Patients with hereditary angioedema (HAE) experience episodes of bradykinin-induced swelling of skin and mucosal membranes. The most common cause is reduced plasma activity of C1-inhibitor, the main regulator of the proteases plasma kallikrein (PKa) and factor XIIa (FXIIa). Recently, HAE patients were described with a Lys311 to glutamic acid substitution in plasminogen (Plg), the zymogen of the protease plasmin (Plm). Adding tissue plasminogen activator to plasma containing Plg-Glu311 results in greater bradykinin generation than in plasma containing wild type plasminogen (Plg-Lys311). Similar results were obtained in plasmas lacking prekallikrein or factor XII (the zymogens of PKa and FXIIa), and in normal plasma treated with a PKa inhibitor, indicating Plg-Glu311 induces bradykinin generation independently of PKa and FXIIa. Plm-Glu311 cleaves high-molecular-weight and low-molecular-weight kininogens (HK and LK, respectively), releasing bradykinin more efficiently than Plm-Lys311. Based on the plasma concentration of HK and LK, the latter may be the source of most bradykinin generated by Plm-Glu311. The lysine analog e-aminocaproic acid blocks plasmin-catalyzed bradykinin generation. The Glu311 substitution introduces a lysine-binding site into the plasminogen kringle 3 domain, perhaps altering binding to kininogens. Plasminogen residue 311 is glutamic acid in most mammals. Glu311 in HAE patients, therefore, represents reversion to the ancestral condition. Substantial BK generation occurs during Plm-Glu311 cleavage of human HK, but not mouse HK. Furthermore, mouse plasmin, which has Glu311, did not liberate bradykinin from human kininogens more rapidly than human Plg-Lys311. This indicates Glu311 is pathogenic in the context of human plasmin when human kininogens are the substrates.

Only 28.3% had their HbA1c at or below 7% and 45% above 9%. One-third of the female and one-fifth of the male patients had coronary artery disease. The prevalence of hypertension was almost equal in both sexes. However, there was a statistically significant higher systolic blood pressure (mean 162.12mmHg vs 147.49mmHg, p=0.01044) among females. The total cholesterol was above 200mg/dl in 42.1% of males and 45.61% of females. The triglyceride was >150mg/dl in 38.6% males and 50.88% females. Low high density lipoprotein (HDL) cholesterol levels were found in 20.07% of males and 41.12% of females (p=0.0445). The mean low density lipoprotein (LDL) was 121.75 (±32.29) CONCLUSION: The mean blood sugar values are found to be high, which will lead to a predictable increase in vascular disease, which in turn will affect the quality of health and productivity of the individual and the economic growth of the society as a whole. Studies suggest that therapeutic interventions to improve glycemic control may reduce the risk of cardiovascular disease and microvascular disease. This study shows that the level of diabetes control in Kerala is unsatisfactory. We need more medications, better strategies and more emphasis on glycemic management than we are currently able to apply.

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Obstructive sleep apnea (OSA) and obstructive sleep apnea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences among the general public as well as the majority of primary care physicians across India is poor. This necessitated the development of the Indian initiative on obstructive sleep apnea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health and Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep-related symptoms or co-morbidities or ≥15 such episodes without any sleep-related symptoms or co-morbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents, and high-risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers, and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography is the “gold standard” for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances (OA) are indicated for use in patients with mild to moderate OSA who prefer OA to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioral measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

Background:Primary total elbow arthroplasty (TEA) is a challenging procedure for orthopedic surgeons. It is not performed as frequently as compared to hip or knee arthroplasty. The elbow is a nonweight-bearing joint; however, static loading can create forces up to three times the body weight and dynamic loading up to six times. For elderly patients with deformity and ankylosis of the elbow due to posttraumatic arthritis or rheumatoid arthritis or comminuted fracture distal humerus, arthroplasty is one of the option. The aim of this study is to analyze the role of primary total elbow arthroplasty in cases of crippling deformity of elbow.Materials and Methods:We analyzed 11 cases of TEA, between December 2002 and September 2012. There were 8 females and 3 males. The average age was 40 years (range 30-69 years). The indications for TEA were rheumatoid arthritis, comminuted fracture distal humerus with intraarticular extension, and posttraumatic bony ankylosis of elbow joint. The Baksi sloppy (semi constrained) hinge elbow prosthesis was used. Clinico-radiological followup was done at 1 month, 3 months, 6 months, 1 year, and then yearly basis.Results:In the present study, average supination was 70° (range 60-80°) and average pronation was 70° (range 60-80°). Average flexion was 135° (range 130-135°). However, in 5 cases, there was loss of 15 to 35° (average 25°) of extension (45°) out of 11 cases. The mean Mayo elbow performance score was 95.4 points (range 70-100). Arm length discrepancy was only in four patients which was 36% out of 11 cases. Clinico-radiologically all the elbows were stable except in one case and no immediate postoperative complication was noted. Radiolucency or loosening of ulnar stem was seen in 2 cases (18%) out of 11 cases, in 1 case it was noted after 5 years and in another after 10 years. In second case, revision arthroplasty was done, in which only ulnar hinge section, hinge screw and lock screw with hexagonal head were replaced.Conclusion:Elbow arthroplasty remains a valuable option for deformed and ankylosed elbows especially in the demanding patients with crippling deformity of the elbow.