Alternative medicine in atrial fibrillation treatment—Yoga,acupuncture, biofeedback and more

The last decade has seen a significant improvement in the management of atrial fibrillation (AF) with the development of newer medications and improvement in catheter ablation techniques. Recurrence of AF remains a significant problem in these patients and medications offer limited supportive role. Complementary and alternative treatment strategies therefore remain a viable option for these AF patients. Several studies have shown improvement in AF symptoms with yoga therapy, acupuncture and biofeedback. There are also several herbal medicine and supplements such as omega-3 fatty acids, antioxidant vitamins, barberry, motherwort, cinchona, Shensongyangxin, hawthorn, Kella and Wenxin Keli that have been evaluated as potential therapeutic options in AF. These studies are however limited by small sample sizes with mixed results. Besides the pharmacological action, metabolism, interactions with other medications and the adverse effects of the herbal medications and supplements remain poorly understood. In spite of the above limitations, complementary therapies remain a promising option in the management of AF and further studies are necessary to validate their safety and efficacy.     

Amaurosis,an Unusual Complication Secondary to Inferior Alveolar Nerve Anesthesia: A Case Report and Literature Review

Ocular complications after an inferior alveolar nerve anesthesia are rare. These complications, although temporary and benign, can be distressing to both the patient and the clinician. A 37-year-old male patient was administered an inferior alveolar nerve block for the root canal treatment of tooth #30. Immediately after the administration of local anesthesia, the patient reported complete loss of vision. The patient recovered completely after 15 minutes. In particular, amaurosis is quite uncommon and usually heralds a more sinister pathology such as stroke. This case report presents an unusual case of ocular complication after an inferior alveolar nerve block. Adequate knowledge of the regional anatomy and physiology of the orbit and its nearby structures, the proposed causes of ocular complications, and prevention and management is necessary to manage such events.     

Effects of high molecular weight solutes on fluid flux across the arterial wall

Summary To investigate the mechanisms controlling the flux of plasma proteins into and through the walls of blood vessels, we have studied the effects of two inert protein analogues, Dextran 500 and Poly-(ethylene)oxide (PEO) on fluid transport across the walls of intact rabbit common carotid arteries. Transmural fluxes were first measured in vessels pressurized to 150cmH₂O with a solution containing 10mg/ml albumin alone (control solution) and then with one containing 10mg/ml albumin plus 10 or 50mg/ml dextran, or 10 or 30mg/ml PEO (test solutions). The macromolecule solutions caused a decrease in transmural filtration; the ratios of fluxes with the test solutions to those with the control solutions were 0.89 ± 0.11 (7), 0.63 ± 0.08 (8), 0.69 ± 0.24 (9) and 0.41 ± 0.09 (4), respectively (Mean ± SD (n)). These reductions in fluid movement through the vessel wall may be explained quantitatively in terms of the formation of concentration-polarized layers of the macromolecules at the luminal surface or interactions of the macromolecules with the endothelial glycocalyx, causing a decrease in its permeability.     

Association of infections and tuberculosis with antitumor necrosis factor alpha therapy

PURPOSE OF REVIEW: Rheumatoid arthritis patients have higher risk for infections due to comorbidities, underlying immunosuppression and use of glucocorticoids and disease modifying antirheumatic drugs. The association between treatment with antitumor necrosis factor alpha agents and serious infections, including opportunistic infections such as tuberculosis, in rheumatoid arthritis patients remains controversial. We present recent literature on this topic with a focus on clinical applications of this new data. RECENT FINDINGS: Prospective cohort studies and population-based registries have described the incidence and risk of serious infections in large rheumatoid arthritis patient populations of antitumor necrosis factor alpha users. Although some studies have suggested a one and one-half to two-fold increased risk, especially immediately after initiating the treatment, not all have shown an elevated risk for serious bacterial infections or tuberculosis. SUMMARY: Although antitumor necrosis factor alpha agents may be independent risk factors for infections there is an absolute low rate of infection in those treated with these agents (approximately 5 per 100 patient-years). Screening for latent tuberculosis with tuberculin skin testing is effective, and compliance with the recommendations for preventing this disease in recipients of antitumor necrosis factor alpha agents has partially decreased the risk of infections. Clinical suspicion toward developing infection in those being treated with antitumor necrosis factor alpha agents, particularly earlier in the treatment course, is important for effective management of patients.     

Biologics and heart failure in rheumatoid arthritis: are we any wiser?

PURPOSE OF REVIEW: To summarize the recent literature concerning the role of TNF-alpha in heart failure, epidemiology of heart failure in rheumatoid arthritis and risk of heart failure associated with biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. RECENT FINDINGS: TNF-alpha has been implicated in the pathogenesis of heart failure. It has direct deleterious effects on the myocardium in the setting of acute injury or chronic heart failure. In animal models, TNF-alpha is important in cardiac remodeling, leading to cardiac dysfunction following acute injury. Both incident and worsening heart failure have been reported in patients with rheumatoid arthritis who are treated with anti-TNF-alpha therapy. Recent cohort studies, however, have shown no increased risk and, in some, a protective effect on the risk of heart failure. Certain traditional cardiovascular risk factors have a relatively lesser contribution to cardiovascular morbidity and mortality in patients with rheumatoid arthritis, suggesting that disease-related perturbations of the cytokine network may contribute to the excess risk of heart failure in these patients. SUMMARY: Overall mortality in rheumatoid arthritis has remained stagnant despite advances in rheumatoid arthritis and heart failure management and improved cardiovascular mortality in the general population. Heart failure prevalence is increased in patients with rheumatoid arthritis and leads to greater mortality. Despite current expert consensus contraindicating the use of anti-TNF-alpha agents in patients with moderate to severe heart failure, epidemiological studies in rheumatoid arthritis have not consistently substantiated this association.