications: Key issue and consensus recommendations for sustainable and ecosafe nanoremediation

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Management protocols for chronic heart failure in India

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