Recurrence of left ventricular pseudoaneurysm after multiple mitral valve replacements.

Left ventricular pseudoaneurysm (LVPA) formation is a potentially lethal complication of myocardial infarction (MI) and mitral valve (MV) replacement that requires prompt diagnosis and treatment. A female patient who had been complaining of exertional dyspnea underwent a two-dimensional transthoracic echocardiogram (TTE) which revealed a functioning mechanical MV with severe paravalvular leak, severe tricuspid regurgitation (TR) and severely elevated pulmonary artery systolic pressure. Moreover, echo-lucent space at the postero-lateral portion of the left ventricle near the MV was seen, suggestive of a large LVPA. Transesophageal echocardiography (TEE) and computed tomography (CT) angiography confirmed these findings. Afterwards, the patient had a surgical repair for the LVPA along with mitral and tricuspid valve (TV) replacement. Three months later, the patient presented with symptoms of congestive heart failure. The LVPA had recurred at the same location of the previous pseudoaneurysm and given the high risk for reoperating on the patient, close monitoring and medical management were deemed as a better option.

Clinical and echocardiographic predictors of outcome in liver transplant patients.

Liver transplant (LT) candidates undergo transthoracic echocardiography (TTE) before surgery to assess cardiac function and evaluate the echocardiographic probability of pulmonary hypertension (PHT). The improvement of pulmonary artery systolic pressure (PAPS) after transplant is associated with higher survival rates in patients with mild or moderate PHT. Although studies analyze the outcomes of LT in patients treated for PHT, the prognostic value of PAPS in patients without PHT in the follow-up is unknown. The aim of our study is to evaluate pre- and post-LT cardiac function, right ventricular function, pulmonary artery pressure, and their association with long-term mortality. 102 patients who underwent LT between 2011 and 2018 were compared for echocardiographic and hemodynamic parameters pre- and post-LT. After LT, systolic blood pressure, heart rate (HR), and PASP significantly increased, while tricuspid annular plane systolic excursion/PAPS decreased. Moreover, the higher difference in HR and PASP between pre- and post-LT was highlighted in those patients who died during the follow-up period after LT. Among all the parameters tested, in the multi-variable Cox regression for mortality, left ventricular ejection fraction and PASP difference were predictors of mortality. This study highlights the importance of TTE in LT screening as a tool to stratify patients at higher risk of death due to advanced cirrhotic cardiomyopathy and the importance of the change of echocardiographic parameters, in particular right and left ventricular hemodynamics, during the follow-up period. These parameters could be used to guide a more aggressive therapy.

Acute abdomen secondary to perforated jejunal gastrointestinal stromal tumor and imatinib-related isolated pericardial effusion in a 50-year-old female patient: A case report and review of literature.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract; occurring most often in the stomach and to a lesser extent in the jejunum. The majority of the tumors express activating mutations in either c-KIT or PDGFRA tyrosine kinases, which respond to tyrosine kinase inhibitors (TKI). Jejunal GIST is considered to be extremely rare and challenging to diagnose due to its non-specific presentation. As a result, patients usually present at an advance stage of the disease, making the prognosis poor and difficult to manage. CASE PRESENTATION: In the present study, we report a 50-year-old female who was diagnosed with metastatic jejunal GIST. She was commenced on Imatinib (TKI) and shortly after she presented to the emergency department with an acute abdomen. A CT scan of the abdomen revealed ischemic changes in the jejunal loops and pneumoperitoneum. The patient required emergency laparotomy due to perforated GIST, and creation of pericardial window due to hemodynamic instability possibly secondary TKI-related isolated pericardial effusion. CONCLUSION: Jejunal GIST is rare and usually presents as emergency due to obstruction, hemorrhage or rarely perforation. Although, systemic therapy with TKI is the principal treatment for advance disease, Jejunal GIST should be removed surgically. It is surgically challenging due to the anatomical complexity of the tumor. Surgeons treating such patients must be cautious for TKI side effects.

Castleman disease: a case report of an unusual adrenal incidentaloma and literature review.

Adrenal incidentaloma (AI) is an incidental detection of an adrenal mass on an image not performed for a suspected adrenal problem. AI has become a commonly encountered lesion that requires further investigations for evidence of hormonal hypersecretion or malignancy potential. According to guidelines, surgical intervention is the standard of care for unilateral AI. We report on a case of a 64-year-old female who presented with a nonfunctional adrenal mass associated with compressive symptoms, which was revealed to be a mixed hyaline vascular and plasma cell variant Castleman disease (CD) after surgical resection. Although hyaline vascular variant and plasma cell variant of CD has been identified in adrenal glands, this is the first report of a mixed hyaline vascular and plasma cell variant in an adrenal mass.

Complementary and alternative medicine use and its association with medication adherence in inflammatory bowel disease and other gastrointestinal diseases.

Background: The use of complementary and alternative medicines (CAMs) has been embedded in populations for decades. In this study, we aimed to determine the rate of their usage among inflammatory bowel disease (IBD) patients and their association with adherence to conventional therapies. Methods: In this cross sectional, survey-based study, IBD patients' (n=226) adherence and compliance were evaluated using the Morisky Medication Adherence Scale-8. A control sample of 227 patients with other gastrointestinal diseases was included to compare trends of CAM use. Results: Crohn's disease represented 66.4% of those with IBD, with a mean age of 35 ± 13.0 years (54% males). The control group had either chronic viral hepatitis B, gastroesophageal reflux disease, Celiac disease, or other non-IBD diseases, with a mean age of 43.5 ± 16.8 years (55% males). Overall, 49% of patients reported using CAMs (54% in IBD group and 43% in the non-IBD group, P =0.024). Across both groups, the most used CAMs were honey (28%) and Zamzam water (19%). There was no significant association between the severity of the illness and use of CAMs. Patients who used CAMs had a lower adherence to conventional therapies vs. those who did not use CAMs (39% vs. 23%, P =0.038). Using the Morisky Medication Adherence Scale-8, low adherence to medications was reported in 35% of the IBD group vs. 11% of non-IBD group (P = 0.01). Conclusion: In our population, patients with IBD are more likely to use CAMs and are less adherent to medications. Furthermore, the use of CAMs was associated with a lower adherence rate to conventional therapies. Consequently, further studies assessing the causes associated with the use of CAMs and nonadherence to conventional therapies should be explored and interventions designed to mitigate nonadherence.

A Randomized Clinical Study of the Plaque Removal Efficacy of a Novel Manual Toothbrush With Micro-Pulse Bristles on Fixed Orthodontic Patients.

Background Fixed orthodontic appliances on tooth surfaces, such as brackets and bands, complicate oral hygiene and increase plaque accumulation, contributing to gingivitis, periodontitis, and tooth decay. While manual toothbrushes are an essential part of oral hygiene, there is little clinical evidence to demonstrate how effective manual toothbrushes with novel designs are at removing plaque from orthodontic patients. This study aims to evaluate three types of manual toothbrushes (Pulsar, conventional flat trim (C-TB), and orthodontic type (O-TB)) for their efficacy in plaque removal among patients undergoing fixed orthodontic treatment. Methodology The study followed the Consolidated Standards of Reporting Trials (CONSORT) guidelines. It was a three-treatment, three-period, examiner-blinded crossover clinical trial conducted with a single brushing exercise. Twenty-four subjects were randomized to one of three different bristle designs (Pulsar, C-TB, and O-TB). The primary outcome measure was the difference (baseline minus post-brushing) in plaque scores assessed using the Turesky-Modified Quigley-Hein Plaque Index during each study period. Results Of the 27 subjects enrolled in the study, 24 met the inclusion criteria and completed all three periods of the study. The mean age was 19.58 ± 1.55 years, with a range of 18-23 years. The differences between treatments in plaque score reduction after brushing were statistically significant (p-value <0.001). The treatment differences were statistically significant (p-value <0.001), favoring the C-TB toothbrush and the O-TB over the Pulsar design. On the contrary, the difference between the O-TB and C-TB types was not statistically significant. Conclusions C-TB and O-TB remove significantly more plaque than Pulsar toothbrushes after a single brushing exercise. Nevertheless, the C-TB tested in this study was more effective in removing dental plaque than the O-TB in patients wearing fixed orthodontic appliances. Considering the limitations of this study, additional research is required before evidence-based advice concerning the relative performance of the Pulsar toothbrushes in fixed orthodontic patients can be proven.

Compliance with the north American Society of Pacing and Electrophysiology guidelines on amiodarone monitoring in Riyadh, Saudi Arabia: a retrospective charts review study.

BACKGROUND: Amiodarone is known for its efficacy as an antiarrhythmic agent; however, its extensive side-effect profile requires careful selection of patients and frequent monitoring. The purpose of this study was to evaluate the performance of the baseline tests before initiating amiodarone therapy and the on-going monitoring based on the North American Society of Pacing and Electrophysiology guidelines recommendations. METHODS: A retrospective descriptive charts review study included all patients who are 18 years of age and older and were started on oral amiodarone with a primary diagnosis of any type of cardiac arrhythmia from January 2016 to December 2018 in King Abdualziz Medical City, Riyadh, Saudi Arabia. The medical charts were reviewed and evaluated based on the performance of the recommended baseline and follow-up of chest X-ray (CXR), liver function test (LFT), thyroid function test (TFT) and electrocardiogram (ECG). The continuous variables were analyzed and presented as mean ± SD and the categorical variables were presented as percentages. RESULTS: Over the study period, 143 eligible participants on amiodarone therapy were included, with an average of 165 ± 207 days on amiodarone. Of patients, 36.4% had the entire recommended baseline assessments before initiating amiodarone. Our results indicated optimal compliance rates to the baseline tests of CXR (79.7%), LFT (79.7%) and ECG (86.7%). However, there was a lower compliance rate to TFT recommendations (40.6%). The compliance rate to the guideline recommendations related to the follow-up tests was minimal. On-going monitoring performance rates were 47.6% of CXR, 49% of LFT, 54.5% of ECG and 22.4% of TFT. CONCLUSION: The compliance with the guideline recommendations related to amiodarone baseline assessments was optimal for all the baseline tests, except for TFT. However, the proportion of patients who received all the recommended baseline assessments was minimal. In addition, the performance of on-going monitoring was suboptimal for all the follow-up tests. Improvements could be made by establishing a local protocol for amiodarone monitoring and pharmacists participating in amiodarone therapy assessments.

Effect of Long-Term Allopurinol Therapy on Left Ventricular Mass Index in Patients with Ischemic Heart Disease; A Cross-Sectional Study.

BACKGROUND: Left ventricular hypertrophy (LVH), as assessed by measurement of left ventricular mass (LVM), is one of the most important cardiovascular risk factors. It is commonly present in patients with ischemic heart disease (IHD), irrespective of the level of blood pressure; recently, oxidative stress has been shown to be an important factor in its development. The question then arises: can this risk factor be modified by antioxidant treatment (e.g., with allopurinol, a xanthine oxidase inhibitor)? METHODS: This is an observational study with a cross-sectional design which explored the association between long-term (>12 months) allopurinol therapy and LV mass index (LVMI) as well as geometry in patients generally receiving standard treatments for IHD. The primary endpoint was LVMI measurement (by 2D-echocardiography) and secondary endpoints included the association of allopurinol use with LV function (ejection fraction), blood pressure, glycemic control, and lipid profile. RESULTS: Ninety-six patients on standard anti-ischemic drug treatment (control group) and 96 patients who were additionally taking allopurinol (minimum dose 100 mg/day) were enrolled. Both groups were matched for age, sex, height, and co-morbidities, but poorer kidney function in the allopurinol group required further sub-group analysis based on renal function. Allopurinol treatment was associated with the lowest LVMI in the patients with normal serum creatinine (median LVMI; 70.5 g/m2): corresponding values were 76.0 and 87.0 in the control group with, respectively, normal and elevated serum creatinine, and 89.5 in the allopurinol group with elevated serum creatinine (P=0.027). In addition, allopurinol was associated with better glycemic control (HbA1c) with a difference of 0.8% (95% CI; 1.3, 0.2) (P=0.004) as compared with control patients. CONCLUSION: In our population, treatment with allopurinol (presumably because of its anti-oxidant properties) has shown a tendency to be associated with smaller LVM in IHD patients with normal serum creatinine, along with better glycemic control.

Genetic Alterations in Oxidant and Anti-Oxidant Enzymes in the Vascular System.

Cardiovascular diseases (CVD) are one of the prime causes of mortality worldwide. Experimental animal models have become a valuable tool to investigate and further advance our knowledge on etiology, pathophysiology and intervention. They also provide a great opportunity to understand the contribution of different genes and effector molecules in the pathogenesis and development of diseases at the sub-cellular levels. High levels of reactive oxygen species (ROS) have been associated with the progression of CVD such as ischemic heart disease (IHD), myocardial infarction, hypertension, atherosclerosis, aortic aneurysm, aortic dissection and others. On the contrary, low levels of antioxidants were associated with exacerbated cardiovascular event. Major focus of this review is on vascular pathogenesis that leads to CVD, with special emphasis on the roles of oxidant/antioxidant enzymes in health and disease progression in vascular cells including vascular endothelium. The major oxidant enzymes that have been implicated with the progression of CVD include NADPH Oxidase, nitric oxide synthase, monoamine oxidase, and xanthine oxidoreductase. The major antioxidant enzymes that have been attributed to normalizing the levels of oxidative stress include superoxide dismutases, catalase and glutathione peroxidases (GPx), and thioredoxin. Cardiovascular phenotypes of major oxidants and antioxidants knockout and transgenic animal models are discussed here.

Subcellular Reactive Oxygen Species (ROS) in Cardiovascular Pathophysiology.

There exist two opposing perspectives regarding reactive oxygen species (ROS) and their roles in angiogenesis and cardiovascular system, one that favors harmful and causal effects of ROS, while the other supports beneficial effects. Recent studies have shown that interaction between ROS in different sub-cellular compartments plays a crucial role in determining the outcomes (beneficial vs. deleterious) of ROS exposures on the vascular system. Oxidant radicals in one cellular organelle can affect the ROS content and function in other sub-cellular compartments in endothelial cells (ECs). In this review, we will focus on a critical fact that the effects or the final phenotypic outcome of ROS exposure to EC are tissue- or organ-specific, and depend on the spatial (subcellular localization) and temporal (duration of ROS exposure) modulation of ROS levels.