Objective Due to the lack of compelling evidence for waist circumference (WC) as a cardiovascular disease (CVD) risk factor in many ethnic groups, the need for local research has been expressed by international authorities. This study was undertaken to determine the optimal cut-off points of WC for predicting incident CVD and metabolic syndrome in an Iranian population. Materials and Methods A total of 6,504 participants from three areas in central Iran were followed over 7 years. Receiver operating characteristics (ROC) and area under the curve (AUC) were used to identify the maximum value of sensitivity and specificity combinations corresponding to the appropriate cut-off points of WC for the detection of the metabolic syndrome and CVD events. The optimal cut-off values were defined as the point at which the value of "sensitivity+specificity-1" reached the maximum value. Finally, Cox proportional hazard modeling was used to determine which cut-off point was better fit in the CVD risk prediction model. Results After 394,418 person-years of follow-up, 427 incident primary CVD events (233 men) were identified. Considering CVD, the optimum cut-off points were 99/103.5 cm (men/women) but these had a low sensitivity (AUC: 0.59, 95%CI 0.55-0.63 in both men and women). The second highest values for discriminating CVD were 93/97 cm that resulted in acceptable sensitivity. Regarding the metabolic syndrome, 92.6/97.8 cm were identified as optimum (AUC: 0.67, 95%CI 0.65-0.69 in men and 0.65, 95%CI 0.63-0.67 in women). The best cut-off values that fit in the Cox regression model were 90/97 cm. Conclusion International recommended WC cut-off values for the Middle East are not appropriate compared to the locally defined cut-off values in Iran.
Background Arterial stiffness is strongly predictive for cardiovascular events in hypertensive individuals and it may increase the risk of stroke. This study was designed to evaluate the possible relationship between arterial stiffness and atrial electromechanical delay and P wave dispersion (PWD), as determinants of AF risk. Materials and Methods The study included 75 hypertensive patients and 45 healthy control subjects. Atrial electromechanical coupling (time interval from the onset of P wave on ECG to the beginning of A wave with tissue Doppler echocardiography [PA]), intraatrial and interatrial electromechanical delay (EMD) and PWD were measured. Stiffness index β & PWV was measured to assess the arterial stiffness. Results The interatrial EMD and PWD were prolonged in hypertensive patients compared to controls (p<0.01 for both), There was increased arterial stiffness (PWV and stiffness index β) in hypertensive patients compared to controls (6.43 ± 1.73 vs. 4.8 ± 1.6 m/sec & 4.9 ± 2.8 vs. 2.63 ± 1.2, p<0.01 for both). By multivariate analysis; PWV and Stiffness index β were independently correlated with interatrial EMD (B ± SE=0.42 ± 1.87, B ± SE=0.39 ± 0.21 p<0.01 for both) and PWD (B ± SE=0.37 ± 1.93, p<0.01, B ± SE=0.25 ± 0.18, p<0.05 respectively). Conclusion In hypertensive patients arterial stiffness indexes increased and showed a significant correlation with interatrial EMD and PWD independent of other variables. Further research is needed to determine whether interventions that reduce arterial stiffness will limit the growing incidence of AF.
Objective We conducted a cohort study to investigate whether diastolic function could predict cardiovascular (CV) events in 161 HD patients with preserved systolic function. Materials and Methods The ratio of early transmitral flow velocity to early mitral annular velocity (E/E') was measured by tissue Doppler imaging. Patients were stratified into two groups based on whether they experienced a CV event. Results During a 4-year follow-up period, 64 patients experienced a CV event. The E/E' values (15.18 ± 5.78) in the CV-event group were significantly higher than in the group who had not experienced a CV event (12.32 ± 4.23). Kaplan-Meier analysis indicated that the incidence of CV events was significantly higher in the group of patients whose E/E' was >15 than in the group whose E/E' was ≤15 (log-rank p=0.0016). Multivariate Cox proportional hazards regression analysis revealed the E/E' ratio to be a significant predictor of CV events in HD patients with preserved LV systolic function. Conclusion The results of this study showed that elevated E/E' ratio in chronic HD patients predicts CV events better than other echocardiographic parameters.
Objective Trends in diabetes and cardiovascular mortality rates are considerably different between women and men; this can be partially explained by differences in diabetes control. The aim of this cross-sectional study was to assess whether sex differences exist in effective control of cardiovascular risk factors among persons with type 2 diabetes treated at the Vuk Vrhovac University Clinic in 2008. Materials and Methods We performed a cross-sectional analysis including 8,775 patients who attended the clinic in 2008. Levels of HbA1c, systolic and diastolic blood pressure (SBP, DBP), LDL-cholesterol (LDL) and triglycerides (TG) were analyzed. Multiple adjusted odds-ratios were calculated for categories of cardiovascular risk factors considered not being in control (HbA1c ≥7%, SBP ≥130 mmHg, DBP ≥80 mmHg, LDL ≥2.5 mmol/L, TG ≥1.7 mmol/L). Results Women had higher levels of HbA1c (7.05 vs. 6.86%; p<0.001), despite the fact that a larger proportion of women were receiving insulin therapy than men (51.3% vs. 44%). Women also had higher mean values of SBP (144.7 vs. 141.9 mmHg; p<0.001) and LDL (2.92 vs. 2.84 mmol/L). There were no differences in DBP (86.1 vs. 86.0 mmHg; p=0.748) and only triglyceride levels were higher in men (2.04 vs. 1.94 mmol/L; p=0.003). In multi-adjusted logistic regression model female sex was associated with a higher odds ratio of having uncontrolled values of HbA1c (OR=1.21; 95%CI 1.11-1.32), SBP (OR=1.21; 95%CI 1.07-1.37) and LDL (OR=1.13; 95%CI 1.04-1.23). Conclusion Women with diabetes have poorer control of main potentially modifiable cardiovascular risk factors than men. This could contribute to disparities in trends in cardiovascular mortality and it demands clinicians' and public health awareness.
Objective Hemorrhagic risk is unknown in patients with moyamoya-like vessels associated with atherosclerotic intracranial cerebral artery occlusion. This study was undertaken to investigate the association between moyamoya-like vessels and cerebral microbleeds (CMBs) in patients with atherosclerotic steno-occlusive disease. Methods The study population comprised 34 patients with steno-occlusive lesions in the intracranial cerebral artery caused by atherosclerosis. We evaluated the presence of moyamoya-like vessels at the base of the brain by cerebral angiography, and the presence of CMBs by T2*-weighted MRI. Patients were divided into 2 groups: those with and those without moyamoya-like vessels; clinical histories and the incidence of CMBs were compared between the groups. Results Sixteen patients had moyamoya-like vessels. Twelve of 16 patients with moyamoya-like vessels had a history of ischemic stroke or transient ischemic attack, whereas only 1 patient had a history of symptomatic cerebral hemorrhage. The incidence of CMBs did not differ between the 2 groups (31% vs. 28%, p=0.82). The location of CMBs varied and was not associated with the site of moyamoya-like vessels. Conclusion CMBs were not associated with moyamoya-like vessels in patients with atherosclerotic cerebral artery occlusion. These patients may not have a high risk of cerebral hemorrhage.
In 2008, a 28-year-old woman consulted our hospital due to general fatigue. Her ALT level was within normal range but she was positive for hepatitis B surface antigen (HBsAg). Her ALT level was nearly within normal range thereafter and she was consistently positive for HBeAg. Later, it was proven that she was negative for HBsAg in 1999. She had been a sex worker in 2007-2008. Complete genome sequencing revealed that her HBV was genotype C. The present case may indicate that it is possible for acute infection with HBV genotype C to progress to chronic infection in adults.
A 46-year-old Japanese man visited our hospital for chronic abdominal pain, persistent diarrhea and discharge of proglottids for 7 years. He had been living in Lao People's Democratic Republic. Ileography using meglumine/diatrizoate sodium (Gastrografin) revealed a long tapeworm. A Taenia saginata including the scolex was excreted through the intestinal tract by the administration of total 780 ml of Gastrografin. Taeniasis is an important disease in the differential diagnosis of imported diseases in Japan. Parasite infection should be suspected in patients with chronic abdominal pain or persistent diarrhea regardless of the findings for small bowel obstruction when there is a history of overseas travel.
Lipomas are benign submucosal tumors composed of mature adipose tissue. Some authors have described patients with persistent abdominal pain who were misdiagnosed as intestinal adenocarcinoma and the diagnosis turned out to be a lipoma on histological examination. We discuss the case of a 57-year-old woman presenting with abdominal pain for 4 weeks. Intestinal adenocarcinoma was found by double-balloon enteroscopy (DBE), but at first only lipoma was found by CT scan. Therefore we want to emphasize that lipoma should not always be regarded as pseudomalignant features, sometimes lipoma conceals intestinal adenocarcinoma, and DBE may be a better way to discover malignancy.
We encountered two consecutive cases with spontaneous ST elevation due to right coronary spasms and subsequent ventricular fibrillation (VF). Their 12-lead ECGs on anterior chest pain showed elevation of ST-segments in the inferior leads, but coronary angiography (CAG) revealed no significant stenosis. Both cases showed dramatically evolving J waves in the inferior leads during the right CAG, but it was not observed during angiography of the left CAG. Neither Brugada-type ECG nor long-QT was evident. In summary, J waves can be produced without ST-segment elevation, and contrast media-induced J waves might be related to the arrhythmogenesis of subsequent VF evoked by right coronary spasms.
A 68-year-old woman was admitted to determine the pathogenesis of weight loss and polyuria. Physical findings on admission showed BMI of 20.9, blood pressure of 147/69 mmHg, and that she had ciliac, axillar and pubic hair loss. Laboratory findings showed that plasma adrenocorticotropic hormone (ACTH) was 4.6 pg/mL with serum cortisol of 1.2 μg/dL. Serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were markedly reduced. Serum growth hormone (GH) and insulin growth factor (IGF)-1 were 0.054 ng/mL and 25 ng/mL, respectively. Serum prolactin was as high as 85.6 ng/mL. The levels of all the pituitary hormones were elevated in response to a mixture of exogenous corticotrophin-releasing hormone (CRH), luteinizing hormone-releasing hormone (LH-RH), thyrotropin-releasing hormone (TRH), and growth hormone-releasing hormone (GRH). However, there was no response of ACTH and GH release to insulin-induced hypoglycemia and no response of LH and FSH release to clomiphene. Urine volume was more than 4,000 mL, with low urine osmolality of 134 mmol/kg. Plasma arginine vasopressin (AVP) was 0.8 pg/mL. There was no increase in urine osmolality and plasma AVP in response to 5% hypertonic saline load. Magnetic resonance imaging revealed Rathke's cleft cyst at the pituitary stalk level, but there was no abnormal finding in the hypothalamus. These findings indicate central diabetes insipidus and hypothalamic type of hypopituitarism, resulting from the atypical location of Rathke's cleft cyst.
We report a case of pulmonary veno-occlusive disease (PVOD) following allogeneic bone marrow transplantation (BMT) for the treatment of acute myeloid leukemia (AML) from an HLA mismatched mother using a reduced-intensity conditioning (RIC) regimen including gemtuzumab ozogamicin. The patient was a 21-year-old male who complained of dyspnea with hypoxemia followed by loss of consciousness. The abnormalities in chest CT and echocardiography were compatible with a diagnosis of PVOD. Treatment with 1 mg/kg of oral prednisolone resolved dyspnea and hypoxemia within a few days, and chest CT abnormalities disappeared in a week. This report is the first to describe PVOD following RIC stem cell transplantation.
A 50-year-old woman with a history of aplastic anemia developed cervical lymphadenopathy and atypical lymphocytosis. Atypical cells of lymph nodes were positive for CD3 and CD30 but negative for anaplastic lymphoma kinase (ALK). Bone marrow examination showed trilineage myelodysplasia. She was diagnosed with ALK-negative anaplastic large cell lymphoma (ALCL) with leukemic transformation and myelodysplastic syndrome (MDS) which presumably developed from aplastic anemia. The lymphoma was resistant to intensive chemotherapies, ultimately leading to death. Leukemic presentation of ALK-negative ALCL as an initial manifestation is extremely rare, and the progression of the disease may be influenced by MDS through alteration of immune functions.
We report a case of a patient with highly active anti-retroviral therapy-resistant human immunodeficiency virus (HIV)-associated progressive multifocal leukoencephalopathy (PML). The patient showed an improvement in imaging findings and clinical symptoms after mefloquine was introduced as an additional treatment. Serial assessment of white matter lesions was conducted by proton magnetic resonance spectroscopy (1H-MRS) and diffusion-weighted imaging (DWI). As the clinical symptoms improved, the N-acetylaspartate/creatine ratio increased, the choline/creatine ratio decreased, and the elevated ADC value decreased. These concomitant changes suggested that 1H-MRS and DWI were useful for the assessment of the therapeutic effect on PML.
A 70-year-old woman developed a headache for a month followed by right upper limb weakness. CT scan and MRI showed multiple ring-enhancing lesions. An intracerebral aspiration of an abscess was performed, but culture results were negative. The nucleotide sequence analysis of the 16S rRNA gene from the specimens identified Streptococcus intermedius. Given this result, S. intermedius was cultured by enrichment culture, and its sensitivities to antibiotics were determined. The patient exhibited complete remission. Thus, 16S rRNA gene analysis was highly useful not only for pathogen identification with negative culture results but also for the appropriate selection of antibiotics.
We report a 35-year-old man who developed weakness in his extremities five months after pegylated interferon α (IFNα)-2b was administered. The serum tumor necrosis factor-α (TNFα) was elevated and nerve conduction studies revealed demyelination both in the distal and intermediate segments. The sural nerve pathology showed mild demyelinating process. The cessation of IFNα and administration of intravenous immunoglobulin improved both his clinical symptoms and the temporal dispersion in motor nerve conduction study. IFNα-induced CIDP is presumably a transient immunological condition that requires immunomodulatory therapy. The elevated serum TNFα may implicate the degree of downstream autoimmunitiy induced by IFNα.