Rupture of chordae tendineae in patients with beta-thalassemia

Cardiac disease is the primary cause of mortality in beta-thalassemia patients. Except for ventricular dysfunction and pulmonary hypertension that represent the main forms of heart disease in these patients, valvular abnormalities including valvular regurgitation, endocardial thickening and calcification and mitral valve prolapse have also been described. Here we present two patients with thalassemia major and mitral chordal rupture, a previously undescribed abnormality in this population. Pathogenesis of this finding may involve thalassemia-related pseudoxanthoma elasticum-like syndrome, a diffuse elastic tissue defect, which is observed with a notable frequency in these patients and has been associated with numerous cardiovascular complications, including valvular ones.     

Management of abdominal wound dehiscence with porcine dermal collagen implant: report of a case

Abdominal wound dehiscence is a major postoperative complication with a high mortality rate. Although the mainstay of management is immediate operative reclosure, critically ill patients are better served by conservative temporary measures and delayed operative closure. The evidence in the literature regarding the use of biosynthetic implants in abdominal wound dehiscence is limited. To expand knowledge of management options, a case of abdominal wound dehiscence post hysterectomy in a critically ill 69-year-old woman managed with placement of a porcine dermal collagen implant is described. The porcine dermal collagen implant was placed in an infected field for the repair of the fascial defect under local anesthesia. No additional surgery was required and, 9 months post surgery, the patient remained healthy without evidence of residual hernia. Biosynthetic implants may be an effective alternative for the acute management of fascial dehiscence in critically ill patients.     

Celiac disease: current concepts in diagnosis and treatment

Celiac disease is a complex autoimmune enteropathy that affects the small bowel in genetically predisposed individuals. It is thought that celiac disease is the result of an inappropriate T cell-mediated immune response against ingested gluten protein. The characteristic lesion of the small intestinal mucosa includes loss of absorptive villi and infiltration of the lamina propria with inflammatory cells. The clinical presentation of celiac disease varies greatly depending on patient's age, duration and extent of the disease, and the presence of extraintestinal manifestations. Unfortunately, most patients with celiac disease have either silent or atypical presentations, thus escaping diagnosis for several years. Medical nutrition therapy with lifelong adherence to a strict gluten-free diet is the only accepted treatment of celiac disease. Individuals at risk for this entity should undergo appropriate serologic testing, but there is no evidence to support mass screening.     

Marginal zone B-cell lymphoma (MALT lymphoma)

Opinion statement The preferred terminology for mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach (variously referred to as MALT lymphoma, MALToma, low-grade MALToma, or pseudolymphoma) is marginal zone B-cell lymphoma (MZBL). MZBL, the hallmark of which is the lymphoepithelial lesion, develops as a consequence of Helicobacter pylori infection in susceptible individuals. In general, MZBL is slow growing, can remain localized for years, and has an excellent prognosis. Staging involves endoscopy with biopsy, computed tomography scanning, and endoscopic ultrasound. In patients with limited disease, eradication of H. pylori leads to remission. In patients who fail eradication therapy or have more extensive disease, surgery, chemotherapy, and radiation alone and in various combinations have been used successfully.     

Effects of renin-angiotensin system blockers on renal outcomes and all-cause mortality in patients with diabetic nephropathy: an updated meta-analysis

BackgroundIn contrast to previous studies, recent data questioned the ability of renin-angiotensin-aldosterone system (RAAS) blockers to delay progression of diabetic nephropathy. This study evaluated the effect of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) in patients with diabetic nephropathy.MethodsA systematic literature search of MEDLINE/PubMed and EMBASE databases was performed to identify randomized trials published up to June 2007 comparing the effects of ACEIs or ARBs with placebo and/or a regimen not including a RAAS blocker on the incidence of end-stage renal disease (ESRD), doubling of serum creatinine (DSC), or death from any cause in patients with diabetic nephropathy. Treatment effects were summarized as relative risks (RRs) using the Mantel-Haenszel fixed-effects model.ResultsOf the 1,028 originally identified studies, 24 fulfilled the inclusion criteria (20 using ACEIs and 4 using ARBs). Use of ACEIs was associated with a trend toward reduction of ESRD incidence (RR 0.70; 95% confidence interval (CI) 0.46-1.05) and use of ARBs with significant reduction of ESRD risk (RR 0.78; 95% CI 0.67-0.91). Both drug classes were associated with reduction in the risk of DSC (RR 0.71; 95% CI 0.56-0.91 for ACEIs and RR 0.79; 95% CI 0.68-0.91 for ARBs) but none affected all-cause mortality (RR 0.96; 95% CI 0.85-1.09 for ACEIs and RR 0.99; 95% CI 0.85-1.16 for ARBs).ConclusionTreatment of patients with diabetic nephropathy with a RAAS blocker reduces the risks of ESRD and DSC, but does not affect all-cause mortality. These findings are added to the evidence of a renoprotective role of RAAS blockers in such patients.American Journal of Hypertension (2008). doi:10.1038/ajh.2008.206American Journal of Hypertension (2008); 21, 8, 922-929. doi:10.1038/ajh.2008.206.     

Type II diabetes mellitus and cardiovascular risk factors: Current therapeutic approaches

Worldwide, approximately 200 million people currently have type II diabetes mellitus (DM), a prevalence that has been predicted to increase to 366 million by 2030. Rates of cardiovascular disease (CVD) mortality and morbidity are particularly high in this population, representing a significant cost for health care systems. Type II DM patients generally carry a number of risk factors for CVD, including hyperglycemia, abnormal lipid profiles, alterations in inflammatory mediators and coagulation/thrombolytic parameters, as well as other 'nontraditional' risk factors, many of which may be closely associated with insulin resistance. Therefore, successful management of CVD associated with diabetes represents a major challenge to the clinicians. An effective way of tackling this problem is to detect the associated risk factors and to target treatment toward their improvement. Targeting hyperglycemia alone does not reduce the excess risk in diabetes, highlighting the need for aggressive treatment of other risk factors. Although the current use of statin therapy is effective at reducing low-density lipoprotein cholesterol, residual risk remains for other independent lipid and nonlipid factors. The peroxisome proliferator-activated receptor-gamma appears to be closely involved in regulating risk markers at multiple levels. A relatively new class of therapeutic agents that activate peroxisome proliferator-activated receptor-gamma, the thiazolidinedione insulin-sensitizing agents, is currently used to manage type II DM. These agents display a number of potential antiatherogenic properties, including effects on high-density lipoprotein cholesterol and triglycerides, as well as other beneficial nonlipid effects, such as regulating levels of mediators involved in inflammation and endothelial dysfunction. Research data suggest that simple strategies combining thiazolidinediones and statins could have complementary effects on CVD risk-factor profiles in diabetes, alongside the ability to control glycemia.     

Breakfast cereal is associated with a lower prevalence of obesity among 10-12-year-old children: the PANACEA study

Background and aimEating behaviours and obesity status among children have already been evaluated in several studies, with conflicting results. The aim of this study is to assess the correlation of breakfast cereal with childhood obesity.Methods and resultsA representative sample of 700 children (323 male) selected from 18 schools located in Athens greater area were enrolled. Children and their parents completed questionnaires that evaluated dietary habits and physical activity. We also retrieved information about the type of breakfast most frequently consumed. Height and weight of the children was measured and body mass index (BMI) was calculated. Simple and multiple logistic regression methods were used in order to determine the relationship between cereal intake for breakfast and obesity.Some boys (8.6%) and girls (9.0%) were obese, whereas 33.9% of boys and 22.1% of girls were overweight. For boys, the adjusted odds ratio for breakfast cereal intake for being overweight or obese was 0.54 (95% confidence interval (CI): 0.45–1.29), while for girls it was 0.41 (95% CI: 0.21–0.79). Moreover, the odds ratio of overweight/obesity for boys who ate daily breakfast was 0.51 (95% CI: 0.25–1.05), and for girls was 0.27 (95% CI: 0.12–0.64), adjusted for physical activity and other potential confounders.ConclusionThese data provide evidence that breakfast cereal as a most frequent choice, and daily consumption of breakfast, are inversely associated with the prevalence of overweight or obesity in 10–12-year-old children.     

Dipstick proteinuria is an independent predictor of high on treatment platelet reactivity in patients on clopidogrel,but not aspirin,admitted for major adverse cardiovascular events

The effectiveness of aspirin and clopidogrel in patients with chronic kidney disease (CKD) suffering from acute cardiovascular events is unclear. High on treatment platelet reactivity (HTPR) has been associated with worse outcomes. Here, we assessed the association of dipstick proteinuria (DP) and renal function on HTPR and clinical outcomes. Retrospective cohort analysis of 261 consecutive, non-dialysis patients admitted for Major Adverse Cardiovascular Events (MACE) that had VerifyNow P2Y12 and VerifyNow Aspirin assays performed. HTPR was defined as P2Y12 reactivity unit (PRU)?>?208 for clopidogrel and aspirin reaction units (ARU)?>?550 for aspirin. Renal function was classified based on the estimated glomerular filtration rate (eGFR), and dipstick proteinuria was defined as ≥30?mg/dl of albumin detected on a spot analysis. All cause mortality, readmissions, and cardiac catheterizations were reviewed over 520 days. In patients on clopidogrel (n?=?106), DP was associated with HTPR, independent of eGFR, diabetes mellitus, smoking or use of proton pump inhibitor (AOR?=?4.76, p?=?0.03). In patients with acute coronary syndromes, HTPR was associated with more cardiac catheterizations (p?=?0.009) and readmissions (p?=?0.032), but no differences in in-stent thrombosis or re-stenosis were noted in this cohort. In patients on aspirin (n?=?155), no associations were seen between DP and HTPR. However, all cause mortality was significantly higher with HTPR in this group (p?=?0.038). In this cohort, DP is an independent predictor of HTPR in patients on clopidogrel, but not aspirin, admitted to the hospital for MACE.