Lack of efficacy of quinapril on vascular damage in limited cutaneous systemic sclerosis

Gliddon et al. conducted a randomized, double-blind, multicenter, placebo-controlled study to evaluate the efficacy of the angiotensin-converting enzyme inhibitor quinapril for the management of vascular damage in systemic sclerosis (SSc). The trial comprised 213 patients with limited cutaneous SSc or Raynaud's phenomenon (mean age 54 years, 182 females) who were randomly assigned to receive 80 mg/day, or the maximum tolerated dose, of quinapril (n = 105) or placebo (n = 108) for 2-3 years. Patients were assessed every 3 months. The number of new ischemic digital ulcers was recorded as the primary end point, while the frequency of Raynaud's phenomenon episodes, skin score, health status, pulmonary artery pressure and treatments for ischemia were also monitored as secondary end points. There were no detectable differences between patients treated with quinapril and those receiving placebo; however, although no severe adverse effects were observed, patients taking quinapril experienced significantly more adverse effects.     

Hypothalamitis: a diagnostic and therapeutic challenge

To report an unusual case of biopsy-proven autoimmune hypophysitis with predominant hypothalamic involvement associated with empty sella, panhypopituitarism, visual disturbances and antipituitary antibodies positivity. We present the history, physical findings, hormonal assay results, imaging, surgical findings and pathology at presentation, together with a 2-year follow-up. A literature review on the hypothalamic involvement of autoimmune hypophysitis with empty sella was performed. A 48-year-old woman presented with polyuria, polydipsia, asthenia, diarrhea and vomiting. The magnetic resonance imaging (MRI) revealed a clear suprasellar (hypothalamic) mass, while the pituitary gland appeared atrophic. Hormonal testing showed panhypopituitarism and hyperprolactinemia; visual field examination was normal. Pituitary serum antibodies were positive. Two months later an MRI documented a mild increase of the lesion. The patient underwent biopsy of the lesion via a transsphenoidal approach. Histological diagnosis was lymphocytic “hypothalamitis”. Despite 6 months of corticosteroid therapy, the patient developed bitemporal hemianopia and blurred vision, without radiological evidence of chiasm compression, suggesting autoimmune optic neuritis with uveitis. Immunosuppressive treatment with azathioprine was then instituted. Two months later, an MRI documented a striking reduction of the hypothalamic lesion and visual field examination showed a significant improvement. The lesion is stable at the 2-year follow-up. For the first time we demonstrated that “hypothalamitis” might be the possible evolution of an autoimmune hypophysitis, resulting in pituitary atrophy, secondary empty sella and panhypopituitarism. Although steroid treatment is advisable as a first line therapy, immunosuppressive therapy with azathioprine might be necessary to achieve disease control.     

Which is the best catheter to perform atrial fibrillation ablation? A comparison between standard ThermoCool,SmartTouch, and Surround Flow catheters

Introduction

Catheter ablation (CA) is an established therapy for atrial fibrillation (AF). The SmartTouch catheter (STc) provides information about catheter tip to tissue contact force (CF). The Surround Flow catheter (SFc) provides a uniform cooling of the tip during ablation. We sought to analyze the impact of STc and SFc on CA of paroxysmal AF in terms of feasibility and acute efficacy.

Methods and results

Sixty-three patients (mean age 57.6?±?9.8 years, 53 males) with paroxysmal AF underwent pulmonary veins (PVs) antral isolation, by using standard ThermoCool catheter (TCc) in 21, STc in 21, and SFc in 21. Total procedural, fluoroscopy, and radiofrequency (RF) delivery times; percentage of persistently deconnected PVs after 30 min; and percentage of isolated PVs at the end of the procedure were measured. The use of both STc and SFc obtained a reduction of fluoroscopy time (TCc 34?±?18 min, STc 20?±?10 min, p?<?0.001; SFc 21?±?13 min, p?=?0.02 vs TCc) and RF time (TCc 41?±?13 min, STc 30?±?14 min, p?=?0.013; SFc 30?±?9 min, p?<?0.01 vs TCc). The use of STc resulted in a reduction of procedural time (TCc 181?±?53 min, STc 140?±?53 min, p?<?0.001; SFc 170?±?51 min, p?=?NS vs TCc). The percentage of isolated PVs was comparable between groups (TCc 96 % vs STc 98 % vs SFc 96 %; p?=?NS). The percentage of deconnected PVs at 30 min was lower in TCc (89 %) than in STc (95 %) and in SFc (95 %) group (p?<?0.05).

Conclusions

Both STc and SFc allowed a simplification of CA of paroxysmal AF. In addition, they reduced early PVs reconnection.

Condensed abstract

Sixty-three patients with paroxysmal AF underwent ablation by standard ThermoCool, SmartTouch, or Surround Flow catheter. Both the SmartTouch and the Surround Flow significantly reduced radiofrequency and fluoroscopy times, as well as pulmonary veins reconnection rate at 30 min. Moreover, the SmartTouch reduced overall duration of the procedure.     

The evolution of craniofacial resection: A new workflow for virtual planning in complex craniofacial procedures

Complex craniofacial surgery has been later to take advantage of computerized planning than traditional maxillofacial procedures. Virtual reality, 3D model navigation, and bioengineering analyses have changed our approach to the surgical planning of craniofacial resection, increasing the benefits of surgery in terms of accuracy while decreasing complication rate.This study introduces a new workflow for 3D reconstruction, virtual model navigation, and alignment analyses, and demonstrates its successful application in a sample of four patients. A case of squamous cell carcinoma of the maxillary and ethmoid sinus in a 62-year-old patient is presented to evaluate the application of the workflow for a combined transfacial and transcranial resection. Results demonstrate that virtual surgical planning was successfully translated into navigational coordinates and reproduced in the operating room.While the literature provides a wide range of applications of virtual planning for traditional maxillofacial procedures, its introduction for complex craniofacial procedures remains difficult. The presented case shows that it is worth investigating the correlation between virtual reality planning and surgical accuracy for craniofacial resection, and related advantages in terms of surgical safety and improved prognosis.     

Lifestyle Modification for Metabolic Syndrome: A Systematic Review

Background

All 5 components of metabolic syndrome have been shown to improve with lifestyle and diet modification. New strategies for achieving adherence to meaningful lifestyle change are needed to optimize atherosclerotic cardiovascular risk reduction. We performed a systematic literature review, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework (PRISMA), investigating optimal methods for achieving lifestyle change in metabolic syndrome.

Methods

We submitted standardized search terms to the PubMed Central, CINAHL, Web of Science, and Ovid databases. Within those results, we selected randomized controlled trials (RCTs) presenting unique methods of achieving lifestyle change in patients with one or more components of the metabolic syndrome. Data extraction using the population, intervention, comparator, outcome, and risk of bias framework (PICO) was used to compare the following endpoints: prevalence of metabolic syndrome, prevalence of individual metabolic syndrome components, mean number of metabolic syndrome components, and amount of weight loss achieved.

Results

Twenty-eight RCTs (6372 patients) were included. Eight RCTs demonstrated improvement in metabolic syndrome risk factors after 1 year. Team-based, interactive approaches with high-frequency contact with patients who are motivated made the largest and most lasting impact. Technology was found to be a useful tool in achieving lifestyle change, but ineffective when compared with personal contact.

Conclusion

Patient motivation leading to improved lifestyle adherence is a key factor in achieving reduction in metabolic syndrome components. These elements can be enhanced via frequent encounters with the health care system. Use of technologies such as mobile and Internet-based communication can increase the effectiveness of lifestyle change in metabolic syndrome, but should not replace personal contact as the cornerstone of therapy. Our ability to derive quantitative conclusions is limited by inconsistent outcome measures across studies, low power and homogeneity of individual studies, largely motivated study populations, short follow-up periods, loss to follow-up, and lack of or incomplete blinding.