Parinda H. Shah

Glycemic control and hypoglycemia: is the loser the winner?

Glycemic control remains a delicate balancing act. The diabetic patient is tasked with maintaining euglycemic blood glucose levels, a goal requiring education, decision strategies, volitional control, and the wisdom to avoid hyper- and hypoglycemia, with the latter defined as plasma glucose less than ∼60 mg/dl. Glucose levels must be controlled continuously and without holidays. Failure to maintain euglycemia results from biological factors and psychosocial factors including overmedication and/or inappropriate choices regarding food, drink, and, in certain cases, exercise. Diabetic patients, especially those treated with insulin, are at risk for developing hypoglycemia. Treatment, even with oral agents such as sulfonylureas, increases this risk. Asymptomatic episodes of hypoglycemia may constitute up to 10% of a 24-h period in diabetic patients (1,2). Individuals with type 1 diabetes average 43 symptomatic episodes annually; insulin-treated individuals with type 2 diabetes average 16 episodes (3). As for severe hypoglycemic episodes, patients with type 1 diabetes experience up to two episodes annually, whereas patients with type 2 diabetes experience about one episode over 5 years. The risk increases with a history of hypoglycemia and an increased number of years of insulin treatment (3,4). Hypoglycemia deprives the brain of the constant supply of glucose needed for energy. Such low levels of blood glucose are sensed by the ventromedial hypothalamus (5). In turn, a counterregulatory hormonal cascade is activated to rapidly restore euglycemia that begins with inhibition of insulin secretion. Thereafter, the release of glucagon and epinephrine elevates endogenous glucose production through increased hepatic glycogenolysis and gluconeogenesis, as well as renal gluconeogenesis. Growth hormone and cortisol are slow-acting adjustments to prolonged hypoglycemia (6). Hypoglycemia may promote oxidative stress and neuronal cell death, primarily as a consequence of neuronal NADPH oxidase activation and extracellular zinc release during glucose reperfusion. Thus, heightened glucose concentrations during reperfusion …

Effects of music on systolic blood pressure, diastolic blood pressure, and heart rate: a meta-analysis

There are a handful of studies that have been done investigating the effect of music on various vital signs, namely systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR). Many studies have also assessed effects of music on self-reported anxiety level, attributing some degree of music-induced anxiety relief to the beneficial impacts of music on vital signs. Several randomised studies have shown varying effects of music on these vital parameters and so a meta-analysis was done to compare the effect of music on them. The fixed effects model was used as studies were homogenous. A two-sided alpha error < 0.05 was considered to be statistically significant. Compared to those who did not receive music therapy, those who did receive music therapy had a significantly greater decrease in SBP before and after (difference in means, -2.629, confidence interval (CI), -3.914 to -1.344, P < 0.001), a significantly greater decrease in DBP (difference in means, -1.112, CI, -1.692 to -0.532, P < 0.001), and a significantly greater decrease in HR (difference in means, -3.422, CI, -5.032 to -1.812, P < 0.001).

Influenza Vaccination and Cardiovascular Morbidity and Mortality Analysis of 292 383 Patients

Studies have documented an association between influenza vaccination and risk reduction in myocardial infarction, all-cause mortality, and major adverse cardiac events. This meta-analysis pooled data from 5 trials with a total of 292 383 patients. Influenza vaccination was found to be associated with significant reductions in myocardial infarction, all-cause mortality, and major adverse cardiac events. The risk reduction afforded by vaccination and the lack of major adverse events related to the influenza vaccination makes it particularly important to vaccinate those with a known cardiovascular disease or those at high risk of developing cardiovascular disease.

The developing role of fetal magnetic resonance imaging in the diagnosis of congenital cardiac anomalies: A systematic review.

Advances in the fetal magnetic resonance imaging (MRI) over the last few years have resulted in the exploring the use of fetal MRI to detect congenital cardiac anomalies. Early detection of congenital cardiac anomalies can help more appropriately manage the infants delivery and neonatal management. MRI offers anatomical and functional studies and is a safe adjunct that can help more fully understand a fetus’ cardiac anatomy. It is important for the obstetricians and pediatric cardiologists to be aware of the recent advancements in fetal MRI and it`s potential utility in diagnosing congenital cardiac anomalies.

Fetal Magnetic Resonance Imaging of Malformations Associated with Heterotaxy.

Magnetic resonance imaging (MRI) is increasingly used as an investigation during fetal life, particularly for assessment of intracranial masses, congenital diaphragmatic hernia, myelomeningocele, and abdominal masses. As the number of scans increases, so is the variety of congenital malformations being recognized. It is axiomatic that interpretation of the findings is enhanced when attention is paid to the likely findings in the setting of known syndromes, this information then dictating the need for additional acquisition of images. One such syndrome is so-called “visceral heterotaxy”, in which there is typically an isomeric, rather than a lateralized, arrangement of the thoracic and abdominal organs. Typically associated with complex congenital cardiac malformations, heterotaxy can also involve the central nervous system, and produce pulmonary, gastrointestinal, immunologic, and genitourinary malformations. In this review, we discuss how these findings can be demonstrated using fetal MRI.

Determining bronchial morphology for the purposes of segregating so-called heterotaxy

UNLABELLED Introduction Heterotaxy is a unique clinical entity in which lateralisation of the thoraco-abdominal organs is abnormal, typically with isomerism of the bronchial tree and atrial appendages. This study was carried out to determine whether routine clinical imaging such as chest radiographs, angiographic images, and CT/MRI can determine bronchial isomerism, and how sidedness of bronchial isomerism correlates with overall features anticipated in hearts with isomeric atrial appendages. Methods and results We identified 73 patients with heterotaxy, in whom imaging clearly demonstrated the bronchial tree, seen at our institution since 1998. We calculated bronchial angles and lengths using all the available imaging modalities to determine the presence and sidedness of bronchial isomerism. This was then compared with the anticipated presence of isomeric atrial appendages based on the overall clinical findings, as the appendages themselves had not specifically been imaged. The ratio of bronchial lengths revealed bronchial isomerism in all patients, with bronchial angles permitting distinction of right as opposed to left isomerism. We noted discordances between the identified bronchial isomerism and the presumed arrangement of the atrial appendages in nearly 20% of the patients in our cohort. CONCLUSION Routine clinical imaging with chest radiographs, angiographic imaging, and CT/MRI can determine the presence of bronchial isomerism in patients with so-called heterotaxy. Right as opposed to left isomerism can be distinguished based on bronchial angles. The finding of bronchial isomerism correlates well, but not totally, with the presumed isomerism of the atrial appendages as predicted from the identified intra-cardiac morphology.

Role of N-Acetylcysteine to Prevent Contrast-Induced Nephropathy: A Meta-analysis.

It is unclear whether N-acetylcysteine is useful in preventing contrast-induced nephropathy in patients undergoing coronary angiography. Because of different inclusion and exclusion criteria and different definitions of studied parameters, various studies have reported different outcomes. A systematic search was done using PubMed, Ovid, and the Cochrane library, and studies were pooled after strict inclusion and exclusion criteria. Separate analysis was conducted for all endpoints including only studies that used an N-acetylcysteine (NAC) dose of 600 mg, and another separate analysis was conducted for all endpoints including only studies that used oral route NAC to study how the dose and route of administration of NAC affect the outcomes. The results of the pooled analysis significantly favored the use of NAC to prevent contrast-induced nephropathy in patients undergoing coronary angiography but failed to show any significant benefit in terms of creatinine levels preangiography and postangiography, need for dialysis, and all-cause mortality. The effects of route and dose of NAC did not show any significant difference except in respect to incidence of postcatheterization nephropathy. This study shows that NAC may not have any impact on clinical outcomes after peripheral or coronary artery catheterization and that dose and route do not seem to have any effect on these outcomes.

Radiologic Considerations in Heterotaxy: The Need for Detailed Anatomic Evaluation.

So-called “heterotaxy” is a laterality defect characterized by isomerism of the thoracic organs and random arrangement of the abdominal organs. These findings go beyond anatomic curiosity and have functional implications. It is, thus, of the utmost importance to be able to properly identify these findings. Radiologic studies can be invaluable in determining anomalies in the central nervous, pulmonary, cardiovascular, gastrointestinal, genitourinary, and immunologic systems in patients with isomerism. Here, we review findings associated with isomerism and their importance in the setting of isomerism with the aim of ensuring that radiologists effectively describe findings in these patients and that cardiologists understand the wide variety of congenital malformations that may be present.

Ideal antiplatelet therapy for coronary artery disease: focus on adenosine diphosphate receptor inhibitors.

With the increasing prevalence of coronary artery disease, antiplatelet therapy after percutaneous coronary intervention is becoming more important. As such realm is still very dynamic, it is important for clinicians to understand the evolution of antiplatelet therapies and current issues that are yet to be settled in the search for an ideal antiplatelet agent. Electronic searches were done using databases such as PubMed and Cochrane Library with appropriate keywords. Randomized controlled trials and retrospective studies found were then assessed for quality, and their references used to find additional studies. The field of study regarding the antiplatelet therapy is still an area in which much has yet to be found. Although clopidogrel and aspirin are cornerstones of therapy currently, other agents such as ticagrelor offer potential alternatives. This review presents an overview of current antiplatelet therapies and their relative risks and benefits.

Association of atrial tachyarrhythmias with atrial septal defect, Ebstein’s anomaly and Fontan patients

The number of adults with congenital heart disease is increasing as medical and surgical palliation for congenital heart lesions improves. With this comes long-term complications of congenital heart disease such as the increased risk of atrial tachyarrhythmias. Atrial septal defect, Ebstein’s anomaly and post-Fontan patient subsets are particularly important to focus on due to their unique characteristics and association with atrial tachyarrhythmias. Reviews, randomized controlled trials, and meta-analyses were obtained using electronic search strategies such as Medline and the Cochrane Library. References of electronically obtained studies were then used to obtain additional relevant studies. Sources were deemed relevant if they discussed the relationship between atrial septal defects/Ebstein’s anomaly/Fontan procedure and atrial tachyarrhythmias in respect to incidence, mechanism, recurrence or treatment. Selected sources were then stratified on the basis of quality. Patients in these subsets of congenital heart disease are at increased risk of atrial tachyarrhythmias for a variety of reasons when compared with the general population. It is necessary for pediatric and adult cardiologists alike to understand these differences, as well as their implications in diagnosis and management of such occurrences.