Syncope in Aortic Stenosis: Not Always What It Seems.

Aortic stenosis is a common valvular pathology and may also have atypical presentations outside the classic triad of chest pain, syncope, and shortness of breath. Some patients may not present with the symptoms of the triad. This patient instead presented with syncope and vomiting. Statistically, the most common cause of syncope at rest in the setting of aortic stenosis is due to an arrhythmia rather than the valve itself limiting cardiac output. In a comorbid Alzheimer's patient who has developed hyperorality, postprandial hypotension can also result in syncope at rest. Therefore, syncope at rest should raise alarm for nonvalvular etiologies such as arrhythmia. This case study also aims to establish an association between syncope at rest and hyperorality in the setting of aortic stenosis, a first study so far. Additionally, it highlights an unusual presentation of aortic stenosis where syncope occurs at rest associated with vomit in the absence of chest pain or shortness of breath.

Gluco-friendly rice consumption: Balancing the palate with the pancreas.

Rice, or Oryza sativa/ Oryza glaberrima is the largest sources of carbohydrates, and calories, for mankind. It is the staple food across many countries of America, Africa and Asia. Hence, we need gluco-friendly ways of incorporating rice-based menus into the cuisine of persons living with diabetes. This multinational article discusses this challenge, and highlights the importance of informed and shared decision making with persons living with diabetes.

Prominent Bilateral Hand Tremor in Hashimoto's Encephalopathy: A Video Demonstration.

BACKGROUND: Hashimoto's encephalopathy often presents with neuropsychiatric manifestations including seizures and movement disorders. CASE REPORT: We describe a patient who presented with bilateral hand tremor and mild cognitive defects that fulfilled the criteria for a diagnosis of Hashimoto's encephalopathy. There was a rapid response to glucocorticoid therapy with relapse following treatment withdrawal. DISCUSSION: Recently published clinical criteria for the diagnosis of Hashimoto's encephalopathy include seizures, myoclonus, hallucinations, or stroke-like episodes but do not include tremor. Our case had mild cognitive dysfunction and a coarse tremor as the predominant clinical features, which probably represent mild disease.

Does the 'slipping slipper sign' in patients with diabetes predict the presence of retinopathy and nephropathy?

BACKGROUND: Previous research had noted that an affirmative response in patients with diabetes to the question 'Have you ever lost your slipper/flip-flop from your feet while walking and not realised that you have done so'? That is, the presence of the 'slipping slipper sign' (SSS) reflected the presence of severe diabetic peripheral neuropathy with a high degree of precision. The objective of the current study was to determine whether the SSS may also predict the presence of diabetic retinopathy and/or nephropathy since microvascular complications are known to cosegregate. SUBJECTS AND METHODS: Among 100 patients with diabetes, including 33 cases with the SSS and 67 controls without the SSS, data on demography, dipstick proteinuria as well as the presence and staging of diabetic retinopathy were obtained. RESULTS: The mean (SD) age of all patients was 54.6 (13.0) years, mean duration of diabetes was 12.7 (10.2) years and mean haemoglobin A1c (HbA1c) 8.42 (1.95) %; 43% were males. All 33 (100%) of the patients with SSS but only 12 (18%) of the patients without SSS were found to exhibit diabetic retinopathy, p<0.001. Among those patients with retinopathy, proliferative retinopathy was far more likely (39%) in the SSS group compared with non-SSS subjects (8%). Similarly, 15 (46%) with SSS and only 4 (6%) without SSS were found to have dipstick proteinuria. The sensitivity of the SSS for retinopathy was 73% and the specificity was 100% with a positive predictive value (PPV) of 100% and negative predictive value (NPV) of 82%. For proteinuria, both the sensitivity and specificity was 78%. CONCLUSIONS: Both diabetic retinopathy and dipstick proteinuria are strongly associated with the presence of the SSS that therefore holds potential as a tool for easier identification of this high-risk group.

Encephalopathy and Neuropathy due to Glue, Paint Thinner, and Gasoline Sniffing in Trinidad and Tobago-MRI Findings.

A 29-year-old male petrol station pump attendant was admitted with ataxia and clinical evidence of a sensorimotor polyneuropathy which developed over the preceding 3 months. He had cognitive dysfunction, hearing loss, and cerebellar clinical abnormalities that came on slowly over the three years. He had a fifteen-year history of sniffing mostly glue, occasionally paint thinners, and, in the recent two years, gasoline. Magnetic resonance brain imaging showed abnormalities of the cerebral cortex, cerebral white matter, corpus callosum, hippocampus, brainstem and cerebellar atrophy, hypointensities of basal ganglia, red nuclei, and substantia nigra as previously described in toluene sniffing. Abstinence for six months led to partial clinical improvement. Clinicians need to be aware of this preventable entity which has peculiar radiological findings which are being increasingly accepted as typical.