Importance of risk factor management in diabetic patients and reduction in Stage B heart failure

BACKGROUND

A number of studies have demonstrated the presence of a diabetic cardiomyopathy, increasing the risk of heart failure development in this population. Improvements in present-day risk factor control may have modified the risk of diabetes-associated cardiomyopathy.

AIM

We sought to determine the contemporary impact of diabetes mellitus (DM) on the prevalence of cardiomyopathy in at-risk patients with and without adjustment for risk factor control.

DESIGN

A cross-sectional study in a population at risk for heart failure.

METHODS

Those with diabetes were compared to those with other cardiovascular risk factors, unmatched, matched for age and gender and then matched for age, gender, body mass index, systolic blood pressure and low density lipoprotein cholesterol.

RESULTS

In total, 1399 patients enrolled in the St Vincent's Screening to Prevent Heart Failure (STOP-HF) cohort were included. About 543 participants had an established history of DM. In the whole sample, Stage B heart failure (asymptomatic cardiomyopathy) was not found more frequently among the diabetic cohort compared to those without diabetes [113 (20.8%) vs. 154 (18.0%), P = 0.22], even when matched for age and gender. When controlling for these risk factors and risk factor control Stage B was found to be more prevalent in those with diabetes [88 (22.2%)] compared to those without diabetes [65 (16.4%), P = 0.048].

CONCLUSION

In this cohort of patients with established risk factors for Stage B heart failure superior risk factor management among the diabetic population appears to dilute the independent diabetic insult to left ventricular structure and function, underlining the importance and benefit of effective risk factor control in this population on cardiovascular outcomes.

Post-operative bilateral adrenal haemorrhage: A case report

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An unusual complication of intra-abdominal sepsis.

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A demonstration of diagnostic difficulty in the post-operative patient.

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A variation from the normal electrolyte profile observed in adrenal insufficiency.

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Highlights the clinical importance of a high index of suspicion for further investigation of ‘on-ward’ electrolyte abnormalities.

INTRODUCTION

Bilateral adrenal haemorrhage is a rare, but serious, illness carrying an estimated 15% mortality.^1,2 The majority of cases occur in patients with acute, stressful illness, however the exact mechanism underlying adrenal haemorrhage remains unclear. This medical emergency carries significant diagnostic difficulty⁴ with non-specific clinical symptoms and variations in electrolyte abnormalities. Timely treatment is important as it prevents both the acute and long-term sequelae of adrenal failure.

PRESENTATION OF CASE

This report describes a medical emergency in a surgical patient following emergency surgery for intra-abdominal sepsis. The patient reported non-specific symptoms of confusion, mild pyrexia and vague abdominal pain during the post-operative phase, with subtle electrolyte abnormalities and a low serum cortisol suggestive of adrenal crisis. Timely medical treatment, with intravenous hydrocortisone and intensive monitoring, and appropriate medical follow-up with addition of long-term fludrocortisone resulted in a satisfactory outcome.

DISCUSSION

This report describes a potentially life-threatening complication of intra-abdominal sepsis with adrenal crisis secondary to bilateral adrenal haemorrhage. In particular, this case highlights the diagnostic difficulty in such surgical patients due to vague symptoms and, in this case, the presence of a presentation variant with acute hyponatraemia and normal potassium.

CONCLUSION

This case highlights the importance of awareness of both the symptoms and signs and variation in electrolyte profile when assessing surgical patients post-operatively. In addition, this case highlights the benefit of early recognition and initiation of treatment and the importance of follow-up as long-term medical management is often required to prevent further relapse.

Proliferation, differentiation and amyloid-β production in neural progenitor cells isolated from TgCRND8 mice

The amyloid precursor protein (APP) and amyloid-β (Aβ) peptide play central roles in the pathology and etiology of Alzheimer's disease. Amyloid-induced impairments in neurogenesis have been investigated in several transgenic mouse models but the mechanism of action remains to be conclusively demonstrated. The changes in neurogenesis during this transition of increasing Aβ levels and plaque formation were investigated in the present study. We found that the proliferation of newborn cell in the dentate gyrus was enhanced prior to elevations in soluble Aβ production as well as amyloid deposition in 5-week-old TgCRND8 mice, which are well-established Alzheimer's disease models, compared to non-transgenic (Non-Tg) mice. The number of BrdU-positive cells remained higher in TgCRND8 vs Non-Tg mice for a period of 8weeks. The numbers of BrdU/NeuN-positive cells were not significantly different in TgCRND8 compared to Non-Tg mice. A significant decrease in BrdU/GFAP but not in BrdU/S100β was found in Tg vs Non-Tg at 6-weeks of age. In addition, a unique observation was made using isolated neuroprogenitor cells from TgCRND8 mice which were found to be less viable in culture and produced substantial amounts of secreted Aβ peptides. This suggests that the proliferation of neural progenitors in vivo may be modulated by high levels of APP expression and the resulting Aβ generated directly by the progenitor cells. These findings indicate that cell proliferation is increased prior to Aβ deposition and that cell viability is decreased in TgCRND8 mice over time.

Ultrasound in regional anaesthesia

Ultrasound guidance is rapidly becoming the gold standard for regional anaesthesia. There is an ever growing weight of evidence, matched with improving technology, to show that the use of ultrasound has significant benefits over conventional techniques, such as nerve stimulation and loss of resistance. The improved safety and efficacy that ultrasound brings to regional anaesthesia will help promote its use and realise the benefits that regional anaesthesia has over general anaesthesia, such as decreased morbidity and mortality, superior postoperative analgesia, cost-effectiveness, decreased postoperative complications and an improved postoperative course. In this review we consider the evidence behind the improved safety and efficacy of ultrasound-guided regional anaesthesia, before discussing its use in pain medicine, paediatrics and in the facilitation of neuraxial blockade. The Achilles' heel of ultrasound-guided regional anaesthesia is that anaesthetists are far more familiar with providing general anaesthesia, which in most cases requires skills that are achieved faster and more reliably. To this ends we go on to provide practical advice on ultrasound-guided techniques and the introduction of ultrasound into a department.

Intramuscular interferon beta-1a in chronic inflammatory demyelinating polyradiculoneuropathy

OBJECTIVE

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) shares immunologic features with multiple sclerosis (MS). Because IM interferon beta-1a (IM IFNbeta-1a) is an effective and safe treatment for MS, we conducted a dose-ranging efficacy study of IFNbeta-1a in patients with CIDP.

METHODS

Adults with IV immunoglobulin (IVIg)-dependent CIDP (n = 67) were enrolled in this 32-week double-blind trial and randomized to IM IFNbeta-1a. Patients received 30 microg once weekly plus placebo (n = 12), IM IFNbeta-1a 60 microg once weekly plus placebo (n = 11), IM IFNbeta-1a 30 microg twice weekly (n = 11), IM IFNbeta-1a 60 microg twice weekly (n = 11), or placebo twice weekly (n = 22). Participants were maintained on IVIg through week 16, when IVIg was discontinued. Patients who worsened were restarted on IVIg. The primary outcome was total IVIg dose (g/kg) administered from week 16 to 32.

RESULTS

There was no difference in total IVIg dose administered after week 16 for patients treated with IFNbeta-1a (1.20 g/kg) compared with placebo (1.34 g/kg; p = 0.75). However, exploratory analyses suggested IFNbeta-1a significantly reduced total dose of IVIg compared with placebo for participants who required either high-dose IVIg (>0.95 g/kg per month) or had greater weakness at baseline (Medical Research Council sum score <51). Adverse events included flu-like symptoms, headache, and fatigue in the IFNbeta-1a groups.

CONCLUSIONS

Interferon beta-1a (IFNbeta-1a) therapy did not provide significant benefit over IV immunoglobulin (IVIg) therapy alone for patients with chronic inflammatory demyelinating polyradiculoneuropathy. However, IFNbeta-1a might be beneficial for patients with more severe disability or those needing high doses of IVIg.

LEVEL OF EVIDENCE

This study was designed to provide Class I evidence for the safety and efficacy of IM IFNbeta-1a in the treatment of CIDP but has been subsequently classified as Class II due to a >20% patient dropout rate. Thus, this randomized, controlled clinical trial provides Class II evidence of no effect on primary and secondary endpoints of 4 dosage regimens of IM IFNbeta-1a added to IVIg in persons with CIDP.