Pancreas bifidum: an extremely rare cause of acute pancreatitis.

A wide spectrum of anomalies of the pancreas, the pancreatic ductal system and the biliary tree are commonly encountered at radiologic evaluation. Pancreas bifidum, also known as bifid pancreas or fish-tail pancreas, is an extremely rare congenital branching anomaly of the main pancreatic duct characterized by its duplication. These 2 separate ducts are laid from the pancreatic tail to neck and they generally join at the pancreas body-tail draining via the major papilla; the pancreatic parenchyma is also bifurcated with separated dorsal and caudal buds. The clinical impact of this condition is not well established: although some authors sustained that probably does not cause or contribute to abdominal pain or overt pancreatic diseases, others argued that could be considered as a possible cause of acute pancreatitis. We herewith describe the case of a 51-year-old woman presenting to our hospital with epigastric pain, nausea, and vomiting. Biochemical tests were suspicious for acute pancreatitis. Ultrasound examination was negative. MRI, including MR cholangiopancreatography revealed bifid pancreas characterized by duplication of the main pancreatic duct with 2 separate ducts that join at the pancreas head and draining via the minor papilla. On T2-weighted images the ventral bud of the pancreas was enlarged and characterized by slightly hyperintensity without peripancreatic fluid collections. The MRI findings were consistent with acute pancreatitis limited to the ventral bud of a bifid pancreas. Patient was treated with intravenous fluid resuscitation, pain control and institution of early enteral nutrition and discharged on the seventh day after admission.

Improved cardiovascular diagnostic accuracy by pocket size imaging device in non-cardiologic outpatients: the NaUSiCa (Naples Ultrasound Stethoscope in Cardiology) study.

Miniaturization has evolved in the creation of a pocket-size imaging device which can be utilized as an ultrasound stethoscope. This study assessed the additional diagnostic power of pocket size device by both experts operators and trainees in comparison with physical examination and its appropriateness of use in comparison with standard echo machine in a non-cardiologic population. Three hundred four consecutive non cardiologic outpatients underwent a sequential assessment including physical examination, pocket size imaging device and standard Doppler-echo exam. Pocket size device was used by both expert operators and trainees (who received specific training before the beginning of the study). All the operators were requested to give only visual, qualitative insights on specific issues. All standard Doppler-echo exams were performed by expert operators. One hundred two pocket size device exams were performed by experts and two hundred two by trainees. The time duration of the pocket size device exam was 304 ± 117 sec. Diagnosis of cardiac abnormalities was made in 38.2% of cases by physical examination and in 69.7% of cases by physical examination + pocket size device (additional diagnostic power = 31.5%, p < 0.0001). The overall K between pocket size device and standard Doppler-echo was 0.67 in the pooled population (0.84 by experts and 0.58 by trainees). K was suboptimal for trainees in the eyeball evaluation of ejection fraction, left atrial dilation and right ventricular dilation. Overall sensitivity was 91% and specificity 76%. Sensitivity and specificity were lower in trainees than in experts. In conclusion, pocket size device showed a relevant additional diagnostic value in comparison with physical examination. Sensitivity and specificity were good in experts and suboptimal in trainees. Specificity was particularly influenced by the level of experience. Training programs are needed for pocket size device users.

Diagnostic criteria for metabolic syndrome: a comparative analysis in an unselected sample of adult male population.

This analysis compares the performance of 7 different diagnostic criteria of metabolic syndrome (MS) with regard to the prevalence of the syndrome, the characteristics of subjects with a positive diagnosis, and the ability to correctly identify individuals at high calculated cardiovascular (CV) risk or with signs of systemic inflammation or early organ damage. The diagnostic criteria proposed by the World Health Organization (1998); European Group for the Study of Insulin Resistance (EGIR) (1999); Adult Treatment Panel III (ATP III) (2001); American Association of Clinical Endocrinologists (AACE) (2003); ATP III (2004); International Diabetes Federation (IDF) (2005); and American Heart Association/National Heart, Lung, and Blood Institute (2005) were applied to the population of 933 men aged 59.5 years (range, 33-81 years) attending the 2002-2004 examination of the Olivetti Heart Study. Standardized measurements were available for body mass index, waist circumference, blood pressure, fasting serum total and high-density lipoprotein cholesterol, triglyceride, glucose, insulin, high-sensitivity C-reactive protein, and microalbuminuria. Insulin resistance was estimated by the homeostasis model assessment index; and CV risk, by the Prospective Cardiovascular Munster algorithm. The MS prevalence ranged from 8.6% (AACE) to 44.5% (IDF). Among MS-positive subjects, insulin resistance ranged from 94.8% (EGIR) to 49.2% (IDF), whereas type 2 diabetes mellitus (excluded by EGIR and AACE criteria) rated 59.9% by World Health Organization and 22% to 24% by ATP III, IDF, or American Heart Association/National Heart, Lung, and Blood Institute. By most criteria, MS-positive subjects had greater calculated CV risk than MS-negative subjects; but in general, the ability to correctly identify individuals at high CV risk was dampened by limited sensitivity (maximum 60%). Lowering the cutoff for abdominal adiposity (waist circumference <94 cm by IDF) did not improve the performance in this regard but identified a larger number of individuals with microalbuminuria (56%) and elevated C-reactive protein (53%).

Genetic variations at the endocannabinoid type 1 receptor gene (CNR1) are associated with obesity phenotypes in men.

CONTEXT: The endocannabinoid system modulates food intake and body weight in animal models. Treatment with the cannabinoid type 1 receptor blocker, rimonabant, reduces body weight in obese individuals. OBJECTIVE: The aim of this study was to determine whether single nucleotide polymorphisms of the gene encoding cannabinoid type 1 receptor, CNR1, are associated with body fat mass and distribution in two independent samples of white European adult men. DESIGN, SETTING, AND PARTICIPANTS: The 3813A/G and 4895A/G single nucleotide polymorphisms at the exon 4 of CNR1 were genotyped in 930 participants to the Olivetti Prospective Heart Study (OPHS) in Southern Italy and in 216 participants to the Wandsworth Heart and Stroke Study in the United Kingdom. Retrospective analysis was also performed on an OPHS subsample (n = 360) for which anthropometric data from 1987 and 1994-1995 examinations were available. MAIN OUTCOME MEASURES: CNR1 genotypes and anthropometric measures of body fat distribution were determined. RESULTS: In the OPHS study, the 3813G allele was associated with increased subscapular skinfold thickness (24.2 +/- 9.1 vs. 22.8 +/- 7.7 mm; P = 0.031) and waist circumference (WC) (99.1 +/- 8.8 vs. 97.7 +/- 8.8 cm; P = 0.050). No association was observed with 4895A/G variant. Haplotype analysis confirmed that the unique haplotype carrying the 3813G was associated with increased WC and subscapular skinfold thickness. Similar results were observed in the OPHS retrospective subsample and the Wandsworth Heart and Stroke Study sample. In the latter, the 3813G was associated with increased WC (96.8 +/- 11.3 vs. 91.6 +/- 10.4 cm; P = 0.006). CONCLUSIONS: Genetic variants at CNR1 are associated with obesity-related phenotypes in men. The detection of polymorphic variants in genes involved in the process of fat accumulation may help identify specific targets for pharmacological treatment of obesity and related metabolic abnormalities.

Circulating leptin levels predict the development of metabolic syndrome in middle-aged men: an 8-year follow-up study.

BACKGROUND: Because high circulating plasma leptin is associated with many features of the metabolic syndrome (MS), such as abdominal obesity, insulin resistance and high blood pressure (BP), we analysed the ability of plasma leptin concentration to predict the risk of developing MS in a prospective investigation of adult male participants of the Olivetti Heart Study (OHS). METHODS AND RESULTS: Three hundred and sixty out of 907 men participating in the 1994-95 and 2002-04 OHS examinations (mean age at baseline 50.4 years, range 25-73 years) were free of MS at first visit according to NCEP-ATP III criteria (modified for the lack of high-density lipoprotein cholesterol measurement at baseline). During an average follow-up period of 8 years, there were 52 incident cases of MS (14.5%) due, in particular, to a rise in the prevalence of high BP (+42.4%), abdominal obesity (+16.4%) and impaired fasting glucose (IFG, +6.1%). In multivariate analyses, a one standard deviation difference in baseline plasma leptin concentration was associated with a 1.58-fold greater risk of developing MS (95% confidence interval = 1.10-2.30, P = 0.016) accounting for age, waist circumference, homeostatic assessment model index, smoking, alcohol consumption and physical activity. In particular, plasma leptin was positively associated with the risk of developing high BP (0.006) and IFG (0.014), after adjustment for confounders. CONCLUSION: In this sample of an adult male population free of MS at baseline, circulating plasma leptin was a significant predictor of the risk of MS and, in particular, of its high BP and IFG components, independently of potential confounders.

Incidence of hypertension in individuals with different blood pressure salt-sensitivity: results of a 15-year follow-up study.

OBJECTIVE: To evaluate the incidence of hypertension and the rate of decline in renal function in a sample of 47 Olivetti Heart Study (OHS) participants whose blood pressure (BP) salt-sensitivity and renal tubular sodium handling had been assessed in 1987-88. METHODS: During the 2002-04 OHS follow-up examination, medical history, physical examination and blood and urine sampling were performed in 36 of the 47 participants to the baseline study (age 60 +/- 6 years; average follow-up = 15.1 +/- 0.6 years). The renal length was measured in 23 participants by kidney ultrasonography. Based on the baseline salt-sensitivity evaluation, the subjects were classified into a lower salt-sensitivity (LSS, n = 20) and a higher salt-sensitivity group (HSS, n = 16). RESULTS: In comparison with the LSS group, HSS participants had a significantly higher incidence of hypertension (87.5 versus 50.0%, P = 0.02), a higher glomerular filtration rate (median, first to fourth quartile: 81.9, 72.3-95.2 versus 72.3, 59.9-81.2 ml/min; P = 0.03) and greater kidney length (median, first to fourth quartile: 68.2, 63.3-72.1 versus 61.9, 58.7-62.7 mm/m of height; P = 0.003). The incidence of hypertension remained significantly higher in HSS individuals after adjustment for age, intercurrent changes in body mass index and baseline blood pressure on low sodium diet (P = 0.04). CONCLUSION: Our findings indicate that individuals with higher BP salt-sensitivity have a higher rate of incident hypertension and suggest an altered renal tubular sodium handling involving a trend to increased glomerular filtration rate and blood pressure over time as a possible mechanism.

Abnormalities of renal sodium handling in the metabolic syndrome. Results of the Olivetti Heart Study.

OBJECTIVE: The mechanisms underlying high blood pressure in the framework of metabolic syndrome (MS) are not clarified: we thus analyzed the relationship of MS and its components to renal tubular sodium handling among participants of the Olivetti Heart Study, an epidemiological investigation of a representative sample of adult white male population in southern Italy. METHODS: Proximal (FPRNa) and distal (FDRNa) fractional sodium reabsorption were estimated by the clearance of exogenous lithium in 702 participants aged 25-75 years examined in 1994-1995. Blood pressure and relevant anthropometric and biochemical variables were also measured. The diagnosis of MS was based on modified National Cholesterol Education Program (NCEP)-Adult Treatment Panel III (ATP III) criteria. RESULTS: FPRNa, but not FDRNa, was directly associated with body mass index (BMI), waist circumference, diastolic pressure, serum triglyceride and uric acid, independently of age and of antihypertensive treatment. After adjustment for age, FPRNa, but not FDRNa, was significantly greater in individuals with MS, as compared to those without [77.6% (95% confidence interval = 76.7-80.1) versus 74.4% (73.7-75.1), P < 0.001]. A similar difference was observed after the exclusion of participants on current antihypertensive treatment (P = 0.018). In untreated individuals, a significant interaction was observed between obesity and insulin resistance as related to FPRNa (P = 0.002): the highest age-adjusted levels of FPRNa were detected in obese hypertensive and obese insulin-resistant participants. CONCLUSION: In this sample of an adult male population, MS was associated with an increased rate of FPRNa. This finding is relevant to the pathophysiology of MS and possibly to the prevention of its cardiovascular and renal consequences.

Site-dependency of the E/e' ratio in predicting invasive left ventricular filling pressure in patients with suspected or ascertained coronary artery disease.

PURPOSE: To test the accuracy of different mitral annular sites of the E/e' ratio in predicting invasive left ventricular filling pressure (LVFP) in patients hospitalized for coronary artery disease (CAD). METHODS: Forty-one patients with suspected or ascertained chronic CAD underwent non-invasive estimation of LVFP the same day as coronary angiography combined with right catheterization for pulmonary capillary wedge pressure (PCWP) assessment. The ratio between E velocity and early diastolic velocity of the mitral annulus (e') was calculated as a surrogate of PWCP by (i) averaging septal and lateral e' (E/e'A2); (ii) averaging septal, lateral, inferior, anterior (E/e'A4); (iii) using the sole septal (E/e'S); or (iv) lateral annulus (E/e'L). Patients were divided in two groups according to the PCWP: 25 with the PCWP <18 mmHg and 16 with the PCWP ≥ 18 mmHg. RESULTS: The two groups were comparable for gender, body mass index, blood pressure, heart rate (HR), E/A ratio, and deceleration time. The ejection fraction (EF) was lower and left atrial volume index (LAVi) greater (both P < 0.02) in patients with the PCWP ≥ 18 mmHg. They also exhibited higher E/e'S (P < 0.05), E/e'L (P < 0.0001), E/e'A2, and E/e'A4 (both P < 0.005) than patients with the PCWP <18 mmHg. In pooled groups, after adjusting for HR EF and LAVi, E/e'L (ß = 0.42, P < 0.01), E/e'A2 (ß = 0.32, P < 0.05), and E/e'A4 (ß = 0.31, P < 0.05) were all independently associated with PWCP. E/e'L ≥ 16.2 predicted PCWP ≥18 mmHg with the highest diagnostic accuracy (AUC = 0.826), sensitivity (81.3%), and specificity (80%). CONCLUSIONS: In patients with CAD, E/e'L is the most accurate parameter in predicting abnormally increased LVFP.

Do statins reduce blood pressure?: a meta-analysis of randomized, controlled trials.

A meta-analysis was performed of the effect of 3hydroxy3methylglutaryl-coenzyme A reductase inhibitors (statins) on blood pressure in humans including the randomized, controlled trials of statin therapy (20 trials and 828 patients) in which concomitant antihypertensive treatment (if any) remained unchanged throughout the study. A total of 291 and 272 patients were given a statin or placebo, respectively, in parallel group trials, whereas 265 took part in crossover trials receiving a statin and placebo (or probucol, in 1 trial). Systolic blood pressure was significantly lower in patients on statin than in those on placebo or control hypolipidemic drug (mean difference: -1.9 mm Hg; 95% CI: -3.8 to -0.1). The effect was greater when the analysis was restricted to studies with a baseline systolic blood pressure >130 mm Hg (Delta systolic blood pressure: -4.0; 95% CI: -5.8 to -2.2 mm Hg). There was a trend for lower diastolic blood pressure in patients receiving statin therapy compared with control: -0.9 mm Hg (95% CI: -2.0 to 0.2) overall and -1.2 mm Hg (95% CI: -2.6 to 0.1) in studies with a baseline diastolic blood pressure >80 mm Hg. In general, the higher the baseline blood pressure, the greater the effect of statins on blood pressure (P=0.066 for systolic blood pressure and P=0.023 for diastolic blood pressure). The blood pressure response to statins was unrelated to age, changes in serum cholesterol, or length of the trial. In conclusion, statin therapy has a relatively small but statistically significant and clinically meaningful effect on blood pressure.