Possible association of acute lateral-wall myocardial infarction and bitter orange supplement

OBJECTIVE: To report a possible incidence of acute lateral-wall myocardial infarction (MI) coinciding with the use of a Citrus aurantium L. (bitter orange)-containing dietary supplement in a patient with undetected coronary vascular disease. CASE SUMMARY: A 55-year-old white woman presented to the emergency department with symptoms of dull aching shoulder and chest pain. A review of medications during cardiac rehabilitation revealed the patient had ingested a multicomponent dietary supplement for weight loss containing 300 mg of bitter orange (Edita's Skinny Pill) for the past year. Although the patient's past medical history did not include hypertension, coronary disease, or hyperlipidemia, an arteriogram revealed a lesion in the left main coronary artery. She did have a smoking history. She was diagnosed with acute lateral-wall MI and hospitalized for 4 days. DISCUSSION: Consumers generally consider dietary supplements safe. However, some supplements taken for weight loss contain ingredients that have been associated with cardiovascular events. Although consumers are becoming more aware of the serious adverse effects secondary to products containing ingredients such as Ma huang and ephedra, reports involving other ingredients are increasing. Bitter orange or synephrine, found in bitter orange, has been associated with adverse cardiovascular reactions. Based on the Naranjo probability scale, C. aurantium is possibly associated with this cardiovascular event. CONCLUSIONS: The use of C. aurantium-containing supplements may present as a risk for cardiovascular toxicity; however, additional studies/case reports are needed to validate this conclusion.     

Coronary artery disease among asymptomatic diabetic and nondiabetic patients undergoing coronary computed tomography angiography

OBJECTIVES: The aim of this study was to determine the prevalence and severity of coronary artery disease (CAD) and the plaque composition in asymptomatic diabetic and nondiabetic patients undergoing coronary computed tomography angiography (CCTA). BACKGROUND: CAD is the major cause of death among patients with diabetes. The true prevalence of CAD in asymptomatic diabetic patients, however, remains unknown. MATERIALS AND METHODS: A total of 328 consecutive patients (each with at least one risk factor or abnormal stress-test results) were referred for cardiac evaluation, 42 with diabetes and 286 without diabetes, all asymptomatic for cardiac-related symptoms. Groups were matched for age, sex, and CAD risk factors. CAD was defined as coronary atherosclerosis, with obstructive or nonobstructive lesions. CCTA was performed and findings compared between patients with diabetes and those without. RESULTS: CAD was present in 39 (93%) diabetic patients and in 211 (73%) nondiabetic patients (P=0.006). Obstructive CAD was more common in diabetic patients than in nondiabetic patients (29 vs. 6.6%, respectively; P<0.0001). In diabetic patients, more coronary segments with atherosclerosis per patient were detected (5.5 segments/patient vs. 2.8 segments/patient in nondiabetics; P<0.0001). The total Agatston score was significantly higher in diabetic patients vs. nondiabetic patients (370+/-96 and 79.9+/-16, respectively; P<0.0001). CONCLUSION: Our results indicate a high prevalence (93%) of CAD in asymptomatic diabetic patients with either nonobstructive or obstructive lesions. CCTA may be a useful imaging modality for selecting patients at high risk who would benefit most from further evaluation for subclinical ischemia.     

Stair climbing test predicts cardiopulmonary complications after lung resection

STUDY OBJECTIVE: To evaluate the capability of the stair climbing test to predict cardiopulmonary complications after lung resection for lung cancer. DESIGN: A prospective cohort of candidates for lung resection. Spirometric assessment and the stair climbing test were performed the day before operation. Univariate and multivariate analyses were performed to identify predictors of postoperative complications. SETTING: Tertiary referral center. PATIENTS: A consecutive series of 160 candidates for lung resection with lung carcinoma from January 2000 through March 2001. RESULTS: At univariate analysis, the patients with complications were significantly older (p = 0.02), had a significantly lower FEV(1) percentage (p = 0.007) and predicted postoperative FEV(1) percentage (p = 0.01), had a greater incidence of a concomitant cardiac disease (p = 0.02), climbed a lower altitude at the stair climbing test (p < 0.0001), and had a lower calculated maximum oxygen consumption (O(2)max) [p = 0.03] and predicted postoperative O(2)max (p = 0.006) compared to the patients without complications. At multivariate analysis, the altitude reached at the stair climbing test remained the only significant independent predictor of complications. CONCLUSIONS: The stair climbing test is a safe and economical exercise test, and it was the best predictor of cardiopulmonary complications after lung resection.     

Pamidronate treatment in rheumatology practice: a comprehensive review

Pamidronate, along with other bisphosphonates, has been used for treatment of bone pain secondary to malignant involvement or metastatic disease for years. Some data, however, have also accumulated on the utility of pamidronate in a variety of benign conditions frequently handled by rheumatologists. This study aims to review the available published data regarding the potential use of pamidronate in rheumatology practice. Methods include the review of relevant articles retrieved by a PUBMED search utilizing the index term “pamidronate”. All available randomized control trials, open trials, and case series, as well as properly reported case studies evaluating usage of pamidronate in rheumatic disorders, have been included in the literature review. The efficacy of pamidronate in patients with spondyloarthropathies; synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome; hypertrophic osteoarthropathy; osteoporotic vertebral fractures; chronic back pain due to disk disease or spinal stenosis; Charcot arthropathy; transient osteoporosis; and complex regional pain syndrome-I, has been demonstrated in more than 40 reports, the majority of which, however, were not controlled studies. In some of reviewed conditions, aside from providing analgesic relief, pamidronate may also have disease-modifying properties. While used in different doses in a variety of rheumatic disorders, pamidronate was generally reported to be well tolerated with an overall good safety profile. Pamidronate may represent an effective and safe choice for a spectrum of rheumatic patients, suffering from intractable musculoskeletal pain, unresponsive to traditionally recommended therapies. Large randomized, controlled studies examining the efficacy of pamidronate in the rheumatic conditions are urgently needed.     

Variants of endothelial nitric oxide synthase gene are associated with components of metabolic syndrome in an Arab population

Genetics plays a crucial role in the development of metabolic syndrome (MetS). Here we examined the association between endothelial nitric oxide synthase (eNOS) gene polymorphisms and MetS in a Saudi Arabian cohort to extend the understanding of the genetic basis of MetS in diverse ethnic populations. Anthropometric, clinical and biochemical parameters as well as genotyping for 894G>T, -786T>C variants of eNOS gene by PCR-RFLP and 4a/b by direct PCR were performed in 886 Saudi Arabians (477 MetS and 409 Non-MetS). The genotype distribution (TT, p=0.001; TC, p=0.001; TC+CC, p=0.001) and allele (T, p=0.007; C, p=0.007) frequency of the -786T>C SNP were significantly different between Non-MetS and MetS subjects which remained significant after Bonferroni correction. Moreover: 1) the GT and GT+TT genotypes of the 894G>T SNP were associated with elevated blood pressure (p=0.017, and p=0.022, respectively); 2) the ab variant of 4a/b polymorphism was associated with decreased HDL levels (p= 0.044); and 3) the TC+CC genotype and C allele of the -786T>C SNP were associated with increased fasting glucose levels (p=0.039, and p=0.028, respectively). Also, G-a-C was identified as the risk haplotype for MetS susceptibility (p=0.034). The results suggest a significant association of 894G>T, 4a/b and -786T>C polymorphisms with MetS and its components is present in an Arab population. A genetic predisposition to develop abnormal metabolic phenotypes, consistent with an increased prevalence of metabolic phenotypes can be detected in this ethnic group.     

Multiple Migrated Superior Vena Cava Stents With Cardiac Injury - A Stepwise Open Cardiotomy Strategy to Mitigate Potential Fatality

Iatrogenic injuries with migrated interventional stents can sometimes be life-threatening. The interventional retrieval management is generally the treatment of choice, as surgical procedures carry a high mortality risk with only a few cases reported. We report a patient with two stents migrated into the right atrium from superior vena cava resulting in cardiac perforation. She was successfully treated using pericardiocentesis followed by surgical intervention with rapid post-operative resolution of symptoms. The technique presented here substantiates the steps for a safe and effective removal of these multiple displaced stents with minimal postprocedural complications.     

Anticoagulant Reversal in Gastrointestinal Bleeding: Review of Treatment Guidelines

Background

Patients receiving anticoagulant therapies, such as vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), commonly experience gastrointestinal (GI) bleeding as a complication and may require anticoagulant reversal prior to endoscopic treatment. Anticoagulant reversal agents include prothrombin complex concentrates (PCCs; including 3 or 4 coagulation factors), plasma, vitamin K, and target-specific DOAC reversal agents (e.g., idarucizumab and andexanet alfa).

Aim

To review current US, as well as international, guidelines for anticoagulant reversal agents in patients on VKAs or DOACs presenting with GI bleeding prior to endoscopy, guideline-based management of coagulation defects, timing of endoscopy, and recommendations for resumption of anticoagulant therapy following hemostasis. Supporting clinical data were also reviewed.

Methods

This is a narrative review, based on PubMed and Internet searches reporting GI guidelines and supporting clinical data.

Results

GI-specific guidelines state that use of reversal agents should be considered in patients with life-threatening GI bleeding. For VKA patients presenting with an international normalized ratio >?2.5, guidelines recommend PCCs (specifically 4F-PCC), as they may exhibit greater efficacy/safety compared with fresh frozen plasma in reversal of VKA-associated GI bleeding. For DOAC patients, most guidelines recommend targeted specific reversal agents in the setting of GI bleeding; however, PCCs (primarily 4F-PCC) are often listed as another option. Resumption of anticoagulant therapy following cessation of GI bleeding is also recommended to reduce risks of future thromboembolic complications.

Conclusions

The utility of anticoagulant reversal agents in GI bleeding is recognized in guidelines; however, such agents should be reserved for use in truly life-threatening scenarios.

     

Biochemical and virologic parameters in patients co-infected with hepatitis C and HIV versus patients with hepatitis C mono-infection

BACKGROUND: Previous studies of patients with hepatitis C virus (HCV) infection looking at the effect of human immunodeficiency virus (HIV) co-infection on biochemical parameters and HCV RNA level have shown conflicting results. Accurate characterization of the effect of HIV is important for evaluation and treatment of HCV in co-infected persons. METHODS: We studied 315 HCV mono-infected and 75 HCV-HIV co-infected subjects to determine the effect of HIV on biochemical parameters and HCV RNA and to determine the predictors of elevated serum alanine aminotransferase (ALT) levels and HCV RNA levels. RESULTS: The co-infected subjects were more likely to be African-American (55% vs 26%, P < 0.0005), have used injection drugs (68% vs 60%, P = 0.02), have detectable HCV RNA (84% vs 70.5%, P = 0.018), have HCV RNA levels >6 log10 IU/mL (60% vs 38%, P = 0.001), and have lower mean serum ALT levels (50.4 IU/mL vs 73.7 IU/mL, P = 0.006). In multivariable analyses, the following factors predicted an ALT level >50 IU/mL: log10 HCV RNA (OR, 1.15; 95% CI, 1.00 to 1.32); HIV co-infection (OR, 0.48; 95% CI, 0.25 to 0.89); and having ever been treated for HCV (OR, 1.92; 95% CI, 1.16 to 3.18). The only significant predictor of HCV RNA level >6 log10 IU/mL was HIV co-infection (OR, 2.75; 95% CI, 1.46 to 5.15). Significant predictors of having a detectable HCV RNA level were female sex (OR, 3.81; 95% CI, 1.18 to 12.25); HIV co-infection (2.45; 95% CI, 1.14 to 5.26); and ever being treated for HCV (OR, 1.96; 95% CI, 1.10 to 3.48). CONCLUSIONS: HCV-HIV co-infected persons have higher HCV RNA levels but lower serum ALT levels than HCV mono-infected patients. Criteria for performing liver biopsy and treating HCV infection in co-infected patients may need to be revisited.