VACS: VAccination disComfort Scale.

The vaccination of children is a crucial tool to protect both individuals and the world in general from various diseases and pathogens. Unfortunately, the vaccination procedure is not a pleasant one for all children, with many experiencing various levels of discomfort, sometimes reaching intolerable levels. In the first part of this work, we develop VACS, a tool that measures the discomfort children experience during vaccination. VACS takes into consideration the complete timeline of the vaccination experience from the perspective of the child, starting from the moment the child enters the doctor's office through to their departure, and also the complete range of manifestations of discomfort, ranging from moaning and crying to facial expressions and posture. Their discomfort is quantified as a number from 0 to 25, with zero corresponding to a smooth vaccination and 25 to maximal/unbearable discomfort. In the second part of the work, we apply VACS to 40 vaccinations of children aged 2 to 12. Our findings show that approximately 40% of the children do not face discomfort during vaccination, but for the rest discomfort of varying degrees is observed. We also find that doctors are content with their patients facing considerably higher discomfort levels than what the children themselves are willing to withstand: doctors are content with VACS values up to 19 whilst children start to suffer when the VACS value exceeds 11. Surprisingly, characteristics such as (a) gender, (b) whether the state's recommended vaccination program has been implemented in full, and even (c) prior negative vaccination experiences are found to be poor predictors of vaccination discomfort. Age on the other hand may be a factor, with younger children experiencing discomfort more often and more intensely; more research is required in order to validate this with higher confidence. The formulation of VACS opens the door for more systematic work towards the mitigation of vaccination discomfort for children.

Anorexia Nervosa and Celiac Disease in an Adult: A Case Report.

Previous studies suggest an association between celiac disease and anorexia nervosa. Research has mainly focused on children and adolescents, and studies among adults are limited. The similar clinical manifestations that characterize both diseases can complicate the diagnosis, and a thorough diagnostic workup is necessary. A focused medical history remains the cornerstone of diagnosis. A delayed diagnosis can lead to a worse quality of life and severe complications. We present the case of a 43-year-old woman with anorexia nervosa who was thereafter diagnosed with celiac disease. The later diagnosis occurred after a long period of persistent diarrhea. Based on the patient's history of autoimmune disease, celiac disease was suspected. Our case highlights the importance of additional work-up in patients with anorexia nervosa who have persistent gastrointestinal symptoms. A further investigation should be based on the medical history, clinical presentation, and laboratory findings.

Aspirin in primary prevention of cardiovascular disease in diabetes.

It is well established that people with diabetes are at an increased risk of cardiovascular disease compared with those without diabetes. Although the protective role of aspirin in secondary prevention is well documented, its role in primary prevention of cardiovascular disease in people with diabetes, after the results of major clinical trials and meta-analyses, is unclear. The observed discrepancies might be explained in part in terms of the differences between the background cardiovascular risks, follow-up periods, age and gender of the study populations. Recently, the results of the ASCEND trial in people with diabetes documented the cardiovascular benefit of aspirin for primary prevention, but with an increased risk of bleeding that might outweigh the observed cardiovascular benefit. Therefore, current guidelines recommend its use for primary prevention in people with and without diabetes under specific circumstances. The purpose of the present review is to summarize the existing literature data regarding the place that aspirin has in primary prevention of cardiovascular disease in people with diabetes.

Effects of Glucagon-like Peptide-1 Receptor Agonists and Sodium-glucose Cotransporter 2 Inhibitors on Cardiorenal and Metabolic Outcomes in People Without Diabetes.

During the last decade, the results of large-scale, randomized, clinical trials on newer antidiabetic agents, glucagon-like peptide-1 (GLP-1) receptor agonists and sodium glucose cotransporter type 2 (SGLT2) inhibitor, have been published showing promising findings on cardiovascular and renal outcomes. Besides improving glycemic control, GLP-1 receptor agonists have been shown to modify cardiovascular risk factors, such as insulin resistance, body weight, blood pressure (BP), and lipid profile. Additionally, SGLT2 inhibitors except for glycemic control have been shown to induce weight loss and decrease BP. However, there are limited data regarding their effect on patients without diabetes. Therefore, the aim of the present review is to summarize the existing literature data regarding the effects of newer antidiabetic therapies on patients without diabetes.

Diabetes and dementia - the two faces of Janus.

Patients with type 2 diabetes are at high risk for cognitive decline and dementia. Despite the limited data on the possible pathogenetic mechanisms, evidence suggests that cognitive decline, and thus dementia and Alzheimer's disease, might arise from a complex interplay between type 2 diabetes and the aging brain, including decreased insulin signalling and glucose metabolism, mitochondrial dysfunction, neuroinflammation, and vascular disease. Furthermore, there is increasing interest on the effects of antidiabetic agents on cognitive decline. There are many studies showing that antidiabetic agents might have beneficial effects on the brain, mainly through inhibition of oxidative stress, inflammation, and apoptosis. In addition, experimental studies on patients with diabetes and Alzheimer's disease have shown beneficial effects on synaptic plasticity, metabolism of amyloid-ß, and microtubule-associated protein tau. Therefore, in the present review, we discuss the effects of antidiabetic agents in relation to cognitive decline, and in particular dementia and Alzheimer's disease, in patients with type 2 diabetes.

The COVID-19 pandemic and diabetes mellitus.

COVID-19, a disease caused by a novel coronavirus, SARS-CoV-2, has reached the proportion of a pandemic and presents with either mild and moderate symptoms or in severe cases with acute respiratory distress syndrome, multiple organ dysfunction syndrome and even death. Older age, hypertension, cardiovascular disease, diabetes mellitus and obesity significantly increase morbidity and mortality in COVID-19 patients. In the present review we summarize the existing, and daily growing, data on the impact of COVID-19 infection on patients with diabetes, their antidiabetic therapy as well as the extra precautions, apart from good glucose control, they have to take in order not to contract the virus. Social distancing and strict hand hygiene are of great importance in order to help the global goal of eradication of the disease.

Association of matrix γ-carboxyglutamic acid protein levels with insulin resistance and Lp(a) in diabetes: A cross-sectional study.

AIMS: The risk of cardiovascular disease (CVD) and mortality is increased in patients with chronic kidney disease (CKD), with a background role of vascular calcification in the development of CVD also reported. Studies have demonstrated that high lipoprotein(a) (Lp(a)) levels accelerate the development of atherosclerolsis and are potentially involved in the vascular calcification. Matrix Gla Protein (MGP) seems to play an important role in vascular calcification. The aim of the study was to examine the potential association of MGP concentrations with Lp(a) and insulin resistance. METHODS: The study involved 100patients divided in four groups: 25 with both CKD stage 4 and Type2 Diabetes (DM) (Group-A), 25 with CKD4 without DM (Group-B), 25 non uremic patients with DM (Group-C) and 25 healthy subjects (Group-D). Serum glucose, Lp(a), MGP, plasma HBA1c and insulin were measured in all patients. Insulin resistance was estimated by the homeostasis model assessment equation (HOMA-IR). RESULTS: A significant positive linear association between MGP and Lp(a) levels (r=0.272, p=0.006) was noted, as well as between MGP and HOMA-IR levels (r=0.308, p=0.002). However, no significant linear association between Lp(a) and HOMA-IR levels was recorded. A similar positive association between MGP and insulin levels (r=0.204, p=0.042) was also found. CONCLUSION: This study concluded that diabetes coexisting with renal disease leads to extreme vascular calcification expressed by elevated MGP levels, resulting in higher frequency of cardiovascular disease in comparison to CKD patients without diabetes. The detected Lp(a) and MGP association in CKD4 patients may also represent the key to the complicated mechanism of their coexisting accelerated atherosclerosis and vascular calcification.

Breast cancer presenting as paraneoplastic erythroderma: an extremely rare case.

The skin may exhibit the first clinical evidence of a systemic disease and may provide the first clues to a diagnosis in malignancies. Erythroderma is defined as generalized redness and scaling and it is a clinical manifestation of a variety of underlying diseases including, rarely, solid tumors. Breast cancer is associated with a variety of skin paraneoplastic manifestations like acanthosis nigricans, erythromelalgia, thrombotic thrombocytopenic purpura, acrokeratosis paraneoplastica, dermatomyositis, systemic sclerosis, and scleroderma. However, in the literature, the correlation of erythroderma with breast cancer is quite infrequent. Here, we describe a case of a 76-year-old woman who presented with a paraneoplastic manifestation of erythroderma due to breast cancer.

Chronic periaortitis (retroperitoneal fibrosis) concurrent with giant cell arteritis: a case report.

INTRODUCTION: Giant cell arteritis is the most common form of large-vessel vasculitides. However, it is probable that extracranial involvement is underdiagnosed in patients with classical giant cell arteritis. In the recent literature most cases of giant cell arteritis have been described in conjunction with aortic aneurysms or dissections. Nonetheless the coexistence of giant cell arteritis and retroperitoneal fibrosis is extremely rare. Here, we describe a case of giant cell arteritis at a very early clinical stage, in a woman with coexistence of retroperitoneal fibrosis. CASE PRESENTATION: We report a case of giant cell arteritis at a very early clinical stage, in a 47-year-old Greek woman with coexistence of retroperitoneal fibrosis who was admitted to our hospital with a history of high-grade fever and mild right periumbilical abdominal pain for the past 30 days. In the context of fever of unknown origin, an abdomen computed tomography was ordered. A temporal artery biopsy was also performed because during hospitalization she complained of a headache. Examination of eosin and hematoxylin slides from biopsy specimens of her temporal artery, showed lesions consisting of predominantly lymphocytes, few plasma cells and occasional polymorphonuclear leucocytes. In addition no giant cells were detected in examining biopsies at multiple levels. This was consistent with giant cell arteritis according to the American college of Rheumatology criteria. An abdomen computed tomography revealed the presence of a retroperitoneal soft-tissue mass located anteriorly to the upper infrarenal aorta at the site of the scintigraphic uptake. The computed tomography and magnetic resonance imaging characteristics of the mass were consistent with retroperitoneal fibrosis, and its morphology suggestive of benignity. Our patient started oral prednisolone and was afebrile from day one. CONCLUSIONS: In our experience this is the first case of retroperitoneal fibrosis due to giant cell arteritis occurring at the same time. Involvement of the aorta (aortitis) and its branches has been also observed in a subset of patients with giant cell arteritis. In addition, giant cell arteritis has been associated with a markedly increased risk of aortic aneurysm particularly thoracic aortic aneurysm.

Bilateral sudden sensorineural hearing loss caused by alcohol abuse and heroin sniffing.

Objective. Acute or chronic heroin abuse has been associated with various central neurologic pathologies and, occasionally, with peripheral nervous system damage. The effect of heroin on hearing has not been adequately documented, although several cases with sudden hearing loss owed to heroin abuse have been reported. We present a young male with bilateral sudden sensorineural hearing loss, following heroin sniffing and alcohol consumption. Methods. Our patient underwent a detailed clinical and audiological evaluation, including auditory brainstem responses and otoacoustic emission. Routine laboratory blood tests and imaging studies were performed. Results. The patient was treated with corticosteroids and magnesium, resulting in complete restoration of hearing after one month. Conclusion. Sudden hearing loss owed to heroin abuse is usually curable, following adequate treatment.

Heart rate variability in advanced chronic kidney disease with or without diabetes: midterm effects of the initiation of chronic haemodialysis therapy.

BACKGROUND: Previous studies in different clinical settings have established heart rate variability (HRV) as a significant independent risk factor for higher mortality and cardiac death. The aim of this study was to examine the effect of chronic haemodialysis therapy on time- and frequency-domain parameters of HRV in diabetic and non-diabetic patients with chronic kidney disease (CKD). METHODS: We studied 25 patients with stage 4 CKD and type 2 diabetes mellitus (CKD4+DM), 25 patients with stage 4 CKD without diabetes (CKD4), 25 patients with type 2 diabetes mellitus (DM) and 25 healthy subjects (HS). The study was performed in two phases. In the first phase, a 24-h Holter electrocardiographic (ECG) monitoring was performed in all subjects. The patients with stage 4 CKD were followed up until they progressed to stage 5, and in the second phase of the study, they underwent a 24-h Holter ECG monitoring after completion of 3 months of conventional haemodialysis treatment. RESULTS: In the first phase of the study, a reduction in cardiac sympathetic activity in CKD4 patients (significantly lower SDNN, SDANN/5 min, SD and VLF vs. HS) and worse autonomic function in CKD4+DM patients (significantly lower SDNN, SDANN/5 min, SD, VLF and LF/HF) vs. HS, DM and CKD4 was observed. After 3 months of dialysis therapy, the patients with CKD+DM showed a significant improvement only in the time-domain parameter SDANN/5 min, while the time-domain parameters SDNN, SDANN/5 min and SD were improved in CKD patients without diabetes. Frequency-domain parameters of HRV remained unchanged in both groups. CONCLUSIONS: CKD is associated with worse cardiac autonomic function. Haemodialysis therapy for 3 months improves some indices of HRV, and this effect is more pronounced in non-diabetic subjects. Our findings suggest that the improvement of HRV after the initiation of chronic dialysis therapy can ameliorate clinical outcomes and survival in patients with end-stage renal disease.

Prediction of long-term functional outcome in patients with acute ischemic non-embolic stroke.

In a prospective observational study, we assessed the relative value of conventional stroke risk factors and emerging markers in the prediction of functional outcome of patients surviving the acute phase of an ischemic non-embolic stroke. All available eligible patients consecutively admitted due to a first-ever acute ischemic non-embolic stroke during a 2-year period were evaluated. In a total of 105 patients (54 males, 51 diabetic) a series of clinical, biochemical and imaging characteristics were recorded, including demographic data, blood pressure, serum glucose, insulin, lipids, inflammatory markers, intima-media thickness of the carotid arteries (IMT), brain damage location and size of the infarct volume. Barthel Activities of Daily Living Index (BI) scale was used to assess the severity of neurological deficit on admission and the functional outcome 6 months after discharge. Brain infarct volume, stroke location in the anterior circulation, age, diabetes mellitus, IMT and plasma interleukin-1beta levels proved to be significant determinants of long-term functional outcome, assessed by BI disability score. ROC curve analyses indicated that the infarct volume is superior to other predictors in the diagnosis of patients with unfavorable functional outcome (BI<95) at 6 months post-discharge (area under the curve, AUC=0.80, 95% confidence interval 0.64-0.95; p=0.003). Significant differences in the mean infarct volume were noted among age tertiles, with the diabetic patients in the 3rd tertile of age experiencing the worst outcome (LSD test, p=0.019). Taken together, the assessment of infarct volume seems to have a significant predictive value regarding long-term functional outcome, especially in the elderly diabetic patients.

Comparison of monotherapy versus combination antihypertensive therapy in elderly patients with essential hypertension.

Authors sought to compare the efficacy of monotherapy versus combination antihypertensive therapy in elderly patients. Patients in this study, aged 65 to 85 years, were divided into 4 groups and entered an 8-week treatment period. First group: 22 patients, amlodipine 5 mg/d increasing to 10 mg; second: 20 patients, eprosartan 600 mg/d increasing to 600 mg twice a day; third: 21 patients, amlodipine 5 mg/d and indapamide 2.5 mg/d, increasing amlodipine to 10 mg/d; fourth: 23 patients, imidapril 10 mg/d and indapamide 2.5 mg/d, imidapril doubled to 20 mg/d. A greater drop in systolic and in diastolic blood pressure was obtained by combination of amlodipine and indapamide compared with amlodipine or eprosartan monotherapy. Imidapril and indapamide showed similar efficacy compared with eprosartan monotherapy but not with amlodipine monotherapy. Amlodipine and indapamide appeared more effective than imidapril and indapamide in diastolic blood pressure. Combination treatment with amlodipine and indapamide or imidapril and indapamide effectively reduces blood pressure in elderly patients with essential hypertension.

High prevalence of subclinical peripheral artery disease in Greek hospitalized patients.

BACKGROUND: Peripheral artery disease (PAD) represents a common manifestation of systemic atherosclerosis that is associated with an increased risk of cardiovascular death and ischemic events but one that may be underdiagnosed in clinical practice. The purpose of this study was to identify PAD using the ankle-brachial index (ABI) in hospitalized patients from a Department of Internal Medicine and to further investigate the association of this index with traditional cardiovascular risk factors. METHODS: We measured ABI in 990 consecutive patients (400 men and 590 women) aged 50 years or older (71.2+/-9.1) without a history or symptoms suggestive of PAD. ABI values below 0.90 were considered abnormal. RESULTS: PAD was detected in 356 patients (36%), and men had a higher prevalence than women (p<0.001). Hypertension (p<0.001), smoking (p<0.001), diabetes (p<0.05), male sex (p<0.001), and dyslipidemia (p<0.05) were statistically more frequent in patients with PAD, whereas obesity had no significant relation to PAD in our series. In a stepwise, logistic regression analysis, hypertension, male sex, diabetes mellitus, smoking, and dyslipidemia were found to be independent risk factors with odds ratios (95% confidence intervals) of 2.46 (1.85-3.27), 2.25 (1.66-3.05), 1.80 (1.32-2.47), 1.78 (1.31-2.42), and 1.64 (1.22-2.19), respectively. CONCLUSIONS: A simple ABI measurement revealed a large number of patients with unrecognized PAD. It is, therefore, recommended that ABI measurement should be included in the evaluation of cardiovascular risk in hospitalized patients aged 50 years or older.

A case of acute pancreatitis possibly associated with combined salicylate and simvastatin treatment.

CONTEXT: Drug-induced acute pancreatitis is a rather rare clinical entity. From time to time, several cases have been reported in which statins or salicylates have been associated with the development of acute pancreatitis. There is only one report which implies the involvement of both drugs in pancreatic inflammation. CASE REPORT: A 58-year-old Caucasian male with a history of coronary heart disease and hypercholesterolemia, under treatment with acetyl-salicylate for 6 years and simvastatin for 2 months, presented to the Emergency Department of our hospital with epigastric pain and vomiting of 24-hour duration. The clinical and laboratory investigation led to the diagnosis of acute pancreatitis. Conservative and rich-in-fluid treatment resulted in clinical and laboratory amelioration, and the patient was discharged on day 15, after full restoration of his health. In our patient, all possible common causes of acute pancreatitis were excluded. CONCLUSION: Conclusion It is a rational assumption to connect this case to the co-administration of simvastatin and acetyl-salicylate. However, the pathophysiological mechanism behind the onset of acute pancreatitis due to a statin, or, even more, due to its combination with salicylate, remains vague.