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Background: Stroke is a major leading global health complication. Identification and management of risk factors associated with stroke can help in prior detection, prevention, and improvement in patient care. Purpose: To investigate the prevalence of hyperhomocysteinemia (HHcy) and Vitamins B6, B12, and folate deficiency in stroke patients and also to assess other risk factors associated with ischemic and hemorrhagic stroke. Methods: Detail history of all the subjects in the study including history of hypertension, anemia, fasting glucose, carotid artery thickness, smoking, alcohol, and dietary intake was recorded. Standard assays for homocysteine (Hcy), Vitamins B6, B12, and folate estimation were done. Lipid and renal profile tests were also performed. The prevalence and odds of having HHcy, Vitamins B6, B12, and folate deficiency, and other risk factors in ischemic and hemorrhagic stroke patients were evaluated. Student's t-tests and chi-square tests were done for statistical validation of the data. Results: Prevalence of HHcy and Vitamins B6, B12, and folate deficiency was not observed in ischemic cases. HHcy and folate deficiency was found to be prevalent in hemorrhagic stroke patients. The odds that a person with HHcy and folate deficiency has hemorrhagic stroke was found to be significantly high. Conclusion: In our study, high Hcy and low folate levels emerged as risk factors for hemorrhagic stroke. [ABSTRACT FROM AUTHOR]

Heavy metals (HMs) have a very significant clinical role in the pathogenesis, progression and management of cardiovascular diseases (CVDs). The prevalence of CVDs was reported to be higher in critically environmentally HM-polluted (EHMP) steel industrial town Mandi-Gobindgarh (India) for the last more than a decade. To ascertain the role of HMs in the onset of CVDs, the present study was chosen to investigate HMs content in myocardial infarction (MI) patients from EHMP steel industrial town Mandi-Gobindgarh. Total of 110 MI patients along with number- and age-matched healthy volunteers were recruited in the present investigation. The CVDs risk factors estimated in MI patients were overweight (higher body mass index), hypertension (higher systolic and diastolic blood pressures), dyslipidaemia (higher serum cholesterol, triglycerides and lower HDL cholesterol), inflammation (higher-serum C reactive protein and aldosterone) and elevated oxidative stress (higher urinary 8-hydroxydeoxyguanosine). An imbalance of serum electrolyte concentrations including Na (hypernatremia), Ca (hypercalcaemia) and K (hypokalaemia) was also observed in MI patients in which CVDs risk factors were found to correlate positively with serum Na and Ca and negatively with serum K, respectively. Hair HM analysis was used as a bio-indicator for monitoring body HM status from past environmental HM exposure in which CVDs risk factors were observed to correlate positively with higher hair concentrations of Zn, Fe, Mo, Pb, As, Ca and Na and negatively with lower hair concentrations of Cu, Mg, Mn and K in MI patients, respectively. Thus, higher hair concentrations of Zn and Pb indicate their higher environmental exposure and possible cause of higher CVDs risk factors in MI patients from Mandi-Gobindgarh. [ABSTRACT FROM AUTHOR]

Diabetic dyslipidemia is characterised by low HDL-C and high triglyceride levels. Unlike the Caucasian population, though LDL-C levels are not very high, there is a preponderance of more atherogenic small, dense LDL particles among Indians. Furthermore, apo B levels are elevated. This, unique 'atherogenic dyslipidemia', is frequently encountered in South Asians with diabetes. People with type 2 diabetes are considered to be at high risk for vascular events. Hence, irrespective of other risk factors such as age, male gender, hypertension, family history, smoking, obesity, and polycystic ovary syndrome in women, they must be screened for dyslipidemia. Other major ASCVD risk factors include family history of hyperlipidemia, low levels of HDL-C, hypertriglyceridemia, and increased levels of total serum cholesterol level, non-HDL-C, LDL-C, apo B, Lp(a), triglyceride-rich remnants, and small, dense LDL-C. In patients with diabetes, dyslipidemia should be assessed at diagnosis and annually thereafter. In patients with type 1 diabetes, screening for dyslipidemia should be initiated from the age of 12 years. Periodical screening for dyslipidemia is recommended in overweight or obese children with a family history of type 2 diabetes, or those from a predisposed race/ethnicity like Asian, American Indian, etc. Both fasting and non-fasting lipid profiles are important for managing Indian patients with dyslipidemia. For routine screening, a fasting lipid profile is not mandatory; the decision to acquire fasting or non-fasting lipid values must be individually tailored. Apolipoprotein B level is considered an enhanced estimate of an individual's exposure to atherosclerotic lipoproteins, and may be predominantly valuable for assessment of risk in individuals where LDL-C measurement underestimates this burden (those with diabetes mellitus, high triglycerides, obesity, or low LDL-C). The QRISK3 assessment tool algorithm calculates an individual's risk of developing a heart attack or stroke over 10 years, and takes into account ethnicity as a risk factor. Considering the possible genetic influence of Indian ethnicity on CVD, the QRISK3 score exemplifies as the current most accurate CVD screening tool available for the Indian population. Stratification of ASCVD risk in Indian diabetic patients: • High risk: diabetes with 0–1 other major ASCVD risk factors and no evidence of target organ damage. • Very high risk: diabetes with ≥2 other major ASCVD risk factors or evidence of target organ damage. High-risk patients necessitate management comparable to that for secondary prevention of CVD. The most important step in defining treatment goals for dyslipidemia in diabetic patients is an extensive assessment of their cardiovascular risk, with LDL-C as the primary target, and non HDL-C, HDL-C, and apo B as secondary targets. A comprehensive strategy is essential in the management of dyslipidemia so as to regulate lipid levels and tackle related metabolic deviations and modifiable risk factors. Essential considerations to improve lipid profile and glycemic control, and reduce CVD risk: • Accomplish healthy weight and aerobic activity level, • Implement an energy-restricted, well-balanced diet, • No or at most moderate alcohol consumption, and • Smoking (or any other tobacco use) cessation. Medical nutrition therapy plays a central part in diabetes management; every individual with diabetes must be actively engaged in self-management, education, and treatment planning with their healthcare team, together with the collective development of an individualised eating plan. Statins are beneficial as a primary or secondary prevention strategy, to reduce the risk of cardiovascular events, in patients with ASCVD or multiple cardiovascular risk factors especially in those with diabetes. Unless contraindicated, first-line cholesterol-lowering therapy includes the use of moderate- to high-intensity statin. Ezetimibe, when combined with statins, provides additive and complementary therapeutic lipid effects, resulting in considerable reductions in LDL-C and significant achievement of target cholesterol levels. It also permits the use of lower dosage of statins without compromising efficacy, reducing the odds of dose-dependent statin adverse effects. Bempedoic acid seems to provide a safe and effective oral therapeutic option for lipid lowering in patients intolerant to statins. PCSK9 inhibitor therapy, in diabetes, induces analogous relative reductions in cardiovascular risk, and is recommended to further reduce LDL-C in patients aged 40–79 years with LDL-C ≥190 mg/dL, with ASCVD risk factors, or other significant additional-high risk markers (including diabetes) and LDL-C ≥100 mg/dL or non-HDL-C ≥130 mg/dL on maximally tolerated statin therapy and/or ezetimibe. Fenofibrate has shown to reduce CVD in diabetic patients with elevated triglycerides and low HDL-C levels. Saroglitazar has well-documented positive effects in the management of diabetic dyslipidemia; not only does it improve lipid parameters (triglycerides, apo B, non-HDL-C), it has a significant impact on glycemic parameters (HbA1c and fasting blood glucose) in dyslipidemic patients. It, hence, appears as a novel therapy for decreasing cardiovascular risk in patients with type 2 diabetes. Omega-3 fatty acids offer additional benefits when administered as an add-on to statins, and could be attributed to the lowering of detrimental chronic inflammatory markers in people with diabetes and high-risk cardiovascular patients. Icosapent ethyl may provide additional risk reduction benefit, beyond a statin, in individuals with ASCVD or diabetes and multiple risk factors and triglyceride ≥150 mg/dL. Considering the evidence in patients with diabetic dyslipidemia combined with the experience and consensus of the experts, we recommend a step-wise approach for the management for diabetic dyslipidemia in the Indian population (Table 7). [ABSTRACT FROM AUTHOR]

Objective: Antiphospholipid antibody syndrome (APS) is one of the most common acquired thrombophilic disorders resulting in arterial and venous thromboses. APS is a major cause for cerebrovascular accidents or stokes, myocardial infarction, venous thromboembolism and recurrent abortions/pregnancy losses especially in young patients. APS patients have an increased risk of atherosclerotic cardiovascular events. There are only two studies on lipid abnormalities in APS patients. None of them have studied the relationship between individual laboratory tests for APS and lipid profile abnormalities. Here we describe the significance of the relationship between various APS tests and lipid profile abnormalities in a subset of APS patients who presented with arterial thrombosis in a tertiary care hospital. Material and Methods: The study was conducted at Government Medical College, which is a tertiary care referral hospital. All patients who presented to the medicine department with APS during a two-year period were studied. A patient was considered to be positive for anticardiolipin (aCL) antibody or anti-ß2 glycoprotein (anti-ß2G) if the titer was more than 15 IU/mL, and a high titer was considered to be more than 40 IU/mL for Immunoglobulin (lg) IgG and IgM isotypes. The fasting lipid profile was measured in all patients, and lipid profile abnormalities were defined with cutoffs of low-density lipoprotein (LDL) levels of >150 mg/dL, triglyceride (TG) levels of >150 mg/dL, and high-density lipoprotein (HDL) levels of <40 mg/dL. The relationship between lipid abnormalities and individual tests for APS, aCL IgG and IgM and anti-ß2G IgG and IgM, were determined by statistical analysis. Results: The study population included 77 APS patients, with 53% of patients between 20 and 40 years. The commonest abnormality in the lipid profile test was elevated TG levels of >150 mg/dL in 51.9% of the patients, followed by low HDL levels (<40 mg/dL) in 38.9% of the patients and high LDL levels (>150 mg/dL) in 40.2% of the patients. There was a statistically significant relationship between anti-ß2G IgG levels and HDL and LDL levels, but not TG levels. Only LDL levels had a statistically significant relationship with aCL IgM levels. None of the lipid abnormalities had any statistically significant relationship with aCL IgG levels. Conclusion: This study highlights the importance of testing lipid profile abnormalities in APS patients and the existence of a statistically significant relationship between antiphospholipid antibody tests and lipid profile abnormalities. [ABSTRACT FROM AUTHOR]

Background and Objective Various epidemiological studies have implied that local infection may increase the levels of systemic inflammatory mediators and lipid mediators, thereby promoting atherosclerosis. The aim of this study was to assess high-sensitivity C-reactive protein (HsCRP) and lipid levels in healthy adults and patients with coronary artery disease ( CAD), with and without periodontitis. Material and Methods A total of 100 subjects were included in the study and categorized into four groups of 25 subjects each, as follows: subjects with chronic periodontitis with angiographically proven CAD; nonperiodontitis subjects with angiographically proven CAD; otherwise healthy subjects with only chronic periodontitis; and systemically and orally healthy individuals. The periodontal parameters measured included plaque index, gingival index, probing pocket depth, clinical attachment level and marginal alveolar bone loss (which was recorded radiographically). Serum samples were collected for estimation of Hs CRP, low-density lipoprotein ( LDL), high-density lipoprotein ( HDL) and triglycerides ( TGs). Results The serum Hs CRP levels in subjects with either CAD or chronic periodontitis were elevated two-fold compared with those of healthy individuals, whereas in subjects with both diseases ( CAD plus chronic periodontitis) the levels were elevated three-fold. The serum LDL level was higher, and the serum HDL level was lower, in all the test groups compared with the healthy group. No significant difference among the groups was detected in the TG levels. Conclusion A persistent infection, such as chronic periodontitis, may influence changes in the systemic levels of Hs CRP, LDL and HDL, which potentially have an impact on inflammation-associated atherosclerotic processes, such as CAD. [ABSTRACT FROM AUTHOR]

Background: High levels of cholesterol in the body can be alarming and point toward a possible cardiac or diabetic problem. Current evidence reveals that the harmful low-density lipoproteins (LDL) cholesterol tend to increase in poorly controlled diabetes, whereas the useful high-density lipoprotein (HDL) cholesterol, known for its protective anti-inflammatory and antioxidant activities, is decreased. With a positive evidence of periodontal disease being implicated in diabetes, it was decided to investigate whether there was any association between serum HDL, LDL, glycated hemoglobin (HbA1c) and periodontal status with Type II diabetes mellitus patients. Materials and Methods: A total of 500 nonsmoking patients (males and females) aged between 35 and 55 years with Type 2 diabetes mellitus and no other systemic disease were selected from the diabetic center, Diacon hospital, Bengaluru, Karnataka, India. Periodontal examination consisted of the clinical parameters, namely, attachment loss, gingival index (GI) and plaque index based on which the patients were divided into periodontally healthy and diseased groups. Blood samples were collected from each patient to evaluate the serum levels of HDL, LDL and HbA1c. Results: No significant differences were observed between the HDL, LDL and HbA1c levels in both the periodontal groups (P > 0.05). Linear regression analysis showed significant positive correlations of clinical attachment level with LDL and negative correlation with HbA1c, whereas GI has a positive correlation with LDL and negatively with HDL and Hba1c levels (P < 0.05). Conclusion: Varied associations were found between dyslipidemia, glycemic control and periodontal inflammation. Further longitudinal as well as interventional studies may be beneficial to ascertain the causal relationship between cholesterol levels, periodontal status and diabetes mellitus. [ABSTRACT FROM AUTHOR]

Pain relief is a major goal for palliative care in India so much that most palliative care interventions necessarily begin first with pain relief. Physical therapists play an important role in palliative care and they are regarded as highly proficient members of a multidisciplinary healthcare team towards management of chronic pain. Pain necessarily involves three different levels of classification-based upon pain symptoms, pain mechanisms and pain syndromes. Mechanism-based treatments are most likely to succeed compared to symptomatic treatments or diagnosis-based treatments. The objective of this clinical commentary is to update the physical therapists working in palliative care, on the mechanism-based classification of pain and its interpretation, with available therapeutic evidence for providing optimal patient care using physical therapy. The paper describes the evolution of mechanism-based classification of pain, the five mechanisms (central sensitization, peripheral neuropathic, nociceptive, sympathetically maintained pain and cognitive-affective) are explained with recent evidence for physical therapy treatments for each of the mechanisms. [ABSTRACT FROM AUTHOR]

A geomorphological instantaneous unit hydrograph (GIUH) is derived from the geomorphological characteristics of a catchment and it is related to the parameters of the Clark instantaneous unit hydrograph (IUH) model as well as the Nash IUH model for deriving its complete shape. The developed GIUH based Clark and Nash models are applied for simulation of the direct surface run-off (DSRO) hydrographs for ten rainfall-runoff events of the Ajay catchment up to the Sarath gauging site of eastern India. The geomorphological characteristics of the Ajay catchment are evaluated using the GIS package, Integrated Land and Water Information System (ILWIS). The performances of the GIUH based Clark and Nash models in simulating the DSRO hydrographs are compared with the Clark IUH model option of HEC-I package and the Nash IUH model, using some commonly used objective functions. The DSRO hydrographs are computed with reasonable accuracy by the GIUH based Clark and Nash models, which simulate the DSRO hydrographs of the catchment considering it to be ungauged. Inter comparison of the performances of the GIUH based Clark and Nash models shows that the DSRO hydrographs are estimated with comparable accuracy by both the models. [ABSTRACT FROM AUTHOR]

Background and Aims: In view of the prevailing controversy about the role of Methylenetetrahydrofolate reductase (MTHFR) C677T mutation in stroke and paucity of studies from India, this study has been undertaken to evaluate MTHFR C677T gene polymorphism in consecutive ischemic stroke patients and correlate these with folic acid, homocysteine (Hcy) and conventional risk factors.Settings and Design: Ischemic stroke patients prospectively evaluated in a tertiary care teaching hospital.Materials and Methods: Computerized tomography proven ischemic stroke patients were prospectively evaluated including clinical, family history of stroke, dietary habits and addictions. Their fasting and postprandial blood sugar, lipid profile, vitamin B12, folic acid and MTHFR gene analysis were done.Statistical Analysis: MTHFR gene polymorphism was correlated with serum folic acid, Vitamin B12 and Hcy levels; family history of stroke in first-degree relatives; and dietary habits; employing Chi-square test.Results: There were 58 patients with ischemic stroke, whose mean age was 50 (4-79) years; among them, 10 were females. MTHFR gene polymorphism was present in 19 (32.8%) patients, 3 were homozygous and 16 were heterozygous. Both serum folate and B12 levels were low in 29 (50%) patients and Hcy in 48 (83%). Hypertension was present in 28 (48%) patients, diabetes in 12 (21%), hyperlipidemia in 52 (90%), smoking in 17 (29%), obesity in 1 (1.7%) and family history of stroke in first-degree relatives in 13 (22.4%). There was no significant relationship of MTHFR gene polymorphism with folic acid, B12, Hcy levels, dietary habits and number of risk factors. Vitamin B12 level was low in vegetarians (P<0.003). In 3 patients with MTHFR TT alleles, Hcy was elevated in all 3, low folic acid in 2 and family history of stroke in 1 patient.Conclusion: MTHFR gene polymorphism was found in one-third of patients with ischemic stroke and was insignificantly associated with higher frequency of elevated Hcy. [ABSTRACT FROM AUTHOR]

Background: Hyperhomocysteinemia has been proposed as an important risk factor for ischemic stroke worldwide, but data available from the Indian subcontinent is scarce.Aim: To study homocysteine levels in patients with ischemic stroke and compare it with age- and sex-matched controls.Settings and Design: Case-control prospective study.Materials and Methods: Fifty-seven patients with ischemic stroke and 30 controls were recruited for the study. They were subdivided into two subgroups (< 40 years and> 40 years of age) and plasma fasting total homocysteine (tHcy) levels were measured.Statistical Analysis Used: Student's 't' test and chi-square test.Results: The tHcy were significantly high in patients with stroke, compared to controls (9.91 +/- 2.25 vs 8.00 +/- 2.74 micromol/l; P vs 8.45 +/- 2.72 micromol/l; P = 0.01) and female patients compared to controls (9.08 +/- 1.81 vs 6.79 +/- 2.60 micromol/l; P = 0.04). The tHcy levels were significantly high in patients with hypertension compared to normotensive patients (10.96 vs 9.49 micromol/l; P = 0.01) and smokers compared to nonsmokers (11.17 vs 9.33 micromol/l; P = 0.01).Conclusions: Hyperhomo-cysteinemia emerged as an important independent risk factor for ischemic stroke. A strong positive correlation was also observed between hypertension, smoking, and high-tHcy levels in the present study. [ABSTRACT FROM AUTHOR]