Prompt and aggressive treatment of deep neck infection in neglected diabetic patient: A case report and literature review.

Background: Deep neck infection (DNI) is an infection that occurs in the deep neck fascia and spaces commonly found in diabetic patients. Impaired immune system due to hyperglycemic condition in diabetic patients leads to different clinical presentations, prognosis, and management and therapy in this group of patients. Case Presentation: We reported a deep neck infection and abscess in a diabetic patient that resulted in acute kidney injury and airway obstruction. We have done CT-scan imaging that supported the diagnosis of a submandibular abscess. Prompt and aggressive treatment of DNI with antibiotics, blood glucose control, and surgical incision has exhibited a favorable outcome. Conclusion: Diabetes mellitus is the most common comorbidity among patients with DNI. Studies showed that hyperglycemia impaired bactericidal functions of neutrophils, cellular immunity, and complement activation. Aggressive treatment, including early incision and drainage of abscess, dental surgery to eradicate the source of infection, prompt empirical antibiotic administration, and intensive blood glucose regulation will result in favorable results without a prolonged hospital stay.

Association polymorphism of guanine nucleotide-binding protein ß3 subunit (GNB3) C825T and insertion/deletion of the angiotensin-converting enzyme (ACE) gene with peripartum cardiomyopathy.

Introduction: Peripartum cardiomyopathy (PPCM) is a potentially life-threatening pregnancy-related heart disease. Genetic roles such as gene polymorphisms may relate to the etiology of PPCM. This study analyzes the association between single nucleotide gene polymorphism (SNP) guanine nucleotide-binding protein beta-3 subunit (GNB3) C825T and insertion/deletion (I/D) of the angiotensin-converting enzyme (ACE) gene with the incidence of PPCM. Methods: An analytic observational study with a case-control design was conducted at the Integrated Cardiac Service Center of Dr. Soetomo General Hospital, Surabaya, Indonesia. PPCM patients of the case and control groups were enrolled. Baseline characteristic data were collected and blood samples were analyzed for SNP in the GNB3 C825T gene and for I/D in the ACE gene by using the polymerase chain reaction, restriction fragment length polymorphism, and Sanger sequencing. We also assessed ACE levels among different ACE genotypes using a sandwich-ELISA test. Results: A total of 100 patients were included in this study, with 34 PPCM cases and 66 controls. There were significant differences in GNB3 TT and TC genotypes in the case group compared with that in the control group (TT: 35.3% vs. 10.6%, p = 0.003; TC: 41.2% vs. 62.5%, p = 0.022). The TT genotype increased the risk of PPCM by 4.6-fold. There was also a significant difference in the ACE DD genotype in the case group compared with that in the control group (26.5% vs. 9.1%, p = 0.021). DD genotypes increased the risk of PPCM by 3.6-fold. ACE levels were significantly higher in the DD genotype group than in the ID and II genotype groups (4,356.88 ± 232.44 pg/mL vs. 3,980.91 ± 77.79 pg/mL vs. 3,679.94 ± 325.77 pg/mL, p < 0.001). Conclusion: The TT genotype of GNB3 and the DD genotype of the ACE are likely to increase the risk of PPCM. Therefore, these polymorphisms may be predisposing risk factors for PPCM incidence. ACE levels were significantly higher in the DD genotype group, which certainly had clinical implications for the management of PPCM patients in the administration of ACE inhibitors as one of the therapy options.

A review on pulmonary and mediastinal synovial sarcoma.

Sarcoma is defined as a tumor located in the thoracic cavity. However, sarcoma can occur on every side of the body. Synovial sarcoma is a rare soft tissue tumor originating from pluripotent with a high malignancy rate. The most common predilection of synovial sarcoma is in the joints. Primary synovial sarcoma of the lung and mediastinum are rare tumors and generally malignant. There are only a few cases have been reported. Definite diagnosis is made by histopathological, immunohistochemistry, and cytogenetic examination. The management strategy for synovial sarcoma requires multimodality treatment with surgery, chemotherapy, and radiotherapy. However, effective and relatively non-toxic therapy for primary synovial sarcoma is still developed. The five years life expectancy is higher if the patient received adjuvant radiotherapy and/or chemotherapy after surgery.

The anatomical snuffbox for transradial access in arteriovenous fistula intervention: Case report and brief review of the literature.

Left distal transradial artery (dTRA) access in the anatomical snuffbox is a relatively novel technique and is considered beneficial when left TRA access is required. This technique offers essential advantages, including improved patient comfort and lower vascular complications. dTRA may provide an entry site for retrograde recanalization of the radial artery. We presented a case of a 65-year-old man with 5-stage chronic kidney disease (CKD) and had left a radio-cephalic arteriovenous fistula (AVF) for routine hemodialysis. There was obstruction of AVF a month after creation. The vascular intervention has been performed using left dTRA access for retrograde recanalization. Angiogram showed cephalic vein obstruction and non-significant stenosis of the proximal radial artery. Percutaneous transluminal angioplasty was successful in improving cephalic vein flow. Hemostatic performed without a hemostatic device. This case report highlights the dTRA access approach in the anatomical snuffbox to recanalize AVF occlusion in the wrist in a patient with CKD.

Recognizing dialysis access steal syndrome with central vein stenosis as arteriovenous fistula complication: A case report.

INTRODUCTION: Ischemic consequences of hemodialysis arteriovenous (AV) access are infrequent, yet they can cause substantial limb impairment or even loss. Ischemia can be caused by many factors, but the most common etiology is reduced blood supply to the distal extremities due to blood flow through the AV fistula (AVF) or AV graft. We reported a case of dialysis access steal syndrome (DASS) in a diabetes mellitus patient. CASE REPORT: A 69-year-old diabetic man with left brachiocephalic AVF on his left upper arm has main complaint of left-hand pain, swelling, and coldness. There are also trophic darkening changes in the distal first, third, and fourth fingers. A duplex doppler examination revealed a normal functional AV shunt with bidirectional distal retrograde inflow. There was also significant stenosis at axillary vein. So, a diagnosis of DASS with suspicion of distal anastomosis stenosis at axillary vein was made. The patient underwent digital amputation and surgical plication of the AV shunt. He also underwent percutaneous transluminal angioplasty at the level of axillary. After 10 days of care, he was later discharged. CLINICAL DISCUSSION: DASS is life and limb-threatening clinical disorder. Not only does the discomfort make it difficult for the patient to tolerate hemodialysis, but the ischemia can cause tissue necrosis and the eventual loss of fingers and possibly the patient's life. Doppler ultrasonography is a non-invasive technique that provides important information about vascular anatomy and hemodynamics. Aggressive treatment, including limb surgery and intensive blood glucose regulation, will result in favourable results. CONCLUSIONS: DASS is a rare condition usually encountered in hemodialysis patients with AVF. Proper diagnosis and management are needed to get an optimal outcome for the patient.

Managing tricuspid valve pathology in multiple valvular heart disease.

Introduction: Multiple valvular heart disease (MVD) is a general term to describe regurgitant and stenotic combination involving the same valve and/or occurring in ≥2 cardiac valves. Limited data and paucity in guidelines render the diagnosis and management. This article aims to provide a state-of-the-art review concerning the diagnosis and management strategies of MVD. Case presentation: We report a 46-year-old female with worsening dyspnea and fatigue. We perform multiple echocardiography parameters. We diagnose patients with the stenotic mitral valve, stenotic-regurgitant aortic valve, and stenotic-regurgitant tricuspid valve (TV). Double mechanical valve replacement and TV commissurotomy with Kay procedure were done with excellent results. Clinical discussion: The prevalence of MVD is 15% in those undergoing cardiac surgery; however only 1% of those who underwent triple valve surgery involve TV. The presence of TV lesion may complicate the natural history, clinical presentation, management, and outcomes. Echocardiography with valid method remains an important tool in assessment of patients with MVD. Multidiscipline heart team discussion is essential in determining individual risk, appropriate management methods, and long-term survival. Conclusion: The expertise of multidisciplinary heart valve team is of utmost importance in determining diagnosis and optimal management strategy.

Association between single nucleotide polymorphism SLCO1B1 gene and simvastatin pleiotropic effects measured through flow-mediated dilation endothelial function parameters.

BACKGROUND: Atherosclerosis is a condition in which the medium to large arteries become inflamed over time. The cornerstone to the atherosclerosis process is endothelial dysfunction. Simvastatin is a cholesterol-lowering drug known for its endothelial cell pleiotropic properties. The role of genetic polymorphisms in simvastatin-resistance difficulties has recently piqued people's interest. This problem is thought to be linked to the pleiotropic action of simvastatin, particularly in terms of restoring endothelial function. The goal of this study is to see if there is a link between the single nucleotide polymorphism (SNP) c.521T>C and the pleiotropic effect of simvastatin as determined by the endothelial function parameter, flow-mediated dilation (FMD). METHODS: This research was a multicentre cross-sectional study including 71 hypercholesterolemia patients who have been on simvastatin for at least 3 months. The real-time polymerase chain reaction identified SNP c.521T>C. The right brachial artery ultrasonography was used to measure FMD. RESULTS: In 71 hypercholesterolemia patients, the SNP c.521T>C was found in 9.9% of them. On χ2 analysis, there was no significant association between SNP c.521T>C (TC genotype) and FMD (p = 0.973). On logistic regression analysis, the duration of simvastatin medication was linked with an increased incidence (Adj. OR (adjusted odds ratio) = 2.424; confidence interval (CI) = 1.117-5.260, p = 0.025) and a reduction in systolic blood pressure (Adj. OR = 0.92; CI = 0.025-0.333, p = 0.001). CONCLUSION: There was no association between FMD and the SNP c.521T>C (TC genotype). The duration of simvastatin medication and systolic blood pressure were both associated to FMD.

Pulmonary aspergilloma coexisting with hamartoma in post pulmonary tuberculosis: A case report.

Introduction: Aspergillosis is a fungal disease caused by the Aspergillus fumigatus. Until now, the management of aspergilloma is still controversial, and there is no consensus among experts. Hamartoma is a benign tumor that can be found in the lung. We report a case of pulmonary aspergilloma coincidentally with hamartoma in pulmonary tuberculosis (TB) patients. Aspergilloma and hamartoma diagnoses are challenging because of various clinical symptoms. Case report: A 46 years old man came to emergency unit with complaints shortness of breath, cough, and chest tightness. He also has a red-black blood streak and terrible odor sputum. He had a history of two episodes of pulmonary TB. Holistic physical and additional examinations were done. Patient was diagnosed with aspergillosis infection in post pulmonary TB. The patient was then undergoing surgery. From the pathology of lung tissue, we found hamartoma features. Antifungal, antibiotic, and supported therapy were given, and his condition improved after a month of hospitalization. Conclusion: Pulmonary aspergilloma and hamartoma coincidence are rare diseases. Aspergilloma diagnosis is made based on clinical symptoms, radiological, and serological examination. Pulmonary hamartoma is generally asymptomatic. In this case, hamartoma was incidentally found in pathology examination. Prompt and precise diagnosis with good therapeutic management yield favorable outcomes.

A "Ping-Pong" left atrial thrombus mimicking left atrial myxoma: A case report.

Introduction: Valvular heart disease is highly prevalent, especially in developing countries. Mitral Stenosis (MS) is a condition where there is narrowing of mitral heart valve. Left atrial (LA) thrombus is often seen in severe MS patients. Case presentation: A 47-year-old woman complained of palpitation and shortness of breath. The heart sounded irregularly irregular, with grade III/IV diastolic murmurs at the apex. Her electrocardiogram showed atrial fibrillation (AF) with rapid ventricular response Transthoracal echocardiography (TTE) showed severe MS, mild tricuspid regurgitation, and LA thrombus. Mitral valve replacement surgery, tricuspid valve repair, and evacuation of the LA thrombus were immediately done. We evacuated a spherical mass with a size of 4 × 3x2.2 cm, layered and easily separated. Microscopic examination showed extensive fibrin and bleeding with mononuclear inflammatory cells and macrophages, corresponding to a thrombus conclusion. Clinical discussion: Atrial thrombus is common in MS patients. The incidence will increase by about two times in patients with AF. TTE is a reliable tool in diagnosing large mobile atrial thrombus and differentiated it from other cardiac masses. However, histopathological examination is still the gold standard to distinguish between LA thrombus and myxoma. Immediate thrombus evacuation and valve replacement, if needed, will give good results and reduce systemic thromboembolism. Conclusion: LA thrombus is often seen in a patient with severe MS. Optimal preoperative preparation involves assessing preoperative risk stratification will give good results.

The physiological insight of Coenzyme-Q10 administration in preventing the incidence of reperfusion arrhythmia among patients undergoing coronary artery bypass grafting surgery.

Reperfusion arrhythmia following cardiac surgery has long been studied as part of myocardial damage. Reperfusion injury is thought to be exacerbated by oxygen-free radicals, whereas arrhythmogenic oscillations in membrane potential are mediated by reactive oxygen. Coenzyme Q10 is a lipid-soluble antioxidant that inhibits lipid peroxidation in biological membranes and supplies ATP cell synthesis, required as the organism's primary energy source. This process explains how Coenzyme Q10 helps stabilize membranes and avoids critical metabolite depletion that may relate to reperfusion arrhythmia. There is a reduction of iatrogenic Coenzyme Q10 after coronary artery bypass surgery (CABG). On the other hand, there is an increased inflammatory process and cellular demand post CABG procedure. It leads to ischemia that can be manifested as arrhythmia. Reperfusion arrhythmia was less common in patients who took Coenzyme Q10. These findings suggest that Coenzyme Q10 supplementation might help patients with heart surgery avoid reperfusion arrhythmia. However, a higher-quality randomized controlled study is needed to determine the effect of Coenzyme Q10 in preventing reperfusion arrhythmia in cardiac surgery patients.

Serum uric acid and the risk of ventricular arrhythmias: a systematic review.

Uric acid (UA) is the end product of purine degradation in humans. It promotes inflammation via activation of pro-inflammatory cytokines and increases oxidative stress. The serum uric acid level has emerged as an independent risk factor of cardiovascular disease such as ventricular arrhythmias (VA). Here we had done a systematic review to assess the association between serum UA levels and the occurrence of VA. This systematic review included a total of four clinical studies with 99.383 patients for analysis. The scientific quality of all four studies was good. Three studies showed that serum uric acid levels were associated with VA in many populations. In contrast, one study with a large sample size evaluated that serum uric acid increases premature ventricle contraction prevalence. A significant association between serum uric acid level and VA was found in four studies (p<0.01; p<0.101; p=0.002; p=0.008). In conclusion, this systematic review shows an association between serum UA levels and VA.

CYP2C19 polymorphism and coronary in-stent restenosis: A systematic review and meta-analysis.

Background: In-stent restenosis (ISR) remains a major drawback in coronary stenting. The association between the CYP2C19 loss of function (LOF) gene and the prevalence of ISR after coronary stenting remains controversial. Previous studies have produced conflicting results and have been limited by their small population sizes. We conducted this systematic review and meta-analysis to determine the association between the presence of the CYP2C19 LOF gene and the prevalence of ISR. Methods: A systematic online database search was performed until April 2021. The primary outcome was ISR and assessed using OR with 95% CI. Publication bias was assessed using the Newcastle Ottawa Scale. I 2 was applied to examine heterogeneities among the studies. Results: A total of 284 patients (four non-randomized controlled trial studies) were included in this study. Two hundred and six patients had wild-type genotypes, while 78 patients had the LOF genotype. Among the 78 patients with the LOF gene, 40 patients had an ISR. Meanwhile, of the 206 patients with a wild-type gene, 69 patients had an ISR. The LOF gene was associated with a higher risk of ISR (OR 95% CI = 2.84 [1.54-5.24], p = 0.0008). A major limitation in our study was the small number of previous studies and small sample sizes. Conclusions: Patients with LOF genes, regardless of the allele variation, treated with clopidogrel, had a higher risk of developing ISR after coronary stenting.

Case Report: Heparin-induced thrombocytopenia during COVID-19 outbreak: the importance of scoring system in differentiating with sepsis-induced coagulopathy.

Background: COVID-19 disease is accompanied by derangement of coagulation with a risk of fatal thromboembolic formation. COVID-19 patients are among those indicative for heparin treatment. Increased heparin administration among COVID-19 patients increased heparin induced-thrombocytopenia's risk with/without thrombocytopenia. Case presentation: We present a 71-year-old male patient who came to the emergency room (ER) with a COVID-19 clinical manifestation followed by positive PCR nasopharyngeal swab result. He was assessed to have acute respiratory distress syndrome (ARDS), as shown by rapid progression of hypoxemic respiratory failure and bilateral pulmonary infiltrate. He was then treated with moxifloxacin, remdesivir, dexamethasone, unfractionated heparin (UFH) pump, and multivitamins. During admission, his respiratory symptoms got worse, so he transferred to the ICU for NIV support. On the ninth day of admission, he had gross hematuria followed by a rapid fall of platelet count. We used two different scoring systems (4Ts and HEP scoring system) to confirm the diagnosis of heparin-induced thrombocytopenia (HIT). Following the discontinuation of UFH injection, the thrombocyte continued to rise, and hematuria disappeared. Conclusion: Heparin-induced thrombocytopenia is associated with an increased risk of severe disease and mortality among COVID-19 patients. The differential diagnosis of HIT could be difficult as thrombocytopenia can also be caused by the progression of infection. We use two scoring systems (4Ts and HEP scoring) in order to help us managing the patient. These could improve the outcomes, thus avoiding morbidity and mortality.

Extracorporeal Membrane Oxygenation Used in Acute Respiratory Distress Syndrome with COVID-19: A Systematic Review and Meta-Analysis.

INTRODUCTION: Protective pulmonary mechanical ventilation, higher positive end-expiratory pressure, neuromuscular blockade, prone positioning, and pulmonary recruitment procedures are all strategies in severe COVID-19 cases. Extracorporeal Membrane Oxygenation (ECMO) can be seen as an alternative to traditional treatment in certain patients when conventional therapy fails. We present a study that intends to systematically review and meta-analysis ECMO use in COVID-19 patients. METHODS: We search major medical databases (Cochrane Library, PubMed, EMBASE, MedRxiv) for clinical trials that were released between January 2020 until February 2021, had full-text availability, were written in English, and humans studies.We used National Heart, Lung, and Blood Institute (NHLBI) quality evaluation methods for retrospective cohort and cross-sectional studies to evaluate the quality of the articles. In addition, we used the Mantel-Haenszel random-effects meta-analysis of using RevMan 5.4. RESULTS: A total of 33 studies involving 3090 patients were included in the systematic review and six studies in the meta-analysis. There were 828 patients admitted to the ICU, of which 779 patients had ARDS (94%). Of the total study, 527 patients received ECMO therapy (17%). ARDS incidence was associated with complications during ICU care compared to non-ICU care (OR 107.98; 95% CI 55.51-210.03; p < 0.00001). Indirect comparisons, the incidence of mortality was associated with ECMO compared with non-ECMO (OR 15.79; 95% CI 4.21-59.28; p < 0.0001). CONCLUSION: The incidence of ARDS was associated with complications during ICU stay, and the incidence of mortality was associated with ECMO. Further study about mechanisms involving illness and death of patients from COVID-19 is needed.

Hyponatremia in heart failure: not just 135 to 145.

One of the most frequent in-hospital electrolyte disturbances is hyponatremia. Hyponatremia in heart failure (HF) is mainly associated with hypervolemia resulting from activation of baroreceptor-mediated hormones, such as arginine vasopressin (AVP), renin-angiotensin-aldosterone system, and catecholamines. Various electrolyte imbalance can occur as heart failure progress. The goal of this review was to outline the current literature on hyponatremia in HF patients.

Evaluation of heart rate variability using 24-hour Holter electrocardiography in hypertensive patients.

BACKGROUND: Hypertension (HTN) remains a serious risk factor for cardiovascular mortality across the world. Hypertensive state has been shown to be associated with autonomic nervous function. This study aimed to explore the association between autonomic nervous impairment assessed by heart rate variability (HRV) and HTN. METHODS: A total of 52 hypertensive and 55 non-hypertensive patients were consecutively studied using 24-hour Holter. The hypertensive patients were grouped into controlled blood pressure (BP) and uncontrolled BP. This study compared HRV in non-hypertensive and hypertensive patients; and hypertensive patients with controlled and uncontrolled BP. HRV parameters include time and frequency domain. RESULTS: Mean age for hypertensive and non-hypertensive patients were 53.58 ± 14.31 and 44.89 ± 16.63 years old, respectively. Median (IQR) SDNN for hypertensive and non-hypertensive group were 109.00 (90.00-145.00) and 129.00 (107.00-169.00), respectively. SDNN, ASDNN, rMSSD, pNN50, BB50, VLF, and HF values were significantly lower in the hypertensive group compared to non-hypertensive group (all P < .05). A multiple regression analysis showed that HRV parameters: SDANN, ASDNN, rMSSD, and LF values were independent risk factors of HTN. SDNN, SDANN, ASDNN, VLF, LF, and HF values were significantly lower in the uncontrolled BP compared to controlled BP group (all P < .05). A multiple regression analysis showed that HRV parameters: SDNN, SDANN, rMSSD, and HF values were independent risk factors of uncontrolled BP in hypertensive patients. CONCLUSIONS: Our study showed that cardiac autonomic nervous impairment, as demonstrated by reduced HRV, is significantly associated with HTN. Decreased HRV was more evident in uncontrolled BP than in controlled BP group.