Secondary Causes of Hypertriglyceridemia are Prevalent Among Patients Presenting With Hypertriglyceridemia Induced Acute Pancreatitis

BackgroundHypertriglyceridemia induced acute pancreatitis (HIAP) is the third common cause of acute pancreatitis. HIAP can result in recurrent attacks of severe AP with significant morbidity and mortality. Hypertriglyceridemia (HTG) could be primary or secondary. Although genetic causes of HTG are well studied, the prevalence of secondary causes of HTG in patients presenting with HIAP is not well characterized. This study aimed to identify the prevalence of risk factors for secondary hypertriglyceridemia among patients presenting with HIAP in a tertiary referral center in a large metropolitan area.MethodsThis is a retrospective analysis of all patients admitted with AP from August 2012–2017. A subgroup of patients with triglycerides >880 mg/dl were included for analysis. Secondary causes of HTG were identified. Secondary analysis evaluating the severity of pancreatitis was performed.ResultsThere were 3,746 patients admitted for AP of which 57 patients had AP and HTG. Of these 57 patients, 70.2% had history of diabetes mellitus, 26.3% had history of heavy alcohol use, 22.8% had chronic kidney disease, 47.3% with obesity, and 21.1% with metabolic syndrome. Two patients were classified as unexplained HTG. Secondary analysis showed a total of 45.6% of patients requiring ICU admission. 26.3% of patients with severe inflammatory pancreatitis and 17.5% of patients with severe necrotizing pancreatitis.ConclusionsIn our cohort of HIAP, 55 out of 57 patients had secondary causes for HTG. Identifying secondary causes of HTG during acute hospitalization is important to tailor outpatient treatment in order to prevent future admissions with HIAP.     

Editorials: Updating sphygmomanometry

Left ventricular function in two cases of restrictive pericardial disease is described. In one, calcification of the pericardium was absent and the restrictive process, as judged by the response to atrial systole, was incomplete. In the other, calcification was extensive and the restrictive process was severe. Both patients had normal myocardial function in the presence of greatly depressed pump function. This apparent discrepancy may be explained on the basis of restriction of end-diastolic fiber stretch and reduction in the potential to augment stroke volume by way of the Frank-Starling mechanism.     

Progressive multifocal leukoencephalopathy in a renal transplant recipient. Increased diagnostic sensitivity of computed tomographic scanning by double-dose contrast with delayed films

A progressive, deteriorating neurologic disorder developed in a 28-year-old white man 10 years after he successfully received a living related donor kidney transplant. An extensive neurologic evaluation was unrevealing, including normal results of computed tomographic scanning of the brain with and without contrast medium. Repeated computed tomographic scanning after a double dose of radiocontrast medium in conjunction with delayed imaging revealed multiple areas of abnormal enhancement. This technique helped to direct brain biopsy, which led to the early diagnosis of progressive multifocal leukoencephalopathy and the institution of specific therapy.     

New approaches to the therapy of mild hypertension

Concern about the initial use of diuretic agents under the stepped-care approach to the treatment of hypertension has been voiced before. Recently, however, the level of concern has risen as the results of various trials have questioned the safety of these agents in mild hypertension. Diuretic-induced hypokalemia has been reported in 10 to 30% of patients on long-term treatment. Recent studies show that hypokalemia may lead to previously unsuspected and potentially fatal arrhythmias, particularly after infarction. Increases in plasma cholesterol of 10 to 20 mg/dl may occur with diuretic therapy. Diuretics are also known to decrease glucose tolerance. Beta-adrenergic blocking drugs, although useful in many situations, are contraindicated in about 25% of the hypertensive population. These agents may also pose a long-term atherogenic risk because of their adverse effect on lipid and glucose metabolism. If all these effects have the potential to increase the risk of coronary heart disease over the long term, then first-line administration of diuretic therapy and, to a lesser extent, beta-blocking therapy, to the 25 to 30 million Americans with diastolic pressure in the 90 to 100 mm Hg range must obviously be reassessed. Various alternative therapies, including withholding drugs for 6 months in patients with diastolic pressure of 90 to 100 mm Hg, using hygienic measures in patients not otherwise at high risk, and using other drugs such as the alpha 1-adrenergic inhibitor prazosin for initial therapy are discussed and evaluated.     

The pathogenesis of benign prostatic hyperplasia

Development of prostatic hyperplasia is an almost universal feature of the aging man and dog, and in both species the process develops only in males with intact testes. As the result of studies of plasma hormone levels as a function of age, measurements of the concentration of androgen and of androgen receptor proteins within the prostate, and studies of the effects of the administration of various hormones on growth of the prostate in the castrated dog, it is possible to provide a working hypothesis as to the pathogenesis. Dihydrotestosterone accumulation within the gland serves as the hormonal mediator for the hyperplasia in both species; the accumulation probably occurs in part because of decreased catabolism of the molecule and in part because of enhanced intracellular binding of the molecule. The process is accelerated by estrogen, which enhances the level of the androgen receptor in the gland; increase in the androgen receptor allows for androgen-mediated growth even in the face of declining androgen production in advanced age. On theoretic grounds the therapeutic implications of this model are exciting; several potential medical treatments may be feasible that do not involve a chemical castration.     

Dissecting aortic aneurysm involving a right-sided aortic arch.

In this case, the first reported instance of aortic dissection involving a right-sided arch, an anomalous fourth arch vessel, the left subclavian artery, arose from a congenital aortic diverticulum. This report emphasizes the need for precise anatomic definition with aortography to permit appropriate therapy when congenital anomalies of the aortic arch are complicated by dissecting hematoma.