Is It a Pheochromocytoma?

The patient is a 44-year-old man with a 4-year history of intermittently elevated blood pressure (BP) controlled by diet and exercise. Three months before evaluation he described daily "spikes" of BP with sharp unilateral headaches. He was seen in the emergency department with a BP of 212/106 mm Hg and was started on hydrochlorothiazide 25 mg daily. He denied palpitations, diaphoretic episodes, pallor, and tremor. The patient did not want to take medication and specifically requested an evaluation to rule out pheochromocytoma. Results from 24-hour urine tests for total metanephrines was 812 mg/24 h (normal, 130-520 mg/24 h), for total catecholamines was 53 mg/24 h (normal, 0-135 mg/24 h), and for vanillylmandelic acid was 4.7 mg/24 h (normal, <7 mg/24 h). Thyroid-stimulating hormone was 0.87 (normal, 0.4-4.0 IU/mL). Physical examination revealed normal optic fundi, negative cardiac examination results, and presence of peripheral pulses without bruits. His BP was now 136/74 mm Hg, with a heart rate of 76 beats per minute.     

Casting a Wider NET: Is It Crohn’s or Is It Neuroendocrine Tumor?

Digestive Diseases and Sciences -     

Microalbuminuria: What Is It? Why Is It Important? What Should Be Done About It? An Update

Microalbuminuria (MA) is defined as a persistent elevation of albumin in the urine of >30 to <300 mg/d (>20 to <200 microg/min). Use of the morning spot urine test for albumin-to-creatinine measurement (mg/g) is recommended as the preferred screening strategy for all patients with diabetes and with the metabolic syndrome and hypertension. MA should be assessed annually in all patients and every 6 months within the first year of treatment to monitor the impact of antihypertensive therapy. It is an established risk marker for the presence of cardiovascular disease and predicts progression of nephropathy when it increases to frank microalbuminuria>300 mg/d. Data support the concept that the presence of MA is the kidney's warning that there is a problem with the vasculature. The presence of MA is a marker of endothelial dysfunction and a predictor of increased cardiovascular risk. MA can be reduced, and progression to overt proteinuria prevented, by aggressive blood pressure reduction, especially with a regimen based on medications that block the renin-angiotensin-aldosterone system, and control of diabetes. The National Kidney Foundation recommends that blood pressure levels be maintained at or below 130/80 mm Hg in anyone with diabetes or kidney disease.     

Is It Open or Is It Closed? Thrombosis of a St. Jude's Tricuspid Valve Prosthesis

A 49-year-old woman with mitral and tricuspid mechanical valve prostheses developed marked weight gain with increasing abdominal girth and facial plethora 4 weeks after anticoagulation was temporarily interrupted for abdominal surgery. Transthoracic and transesophageal echocardiography documented severe tricuspid stenosis and regurgitation. The two discs of the tricuspid prosthesis were immobilized, half open and half closed. The prosthesis was replaced and the patient did well.     

Is Unstable Angina a Contraindication to Intracoronary Stent Insertion?

BACKGROUND: Percutaneous transluminal coronary angioplasty is associated with higher rates of acute complications and restenosis when performed in the clinical setting of unstable angina. Coronary stent insertion has been shown to reduce restenosis when performed electively. The effect of unstable angina on clinical outcome after stent deployment is currently unclear. OBJECTIVE: To compare the clinical outcome after coronary stents inserted in patients with unstable and stable angina. DESIGN: A retrospective analysis of all patients receiving Palmaz-Schatz stents electively or for sub-optimal angioplasty result in patients with stable and unstable angina. PATIENTS: One-hundred fifty-seven patients received 178 Palmaz-Schatz stents electively or for the treatment of sub-optimal result. Thrombolysis in Myocardial Infarction Study (TIMI) grade 3 flow was present in all patients at the time of stent delivery. Unstable angina was defined as pain at rest despite anti-anginal therapy (Braunwald class II, III). Eighty-three patients (mean age 58 years) with unstable angina received 95 stents and 74 patients (mean age 57 years) with stable angina received 83 stents. MAIN OUTCOME MEASURES: Subacute stent thrombosis (SAST), myocardial infarction (MI), need for repeat angiography, coronary bypass graft surgery (CABG) and death. RESULTS: The early complications (within 2 weeks) comparing the unstable and stable groups respectively were: No deaths, SAST 3/83 (3.6%) vs. 2/74 (2.7%), MI 2/83 (2.4%) vs. 2/74 (2.7%) and CABG 6/83 (7.2%) vs. 2/74 (2.7%). After 2 weeks no patient had a MI or CABG. Clinical follow-up was continued up to 6 months. Two patients in each group had repeat angiography for recurrent symptoms. One patient in the stable group died from non-cardiac causes. CONCLUSIONS: There appears to be no difference in the early or late clinical outcome of patients with unstable or stable angina treated with coronary stent insertion when TIMI flow is normal at the time of stent insertion.     

Transplant or VAD?

Major advances in vascular assist device (VAD) technology and the clinical acceptance of destination therapy for patients with contraindications to transplant raise the questions of what patient benefit is necessary to recommend VAD implant for long-term support in patients who are transplant candidates. What are the appropriate indications for use and timing considerations for long-term VAD therapy in patients who qualify for transplant but are unlikely to obtain a donor? The authors suggest that VAD implantation for the indication of "maintenance therapy" where patients must remain on the VAD for two years before becoming transplant eligible, would constitute an appropriate clinical avenue to study these issues.     

Early Decision for Precut Sphincterotomy: Is It a Risky Preference?

The aim of this prospective study was to evaluate the results and the complications at a tertiary referral center which frequently uses precutting techniques for biliary cannulation. Four hundred seventy patients with naive papilla for whom biliary intervention was planned were included in the study. If the selective cannulation was not achieved after a few trials, precutting sphincterotomy was performed. The results were evaluated for the frequency, success, and complication rates of precutting. Precutting was performed on 238 (50.6%; 117 male, 121 female; mean age, 58.5±16.2 years) of 470 patients. Total success rate of endoscopic retrograde cholangiopancreatography (ERCP) was 99.2% (236/238). The rate of complications in patients with versus without precutting was 7 (2.9%) versus 3 (1.3%) for pancreatitis, 2 (0.8%) versus 1 (0.4%) for perforation, and 7 (2.9%) versus 3 (1.3%) for bleeding. The differences between the rates were not significant. Early precutting can be preferable in prolonged cannulation trials of therapeutic ERCP.