Diabetes mellitus in coronary artery disease

Funding Acknowledgements

Type of funding sources: None.

Background

Morbidity and mortality are increased in patients with myocardial infarction that also have co-existing diabetes mellitus (DM) making it an important risk factor for coronary artery disease (CAD). Overall, diabetes mellitus worsens the prognosis in CAD patients.

Purpose

This paper was done from a study, that enabled us to measure the prevalence of diabetes mellitus in patients with coronary artery disease, in relevance to other CAD risk factors (age, gender, systolic blood pressure, LDL-C and smoking). These results would give us the ability to compare it with the outcomes of the EUROSPIRE IV study published in 2015 (1).

Methods

Retrospective observational study of consecutive patients from the Registry of Cyprus Heart Survey, examined in the Cardiology Clinic of Nicosia General Hospital, between the years 2011-14. The total number of patients was 371 (11.5% females and 88.4% males). These patients had a history of myocardial infarction and underwent either a PCI or a CABG.

Results

From the total amount of patients, 36.9% had history of diabetes mellitus. The percentage adjusted to gender shows that 44% of females and 35.6% of males included in the study had diabetes. The mean age of people that had diabetes and coronary artery disease was 68.65 (CI: 67.18, 70.12). The prevalence of diabetics with hypertension and coronary artery disease was 75.91% while the average systolic blood pressure (SBP) was 138 mmHg (CI: 135.33, 140.67). The systolic blood pressure was ≥140 mmHg in half of the diabetic individuals. Smoking was also assessed as a risk factor in patients with diabetes and CAD. The prevalence of ex-smokers was 28.46%, of smokers 18.24% and of non-smokers 53.28%. Finally, values of low density lipoprotein cholesterol (LDL-C) were measured in 90.5% of diabetic patients, 88.7% of them had an LDL-C ≥1.8 mmol/L (≥70mg/dL) and 53.22% had an LDL-C ≥2.5 mmol/L (≥100mg/dL). The average LDL-C value was 109.19 mg/dL.

Conclusions

The outcome of the study revealed that a substantial number of patients with CAD suffer from diabetes. Therefore, diabetes was verified as a major risk factor in patients with CAD and the development of acute coronary syndrome. Regarding those patients, other risk factors proved to have a negative impact on their cardiovascular health. Moreover, the risk factors in patients with DM and CAD of this study were compared with the well known study, EUROASPIRE IV (1). The prevalence of diabetes in the present study was 36.9%, compared to 26.8% in EUROASPIRE IV, indicating a higher prevalence in our study. We concluded that marked reduction in the events of myocardial infarction can be seen if we reduce the prevalence of uncontrolled diabetes mellitus occurrences with medication or better control of the risk factors of CAD early in the diagnosis to reduce complications.

Assessing the prevalence of hypertension in patients with chronic coronary artery disease in Cyprus

Funding Acknowledgements

Type of funding sources: None.

Introduction

Coronary Heart Disease (CHD) is the most common type of heart disease and a major cause of mortality worldwide, since according to CDC and WHO, it accounts for 18.2 million cases and 17.9 million deaths annually, respectively. Hypertension can precipitate the condition significantly, thus controlling it plays an important role in the secondary prevention of the disease.

Aim

The aim of this study is to highlight the significance of hypertension as a risk factor in patients with CAD, as well as, to compare its prevalence to those of the EUROASPIRE IV and the statistics published from the ESC Atlas of Cardiology in 2019.

Methods

A retrospective, observational study was created, from the Registry of Cyprus Heart Survey, where 375 individuals (88% Males, 66 years old on average) were examined in Nicosia General Hospital Cardiology Clinics with CAD, between the years 2011 and 2014. Their past medical history in regards to hypertension was noted and the data was analyzed by using Microsoft Excel software.

Results

The total prevalence of hypertension, based on the past medical history of the patients was 59% (females 61% and males 68%). Out of these, 44% still had abnormally elevated blood pressure on their visit to the Cardiology Clinic (females 36% and males 45%). Additionally, the EUROASPIRE IV study showed a prevalence of hypertension of 42.7% and ESC Atlas 24.8%, with median rates 22.3% for females and 27.0% for males. The total mean systolic blood pressure amongst all patients in our study was 136 mmHg, with no significant differences between males and females (136 mmHg and 137 mmHg respectively), while in ESC Atlas, the median SBP levels were noted to be 123.0mmHg in females and 130.0 in males.

Conclusion

Comparing the results from this group of consecutive patients from the Cyprus Heart Survey to the results of EUROASPIRE IV and ESC, it is made clear that all three studies point to the same conclusion. Firstly, it is important to acknowledge the difference between the two genders, with males recording a higher prevalence of hypertension. Moreover, despite the improvement observed in the management of hypertension that has been noted in our study, the secondary prevention guidelines are still not appropriately met. Managing appropriately hypertension, is of utmost importance in lowering the risk of recurrence of CAD in the context of secondary prevention measures.

Prevalence and impact of high BMI in CAD patients

Funding Acknowledgements

Type of funding sources: None.

Background

High body mass index (BMI) is a precursor to coronary artery disease (CAD) and an aggravator of the other co-existing CAD risk factors such as diabetes and hypertension. Lifestyle changes (e.g. balanced diet and exercise) in patients with high BMI are usually overlooked, although they contribute positively to prevention and improvement of CAD.

Purpose

The aim of this study is to calculate the prevalence of overweight and obesity in known CAD patients in both genders, in correlation with diabetes, hypertension, exercise and diet in CAD patients and to compare the findings to EUROASPIRE IV conducted in 2015 (1).

Methods

This study retrospectively included 362 patients (88% male; mean age 67 years) with a history of CAD (MI, PCI or CABG) from the registry of Cyprus heart survey in a hospital, in Nicosia from 2011 to 2014. Age, gender, date of myocardial infarction event, date of PCI or CABG surgery as well as CAD risk factors such as BMI, exercise, diet, hypertension and diabetes were noted on their visit to the cardiac clinic.

Results

Our study showed an overall similarity in BMI prevalence across both genders. The prevalence increased from 17.7% in patients with normal BMI (18.5-24.9) to the highest CAD prevalence of 49.2% which was seen in overweight (BMI = 25 –29.9) patients. However, there was a drop in the prevalence of obese (BMI = 30+) patients to 32.9%. This is supported by EUROASPIRE IV (1) which highlighted that CAD prevalence was higher in overweight patients (male = 83%; female = 80%) than obese patients (male = 36%; female = 44%) by nearly 2-fold. Furthermore, within the higher-than-normal BMIs, we recognized more non-diabetic CAD patients (115 overweight; 67 obese) in our study than diabetic CAD patients (62 overweight; 55 obese). On the contrary, hypertensive CAD patients (106 overweight; 80 obese) were more frequent than non-hypertensive CAD patients (71 overweight; 43 obese). Overweight patients split in nearly half when it came to exercise and diet (96 exercise, 82 do not; 90 diet, 88 do not). While in obese patients there was a higher proportion of patients not exercising or following a diet (47 exercise, 72 do not; 32 diet, 87 do not). According to EUROASPIRE IV (1), obesity contributed to higher prevalence of diabetes as patients did not lose weight.

Conclusion

Overweight and obese patients make up a large percentage of CAD patients. High BMI had a negative additive effect with hypertension but not with diabetes on the risk prevention in CAD patients which mismatches with the EUROASPIRE IV (1) findings. Despite BMI being a modifiable risk factor, not adhering to a diet or exercise was noticed in overweight and obese patients, which in return weakens their prevention of CAD.

Mechanical Properties of Low-Performance Concrete (LPC) and Shear Capacity of Old Unreinforced LPC Squat Walls

Low-performance concrete (LPC) is characterized by its low strength and commonly by the presence of large aggregates. This type of concrete was used for construction of load carrying, commonly unreinforced walls in old buildings. The resistance of these buildings with LPC squat walls (of relatively low height-to-length ratio), to in plane horizontal loads, was experimentally investigated in this study. The low compressive strength of these walls, well below that of standard concrete, requires estimation of the relation between the actual LPC compressive strength and its tensile strength, and identification of their failure mode and corresponding shear capacity when subjected to in plane horizontal loads. In this study, compressive and splitting tensile strengths of authentic LPC specimens were measured, and based on them, a relation between the compressive and tensile strengths is proposed. Then, diagonal compression tests were performed on authentic LPC specimens, as well as specimens made of standard concrete. These tests yielded the expected mode of failure of vertical cracking and their analysis shows that their shear capacity needs to be evaluated based on their tensile strength (rather than the flexural shear capacity of unreinforced concrete beams). Thus, the load-bearing (both horizontal and gravitational) capacity to prevent diagonal tension failure of an unreinforced LPC wall can be evaluated by comparing the LPC tensile strength to the major principal stress caused by the load. Assessment of the tensile strength can be based on the relation between the compressive and tensile strengths proposed in this work.

Acoustic Emission Monitoring of High-Strength Concrete Columns Subjected to Compressive Axial Loading

Acoustic Emission (AE) nondestructive tests have attracted great interest for their use in the determination of structural properties and behavior of reinforced concrete (RC) elements. One of the applications this method can contribute to is in high-strength concrete (HSC) columns. These elements have a great advantage in the lower stories of high-rise buildings. However, the premature failure of the concrete cover and the brittleness nature of the failure is of a concern for engineers. This paper presents a study on the AE monitoring of HSC columns subjected to compressive axial loading. The study consists of four large-scale reinforced HSC columns with different confinement reinforcement and height. It is shown that the AE distributions in the columns are categorized by three stages. Moreover, the levels of loads reached at the first AE macro event are similar to the lower range levels of the nominal axial compressive strengths of the tested specimens, while the majority of macro AE events are located at the concrete cover. Based on the results of this study, AE monitoring can provide indications for the damage and load levels attained by reinforced high-strength concrete columns subjected to compressive axial loading.

Serum RANKL, osteoprotegerin (OPG) and RANKL/OPG ratio in children with systemic lupus erythematosus

Background

Systemic lupus erythematosus (SLE) patients have lower bone mineral density (BMD) compared with healthy individuals because of general, genetic, disease and medication-related factors. The disturbance of the receptor activator of nuclear factor-κB ligand (RANKL)/osteoprotegerin (OPG) ratio has been reported to be associated with low BMD in many disorders in adults and children alike.

Objectives

The objectives of this study were (i) to assess serum OPG, RANKL and RANKL/OPG ratio levels in SLE children and controls, (ii) to determine whether the cumulative glucocorticoid (CGCS) dose had any effect on the concentration of serum RANKL, OPG and RANKL/OPG ratio, and (iii) to determine the relation of these parameters to BMD.

Methods

We evaluated 50 SLE children and 50 age- and sex-matched healthy controls. RANKL and OPG were assessed in serum and compared between patients and controls. For SLE patients, a univariate followed by multivariable analysis were carried out to detect the possible predictors of the changes in RANKL, OPG and RANKL/OPG ratio levels. Lumbar BMD for all patients was assessed by dual-energy X-ray absorptiometry (DXA) scan and then correlated to different probable correlated factors.

Results

RANKL, OPG and RANKL/OPG ratio were significantly higher in SLE patients ( p ≤ 0.001). Univariate analysis showed significant correlations of RANKL with CGCS ( p ≤ 0.001) and with DXA scan z-score ( p = 0.007): OPG was significantly correlated to Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score ( p = 0.001) and anti-double-stranded DNA ( p = 0.001), whereas RANKL/OPG was significantly correlated to duration of illness and DXA z-score ( p = 0.002). The multivariable analysis showed that DXA z-score was an independent predictor of RANKL and RANKL/OPG ratio ( p = 0.019 and 0.008, respectively), whereas SLEDAI score was an independent predictor of OPG levels. BMD was negatively correlated to disease duration ( p = 0.008) and CGCS dose ( p = 0.015), but no significant correlation has been found between BMD and cumulative SLEDAI score ( p = 0.29).

Conclusions

Serum RANKL/OPG ratio is elevated in Egyptian children with SLE and is considered a risk factor for reduced bone mass in these children. Other risk factors for low BMD include high CGCS dose and disease duration, supporting that osteoporosis in SLE is multifactorial.

Interferon regulatory factor 5 gene polymorphism in Egyptian children with systemic lupus erythematosus

Background

Increased expression of interferon-inducible genes is implicated in the pathogenesis of systemic lupus erythematosus (SLE). Interferon regulatory factor 5 (IRF5) is one of the transcription factors regulating interferon and was proved to be implicated in the pathogenesis of SLE in different populations.

Objectives

The objective of this study was to investigate the correlation between polymorphisms of the IRF5 gene and SLE susceptibility in a cohort of Egyptian children and to investigate their association with clinico-pathological features, especially lupus nephritis.

Subjects and methods

Typing of interferon regulatory factor 5 rs10954213, rs2004640 and rs2280714 polymorphisms were done using polymerase chain reaction-restriction fragment length polymorphism for 100 children with SLE and 100 matched healthy controls.

Results

Children with SLE had more frequent T allele and TT genotype of rs2004640 ( Pc = 0.003 and 0.024, respectively) compared to controls. Patients with nephritis had more frequent T allele of rs2004640 compared to controls ( Pc = 0.003). However the allele and genotype frequencies of the three studied polymorphisms did not show any difference in patients with nephritis in comparison to those without nephritis. Haplotype GTA of rs10954213, rs2004640 and rs2280714, respectively, was more frequent in lupus patients in comparison to controls ( p = 0.01) while the haplotype GGG was more frequent in controls than lupus patients ( p = 0.011).

Conclusion

The rs2004640 T allele and TT genotype and GTA haplotype of rs rs10954213, rs2004640, and rs2280714, respectively, can be considered as risk factors for the development of SLE. The presence of the rs2004640 T allele increases the risk of nephritis development in Egyptian children with SLE.

Chemotherapy-induced differentiation to cure botryoid rhabdomyosarcoma: a case report and review of the literature

Rhabdomyosarcoma (RMS) occurs rarely in adults and constitutes 2-6% of all uterine neoplasms. The authors report the case of a 26-year-old woman diagnosed with botryoid RMS that presented discordant progression results on follow up imaging and cytodifferentiation on pathologic control. This case showed that radiological evaluation could be misleading as the tumor demonstrated chemotherapy-induced differentiation without volume reduction. This case illustrates the limitations of using the imaging anatomical dimensions of sarcomas for treatment planning and highlights the potential role of functional imaging to assess the response to treatment.

The emergence of systemic lupus erythematosus in hypothyroid patients: two case reports and mini review

Systemic lupus erythematosus (SLE) is a multi-systemic autoimmune disease that involves almost all the organs in the human body and is characterized by auto antibodies formation. Autoimmune thyroid diseases (AITD) are organ-specific diseases that are associated with a production of a variety of antibodies such as antinuclear antibodies, anti-double-stranded DNA, anti-Ro antibodies, anti-cardiolipin antibodies, and others. The diagnosis of AITD in patients with SLE is well known, but the reverse is rarely reported. We present two cases of adolescent girls in whom SLE evolved one year after being diagnosed with hypothyroidism.

Hermansky-Pudlak syndrome with colitis and pulmonary fibrosis

Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessively inherited disease with oculocutaneous albinism, hemorrhagic diathesis, and multisystemic deposition of ceroid lipofuscin. We report a case with all symptoms characteristic of HPS. The patient was a mentally retarded albino with mild bleeding diathesis, and her course was complicated by granulomatous colitis refractory to medical treatment and progressive, fatal pulmonary fibrosis.

The limb/LPM enhancer of the murine Hoxb6 gene: reporter gene analysis in transgenic embryos and studies of DNA-protein interactions

Homeobox genes are expressed in stage-, region-, and tissue-specific patterns during embryonic development of the mouse. In order to study cis-acting regulatory elements of murine homeobox genes, transgenic mouse embryos were generated which contained the LacZ reporter gene under the control of different fragments from the murine Hoxb6 gene. A 2 kb limb/LPM (lateral plate mesoderm) enhancer region was identified which reproduced several aspects of the endogenous Hoxb6 gene expression pattern in the mesenchyme of the developing limb buds and the ventro-lateral body region. Both tissues represent derivatives of the lateral plate mesoderm. In order to describe proteins interacting with specific DNA sequences in the limb/LPM enhancer, electro mobility shift assays were performed using nuclear extracts prepared from embryonic tissues. Several specific DNA-protein complexes could be detected, suggesting that these DNA-protein interactions are important for the regulation of Hoxb6 gene expression.

Conserved regulatory element involved in the early onset of Hoxb6 gene expression

We have identified a 338 bp DNA fragment, the lateral plate mesoderm (LPM) enhancer, that is highly conserved between mouse and human. The LPM enhancer directs gene expression into the posterior lateral plate mesoderm and hindgut endoderm at early stages of development. By reporter gene analysis in transgenic mice, we demonstrate that both mouse and human DNA sequences possess similar enhancer activity. The expression patterns of the transgene and Hoxb6 during early stages of mouse development are identical, suggesting that the LPM enhancer is involved in the initial activation of Hoxb6 gene expression in posterior regions of mammalian embryos.

Stage-specific gene expression in asynchronous tetraploid mouse embryos formed by fusion of blastomeres and fertilized eggs

Asynchronous tetraploid mouse embryos were generated by electrofusion of fertilized eggs with blastomeres from different cleavage stages. The majority of the cytoplasm was always contributed by the egg. The best development was observed when eggs were fused with 2-cell blastomeres. Both genomes became active in fusion embryos (at least the genes for glucose phosphate isomerase did). Stage-specific protein synthesis seemed to be more adjusted to the developmental stage of the egg's than of the blastomere's genome, but at the 2-cell stage both contributed slightly differently to the protein patterns. Also, the time range of the first appearance of the stage-specific embryonic antigen SSEA-1 was wider in fusion embryos than in controls. It seems that the two genomes are not completely synchronized in these tetraploid embryos, a further indication that, in the mouse, the cytoplasm of fertilized eggs might not be compatible with older embryonic nuclei.

Analysis of LacZ reporter genes in transgenic embryos suggests the presence of several cis-acting regulatory elements in the murine Hoxb-6 gene

Homeobox genes are expressed in stage-, region-, and tissue-specific patterns during embryonic development of the mouse. In order to understand the underlying regulatory mechanisms the murine homeobox gene Hoxb-6 was analyzed for the presence of cis-acting regulatory elements. Transgenic mouse embryos and lines were generated which contained the LacZ reporter gene under the control of different fragments from the Hoxb-6 gene. In total, 13.2 kb of genomic DNA covering the entire Hoxb-6 region were analyzed. Our results suggested the presence of three regulatory regions in the Hoxb-6 gene: a limb/LPM element which directed gene expression into restricted regions of the developing limb buds and the ventro-lateral and visceral mesenchyme, a regulatory element required for gene expression into ventral regions of the developing spinal cord, and a third element necessary for directing gene expression into developing mesonephric tubules and mesonephric ducts. We demonstrated that the limb/LPM element functions as an enhancer in a promoter- and orientation-independent manner. The comparison of the expression patterns of the reporter gene constructs and the endogenous Hoxb-6 gene revealed that the regulatory regions were able to reproduce part of the Hoxb-6 pattern. However, not all control elements necessary to completely mimic the endogenous Hoxb-6 expression pattern could be detected, although the entire Hoxb-6 genomic region has been analyzed. These observations suggest that for some aspects of Hoxb-6 gene regulation the integrity of large genomic regions of the Hoxb cluster is required.

A regulatory region from the mouse Hox-2.2 promoter directs gene expression into developing limbs

To characterize cis-acting regulatory elements of the murine homeobox gene, Hox-2.2, transgenic mouse lines were generated that contained the LacZ reporter gene under the control of different fragments from the presumptive Hox-2.2 promoter. A promoter region of 3600 base pairs (bp) was identified, which reproducibly directed reporter gene expression into specific regions of developing mouse embryos. At 8.5 days postcoitum (p.c.) reporter gene activity was detected in posterior regions of the lateral mesoderm and, in subsequent developmental stages, expression of the LacZ gene was restricted to specific regions of the developing limb buds and the mesenchyme of the ventrolateral body region. This pattern of Hox-2.2-LacZ expression was found in all transgenic embryos that have been generated with the 3.6 kb promoter fragment (two founder embryos and embryos from five transgenic lines). In addition, embryos from two transgenic mouse lines expressed the reporter gene at low levels in the developing central nervous system (CNS). Our results are consistent with the idea that in addition to their presumptive role in CNS and vertebrae development, Hox-2.2 gene products are involved in controlling pattern formation in developing limbs.