Reporting on sex-based analysis in clinical trials of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker efficacy

BACKGROUND

Clinical practice recommendations for hypertension do not make recommendations specific to men or women. However, the sex hormones appear to modulate differently the renin-angiotensin system (RAS), which plays a central role in the regulation of blood pressure. Today, little is known about the effects of sex on the efficacy of therapies that antagonize the RAS, such as angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs).

OBJECTIVE

To identify randomized controlled trials evaluating the efficacy of ACEIs and ARBs in preventing major cardiovascular outcomes, determine what proportion of the trial participants were female, and evaluate whether there was any evidence of a sex difference in the efficacy of these agents.

METHODS

A systematic review of the literature was conducted to identify randomized controlled trials that used either ACEIs or ARBs for the treatment of hypertension.

RESULTS

Thirteen ACEI trials and nine ARB trials were identified. Sex-specific outcome data were available in six of the ACEI trials and three of the ARB trials. These trials enrolled 74,105 patients; 39.1% were women. Seven of the nine trials indicated that ACEIs or ARBs may be slightly more beneficial in men. The magnitude of these differences, in most trials, was small.

CONCLUSIONS

Sex-specific data are reported in 43% of large hypertension clinical trials. Review of the trials reporting sex-specific effect sizes indicates that ACEIs and ARBs may be more effective in men.

Flavanol and flavonol contents of cocoa powder products: influence of the manufacturing process

Major brands of cocoa powder products present in the Spanish market were analyzed for monomeric flavanols [(+)-catechin and (-)-epicatechin] and flavonols [quercetin-3-glucuronide, quercetin-3-glucoside (isoquercitrin), quercetin-3-arabinoside, and quercetin]. In addition, the influence of the manufacturing process of cocoa powder products, in particular, the alkalinization treatment ( Dutching), on the original content of these flavonoids has been studied. (-)-Epicatechin was in the range of 116.02-730.26 microg/g, whereas (+)-catechin was in the range of 81.40-447.62 microg/g in the commercial cocoa products studied. Among flavonols, quercetin-3-arabinoside and isoquercitrin were the major flavonols in the cocoa powder products studied, ranging from 2.10 to 40.33 microg/g and from 3.97 to 42.74 microg/g, respectively, followed by quercetin-3-glucuronide (0.13-9.88 microg/g) and quercetin aglycone (0.28-3.25 microg/g). To our knowledge, these results are the first quantitative data in relation to the content of individualized flavonol derivatives in commercial cocoa powder products. The alkalinization treatment resulted in 60% loss of the mean total flavonoid content. Among flavanols, (-)-epicatechin presented a larger decline (67%, as a mean percentage difference) than (+)-catechin (38%), probably because of its epimerization into (-)-catechin, a less bioavailable form of catechin. A decline was also confirmed for di-, tri-, and tetrameric procyanidins. In the case of flavonols, quercetin presented the highest loss (86%), whereas quercetin-3-glucuronide, quercetin-3-arabinoside, and isoquercitrin showed a similar decrease (58, 62, and 61%, respectively). It is concluded that the large decrease found in the flavonoid content of natural cocoa powder, together with the observed change in the monomeric flavanol profile that results from the alkalinization treatment, could affect the antioxidant properties and the polyphenol biovailability of cocoa powder products.

Ultrasound - first imaging modality in the detection of parathyroid adenomas

Abstract We present a series of 12 patients in whom the typical ultrasound features of parathyroid adenomas were accurately demonstrated. High resolution ultrasound [in experienced hands] is a highly sensitive accurate, safe and non invasive method of localizing parathyroid adenomas especially in patients with typically located glands and an absence of thyroid pathology. Our aim was to compare ultrasound with nuclear medicine as an imaging gold standard in patients with thyroid adenomas.

Simultaneous lymphoma and squamous cell carcinoma presenting as a neck lump

We describe the unusual presentation of a patient with simultaneous follicular lymphoma and metastatic head and neck squamous cell carcinoma. He was initially treated for his lymphoma and then, following no regression in his cervical lymphadenopathy was referred for further assessment. This revealed squamous cell carcinoma arising from the left tongue base with metastatic disease in the left neck.

Hypothyroidism determines the clinical and immunological manifestations of Arabs with lupus

Abstract

Data on thyroid disease in Arabs with lupus is scarce. We conducted a cross-sectional and retrospective case–control study to report the prevalence of thyroid diseases in 110 Arabs with lupus who attended our Rheumatology Clinic between January 2002 and January 2007, and to delineate the clinical and immunological features of Arabs lupus patients with thyroid diseases. We found hypothyroidism in 15 (13.7%) patients. Overall, 25.6% had elevated thyroid peroxidase antibodies, 14.6% had elevated anti-thyroglobulin antibodies, and 13.7% were positive for both antibodies. Lupus patients with hypothyroidism had a significantly higher frequency of polyarthritis (OR = 9.3, CI: 2.0–41.7, P < 0.001), cutaneous manifestations (OR = 5.6, CI: 2.4–14.3, P < 0.0001), positive anti-thyroglobulin antibodies (OR = 19.9, CI: 8.38–47.4, P < 0.0001), and thyroid peroxidase antibodies (OR = 12.3, CI: 6.27–24.1, P < 0.0001) than lupus patients with normal thyroid function. Furthermore, neuropsychiatric (OR = 0.36, CI: 0.14–0.93, P < 0.05) and hematological (OR = 0.52, CI: 0.29–0.91, P < 0.05) manifestations were significantly lower in patients with hypothyroidism than in euthyroid patients. Surprisingly, the prevalence of anticardiolipin antibody immunoglobulin G (aCL IgG) (OR = 0.34, CI: 0.13–0.86, P < 0.05), lupus anticoagulant (OR = 0.02, CI: 0.001–0.35, P < 0.0001), and anticardiolipin syndrome (OR = 0.02, CI: 0.001–0.43, P < 0.0001) were significantly lower in lupus patients with hypothyroidism than in lupus patients with normal thyroid function. In conclusion, the prevalence of hypothyroidism in Arabs with lupus is comparable to that reported in the literature. Arab lupus patients with hypothyroidism have distinctive clinical and immunological features that differentiate them from euthyroid patients.

Quinoid radio-toxin (QRT) induced metabolic changes in mice: an ex vivo and in vivo EPR investigation

Radio-toxins are toxic metabolites produced by ionizing irradiation and have toxic effects similar to those caused by direct irradiation. We have investigated the effect of a quinoid radio-toxin (QRT) obtained from gamma-irradiated potato tuber on various organs in mice using ex vivo and in vivo EPR spectroscopy. Results indicate a decrease in the activity of ribonucleotide reductase enzyme in spleen of mice treated with 0.2mg QRT. A dose of 2mg QRT was fatal to mice within 45-60 min of treatment. Nitrosyl hemoglobin complexes alpha-(Fe(2+)-NO)alpha-(Fe(2+))beta-(Fe(2+))(2) were detected from spleen, blood, liver, kidney, heart, and lung tissue samples of mice treated with lethal doses of QRT. A significant decrease of pO(2) in liver and brain was observed after administration of QRT at the lethal dose. The time of the appearance of the nitrosyl hemoglobin complex and its intensity varied with the dose of QRT and the type of tissue. These results indicate that the effect of the QRT is more prominent in spleen and to a lesser extent in liver and blood. The QRT action at the lethal doses resulted in an increased hypoxia over time with disruption of compensatory adaptive response. The results indicate similar outcome of QRT as observed with gamma-irradiation.

Comparison of emergency caesarean section to misoprostol induction for the delivery of antepartum eclamptic patients: a pilot study

BACKGROUND

Eclampsia has now emerged as one of the commonest cause of maternal mortality in Nigeria. There is need for research on best modality for delivery of eclamptics.

METHODOLOGY

The pilot study was conducted on 50 eclamptic patients at the Federal Medical Centre, Azare. The patients were randomized for delivery either by caesarean section (CS) or induction of labour. The fetomaternal outcome of the two groups was compared.

RESULTS

25 of the patients had CS and 25 had induction of labour with misoprostol. The mean decision delivery interval was 4.1 hours and 13.08 hours for the CS and misoprostol groups respectively. Misoprostol failure was recorded in 4 (16%) patients and they were subsequently delivered by CS. The duration of admission was longer in the CS group (mean of 10.1 days) compared to the misoprostol group (mean of 6.08 days). There were more maternal complications and admissions of babies into the SCBU in the CS group. Maternal mortality in the two groups was similar (2% each).

CONCLUSION

Misoprostol is cheap, available and safe for delivery of antepartum eclamptics. In the event of delay at caesarean section for antepartum eclamptics patients, misoprostol induction should be started. A multicenter study is called for.

Hemorrhagic cerebral dissecting aneurysms: surgical treatments and results

INTRODUCTION

Cerebral dissecting aneurysms are an increasingly recognized etiology of subarachnoid hemorrhage SAH and cerebral stroke. Hemorrhagic dissecting aneurysms of the anterior circulation have been considered to be somewhat different to those of the posterior circulation not only in terms of their pathophysiology, but also in terms of their management. Herewith our series of hemorrhagic dissecting aneurysms of the internal carotid artery ICA, vertebral artery VA, basilar artery BA and some of those of distal cerebral arteries is presented and compared to the series reported in the literature. Therapeutic consideration in the light of our experiences emphasizing the significance of aneurysm entrapment in combination with bypass surgery is presented.

MATERIAL AND METHODS

During the last 13 years over 1000 patients with cerebral aneurysms were treated surgically in our department. Hemorrhagic dissecting aneurysms were diagnosed in 26 patients. Diagnosis was based on neuroradiological findings as well as intraoperative findings. All patients underwent surgical intervention. Clinical findings of these patients were analysed retrospectively. Follow-up outcomes were evaluated according to the Glasgow Outcome Scale GOS at 3 months after treatments.

RESULTS

Location of 26 dissecting aneurysms was: ICA 11 cases (42%), VA 9 cases (35%), BA 3 cases, MCA 2 cases and PCA (P1 segment) one case. Primary surgical treatments were performed on day 3.7 of SAH on average. Clinical manifestation of dissecting aneurysms of the ICA and their outcome was more severe compared with those of the VA (p < 0.01): WNFS grade 3.1 vs 2.4 and GOS score 3.4 vs 4.3. As a conventional neck clipping procedure was problematic or impossible (aneurysm recurrence after clipping, premature rupture at the time of exposure or clipping), entrapment (or proximal ligation) plus EC-IC bypass procedure was the most frequent final definitive method of surgical treatment (9/26 35%: ICA 6/11, VA 1/9 and MCA 2/2) followed by proximal ligation or trapping only 7/26, neck clipping 7/26 and coating 4/26.

CONCLUSIONS

Hemorrhagic dissecting aneurysms still remain problematic in their diagnosis and treatment. One has to be aware of the diagnostic possibility of dissecting aneurysms as an etiology of SAH. Neurosurgeons have to be prepared to be able to manage complex surgical situations also by the use of EC-IC bypass, as its combination with entrapment procedure can be the final treatment of choice. Less invasive endovascular technique is in evolution but its availability and superiority are still to be settled.

Moyamoya angiopathy in Europe: the beginnings in Zurich, practical lessons learned, increasing awareness and future perspectives

The number of patients, especially children, diagnosed with Moyamoya angiopathy and being referred to us for treatment from all across Europe, has increased over the last few years. An increase in awareness of the occurrence of stroke in children in the general and medical population might be the main cause of this phenomenon. Increasing awareness does not happen "spontaneously" nor does it manifest overnight! It requires regular platforms of communication between the general population and amongst the different medical specialists mainly neurologists, paediatric neurologists, neuropsychologists, neuroradiologists, neurorehabilitation specialists, nursing staff and neurosurgeons. Presently we were lucky to conduct the first Moyamoya Symposium ever to be conducted at a European-Japanese level with participation of specialists of this particular field from across Europe and Japan. Ever since the first child with Moyamoya was managed at the University hospital in Zurich some 7 years ago the number of patients referred to us from all across Europe increased rapidly. The importance of interdisciplinary communication, trust and support amongst specialists and increasing the awareness of the disease among the patients, medical personnel was and remains to be just as important as making the correct diagnosis and treatment of choice in these patients. We present the lessons we learned during these previous years and look into the future perspectives that require our further and urgent attention.

Bonnet bypass in multiple cerebrovascular occlusive disease

The rationale and technique of the bonnet bypass procedure is discussed in two cases of multiple cerebrovascular occlusive disease.

METHOD

Cerebral revascularization was achieved using respectively a radial artery interposition graft and a brachiocephalic vein interposition graft to connect the contralateral STA with a cortical branch of the ipsilateral MCA.

FINDINGS

This alternate bypass technique proved to be an effective means of cerebral revascularization in selected cases where ipsilateral extracranial donor vessels were unavailable for classic STA-MCA bypass surgery.

CONCLUSION

Clinical and hemodynamic improvement can be achieved by a bonnet bypass in selected cases of multiple cerebrovascular occlusive disease. In addition to its previously described role in skull base tumor surgery, the procedure should therefore earn consideration in the treatment of cerebral ischemia and stroke prevention.

The radiological manifestations of intramuscular haemangiomas in adults: magnetic resonance imaging, computed tomography and ultrasound appearances

OBJECTIVE

Intramuscular haemangiomas in adults may appear similar to soft tissue sarcomas on imaging. This study evaluates the imaging characteristics of intramuscular haemangiomas on magnetic resonance imaging (MRI), computed tomography (CT) and ultrasound.

SUBJECTS AND METHODS

Retrospective review of medical records, imaging and pathology details of 34 patients presenting with intramuscular haemangiomas was performed. Age of patient, size, site of lesion and type of imaging was recorded. Lesions were evaluated for calcification, presence of fat, outline, texture, vascularity, enhancement and involvement of local structures.

RESULTS

There were 12 male and 22 female patients aged between 9 years and 90 years (mean 39 years). Twenty-two lesions involved muscles of the extremities and 12 involved muscles of the trunk. Mean duration of the lesions was long: 59.3 months (range 3-240 months), with an average size of 7.5 cm (1.5-15 cm). Imaging comprised 27 MR studies, seven CT scans, 19 ultrasounds, and eight plain films. All lesions were well defined, lobulated and heterogeneous. None showed local invasion. On MRI and CT, 93-100% showed the presence of fat and 100% showed vascular channels and enhancement on MRI, CT and ultrasound. Phleboliths were seen on four plain films (50%) and on the corresponding MR images. On MRI, 70% of lesions had mildly hyperintense signal on T1-weighted sequences and 96% had hyperintense signal on T2-weighted sequences (relative to skeletal muscle). Histopathology confirmed diagnosis in all cases, showing the presence of fat, medium/large vessels and skeletal muscle.

CONCLUSION

Intramuscular haemangiomas have characteristic appearances on MRI, CT and ultrasound. Long history, presence of fat, calcification and internal vessels should alert the radiologist to this diagnosis prior to biopsy.

Ultrasound changes in the extensor pollicis longus tendon following fractures of the distal radius--a preliminary report

Extensor pollicis longus tendon rupture occurs in 0.2% to 3% of fractures of the distal radius. The underlying mechanism, or mechanisms, of rupture are unknown. This study evaluated this tendon and its surrounding structures using high-resolution ultrasound in 62 patients with distal radius fracture at 6 weeks after injury. The uninjured wrist was examined as a control. The ultrasound measurements at 6 weeks were then correlated with the patients' presenting X-rays. Significant findings included a reduced peak velocity of tendon movement and an increased thickness of both the extensor retinaculum and the tendon sheath on the fractured side. In respect of tendon sheath thickness, these changes were particularly associated with intraarticular fractures. We postulate that the increased thickness of the EPL tendon sheath may further impair an already tenuous blood supply and/or affect the diffusion of nutrients to the tendon within the third extensor compartment, leading to tendon attrition and rupture.

System size, energy, pseudorapidity, and centrality dependence of elliptic flow

This Letter presents measurements of the elliptic flow of charged particles as a function of pseudorapidity and centrality from Cu-Cu collisions at 62.4 and 200 GeV using the PHOBOS detector at the Relativistic Heavy Ion Collider. The elliptic flow in Cu-Cu collisions is found to be significant even for the most central events. For comparison with the Au-Au results, it is found that the detailed way in which the collision geometry (eccentricity) is estimated is of critical importance when scaling out system-size effects. A new form of eccentricity, called the participant eccentricity, is introduced which yields a scaled elliptic flow in the Cu-Cu system that has the same relative magnitude and qualitative features as that in the Au-Au system.

Human papillomavirus in high- and low-risk areas of oesophageal squamous cell carcinoma in China

To examine the potential roles of human papillomavirus (HPV) in oesophageal squamous cell carcinoma (ESCC) development, we examined the presence of HPV DNA in paraffin-embedded ESCC tissues collected from two areas with different ESCC incidence rates in China, that is, Gansu (n=26) and Shandong (n=33), using PCR with SPF10 primers, or PCR with GP5+/GP6+ primers combined with Southern blot hybridisation. HPV genotype was determined by the INNO-LiPA HPV genotyping kit. HPV DNA was detected in 17 cases (65%) in Gansu, where ESCC incidence is much higher than in Shandong, where HPV was positive in two samples (6%). HPV genotypes 16 and 18 were detected in 79 and 16% of HPV-positive samples, respectively. Real-time PCR analysis suggested the presence of integrated form of HPV DNA in all the HPV-16-positive samples, but its viral load was estimated to be only <1–2 copies cell⁻¹. We could not detect HPV 16/18 E6 protein expression by immunostaining in any of the HPV-16-positive samples. Neither p16^INK4a nor p53 expression was related to HPV presence in ESCCs. Further studies seem warranted to examine the possible aetiological roles of HPV in ESCC.

High resolution ultrasound of ophthalmic patients in a tertiary hospital

The study was done to find out pathologic processes in ophthalmic patients in different age group to understand the use, role and limitations of ultrasonography in the diagnosis of ocular pathology in this locality. A prospective study was done on total 143 patients from September 2004 to January 2006 who attended Centre for Nuclear Medicine & Ultrasound, Mymensingh for ultrasound evaluation of eye. Total 100 (69.93%, n=100) cases were male and 43 (30.06%, n=43) cases were female. The age ranges were 2 months to 80 years. A variety of ocular pathology was diagnosed with the help of high resolution ultrasound (HRUS) with unique ultrasound appearance. Bulk of the referral patients had history of ocular trauma (38.46 %, n= 38) and most commonly detected pathology in these group are vitreous hemorrhage (34.44%, n=34) and cataract formation (28.28%, n=28). Almost all of the patients did not have conclusive diagnosis clinically and by conventional means available before ultrasonography were performed. High resolution sonography may be used as a valuable tool for evaluation of ophthalmic pathology as a well suited, noninvasive method, and only practical imaging modality for assessing those cases particularly when light conducting media are opaque.