Acute Coronary Syndrome in the Patient with Diabetes: Is the Management Different?

Diabetic patients who present with an acute coronary syndrome (ACS) have a particularly adverse prognosis, largely contributed by increased platelet reactivity and higher burden of disease severity. Diabetic patients with ACS derive a greater benefit from established therapies, particularly platelet-inhibiting therapies, including clopidogrel pretreatment, and glycoprotein IIb/IIIa inhibitor use. Recent data show intense ADP-P2Y12 platelet receptor inhibition with prasugrel is of particular clinical value in the diabetic patient with ACS, without excessive bleeding. Diabetic patients with ACS also benefit more from aggressive revascularization strategies. Recent data show the benefit of drug-eluting stents in the setting of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction in decreasing target vessel revascularization up to 2 years, particularly in patients at highest risk for restenosis with bare metal stents (likely diabetic patients). This review summarizes the data supporting the key pharmacologic and revascularization management strategies to guide the clinician in taking care of diabetic patients who present with an ACS event.     

Cysteinyl leukotriene levels in esophageal mucosal biopsies of children with eosinophilic inflammation: are they all the same?

OBJECTIVES: Allergic eosinophilic esophagitis (AEE) is characterized by intense eosinophilic inflammation of the esophageal mucosa. Cysteinyl leukotrienes (CysLT) are eosinophil chemoattractants. We studied CysLT levels in esophageal mucosa of children with AEE and controls. METHODS: CysLT levels (pg CysLT/microg protein) were quantified by Enzyme-linked Immunosorbent Assay (ELISA) on endoscopically obtained esophageal mucosal biopsies. RESULTS: Twelve children with AEE (eight boys, mean age 6.6 yr, range 1.0-14.5 yr) and 10 controls (six boys, mean age 9.56 yr, range 1.08-15.08 yr) were enrolled. None were on anti-LT or corticosteroid therapy. All controls had histologically normal mucosal biopsies of the esophagus, stomach, and duodenum. Patients with AEE had intense eosinophilic inflammation of the esophageal mucosa (mean 39 eosinophils/hpf, range 15-70 eosinophils/hpf) and a normal 24-h pH probe study. CysLT levels were similar between the two groups: mean levels were 12.44 (median 10.87, range 2.54-28.29) in AEE patients and 9.52 (median 9.26, range 1.71-21.64) in controls. CysLT levels did not correlate with the degree of esophageal eosinophilic inflammation. Incidentally, five patients with eosinophilic gastroduodenitis, in addition to esophagitis, were enrolled; their CysLT levels were statistically higher than those of controls. CONCLUSIONS: This is the first study to examine CysLT levels in esophageal mucosal biopsies of children with AEE and normal children. CysLT levels in AEE patients are similar to those in controls, and independent of the severity of inflammation. While this would argue against the use of CysLT antagonists in the treatment of AEE, further studies into the expression of the CysLT receptor itself are needed.     

Pericardial effusion in the elderly: A different disease?

INTRODUCTION AND OBJECTIVES: The aim of the present study was to assess possible differences in etiologic spectrum and clinical course of pericardial effusion in elderly patients, as has been previously suggested, and therefore determine whether clinical, management should be based on patient age. METHODS: All echocardiograms performed in our hospital from 1990 to 1996 were screened for pericardial effusion, and those with moderate or large effusions were selected. Patients under 66 years of age were included in group I, and those above 65 years were assigned to group II. RESULTS: We selected 322 patients with moderate (122) or with large (200) effusions. 221 patients being included in group I (aged 15-65, mean 47) and 101 in group II (aged 66-88, mean 72.5). Effusion was large in 60% of group I and in 66% of group II (p = NS), and tamponade occurred in 36% and 38.6%, respectively (p = NS). Specific pericardial infections (tuberculous and purulent pericarditis) were more frequent in group I (5.9 versus 0.9%; p < 0.05). No significant differences were found in incidence of idiopathic (33 vs 38%) or neoplastic (14.4 vs 10.8%) etiologies. During follow-up (96% of the patients, median time of 11 months, range 1-58 months) the mortality (24 vs 30%) and evolution to cardiac constriction (4 vs 2%) were similar in the two groups, but persistence of effusion was more common in group II (6.3 vs 14%; p < 0.05). CONCLUSIONS: Our study suggests that etiology, clinical course and prognosis of moderate and large pericardial effusion are, in general, similar in elderly and younger patients. Thus, management should be similar in the different age groups, and no etiologic form of pericardial disease should be ruled out because of patient's age when considering the differential diagnosis.     

Repeated thoracentesis: an important risk factor for eosinophilic pleural effusion?

BACKGROUND: Eosinophilic pleural effusion (EPE) is a relatively rare clinical condition. Repeated thoracenteses (RTs) are normally considered a frequent cause of EPE. Yet, to our knowledge, there is no firm evidence (apart from anecdotal case reports) supporting such a statement. OBJECTIVE: To investigate potential relationships between the number, type (with or without pleural biopsy) and time elapsed between RTs and the number of eosinophils present in pleural fluid samples. METHODS: We reviewed retrospectively 273 pleural fluid samples belonging to 120 patients (79 males, 41 females), attended in our institution from 1992 to 2000, whose clinical management had required RTs. Apart from the anthropometric and clinical data of each patient, we included the following variables in the analysis: number of thoracenteses performed in each individual, number of pleural biopsies carried out at each thoracentesis and time between consecutive thoracenteses. We also recorded the total (and differential) leukocyte count, red blood cell count, as well as the main biochemical, microbiological and histological data of both the pleural fluid and peripheral blood samples. RESULTS: We did not observe any significant change in the percentage of eosinophils in relation to the number of thoracenteses performed per patient. This lack of relationship was also observed in the subgroup of patients who required one (or more) pleural biopsies (n = 111) (regardless of the number of biopsies). Our results suggest that RTs are not an important risk factor for the development of EPE, regardless of the time elapsed between two thoracenteses. CONCLUSION: We believe, therefore, that multiple punctures should not longer be considered a prevalent cause of pleural eosinophilia.     

Meigs’ syndrome: a rare cause of recurrent pleural effusion in scleroderma

Meigs’ syndrome represents a triad of pleural effusion, ascites, and an ovarian tumor, usually benign, occurring together. We describe here a case of Meigs’ syndrome in a patient with systemic sclerosis, the first such report to our knowledge, in systemic sclerosis. A 53-year-old woman with systemic sclerosis presented with recurrent right-sided pleural effusion, which led to symptoms of shortness of breath, chest tightness, and a non-productive cough. Physical examination revealed a palpable, mobile mass in the right lower quadrant, in addition to typical physical features of scleroderma. Thoracentesis yielded exudative pleural fluid with cytology negative for malignancy. Pleural biopsy was consistent with inflammatory changes, but negative for malignancy. CT scan of the chest, abdomen, and pelvis revealed a soft tissue mass in the pelvis, which appeared to arise from the left ovary. The patient’s cancer antigen 125 (CA-125) level was elevated at 222 U/mL (normal range, 0–30 U/mL). The patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histology of the left ovarian mass was consistent with an ovarian fibrothecoma, a benign tumor of the ovary. At her 1-month follow-up appointment, the patient had complete resolution of the right-sided pleural effusion. To date, at 10 months past the initial presentation, she has not had recurrence of pleural effusion. Although rare, Meigs’ syndrome should be considered as a possible cause of recurrent serositis in women with rheumatologic diseases. Removal of the ovarian tumor leads to prompt resolution of the serositis.