White-coat effect in normotension and hypertension

OBJECTIVES: The difference between clinic and daytime ambulatory blood pressure is referred to as the white-coat effect. In this study, we investigated (i) the magnitude of the white-coat effect in subjects with different daytime ambulatory blood pressure levels, and (ii) the association of the white-coat effect with left ventricular mass. METHODS: A total of 1581 subjects underwent clinic blood pressure readings, 24-h ambulatory blood pressure monitoring and left ventricular echocardiographic assessment. Their mean daytime systolic blood pressure varied from 88.0 to 208.9 mmHg and their mean daytime diastolic blood pressure from 40.3 to 133.0 mmHg. RESULTS: A negative correlation was found between the systolic or diastolic white-coat effect and the systolic or diastolic daytime ambulatory blood pressure (r = -0.22, P < 0.000 and r = -0.50, P < 0.000, respectively). Left ventricular mass significantly correlated with ambulatory blood pressure (P < 0.001), but there was no association between left ventricular mass and clinic blood pressure or white-coat effect. Furthermore, the white-coat effect was reversed at the highest level of systolic or diastolic daytime ambulatory blood pressure (systolic over 170 mmHg or diastolic over 100 mmHg) when systolic or diastolic daytime ambulatory blood pressure was higher than systolic or diastolic clinic blood pressure (ambulatory blood pressure hypertension). CONCLUSIONS: The white-coat effect shows an inverse association with daytime ambulatory blood pressure level (systolic or diastolic), being significantly more prominent for levels below 140/80 mmHg for systolic/diastolic daytime ambulatory blood pressure and reversed with daytime ambulatory blood pressure levels above 170/100 mmHg.     

Hepatic Injury Due to Combined Choline-Deprivation and Thioacetamide Administration: An Experimental Approach to Liver Diseases

Background

The induction of prolonged choline-deprivation (CD) in rats receiving thioacetamide (TAA) is an experimental approach of mild hepatotoxicity that could resemble commonly presented cases in clinical practice (in which states of malnutrition and/or alcoholism are complicated by the development of other liver-associated diseases).

Aim

The present study aimed to investigate the time-dependent effects of a 30-, a 60- and a 90-day dietary CD and/or TAA administration on the adult rat liver histopathology and the serum markers of hepatic functional integrity.

Methods

Rats were divided into four main groups: (a) control, (b) CD, (c) TAA and (d) CD?+?TAA. Dietary CD was provoked through the administration of choline-deficient diet, while TAA administration was performed ad libitum through the drinking water (300?mg/l of drinking water).

Results

Histological examination of the CD?+?TAA liver sections revealed micro- and macro-vesicular steatosis with degeneration and primary fibrosis at day 30, to extensive steatosis and fibrosis at day 90. Steatosis was mostly of the macrovesicular type, involving all zones of the lobule, while inflammatory infiltrate consisted of foci of acute and chronic inflammatory cells randomly distributed in the lobule. These changes were accompanied by gradually increasing mitotic activity, as well as by a constantly high alpha-smooth muscle actin immunohistochemical staining. The determination of hepatocellular injury markers such as the serum enzyme levels?? of alanine aminotransferase and aspartate aminotransferase demonstrated a decrease at day 30 (they returned to control levels at days 60 and 90). However, the determination of those serum enzymes used for the assessment of cholestatic liver injury (gamma-glutamyltransferase, alkaline phosphatase) revealed a constant (time-independent) statistically-significant increase versus control values.

Conclusions

Long-term combined dietary CD and TAA administration could be a more realistic experimental approach to human liver diseases involving severe steatosis, fibrosis, stellate cell activation and significant regenerative hepatocellular response.     

Transapical Closure of a Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a rare but serious sequela of endocarditis or valve replacement surgery. Because open-heart surgery is a high-risk treatment option, alternative methods are sought. We present the case of a 77-year-old man with a noninfected mechanical mitral valve whose pseudoaneurysm was repaired by introducing an occluder device into the defect by a transapical approach. Upon follow-up imaging, the defect was successfully closed. We conclude that percutaneous closure of pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a viable alternative to surgery and that a transapical approach is an appropriate method of access.     

Utility of Three-Dimensional Echocardiography in Percutaneous Closure of Paravalvular Leak

The images and videos presented in this case report demonstrate the utility of live three-dimensional (3D) transoesophageal echocardiography (TEE) in guiding the percutaneous closure of paravalvular leak (PVL). This method provides high-quality real time assistance for transseptal puncture and deployment of the closure device through the PVL.     

A comparison of HIV-positive patients with and without infective endocarditis: an echocardiographic study--the Emory Endocarditis Group experience

OBJECTIVE: To determine the clinical features in HIV-positive patients with and without infective endocarditis (IE). PATIENTS AND METHODS: All bacteremic, HIV-positive patients with suspected IE admitted over a four-year period who underwent either transesophageal echocardiography (TEE) or transthoracic echocardiography (TTE) were retrospectively reviewed with regard to clinical, laboratory, and demographic characteristics. RESULTS: Ten (11.5%) of 87 HIV-positive patients had a clinical diagnosis of IE based on the Duke Criteria. The mean age of patients with IE was 37.8 years and without IE 39.9 years (P = NS). Both patient groups were similar with respect to gender, race, IVDA, renal failure requiring hemodialysis, history of predisposing heart disease, origin of infection, and causative organism of infection. The mean CD4 count (cells/microL) was 200.7 in patients with IE and 95.9 in patients without IE (P = NS). Of 10 HIV-positive patients with IE, seven had left-sided heart involvement, two had complications related to IE, three required cardiothoracic surgery, and three died. CONCLUSIONS: There were no differences found with regard to the clinical characteristics of HIV-positive patients with and without IE. No correlation could be drawn between mortality and the degree of immunosuppression in patients from this study. The high incidence of IE (11.5%) and mortality rate (30%) in this study suggests that IE in HIV-positive patients, including non-intravenous drug abusers, represents a real concern for clinicians and their management of these patients.     

Effect of ascorbic acid on forearm reactive hyperaemia in patients with hypercholesterolaemia.

BACKGROUND: This study was designed to research the effect of hypercholesterolaemia and ascorbic acid on forearm blood flow (FBF) reactive hyperaemia (RH). Reactive hyperaemia seems to be at least partly endothelium-dependent. Endothelial dysfunction has been described in patients with hypercholesterolaemia, and has been reversed with ascorbic acid administration. METHOD: Forearm blood flow was studied with venous occlusion plethsmography in 26 healthy volunteers and 46 hypercholesterolaemic patients. Hypercholesterolaemic patients were divided into two groups. Group A comprised 25 patients, who received ascorbic acid and group B comprised 21 patients, who received placebo. All subjects underwent measurement of FBF at baseline and during RH (phase A). Forearm blood flow during RH was measured every 15 seconds for three minutes. Subsequently patients in group A received 2 g of ascorbic acid orally in the form of effervescent tablets, and patients in group B received placebo orally in the same form. Forearm blood flow measurements at baseline and during RH were repeated two hours later (phase B). RESULTS: Maximal percent increase of FBF was significantly higher in healthy subjects than in hypercholesterolaemic patients (139.1+/-12.1% versus 73.1+/-11.0% respectively, P<0.05). Duration of RH was smaller in hypercholesterolaemic patients compared to normal subjects (60.9+/-17.1 seconds versus 105.6+/-10.2 seconds, P<0.05). Administration of ascorbic acid but not of placebo increased the duration of RH (69.1+/-11.1 seconds versus 104.1+/-12.2 seconds, P<0.05) but not of peak RH FBF. CONCLUSION: Hypercholesterolaemia seems to impair both the early and late phase of RH. Ascorbic acid improves only the duration of RH, possibly due to its antioxidant effect on endothelium.     

Histone deacetylase inhibitors in oral squamous cell carcinoma treatment

Introduction: The involvement of the histone deacetylases (HDACs) family in tumor development and progression is well demonstrated. HDAC inhibitors (HDACis) constitute a novel, heterogeneous family of highly selective anticancer agents that inhibit HDACs and present significant antitumor activity in several human malignancies, including oral squamous cell carcinoma (OSCC).

Areas covered: This review summarizes the current research on the anticancer activity of HDACis against OSCC. The review also presents the molecular mechanisms of HDACis action and the existing studies evaluating their utilization in combined therapies of OSCC.

Expert opinion: The currently available data support evidence that HDACis may provide new therapeutic options against OSCC, decreasing treatment side effects and allowing a more conservative therapeutic approach. Future research should be focused on in vivo and clinical evaluation of their utilization as combined therapies or monotherapies. Before HDACis can be brought into clinical practice as treatment options for OSCC, further evaluation is needed to determine their optimal dosage, the appropriate duration of treatment and whether they should be used in combination or as stand-alone therapeutics.     

Prediction of response to cardiac resynchronization therapy using left ventricular pacing lead position and cardiovascular magnetic resonance derived wall motion patterns: a prospective cohort study

Background

Despite marked benefits in many heart failure patients, a considerable proportion of patients treated with cardiac resynchronization therapy (CRT) fail to respond appropriately. Recently, a “U-shaped” (type II) wall motion pattern identified by cardiovascular magnetic resonance (CMR) has been associated with improved CRT response compared to a homogenous (type I) wall motion pattern. There is also evidence that a left ventricular (LV) lead localized to the latest contracting LV site predicts superior response, compared to an LV lead localized remotely from the latest contracting LV site.

Methods

We prospectively evaluated patients undergoing CRT with pre-procedural CMR to determine the presence of type I and type II wall motion patterns and pre-procedural echocardiography to determine end systolic volume (ESV). We assessed the final LV lead position on post-procedural fluoroscopic images to determine whether the lead was positioned concordant to or remote from the latest contracting LV site. CRT response was defined as a ≥ 15 % reduction in ESV on a 6 month follow-up echocardiogram.

Results

The study included 33 patients meeting conventional indications for CRT with a mean New York Heart Association class of 2.8 ± 0.4 and mean LV ejection fraction of 28 ± 9 %. Overall, 55 % of patients were echocardiographic responders by ESV criteria. Patients with both a type II pattern and an LV lead concordant to the latest contracting site (T2CL) had a response rate of 92 %, compared to a response rate of 33 % for those without T2CL (p = 0.003). T2CL was the only independent predictor of response on multivariate analysis (odds ratio 18, 95 % confidence interval 1.6-206; p = 0.018). T2CL resulted in significant incremental improvement in prediction of echocardiographic response (increase in the area under the receiver operator curve from 0.69 to 0.84; p = 0.038).

Conclusions

The presence of a type II wall motion pattern on CMR and a concordant LV lead predicts superior CRT response. Improving patient selection by evaluating wall motion pattern and targeting LV lead placement may ultimately improve the response rate to CRT.