Giant High-Grade Immature Teratoma of the Central Nervous System (CNS) in an Infant: A Case Report.

BACKGROUND The central nervous system (CNS) is a rare point of origin for mature or immature teratomas. However, immature teratomas are extremely rare. CNS teratomas have been known for poor patient prognosis and recovery and also reduce survival. However, chemoradiotherapy has been reported to increase patient survival. CASE REPORT This study presents a rare giant immature teratoma invading a newborn infant's brain tissue and CNS. The tumor was surgically removed, and in a further 1-year follow-up, it did not need chemotherapy or radiotherapy according to alpha-fetoprotein (aFP) level and other serum markers. The teratoma had affected multiple loci of his brain's left hemisphere, including parietal, frontal, temporal, and occipital lobes. A teratoma was diagnosed lateral to the midline, which is not common in CNS teratomas, as they mainly occur in or near the midline. The tumor was excised completely. The patient was followed up for 1 year, and no further recurrence was observed. CONCLUSIONS Early diagnosis and treatment of immature teratomas are essential in patient prognosis. Chemotherapy is not always needed, but complete surgical removal and patient follow-up are always a necessity. In addition, adequate follow-up of these patients is critical to evaluate their further treatment plan and recurrence risk.

Inadequate achievement of ABC goals (HbA1c, blood pressure, LDL-C) among patients with type 2 diabetes in an Iranian population, 2012-2017.

AIMS: This study was designed to evaluate the meeting of ABC goals in patients with type 2 diabetes. The ABC goals were defined as meeting the HbA1c <7%, systolic blood pressure <130 mmHg and diastolic blood pressure <80 mmHg, and LDL-C <100 mg/dL. We also determined the associated factors with meeting the ABC goals, as well as the effectiveness of statin therapy. METHODS: We designed a cross-sectional study of 2008 type 2 diabetes patients attending the diabetes clinics of Valiasr Hospital of Imam Khomeini Hospital Complex. Meeting ABC goals and their associated factors were analyzed from the registered data. RESULTS: At the end of the year 2014, 61.3% of patients met the HbA1c goal, which increased to 77.8% in 2017. Blood pressure of 79.5% of patients met the ADA recommendations by the end of the year 2014, reaching 86.6% in 2017. Moreover, 84.5% and 93.8% could reach the LDL-C goal in 2014 and 2017, respectively. The proportion for the patients meeting all three ABC goals were 23.2% and 42.1% in 2014 and 2017, respectively. CONCLUSIONS: The level of achievement of ABC goals in Iran is lower than expected and it requires a lot of programming effort and follow-up. As patients are followed over the years, controlling ABC becomes much more favorable.

Board examination stress effect on diastolic function.

BACKGROUND: To this date, effects of mental stress on cardiac function have not been clearly investigated. Although hemodynamic and neuroendocrine adverse effects of daily mental stress on cardiovascular morbidity and mortality have been reported, its direct impact on diastolic function of the heart has not been previously studied. In this study, we aimed to assess the role of Board Exam anxiety on right and left ventricular diastolic function in medical residents. METHODS: Forty medical residents prior to participation in the medical board exam were enrolled in our study. Right prior to as well as 2 month after the exam, all residents underwent trans-thoracic Doppler echocardiography. Right ventricular systolic and diastolic functions and echocardiography indices were measured. Levels of anxiety were measured using Beck Anxiety Inventory Questionnaire before and after the exam. Pre exam and post exam results of study population as well as low and high anxiety groups were evaluated. RESULTS: Early to late mitral inflow velocity (E/A ratio) in LV inflow increased after board exam (P-value <.001). E/A ratio in RV inflow increased after board exam (P-value: .002). Early mitral inflow to its annular velocity (E/E' ratio) in septal wall decreased after board exam (P-value<.001). The change in E/E' RV free wall did not reach statistical significance (P = .57). Mitral annuls velocities measured by TDI in septal and lateral wall and also tricuspid annulus velocity increased after board exam (P-value<.05). The comparison of these changes between the high-stress and low-stress groups of residents revealed significant differences. Comparison of changes of E/A ratio in the mitral and tricuspid inflow as well as the E/E' in the septum and free wall of the right ventricle before and after the Board Exam between high-stress and low-stress groups was not statistically significant, although there was a trend of more changes in high- stress group residents. CONCLUSION: This is the first report of comprehensive sequential assessment of left and right ventricular diastolic functions during and after a real subacute stress occasion. The finding of a decreased E/A and E' in response to mental stress suggests that repetitive mental stress may induce diastolic dysfunction which is a mechanism of diastolic heart failure in individuals at risk.

Pancreatic Tuberculosis in an Immunocompetent Patient: A Case Report and Review of the Literature.

Pancreatic tuberculosis is extremely rare and its clinical and radiological findings are similar to those of pancreatic malignancy. The diagnosis of pancreatic tuberculosis is not usually made prior to surgery. Here, we report a case of pancreatic tuberculosis, presented with abdominal pain and weight loss. Abdominal computed tomography (CT) showed a 62 mm × 32 mm septate solid-cystic mass in the pancreatic head area with extension into the hilum of the liver. There was no evidence of inflammation or pancreatitis. Endoscopic ultrasound-fine needle aspiration (EUSFNA) could not yield the diagnosis. Exploratory laparotomy and further pathological evaluation suggested pancreatic tuberculosis. Response to antituberculosis treatment confirmed the diagnosis. Finally, previous case reports and case studies of pancreatic tuberculosis in the literature are fully investigated.

All-Cause and Cardiovascular Mortality following Treatment with Metformin or Glyburide in Patients with Type 2 Diabetes Mellitus.

BACKGROUND: Both metformin and sulfonylurea (SU) drugs are among the most widely-used anti-hyperglycemic medications in patients with type 2 diabetes mellitus (T2DM). Previous studies have shown that treatment with SUs might be associated with decreased survival compared with metformin. This study aimed to evaluate all-cause and cardiovascular mortality rates between glyburide and metformin in patients diagnosed with T2DM. METHODS: This was a cohort study on 717 patients with T2DM (271 undergoing monotherapy with glyburide and 446 with metformin). Data were gathered from 2001 to 2014. All-cause and cardiovascular mortality were end-points. RESULTS: During the follow-up, 24 deaths were identified, of which 13 were cardiovascular in nature. The group with glyburide monotherapy had greater all-cause mortality (17 (6.3%) in glyburide vs. 7 (1.6%) in metformin, P = 0.001) and cardiovascular mortality (11 (4.1%) in glyburide vs. 2 (0.4%) in metformin; P = 0.001). Metformin was more protective than glyburide for both all-cause (HR: 0.27 [0.10 - 0.73] P-value = 0.01) and cardiovascular mortality (HR: 0.12 [0.20 - 0.66], P-value = 0.01) after multiple adjustments for cardiovascular risk factors. Among adverse cardiovascular events, non-fatal MI was higher in glyburide compared to metformin monotherapy group (3.2% vs. 0.8%; P-value = 0.03), but not coronary artery bypass grafting (P-value = 0.85), stenting (P-value = 0.69), need for angiography (P-value = 0.24), CCU admission (P-value = 0.34) or cerebrovascular accident (P-value = 0.10). CONCLUSION: Treatment with glyburide is associated with increased all-cause and cardiovascular mortality in patients with T2DM.

Two-dimensional echocardiographic right ventricle measurements adjusted to body mass index and surface area in a normal population.

BACKGROUND: To determine reference echocardiographic values in a normal population and assess their correlation with body mass index (BMI) and body surface area. METHODS: An expert cardiologist performed two-dimensional echocardiography with triplicate right ventricle (RV) size measurements in 80 subjects with normal heart condition. Results were correlated with anthropometric data. RESULTS: Base-to-apex length in four-chamber view (RVD3) and above-pulmonic valve in short-axis view in males, as well as mid-RV diameter in standard four-chamber view (RVD), basal RV diameter, and mid RV diameter in RV-focused four-chamber view in females, were significantly correlated with BMI. All RV variables were significantly correlated with BMI in 20-30-year-old subjects. All RV variables except RVD3 and above-aortic valve in short-axis view (proximal) were significantly correlated with BMI in 35-55-year-old subjects. All RV parameters were significantly correlated with body surface area, except for RVD and in 20-35-year-old subjects. CONCLUSIONS: RV echocardiographic values must be adjusted to anthropometric characteristics for proper diagnosis and management of cardiac disorders. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:204-210, 2017.

Absence of a positive correlation between CRP and leptin in rheumatoid arthritis.

AIMS: Rheumatoid Arthritis (RA) is a model of chronic inflammatory disease. In this study we evaluated the correlation of leptin and CRP in patients with RA and normal controls. MAIN METHODS: A total of 75 patients with RA and 40 healthy adults were recruited in this case-control study. RA patients were categorized into high (DAS-28 > 3.2) and low activity (DAS ≤ 3.2) group according to their DAS-28 score. KEY FINDINGS: Leptin level was significantly correlated with CRP in healthy controls (r = 0.365; p < 0.05), but this correlation was lost in RA patients (r = 0.095, p = 0.41). Patients with RA had higher serum leptin levels compared to healthy controls (P < 0.01). No difference in serum leptin level was observed between patients with high and low activity disease. Also leptin was correlated with BMI in healthy controls (r = 0.326, p = 0.037). This correlation was not present in RA patients (r = 0.039, p = 0.756). SIGNIFICANCE: We observed that the physiologic correlation between leptin and CRP and BMI and CRP was not present RA patients. This is a new study reporting the lost correlation between leptin and CRP in RA patients.

Inhibitory effect of curcumin on angiogenesis in a streptozotocin-induced diabetic rat model: An aortic ring assay.

BACKGROUND: Curcumin (diferuloylmethane) has been associated with the inhibition of angiogenesis, as well as the prevention of cancers and inflammatory processes. The aim of this study was to assess the efficacy of curcumin in suppressing angiogenesis in the cultured endothelial cells of rat aortic rings. METHODS: Eight-week-old male Wistar rats were randomized into five groups each with a different treatment and cell culturing paradigm: controls cultured in the absence of VEGF (vascular endothelial growth factor) (C), controls cultured in the presence of VEGF (C-V), controls treated with curcumin and then cultured in media lacking VEGF (C-TC), diabetics cultured in media supplemented with VEGF (D-V) and diabetics treated with curcumin and then cultured in media supplemented with VEGF (D-V-TC). Each group consisted of 8 animals. Diabetes was induced in by streptozotocin (STZ; 60 mg/kg body weight, IV). After 8 weeks, animals were sacrificed and their aortas were excised. Ring-shaped explants were embedded in a 96-well culture plate. Angiogenesis response was measured by counting the number of primary microtubules in each well. RESULTS: Optic microscopy revealed that the D-V group had the highest number of microvessels, while angiogenesis was not observed in the C or C-TC groups. The number of primary microtubules was significantly lower in the D-V-TC group compared to the D-V group (P < 0.05). The D-V-TC group had a significantly higher number of microvessels compared to the C-TC group (P < 0.05). CONCLUSION: Curcumin attenuates angiogenesis response in stertozotocin-induced diabetic rats.

Pulse pressure does not predict the response of diabetic nephropathy to glucose-lowering therapy.

We aimed to study whether pulse pressure (PP) predicts the response of diabetic nephropathy to glucose-lowering treatment. Patients with uncontrolled type 2 diabetes were followed for decrease in albuminuria after insulin/oral-hypoglycemic treatment. A total of 143 patients were followed for a median time of 10.5 months in a cohort study. Fasting blood sugar and HbA1C significantly decreased, while systolic, diastolic and pulse pressures remained constant during intervention. Median albuminuria decreased from 18.4 mg/day [10-40] to 16.4 mg/day [9-28] at the end of study (p-value < 0.005). The number of patients with normo/micro/macro-albuminuria changed from 98/36/9 to 108/31/4 (p-value < 0.001). No significant difference in baseline PP (47.5 ± 1.61 vs. 45.9 ± 1.81 mmHg; p-value = 0.51) or final PP (47.0 ± 2.41 vs. 49.4 ± 2.38 mmHg; p-value = 0.47) existed between those with decreased and increased albuminuria. PP was not a significant predictor of albuminuria changes in receiver operating characteristic curve (p-value = 0.77) and regression (p-value = 0.98) analyses. Benefits of glycemic control in diabetic nephropathy are independent of PP.

Metabolic syndrome in premenopausal and postmenopausal women with type 2 diabetes: loss of protective effects of premenopausal status.

BACKGROUND: Diabetes is probably responsible for worsening of metabolic syndrome (MetS)components. The aim of the present study was to compare the components of MetS between premenopausal and postmenopausal women with type 2 diabetes (T2DM). METHOD: In this cross sectional study, we studied 639 women with T2DM that were divided in pre-menopausal (n = 221) and post-menopausal (n = 418) group. They were selected from participants of a diabetes clinic and assessed for MetS and its components. All MetS components were evaluated to follow age and duration of diabetes adjusted according to the ATP III criteria. RESULTS: The mean ages of pre-menopausal and post-menopausal were 43.33 ± 0.47 and 60.35 ± 0.38 years, respectively. MetS was defined for 88.3% of total subjects (87.5% and 87.7% in pre-menopausal and post-menopausal women with T2DM respectively). Systolic blood pressure (SBP) and waist circumference (WC) were significantly higher in post-menopausal women with T2DM in comparison with pre-menopausal ones. There were no significant differences in triglyceride (T.G) level, diastolic blood pressure (DBP) and high density lipoprotein cholesterol (HDL-C) between the two groups. Myocardial infarction (MI) occurred in 1% total subjects (1.3% and 1.8%) in pre-menopausal and post-menopausal women with T2DM, respectively (p = 0.21). CONCLUSION: Worsening of MetS and its components except for SBP and waist circumference has been shown in pre-menopausal women with T2DM similar to post-menopausal ones. The observed differences may be explained by increasing age. With respect to increasing of myocardial infarction in premenopausal subjects, we suggest that diabetes can abolish the protective effects of premenopausal status for MetS and MI.

Manual or automated sphygmomanometer? A historical cohort to quantify measurement bias in blood pressure recording.

The authors aimed to quantify end-digit and threshold biases in blood pressure (BP) measurement with manual and digital sphygmomanometers. In a 3-year follow-up, end-digit and threshold biases were investigated and a new index, called the deviation index, was used to quantify measurement bias. The distribution of systolic and diastolic BPs became close to normal after implementation of digital sphygmomanometers. The appearance of zero end digits decreased from 97% to 30% (P<.0001). The deviation index decreased from 97% to 20% (P<.0001). Mean systolic and diastolic BPs increased immediately after implementation of automated sphygmomanometers (124.22±0.83 vs 132.90±0.78 and 74.38±0.50 vs 80.43±0.51, respectively; P<.0001 for both) but showed a linear decreasing trend during follow-up (systolic -3.59 mm Hg per year; 95% confidence interval, -5.57 to -1.61 [P<.0001]; diastolic: -2.52 mm Hg per year; 95% confidence interval, -3.78 to -1.26 [P<.0001]). Threshold bias decreased from 12.94% to 6.68% (P<.0001). Replacing manual sphygmomanometers with digital devices decreased end-digit and threshold biases in BP measurement. The deviation index can be used to quantify the magnitude of measurement bias.

The degree of resistance of erythrocyte membrane cytoskeletal proteins to supra-physiologic concentrations of calcium: an in vitro study.

Calcium is a key regulator of cell dynamics. Dysregulation of its cytosolic concentration is implicated in the pathophysiology of several diseases. This study aimed to assess the effects of calcium on the network of membrane cytoskeletal proteins. Erythrocyte membranes were obtained from eight healthy donors and incubated with 250 µM and 1.25 mM calcium solutions. Membrane cytoskeletal proteins were quantified using SDS-PAGE at baseline and after 3 and 5 days of incubation. Supra-physiologic concentrations of calcium (1.25 mM) induced a significant proteolysis in membrane cytoskeletal proteins, compared with magnesium (p < 0.001). Actin exhibited the highest sensitivity to calcium-induced proteolysis (6.8 ± 0.3 vs. 5.3 ± 0.6, p < 0.001), while spectrin (39.9 ± 1.0 vs. 40.3 ± 2.0, p = 0.393) and band-6 (6.3 ± 0.3 vs. 6.8 ± 0.8, p = 0.191) were more resistant to proteolysis after incubation with calcium in the range of endoplasmic reticulum concentrations (250 µM). Aggregation of membrane cytoskeletal proteins was determined after centrifugation and was significantly higher after incubation with calcium ions compared with control, EDTA and magnesium solutions (p < 0.001). In a supra-physiologic range of 1.25-10 mM of calcium ions, there was a nearly perfect linear relationship between calcium concentration and aggregation of erythrocyte membrane cytoskeletal proteins (R(2) = 0.971, p < 0.001). Our observation suggests a strong interaction between calcium ions and membrane cytoskeletal network. Cumulative effects of disrupted calcium homeostasis on cytoskeletal proteins need to be further investigated at extended periods of time in disease states.

Limited knowledge of chronic kidney disease and its main risk factors among Iranian community: an appeal for promoting national public health education programs.

BACKGROUND: The aim of this survey was to explore the baseline knowledge of the Iranian community about Chronic Kidney Disease (CKD) definition and its two main risk factors, i.e. diabetes and hypertension. This study also introduced a model of public education program with the purpose of reducing the incidence of CKD in high-risk groups and thereby decreasing the economic burden of CKD in Iran. METHODS: This cross-sectional study was conducted on world kidney day 2013 in Isfahan, Iran. Self-administered anonymous questionnaires evaluating the knowledge of CKD and its risk factors were distributed among subjects who participated in a kidney disease awareness campaign. Chi-square test and logistic regression analysis were used to examine the differences in the level of knowledge across different socio-demographic groups. RESULTS: The questionnaires were completed by 748 respondents. The majority of these respondents believed that "pain in the flanks" and "difficulty in urination" was the early symptoms of CKD. Roughly, 10.4% knew that CKD could be asymptomatic in the initial stages. Only 12.7% knew diabetes and 14.4% knew hypertension was a CKD risk factor. The respondents who had a CKD risk factor (i.e. diabetes and/or hypertension) were significantly more likely than respondents without CKD risk factor to select "unmanaged diabetes" [Odds Ratio (OR)= 2.2, Confidence Interval (CI) (95%): 1.4-3.6] and "unmanaged hypertension" [OR= 1.9, CI(95%): 1.2-3.0] as "very likely to result in CKD". No more than 34.6% of all respondents with diabetes and/or hypertension reported that their physician has ever spoken with them about their increased risk for developing CKD. CONCLUSION: The knowledge of Iranian population about CKD and its risk factors is low. Future public health education programs should put efforts in educating Iranian community about the asymptomatic nature of CKD in its initial stages and highlighting the importance of regular renal care counseling. The high-risk individuals should receive tailored education and be encouraged to adopt lifestyle modifications to prevent or slow the progression of CKD.