Chronic and acute effects of cocoa products intake on arterial stiffness and platelet count and function: A systematic review and dose-response Meta-analysis of randomized clinical trials.

The findings of trials investigating the effect of cocoa products consumption on vascular stiffness and platelet are controversial. The aim of this study is to summarize the findings on the acute and chronic effects of different forms of cocoa on the risk factors of cardiovascular disease. We searched SCOPUS, Pub Med and Web of Science from inception to Jan 2020. Finally, the random-effect model was used to report the pooled effect sizes. Results are expressed as weighted mean difference (WMD) with 95% confidence intervals (CI).Overall, 41 trials were included, of which only 14 studies met the eligibility criteria for analysis, including 11 long-term RCTs (more than a week was considered as a chronic phase) and 7 short-term RCTs (less than a week was considered as an acute phase). According to the result of 11 long-term RCTs, cocoa products had a negative significant effect on pulse wave velocity; PWV (WMD: -0.33 m/s, P < 0.0001), Augmentation index; AIx (WMD: -4.50%, P = 0.001) but had no significant effect on platelet count (WMD: -10.41 109/L, P = 0.053). Also, according to the results of 7 short-term RCTs, cocoa products had a negative significant effect on PWV (WMD: -0.27 m/s, P = 0.019), AIx (WMD: -4.47%, P = 0.003).Current study indicated the beneficial effect of acute and chronic consumption of cocoa-based products ingestion on platelet function and arterial stiffness in healthy adult regardless of age especially in male and for consumption (≤4 weeks) in the chronic intake and (≤120 minutes) in acute intake, but did not affect on platelet count. However, further studies are required to shed light on this issue.

Acceleration rate of mitral inflow E wave: a novel transmitral doppler index for assessing diastolic function.

BACKGROUND: We performed comprehensive transmitral and pulmonary venous Doppler echocardiographic studies to devise a novel index of diastolic function. This is the first study to assess the utility of the acceleration rate (AR) of the E wave of mitral inflow as a primary diagnostic modality for assessing diastolic function. METHODS: Study group consisted of 84 patients (53 + 11 years) with left ventricle (LV) diastolic dysfunction and 34 healthy people (35 ± 9 years) as control group, who were referred for clinically indicated two-dimensional transthoracic echocardiogram (TTE) during 2012 and 2013 to Imam Hospital. Normal controls were defined as patients without clinical evidence of cardiac disease and had normal TTE. LV diastolic function was determined according to standardized protocol of American Society of Echocardiography (ASE). As our new parameter, AR of E wave of mitral inflow was also measured in all patients. It was represented by the slope of the line between onset of E wave and peak of it. Correlation between AR of E wave and LV diastolic function grade was measured using the Spearman correlation coefficient. Receiver operating characteristic (ROC) curve was used to determine the sensitivity and specificity of AR of E wave in diagnosing LV diastolic dysfunction in randomly selected two-thirds of population then its derived cutoff was evaluated in rest of the population. The institutional review board of the hospital approved the study protocol. All participants gave written informed consent. This investigation was in accordance with the Declaration of Helsinki. RESULTS: The mean value of AR was 1010 ± 420 cm/s(2) in patients whereas the mean value for the normal controls was 701 ± 210 cm/s(2). There was a strong and graded relation between AR of E wave of mitral inflow and LV diastolic function grade (Spearman P ≤0.0001, rs =0.69). ROC curve analysis revealed that AR of E wave of mitral inflow =750 cm/s(2) predicted moderate or severe LV diastolic dysfunction with 89 % sensitivity and 89 % specificity (area under curve [AUC] = 0.903, P <0.0001). Application of this cutoff on test group showed 96 % sensitivity and 77 % specificity with AUC = 0.932 and P <0.0001. CONCLUSION: AR of E wave of mitral inflow could be used for assessment of diastolic function, especially moderate or severe diastolic dysfunction. However, before its clinical application, external validation should be considered.

Feigned symptoms among defendants claiming psychiatric problems: Survey of 45 Malingerers.

OBJECTIVE: In many jurisdictions, psychiatric problems are intended for commutation. Therefore, a forensic psychiatrist has an important role in detection of malingering. While several studies evaluate diagnostic tests, it is less known what symptoms are more likely to be imitated by malingerers. METHOD: In a prospective study 45 malingerers, who were diagnosed according to interviews by two forensic psychiatrists, from defendants with a judicial order for evaluation of mental status and criminal responsibility during a period of eighteen months were examined in legal medicine center of Tehran. Participants were assessed in another interview to determine symptoms. Dichotomous symptoms in felony and misdemeanor groups were analyzed using fisher's exact test. The level of statistical significance was set at P < 0.05. RESULTS: Thirty-eight malingerers were charged with misdemeanors and seven with felonies. Behavioral symptoms were most frequently faked by 35 participants (77.8%). Participants charged with criminal accusation had a significantly lower mean age (P=0.032) and a higher level of education (P=0.008) than other non-criminal defendants. A statistically significant increase in memory function problems was demonstrated in the misdemeanor group (P=0.040). With regard to dual symptom imitation, statistically significant correlations were observed between thought content and perceptual symptoms (P=0.048) for felonies and mood & affect and thought process symptoms (P=0.034), mood & affect and behavioral symptoms (P=0.000) and cognitive function and behavioral symptoms (P=0.039) for misdemeanors. In general, many simulators attempted to mimic simple symptoms of behavioral disorders. Probably felony offenses need less accurate programming; therefore, their rates are higher in older, less educated participants. CONCLUSION: This study demonstrated that differences between presenting symptoms among different offenses may not be useful in detection of malingering,; however, unusual dual symptom imitations may be useful, particularly when standard tests are not performed.

Is antibiotic prophylaxis necessary in patients undergoing ureterolithotripsy?

Transurethral Ureterolithotripsy (TUL) is a frequently used procedure in urology departments. Many urologists perform TUL without antibiotic prophylaxis; however the use of chemoprophylaxis before TUL remains a controversial issue in urology. This study was carried out to assess the safety of omitting antibiotic prophylaxis prior to TUL. In a prospective randomized clinical trial from January 2005 to December 2007, 114 patients with ureteral stones were enrolled; Fifty seven had preoperative antibiotic prophylaxis administered before TUL and fifty seven patients underwent TUL without antibiotic prophylaxis. The rate of postoperative infectious complications (fever, positive blood culture, significant bactriuria), the length of hospital stay and overall stone free rate were compared between the two groups. There was no statistically significant difference between two groups in the operation time, length of hospital stay, postoperative bacteriuria, positive urine culture, postoperative fever and overall success rate of TUL. It appears that the incidence of infectious complications does not increase in patients undergoing TUL without antibiotic prophylaxis if they have negative pre-operative urine culture and antiseptic technique have been performed thorough the procedure.

Malnutrition predicting factors in hemodialysis patients.

Malnutrition is a predictor of increased mortality in chronic hemodialysis (HD) patients. Various factors may contribute to malnutrition in these patients including energy and protein intake, inflammation, and comorbidity. To determine the importance of these factors in malnutrition of chronic HD patients, we studied 112 chronic HD patients in two centers was evaluated with the Dialysis Malnutrition Score (DMS) and anthropometric and biochemical indices. Seventy six (67.8%) patients were classified as malnourished. According to DMS score, poor protein intake (r= -0.34, P< 0.01), comorbidities (r= -0.24, P< 0.05), poor energy intake (r= - 0.18, P< 0.005), and inflammation (r= -0.16, P< 0.05) were significant predictors of malnutrition in descending order of importance. Multiple regression analysis showed that only poor protein intake was the explanatory variable of anthropometric measurements decline including body mass index, triceps skin fold thick-ness, mid arm circumference, mid arm muscle circumference, fat free mass, fat mass, albumin, creatinine and transferrine. None of the mentioned factors predicted the decrease of biochemical markers. We conclude that the frequency of malnutrition is high in our population and poor protein intake is the primary contributing factor for this condition. Therefore, providing enough protein may be a simple and effective way in preventing malnutrition in these patients.

The lack of correlation between mast cells and microvessel density with pathologic feature of renal cell carcinoma.

OBJECTIVE: The growth of solid tumors requires angiogenesis. Evidence indicates that mast cells (MCs) play an important role in tumor angiogenesis but results are not definitive. The aim of this study is to investigate the possible effects of angiogenesis and the presence of MCs on the prognosis of renal cell carcinoma (RCC). PATIENTS AND METHODS: The study involved 40 patients with RCC (24 men and 16 women who were treated with radical nephrectomy between 1995 and 2006, at our institution. The routine mast cell tryptase staining method was used to assess the MCs in both normal tissue and tumoral tissue. The immunohistochemical staining for CD34 antigen was used for determination of microvessel density. The relation between MC count and tumor status such as tumor stage, size, grade, and other clinicopathologic parameters in RCC were evaluated in this study. RESULTS: We found no relationship between the number of MCs and patient age, sex, tumor stage, grade, size. No association was noted between angiogenesis and either patient sex or age, tumor size, stage, and grade. No statistically significant correlation was found between the number of MCs and microvessel density in RCC (P-value = 0.45) but the max value of MCs and MVD were in clear cell carcinoma. CONCLUSIONS: The MC count was not associated with tumor status such as tumor stage, size, grade, and other clinicopathologic parameters, however, MCs may be related to tumor angiogenesis and acceleration of tumor growth in RCC and therefore need further evaluation in RCC.

Avoiding cardiopulmonary bypass in extracardiac cavopulmonary connection: does it really matter?

OBJECTIVES: We examined the effect of avoiding cardiopulmonary bypass on the early outcome variables after fenestrated extracardiac total cavopulmonary connection. METHODS: Between May 2001 and January 2009, 102 patients with univentricular heart physiology underwent fenestrated extracardiac total cavopulmonary connection. Patients were divided into one of 2 groups: the cardiopulmonary bypass (n = 48) group and the no cardiopulmonary bypass (n = 54) group. In both groups there were patients with primary and staged fenestrated extracardiac total cavopulmonary connection. Duration of mechanical ventilation, pleural effusion, hemodynamic status, incidence of arrhythmia, and mortality were compared between the 2 groups. RESULTS: Both groups were matched, except for more cases of tricuspid atresia in the no cardiopulmonary bypass group (P = .014) compared with other diagnostic morphologies and higher preoperative hemoglobin levels in the no cardiopulmonary bypass group (P = .01). Avoiding cardiopulmonary bypass did not reveal any significant effect on postoperative outcomes. A cardiopulmonary bypass time of more than 120 minutes caused not only a meaningful increase in the mean of mechanical ventilation duration (35 +/- 9.6 vs 13 +/- 2.1 hours, P = .026) but also increased the incidence of mechanical ventilation for more than 12 hours (P = .04). Bypass time of more than 120 minutes did not have influence on any other postoperative variables. CONCLUSION: Avoiding cardiopulmonary bypass in fenestrated extracardiac total cavopulmonary connection had no direct effect on the early outcome variables.

Diagnostic accuracy of CT scan in abdominal blunt trauma.

OBJECTIVE: To evaluate the sensitivity and specificity of CT scan findings in patients with blunt abdominal trauma admitted to the university hospital. METHODS: All the patients with blunt abdominal trauma admitted at a tertiary teaching trauma center in Iran between 2005 and 2007 were enrolled in this study. In the absence of any clinical manifestations, the patients underwent a diagnostic CT scan. Laparatomy was performed in those with positive CT results. Others were observed for 48 hours and discharged in case no problem was reported; otherwise they underwent laparatomy. Information on patients?demographic data, mechanism of trauma, indication for CT scan, CT scan findings, results of laparotomy were gathered. The sensitivity, specificity and accuracy of the CT-scan images in regard with the organ injured were calculated. The sensitivity, specificity and accuracy of the CT scan were calculated in each case. RESULTS: CT scan had the highest sensitivity for detecting the injuries to liver (100%) and spleen (86.6%). The specificity of the method for detecting retroperitoneal hematoma (100%) and injuries to kidney (93.5%) was higher than other organs. The accuracy of CT images to detect the injuries to spleen, liver, kidney and retroperitoneal hematoma was reported to be 96.1%, 94.4%, 91.6% and 91.6% respectively. CONCLUSION: The findings of the present study reveal that CT scan could be considered as a good choice, especially for patients with blunt abdominal trauma in teaching hospitals where the radiologic academic staff is not present in the hospital in the night shifts.

Reproducibility determination of WHO classification of endometrial hyperplasia/well differentiated adenocarcinoma and comparison with computerized morphometric data in curettage specimens in Iran.

BACKGROUND: Management of endometrial precancerous lesions has been of much debate due to inconsistencies in their classification, natural history and histologic diagnosis. Endometrial hyperplasia constitutes a wide range of histomorphologic features associated with high intra and interobserver diagnostic variability.Although traditional microscopic diagnosis is by far the most applicable method and the gold standard for histomorphologic diagnosis, digitized image analysis has been used as a powerful adjunct to maximize the histologic data retrieval and to add some detailed objective criteria for correct diagnosis in difficult cases. METHODS: A series of 100 endometrial curettage specimens with diagnosis of endometrial hyperplasia or well differentiated adenocarcinoma were blindly reviewed by 5 pathologists; their intra and interobserver reproducibility determined and further compared to the objective morphometric data i.e. D-score and volume percent of stroma (VPS). RESULTS: The results were assessed using the weighted kappa statistics. Mean intraobserver kappa value was 0.8690 (99.44% agreement). Mean interobserver kappa values by diagnostic category were: simple hyperplasia without atypia: 0.7441; complex hyperplasia without atypia: 0.3379; atypical hyperplasia: 0.3473, and well-differentiated endometrioid carcinoma: 0.6428; with a kappa value of 0.5372 for all cases combined.Interobserver agreement was in substantial rate for simple hyperplasia (SH) and well differentiated adenocarcinoma (WDA) but was in fair limit for complex hyperplasia (CH) and atypical hyperplasia (AH). Intraobserver agreement was almost perfect. The specimens were divided in two groups according to the computerized morphometric analysis: Endometrial Hyperplasia (EH) ( D Score > or = 1 or VPS > or = 55%) and Endometrial Intraepithelial Neoplasia (EIN) (D-Score < 1 or VPS < 55%). Morphometric findings were closely compatible with routine WHO classification made by one expert pathologist; however; diagnosis of (CH) and (AH) made by other pathologists were not concordant with morphometric data. CONCLUSION: It may be necessary to make some revisions in WHO classification for endometrial hyperplasia and precancerous lesions.

Gabapentin and uremic pruritus in hemodialysis patients.

BACKGROUND: Pruritus is a common and bothersome problem in 30-50% of hemodialysis patients. The aim of this study was to determine the effect of gabapentin, 100 mg/three times a week (after each hemodialysis session), on uremic pruritus. STUDY DESIGN: Patients older than 18 years who had undergone hemodialysis for more than three months were enrolled in this double-blind clinical trial. They had experienced pruritus refractory to antihistamines for at least two weeks. The patients were assigned to receive gabapentin 100 mg following hemodialysis for a period of four weeks, and after a washout week, they received the placebo for another four weeks. They were asked to evaluate the severity of their pruritus using a visual analogue scale (VAS). The reduction of pruritus >or= 50% was accepted as the response. RESULTS: The mean pruritus score reached 6.44 +/- 8.4 (p < 0.0001), 15 +/- 11.2 (p < 0.001), and 81.11 +/- 11.07 (p < 0.001) during gabapentin, washout, and placebo periods, respectively. No significant correlation was found between age, sex, duration of dialysis, underlying diseases, and systolic and diastolic blood pressures and the gabapentin effect. CONCLUSION: Gabapentin is an effective agent in treating uremic pruritus.

Totally tubeless percutaneous nephrolithotomy in renal anomalies.

OBJECTIVES: To assess the outcome and safety of the totally tubeless percutaneous nephrolithotomy in renal anomalies. PATIENTS AND METHODS: During a prospective clinical trial from December 2002 to November 2006, 60 patients with renal anomalies and nephrolithiasis were included in our study. The anomalies consisted of the horseshoe kidney, rotational anomalies of pyelocalyceal system, and ectopic kidney. The patients were randomly divided in two groups: the "totally tubeless" procedures performed in 30 patients (the nephrostomy tube and internal stent were not used in any patient), and 30 patients underwent standard percutaneous nephrolithotomy (PCNL; using both nephrostomy tube and ureteral stent). The incidence of complications, hospital stay, transfusion requirements, and stone-free rates were compared in the two groups. RESULTS: In the group of patients that underwent totally tubeless PCNL for the stone extraction, the mean stone burden was 2.54 cm(2) (standard deviation [SD] = 0.96). Patients' stay in the hospital averaged 1.3 (SD = 0.43) days. The average analgesics requirement was 4.5 (SD = 1.6) mg of morphine. The patients returned to normal activity in 10 (SD = 3.2) days. The postoperative complications were blood transfusion in one patient (3.3%) and fever in one patient (3.3%). An 83.3% stone-free rate was achieved. For the standard PCNL group, the mean stone size was 2.83 (SD = 0.76) cm(2), and the mean length of hospitalization was 2.6 (SD = 0.65) days. The average analgesics requirement was 10.4 (SD = 3.2) mg of morphine, and the time to return normal activity was 15.5 (SD = 3.2) days. Only 2 (6.7%) patients required a transfusion, and 1 (3.3%) patient had postoperative complications (penumothorax). Of the 30 patients, 86.7% became stone free. The differences between operation time, transfusion rates, complications, retreatment, and overall stone-free rate were not statistically significant in the two groups but days of hospitalization (P < 0.001), analgesics requirement (P < 0.001), and time of return tonormal activity (P < 0.001) were statistically significant. CONCLUSIONS: Totally tubeless percutaneous renal surgery is a safe and effective procedure in renal anomalies and can be performed in patients even with a moderate to large stone burden.

Effects of normal saline vs. lactated ringer's during renal transplantation.

AIM: We hypothesized that normal saline (NS) may have more deleterious effects compared with lactated ringer (LR) in kidney transplant recipients because of the higher risk of acidosis and higher levels of serum potassium. Thus, the aim of this study was to determine the safety of LR if used during a renal transplant. METHODS: Adults undergoing kidney transplantations were enrolled in a double-blinded randomized prospective clinical trial. They were divided into two groups in order to receive NS and LR infusion as intraoperative IV fluid replacement therapy. RESULTS: There was a significant difference in the serum potassium level (p = .000) and the PH (p = .007) between the two groups at the end of transplantations. Two patients in the LR group lost their kidneys due to vascular graft thrombosis. In other words, hyperkalemia and acidosis occurred more frequently in the NS group while thrombotic events may be of concern in the LR group. CONCLUSION: Compared with NS, LR infusion may lead to a lower serum potassium level and a lower risk of acidosis, while there is major concern of the hypercoagulable state in these patients.

Risk factors of erythrocytosis post renal transplantation.

Post-transplant erythrocytosis (PTE) is characterized by persistently elevated hematocrit level >or= 51%. This complication is reported to develop in 10-20% of renal allografts recipients, mostly 2 years after kidney transplantation. PTE is self-limited in 25% of the patients; however it may persist in patients with an increased susceptibility for thrombosis and potential fatal outcome. To evaluate the prevalence and risk factors of PTE in our center, we reviewed the records of 235 patients who received renal allografts from 1999 to 2004. Polycythemia was found in 45 (19%) patients. There was no significant correlation of polycythemia and age, history of hypertension, diabetes, pre-transplant hematocrit level, pre-transplant history of transfusion, graft's function, and source of kidney. A significantly higher proportion of PTE patients were males, patients with history of polycystic kidney disease, and patients with glomerulonephritis. We conclude that PTE is an important complication of kidney transplantation. There are several risk factors that should be addressed to prevent this complication.

Effects of prophylactic insertion of Double-J stents to decrease episodes of renal colic in patients with recurrent ureteral stones.

PURPOSE: To evaluate the hypothesis that prophylactic insertion of Double-J stents after uncomplicated transurethral lithotripsy (TUL) can decrease the number of episodes of renal colic and their intensity in patients with recurrent ureteral stones (those with three or more episodes of stone formation). PATIENTS AND METHODS: During a prospective randomized clinical trial from May 1999 to January 2004, 195 patients with recurrent ureteral stones were included in our study; 94 had stents in place for 4 weeks, and 101 patients remained stentless (control group). A few patients in each group had residual stone disease. All patients were followed-up for a mean period of 24 months and questioned about the number and intensity of their episodes of renal colic, and were also evaluated for their rates of spontaneous stone passage. RESULTS: Spontaneous passage of stones was seen in 43 patients (45.7%; CI 95%, 35.7, 55.8) who underwent stenting, and 35 patients (34.7%; CI 95%, 25.4, 43.9) in the stentless group (P > 0.05). The number of episodes of renal colic was significantly lower in the stented group (P < 0.001). CONCLUSION: Insertion of Double-J stents for 4 weeks after uncomplicated TUL in patients with recurrent ureteral stones significantly decreases the number of episodes of ureteral colic, although it does not decrease the rate of stone formation.