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This page contains the abstracts of lectures given at the Annual KGMCAANA Meet in New Orleans.

Atherosclerosis and Lipids in Children

Based on a recent intravascular ultrasound study, 16% of teenagers have coronary atherosclerotic lesions.¹ Despite the fact that atherosclerosis starts early, efforts for coronary artery disease prevention have been primarily directed toward adults. A detail family history of heart disease is crucial during the initial evaluation of children. When ordering lipid studies, full lipid profile is indicated in all children and adolescents if the family history reveals a premature heart disease in first-degree relatives or if there are other cardiovascular risk factors. Recent data strongly support additional profile on High-sensitivity C-reactive protein, ² homocysteine levels,³Lp(a) and fractionated HDL. In children also, excess body weight is associated with a state of chronic low-grade inflammation indicating the usefulness of C-reactive protein. ⁴ With all the attention to lipids, lest we forget nonlipid-risk factors such as smoking, hypertension, obesity, diabetes and impaired glucose tolerance. ⁵ The importance of Lp(a), ⁶ impaired glucose tolerance, and C-reactive protein cannot be overemphasized in patients of Indian origin who have normal lipid profile including normal HDL levels. ^7,8 Unless the family history and lipid levels are of serious concern, in most cases, non-pharmacological treatment alone such as dietary changes and regular exercise would suffice in children who are ten-year old or younger. Our experience with the newer Stanol/sterol ester-containing foods is limited. ⁹ A recent study on the effectiveness of diet in preschool boys may be of interest. ¹⁰ Statin therapy is effective in subjects with hypercholesterolemia and in persons with low lipid levels but with elevated levels of C-reactive protein.^11,12 Experience with the use of Statin among adolescents is limited; ¹³ therefore, discretion is advised regarding their use in this population.

References:

1. Tuzcu EM et al. High prevalence of coronary atherosclerosis in asymptomatic teenagers and young adults. Circulation 2001:103:2705-2710.
2. Ridker PM. High-sensitivity C-reactive protein. Potential adjunct for global risk assessment in the primary prevention of cardiovascular disease. Circulation 2001;103:1813-1818.
3. Chai AU et al. Homocysteine: A new cardiac-risk factor. Clin Cardiol 2001;24:80-84.
4. Ford ES et al. C-reactive protein and body mass index in children: Findings from the third national health and nutrition examination survey, 1988-1994. J Pediatr 2001;138:486-492.
5. McGill HC et al. Effects of Nonlipid risk factors on atherosclerosis in youth with a favorable lipoprotein profile. Circulation 2001;103:1546-1550.
6. Enas EA. Lipoprotein (a) is an important genetic risk factor for coronary artery disease in Asian Indians. Am J Cardiol 2001;88:201.
7. Zindrou D et al. Comparison of operative mortality after coronary artery bypass grafting in Indian subcontinent Asians Vs Caucasians. Am J Cardiol 2001;88:313-316.
8. Chambers JC et al. C-reactive protein, insulin resistance, central obesity, and coronary heart disease risk in Indian Asians from the United Kingdom compared with European whites. Circulation 2001;104:145-150.
9. Lichtenstein AH et al. Stanol/sterol ester-containing foods and blood cholesterol levels. Circulation 2001;103:1177-1179.
10. Nissila LR et al. Prospective, randomized, infancy-onset trial of the effects of a low-saturated-fat, low-cholesterol diet on serum lipids and lipoproteins before school age. Circulation 2000;102:1477-1483.
11. Ridker PM et al. Measurement of C-reactive protein for the targeting of Statin therapy in the primary prevention of acute coronary events. N Engl J Med 2001;344:1959-1965.
12. Munford RS. Statin and the acute-phase response (editorial). N Engl J Med 2001;344:2016-2018.
13. Stein EA et al. Efficacy and safety of Lovastatin in adolescent males with heterozygous familial hypercholesterolemia. JAMA 1999;281:137-144.

"Role of botulinum toxin injections in the management of neuromuscular disorders"

S.Sharma MD, FRCP(C)

University Health Network and Sunnybrook Health Science Center, University of Toronto, Canada.

The neurotoxin produced by the Clostridium Botulinus bacteria is now used as primary therapy in blepherospasm, hemifacial spasm and spastic dysphonia. It can also be effectively used in controlling spastic contractures following strokes, traumatic brain and spinal cord injuries to facilitate rehabilitation. There are many other uses which are under study i.e. for relief of muscular pain, anismus, vaginismus, trismus and headaches. Kinetic, kinmetic and dynamic EMG studies was undertaken by the primary author to document that the decreased spasticity in gastrosoleus muscles will result in decreased stresses at the knee and hip joints in stroke patients and improve the ambulation. A 428.9% improvement in ankle dorsiflexion was recorded in the hemiplegic limb after injection of botulinum toxin (Botox) in the gastrosoleus muscles leading to decreased hyperextension forces at the knee joint and normalization of the EMG activity.

Dr. Satish Mullick

Asian Indians have a very high incidence of periodontal disease and recent studies have shown that they as a group have a much higher incidence of cardiovascular diseases as well. As that group ages the incidence of these diseases would more likely increase. There has been a revival in the belief in the theory of ‘Focal Infection.’ Several investigators have published their work in Dental as well as Medical literature on the relationship of periodontal disease to cardiovascular diseases and to stroke. A number of these were based on the analyses of the periodontal health of subjects from the various National Health and Nutrition Examination Surveys. The possible mechanisms by which oral infection may contribute to atherosclerosis could be: 1. Direct effects of infectious agents in atherosclerosis. 2. Host mediated effects triggered by infection. 3. Common genetic predisposition for periodontal disease and atherosclerosis. 4. Common risk factors for periodontal disease and atherosclerosis. Other studies have shown that most probably there is no relationship between the periodontal disease and coronary artery disease but perhaps there is a relationship between it and non-hemorrhagic strokes. A very recent study has shown a possible link between periodontal disease and chronic obstructive pulmonary disorder.

There were many questions form the audience. I mentioned that most people do not know the correct technique of brushing and, perhaps what is even more important, do not brush long enough for the toothpaste to be effective. Just like for a medicine to be effective it must remain in the system for sufficient length of time the toothpaste must stay in the mouth for some time to be effective. If one takes a pill and within seconds it comes out from the other end it would not be very effective. The recommendation were to use a soft tooth brush, use a toothpaste that has a Seal of Approval from the American Dental Association and brush for at least two and a half to three minutes.

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