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Initial dietary approach to stop hypertension (DASH) diet feeding trials showed blood pressure (BP)-lowering effects that corresponded to higher degrees of concordance with the diet. These results popularized the idea that adherence to a DASH diet could reduce coronary artery disease (CAD) risk for patients. Recent evidence shows that the impact of DASH on CAD incidence and risk is less clear. While many studies show that the DASH diet impacts CAD risk factors, others suggest that these effects do not remain when important confounders are controlled. Also, the evidence from meta-analyses that the DASH diet impacts incident CAD is still inconclusive. Reassessment of the DASH diet, and the search for an ideal diet to prevent CAD will require a better understanding of the mechanisms through which the DASH diet works. Proposed mechanisms for its benefit include preventing inflammation and atherosclerosis progression as well as providing a heathy balance of dietary sodium and potassium intake.
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INTRODUCTION: Pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial blood pressure secondary to increased pulmonary vascular resistance. AREAS COVERED: Invasive hemodynamic assessment by heart catheterization (RHC) remains the gold standard to confirm the diagnosis, to determine the severity of right ventricular dysfunction and to test for pulmonary vasoreactivity. After diagnosis and initiation of therapy, many PAH centers continue to perform RHC at regular intervals to monitor for disease progression and alter management. We discuss the importance of risk stratification in PAH, the role of RHC in the evaluation and treatment of these patients and compare non-invasive risk assessment tools to that of RHC. EXPERT OPINION: RHC is useful for diagnosis of PAH, assessing the risk of mortality and morbidity, directing the escalation and de-escalation of therapy, and monitoring for disease progression. In the current era of improved non-invasive cardiac hemodynamic assessment, the role for routine follow-up serial RHC in patients with PAH needs to be reassessed in future studies. With the availability of non-invasive risk assessment tools such as REVEAL Lite 2, it may be reasonable to reconsider the role of annual or protocoled RHC, and instead, move on to an "as needed" and individual approach.
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Hipertensão Pulmonar , Hipertensão Arterial Pulmonar , Cateterismo Cardíaco , Progressão da Doença , Hipertensão Pulmonar Primária Familiar , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/terapia , Hipertensão Arterial Pulmonar/diagnóstico , Hipertensão Arterial Pulmonar/terapia , Medição de RiscoRESUMO
BACKGROUND: We compared the in-hospital complications, outcomes, cost, and length of stay (LOS) between angiography-guided percutaneous coronary intervention (PCI) and intravascular ultrasound (IVUS)-guided PCI in patients with ST-elevation myocardial infarction (STEMI) in the USA. METHODS: A nationwide inpatient database was queried to identify patients >18â¯years with STEMI who underwent angiography-guided and IVUS-guided PCI from January 2016 to December 2016. We compared the in-hospital mortality, complications, cost, and LOS between the two groups. RESULTS: We identified 100,485 patients who underwent angiography-guided PCI and 5,460 patients who underwent IVUS-guided PCI. In-hospital mortality was not statistically different (odds ratio [OR] 0.76, 95% CI 0.46 - 1.22, P = 0.24). Patients who underwent PCI with IVUS were more likely to have coronary artery dissection (OR 4.26, 95% CI 2.34 - 7.7, p = <0.01), and both groups had a similar incidence of acute kidney injury requiring hemodialysis. The mean LOS was similar, but the mean total cost was higher in the group that underwent PCI under IVUS guidance. CONCLUSIONS: The in-hospital mortality, hemodialysis, and the use of support devices did not reach a statistical difference between the two groups. However, we observed higher rates of coronary dissection with the use of IVUS in STEMI management.
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Gastrointestinal (GI) angioectasia is an important cause of acute GI bleed, particularly in the elderly; however, GI angioectasia is an uncommon cause of upper GI bleeding related to cirrhosis. With the increasing incidence of liver cirrhosis and recent improvements in the treatment of advanced cirrhosis, this condition may become more common and should be considered a differential diagnosis in patients with cirrhosis who present with occult or overt GI blood loss. We present the case of a 66-year-old man with liver cirrhosis admitted with acute upper GI bleeding that was found to have antral and duodenal angioectasia during esophagogastroduodenoscopy (EDG). Argon plasma coagulation (APC), which is considered the gold standard treatment for angioectasias was performed for hemostasis but was not successful in our case. The next option was a combination of estrogen and progesterone, which was refused by the patient. Finally, thalidomide was administered and the patient responded to the medication, which was evident by the resolution of angioectasia during a repeat endoscopy done six months after treatment.
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Although atrial fibrillation (AF) has been correlated with hyponatremia, it has not been described in association with the correction of chronic hypernatremia in previous studies. Here, we describe three elderly patients who had hypernatremia on presentation, most likely secondary to dehydration. Their electrocardiogram (EKG) on presentation was normal, and they had no known history of AF but developed transient AF during the course of hypernatremia correction. Similar occurrences have not been reported previously though there have been studies showing the relation between hyponatremia and AF. It is known that atrial stretch can increase the propensity of rapid firing from the pulmonary veins as a result of stretch-sensitive ion channels. Therefore, the occurrence of AF in these patients could be explained by the phenomenon of increase in right atrial diameter, i.e atrial stretch, in response to the increase in preload during the course of treatment. However, there are many other clinical scenarios where boluses of fluid are given during treatment but no occurrences of AF have been reported so far. So, we put forward the possibility of the occurrence of AF being independently associated with the drop in sodium level. Further studies like speckle tracking echo might shed more light on these findings.
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Percutaneous endoscopic gastrostomy (PEG) feeding is a common and widely performed procedure appropriate for long-term enteral nutrition in patients with multiple indications. We present the case of a 59-year-old woman with a PEG tube placed owing to complication following thyroid surgery approximately 20 years ago, representing the most extended duration of PEG tube feeding without any significant complication for chronic mechanical dysphagia. This case highlights the importance of PEG feeding, where this route can be used indefinitely in an appropriate clinical setting without complications. Interestingly, self-replacement of PEG tube was performed by the patient herself whenever she noticed clogging up of tube while self-feeding.
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Ventriculoperitoneal (VP) shunt placement is one of the more common procedures in neurosurgery and has a variety of indications. However, shunt placement can be associated with multiple complications, one of which is proximal and distal shunt migration. There have been reported cases of migration of the distal end of a VP shunt from the intraperitoneal cavity into different organs resulting in a variety of complications. Most of the reported cases are the result of spontaneous migration. However, shunt catheter migration could be iatrogenic as well. We present a case of intragastric VP shunt migration in a patient following placement of a percutaneous endoscopic gastrostomy tube.
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Dronedarone is a class III antiarrhythmic agent and a potent blocker of multiple intracardiac ion channels with many electrophysical properties common with amiodarone. Oral dronedarone, 400 mg twice daily, is approved for the maintenance of normal sinus rhythm in patients with a history of atrial fibrillation (AF) or atrial flutter. It is primarily used for the maintenance of sinus rhythm in patients with paroxysmal or persistent AF or atrial flutter. Dronedarone is a relatively new therapeutic agent which is a non-iodinated congener of amiodarone and hypothesized to have far lesser side effects. Photosensitivity is an uncommon side effect of dronedarone and not much has been described in the literature. Here we describe a patient with such complication.
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An isolated descending colonic stricture is an unlikely complication of acute pancreatitis, with the nonspecific symptoms of colonic stricture making the overall diagnosis difficult. Crohn's disease (CD) and tuberculosis (TB) are the two common etiologies of an isolated colonic stricture and may present similarly to colonic stricture related to acute pancreatitis. Unfortunately, colonoscopy and biopsy often cannot determine the etiology, and surgical resection may be needed to provide both symptomatic relief and confirm the diagnosis. As a result, descending colonic stricture may produce a diagnostic dilemma with CD and TB as all 3 conditions may be radiologically and endoscopically indistinguishable. We describe a young male with weight loss and abdominal pain. TB testing was negative, with radiography and ELISA (enzyme-linked immunosorbent assay) testing supporting a diagnosis of the CD. The patient was initiated on sulfasalazine but worsened over the next month. Further investigations revealed that the patient had descending colonic stricture without CD. Therefore, the stricture's etiology was most likely related to an episode of acute pancreatitis the patient had 2 months before admission and was found to have left colonic segment adherent to the pancreas eventually requiring segmentectomy. Although the pathophysiology of colonic stricture after pancreatitis is unclear, we speculate that inflammatory injury to the colon is an important component. Finally, we emphasize that colonic stricture is a rare complication of pancreatitis.
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Doenças do Colo/etiologia , Constrição Patológica/etiologia , Pancreatite/complicações , Doença Aguda , Adulto , Colo/patologia , Doenças do Colo/patologia , Colonoscopia , Humanos , Masculino , Tomografia Computadorizada por Raios XRESUMO
INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is associated with systemic inflammation. Weight loss seen in patients with COPD is a consequence of this inflammation. We hypothesized that higher grades of COPD are associated with greater degree of weight loss. MATERIALS AND METHODS: In this cross-sectional study, we assessed the body mass index (BMI) of 34 patients with COPD proven by handheld spirometer. The difference in BMI among various grades of COPD was compared. RESULTS: BMI was found to be inversely related to the grades of COPD in our study (P = 0.001). No significant difference was seen among the patients with regards to age and duration of symptoms before presentation. CONCLUSION: Advanced COPD is associated with greater degree of weight loss.
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Refractory alcohol withdrawal delirium is uncommon in day-to-day clinical practice. This case report presents a rare case of delirium tremens of unusually long duration that was complicated by the difficulty in tapering down benzodiazepines despite adding midazolam drip as well as phenobarbitone to the management regimen and excluding other possible diagnoses.
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Delirium por Abstinência Alcoólica/diagnóstico , Delirium por Abstinência Alcoólica/reabilitação , Benzodiazepinas/administração & dosagem , Encéfalo/diagnóstico por imagem , Diagnóstico Diferencial , Humanos , Hipnóticos e Sedativos/administração & dosagem , Masculino , Midazolam/administração & dosagem , Pessoa de Meia-Idade , Fenobarbital/administração & dosagem , Tomografia Computadorizada por Raios XRESUMO
Background Non-alcoholic fatty liver disease (NAFLD) is the deposition of fat inside liver cells in the absence of secondary causes. It is considered as a hepatic complication of metabolic syndrome. The metabolic syndrome consists of dyslipidemia, hypertension, diabetes, and obesity. This study aims to determine the prevalence of metabolic syndrome in Nepalese patients with NAFLD from mid-Western part of Nepal. Method This was a descriptive cross-sectional study. Three different sites were chosen in and around Butwal sub-metropolitan city of Rupandehi district, Nepal. A one-day health camp for the screening of fatty liver disease by ultrasonography (USG) was conducted at these sites. Participants with fatty liver were then classified into three grades by USG and the presence of metabolic syndrome was assessed by the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATPIII) criteria. Results A total of 385 participants with NAFLD were evaluated. Presence of metabolic syndrome by NCEP-ATPIII criteria was found to be in 57.6% participants; whereas, at least one component of metabolic syndrome was found in 91.4% of participants with radiologic features of fatty liver. Higher proportion of patients with NAFLD were males. Increased waist circumference followed by low high-density lipoprotein (HDL) level were the most common components of metabolic syndrome in participants with NAFLD. Conclusions Metabolic syndrome is common in Nepalese community patients with NAFLD.
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Ecstasy or 3,4-methylenedioxymethamphetamine (MDMA) is an illicit recreational drug. Effects include euphoria, increased sensory awareness, and central stimulation. Although various arrhythmias, as well as dilated cardiomyopathy, have been previously noted to occur with chronic use, cardiac toxicities are seldom reported in an acute setting. Herein, we present a 28-year-old female patient with no prior medical condition that presented to the Emergency Department with chest pain following intake of MDMA. Electrocardiographic findings, as well as laboratories, were suggestive of possible Acute Non-ST elevation myocardial infarction. Upon admission, cardiac catheterization revealed patent coronary arteries. Stark regional wall motion abnormalities were observed along with reduced ejection fraction. Acute systolic heart failure was treated with standard medical management. Subsequent reassessment of ventricular function with Echocardiography revealed marked improvement. This article describes a case of MDMA induced heart failure, including details of evaluation, management, and monitoring of patient progress. It brings further attention to potential acute harmful effects of MDMA on cardiac function and viability.
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Background Hepatic encephalopathy (HE) is a common cause of hospital admission in patients with liver cirrhosis (LC). The aims of this study were to evaluate the precipitant factors and analyze the treatment outcomes of HE in LC. Methods All the LC patients admitted between February 2017 and January 2018 for overt HE were analyzed for precipitating factors and treatment outcomes. Treatments were compared among three treatment groups: receiving lactulose, lactulose plus L-ornithine L-aspartate (LOLA), and lactulose plus rifaximin. The primary endpoints were mortality and hospital stay. The chi-square test was used to compare the different treatment outcomes with hospital stay and mortality with significance at p<0.05. Results A total of 132 patients (mean age 49.2 ± 10.2 years; male/female ratio of 103:29) were studied. The most common precipitating factor of HE was infection 65 (49.2%), followed by electrolyte imbalance 54 (41%), constipation 44 (33.33%), and gastrointestinal bleeding 21 (16%) patients. At the time of admission, 29 (22%), 76 (57.5%), 21 (16%), and six (4.5%) patients had grade I, II, III, and IV HE, respectively. The difference in mortality was not statistically significant (p=0.269) in three groups but the hospital stay was shorter among patients in groups B and C than in group A alone (7.36 ± 4.58 and 7 ± 3.69, 9.64 ± 5.28 days, respectively, p=0.015). Conclusions Infection, especially spontaneous bacterial peritonitis, was the commonest precipitating factor of HE. The combination of lactulose either with LOLA or rifaximin is equally effective in improving HE and reducing the duration of hospital stay than lactulose alone.
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AIM: Heart failure (HF) constitutes a major public health problem in the USA due to its high morbidity and mortality. Age at diagnosis of HF would refine burden quantification, budgeting, disease surveillance and assessment of interventions. We set out to determine the median age at diagnosis of HF and drivers of young age at diagnosis among patients 20â¯years or older in the USA. METHODS AND RESULTS: We utilized NHANES data collected across five survey cycles (2007-2016). Included were individuals aged 20 to 80â¯years diagnosed of HF with valid entries for age at diagnosis. Differences in age at diagnosis between groups and major drivers for younger age at diagnosis were assessed using linear regression models with p-values <0.05 considered statistically significant. The prevalence of HF in the USA was 2.44% with a median age at diagnosis of 59â¯years (IQR 47-70). Non-Hispanic (NH) Blacks -4.94â¯years (95% CI -7.95 to -1.93), individuals living below the poverty line -5.79â¯years (95% CI -10.36 to -1.01), obese persons -5.63â¯years (95% CI -8.35 to -2.92), individuals without health insurance -4.31â¯years (95% CI -7.87 to -0.75) and those without hypertension -3.99â¯years (95% CI -7.19 to -0.78) were diagnosed at significantly younger ages than their respective counterparts. CONCLUSION: The median age at diagnosis of HF in the USA is 59â¯years. NH Blacks, living in poverty, lack of health insurance and obesity are the main drivers of early age at diagnosis of HF in the USA.
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Índice de Massa Corporal , Disparidades nos Níveis de Saúde , Insuficiência Cardíaca/economia , Insuficiência Cardíaca/etnologia , Fatores Socioeconômicos , Adulto , Idade de Início , Idoso , Idoso de 80 Anos ou mais , Etnicidade , Feminino , Insuficiência Cardíaca/diagnóstico , Humanos , Masculino , Estado Civil/etnologia , Pessoa de Meia-Idade , Inquéritos Nutricionais/métodos , Estados Unidos/etnologia , Adulto JovemRESUMO
BACKGROUND: Liver cirrhosis is one of the major causes of morbidity and mortality. The threatening complication of Liver cirrhosis is variceal bleeding. Early diagnosis and initiation of therapy can reduce mortality associated with variceal bleeding. This study is designed to predict the esophageal varices by non-invasive method using aspartate aminotransferase to platelet count ratio index (APRI). METHODS: A total of 100 patients were studied between March 2016 and February 2017 with the diagnosis of Liver cirrhosis admitted at Bir Hospital fulfilling the inclusion and exclusion criteria. Ethical approval was obtained from Institutional review board of National Academy of Medical Sciences. RESULTS: Out of one hundred patients, 80 were males and 20 females. On endoscopy, small varices were present in 28 (28%) patients and large varices in 51(51%) patients. APRI with a cutoff value of 0.908 has sensitivity of 87.3% and specificity of 71.4%, positive predictive value of 92% and negative predictive value of 60% (p=0.001) for the detection of varices. CONCLUSIONS: Aspartate aminotransferase to platelet count ratio index can be a useful tool to indirectly predict esophageal varices in a patient with Liver Cirrhosis.
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Aspartato Aminotransferases/sangue , Varizes Esofágicas e Gástricas/etiologia , Cirrose Hepática/complicações , Contagem de Plaquetas , Varizes Esofágicas e Gástricas/sangue , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/enzimologia , Esofagoscopia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Helicobacter pylori (H. pylori) is one of the most common human infections worldwide particularly in the developing countries. We aimed to study an association of H. Pylori infection with endoscopic and histological findings in the Nepalese population. MATERIALS AND METHODS: We conducted a study between Oct 2014 and Jan 2015 after meeting inclusion and exclusion criteria. Institutional Review Board approval was obtained from National Academy of Medical Sciences. Endoscopic findings and histopathological diagnosis were documented and data were analysed. RESULTS: A total of 113 patients who had complete endoscopy were enrolled. The prevalence of H. pylori infections recorded was 27 (23.9%) patients. There were 17 (62%) male and 10 (37%) female infected with H. pylori (P = 0.33). All biopsied specimens were sent to pathology lab for examination. The most common endoscopic findings was erythematous antral gastritis (40.7%) followed by erosive gastritis 34 (30.1%), pangastritis 10 (8.8%), duodenal ulcer 13 (11.5%), gastric ulcer 9 (8%), erosive fundal gastritis 2 (1.8%), reflux esophagitis 10 (37%) (P < 0.04). Histology revealed that 23 (85.2%) patients had chronic active gastritis (CAG); (P < 0.001). CONCLUSIONS: Our study revealed that H. pylori infection is strongly associated with chronic active gastritis (CAG) and Reflux esophagitis in Nepalese adults.
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Introduction. Myocardial infarction in the setting of anaphylaxis may result from the anaphylaxis itself or from the epinephrine used to treat the anaphylaxis. While cases of myocardial infarction due to large doses of intravenous epinephrine have previously been reported, myocardial infarction after therapeutic doses of intramuscular epinephrine is rarely reported. Case Report. A 23-year-old male presented with sudden onset of difficulty in swallowing and speech after eating takeout food. He was treated with intramuscular epinephrine for presumed angioedema following which he immediately developed chest tightness associated with ST elevation on electrocardiogram and elevated serum troponin. His symptoms and electrocardiogram findings were transient and resolved within the next 10 minutes. Conclusion. Epinephrine is lifesaving during anaphylaxis and should be promptly used. Health care providers, however, need to be aware and vigilant of this rare complication of epinephrine.
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Renal and neurological involvements are frequently seen in thrombotic thrombocytopenic purpura (TTP). Cardiac involvement, however, has been rarely reported. In this article, we present 2 cases of myocardial infarction in patients with TTP. In the first case, a young man presented with non-ST-segment elevation myocardial infarction that resolved promptly with plasmapheresis. The second patient developed ST-segment elevation myocardial infarction early in the course of the disease and died before plasmapheresis could be initiated. Hence, a high degree of suspicion with prompt diagnosis and treatment is needed to prevent mortality associated with cardiac involvement in TTP.
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Background Non-alcoholic fatty liver disease (NAFLD) is emerging as the most common chronic liver condition. Approximately 70% of type 2 diabetes mellitus (T2DM) patients have a fatty liver; the progression to non-alcoholic steatohepatitis (NASH) dramatically increases the risks of cirrhosis and hepatocellular carcinoma. The aim of our study was to assess the profile of liver enzymes in subjects with T2DM and NAFLD. Method This was a cross-sectional clinic-based study in patients with T2DM. An ultrasonography of the abdomen was done in all patients in order to examine the presence of a fatty liver. Body mass index (BMI), lipid profile, and liver enzymes were also analyzed in all patients. Institutional Review Board (IRB) approval was provided by the National Academy of Medical Sciences, Bir Hospital, Nepal. Unpaired t-test, Chi-square/Fisher's exact test (for categorical variables), and the Pearson/Spearman correlation test were used to find a significant difference, association, and correlation between two or more groups, respectively. The Statistical Package for Social Sciences (SPSS)® Statistics, version 16 (IBM SPSS Statistics, Armonk, NY) was used to analyse the data. Results The study was carried out in 210 patients, and out of the 210 patients, 119 (56.6%) were male and 91 (43.3%) were female. The patients were divided into two groups, i.e., the normal alanine aminotransferase (ALT) group and the elevated ALT group. The mean age of the patients was 56.28 ± 12.3 years in the normal alanine aminotransferase (ALT) group and 58.6 ± 24.7 in the elevated ALT group. The number of T2DM patients with a fatty liver was 117 (55.7%) and those with a non-fatty liver was 93 (44.2%) based on an ultrasonography scan. Subjects with NAFLD had a significantly higher ALT (p < 0.001) but no significant rise in serum aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), and alkaline phosphatase (ALP) levels. The area under the receiver operating characteristic (AUROC) curve for the prediction of fatty liver based solely on the ALT was 0.84 with the confidence interval (CI) between 0.76 and 0.92 (p < 0.05). Conclusions Non-alcoholic fatty liver disease is highly prevalent in patients with T2DM. Timely diagnosis and management of the abnormal liver parameters may help to minimize liver-related morbidity and mortality in the diabetic population.