Late diagnosis of coarctation of the aorta in a 44-year-old male: a case report

Background Coarctation of the aorta is a rare congenital disease. In adults, the main manifestations include hypertension, weak or absent femoral pulses, heart failure, and left ventricular hypertrophy. Case presentation We present a case involving a late diagnosis of coarctation of the aorta detected during aortography in a 44-year-old man. The patient underwent stent implantation and aortoplasty. After 2 years of follow-up, the patient was in good condition. Conclusions This case shows that coarctation of the aorta can be cured and that hypertension caused by the condition can be controlled to some extent with medication. Based on our findings, we recommend a detailed physical examination for all patients suspected of having coarctation of the aorta; the examination should include blood pressure measurements of both the upper and lower extremities. The case of coarctation of the aorta is not common or easy to be found in medium-aged population. Better BP control, earlier repair, and transcatheter intervention may result in a good outcome in that case.

Just the Facts: Diagnosis and management of small bowel obstruction

A 63-year-old female patient presents with abdominal pain, vomiting, and abdominal distention. She has previously had a cholecystectomy and hysterectomy. She has had no prior similar episodes, and denies fever, hematemesis, or diarrhea. She takes no medications. Vital signs include blood pressure 123/61 mm Hg, heart rate 97, oral temperature 37.2°C, respiratory rate 18, oxygen saturation 97% on room air. Her abdomen is diffusely tender and distended.

Renal Benefits of SGLT 2 Inhibitors and GLP-1 Receptor Agonists: Evidence Supporting a Paradigm Shift in the Medical Management of Type 2 Diabetes

Diabetic nephropathy (DN) is one of the most perilous side effects of diabetes mellitus type 1 and type 2 (T1DM and T2DM).). It is known that sodium/glucose cotransporter 2 inhibitors (SGLT 2i) and glucagone like peptide-1 receptor agonists (GLP-1 RAs) have renoprotective effects, but the molecular mechanisms are still unknown. In clinical trials GLP-1 analogs exerted important impact on renal composite outcomes, primarily on macroalbuminuria, possibly through suppression of inflammation-related pathways, however enhancement of natriuresis and diuresis is also one of possible mechanisms of nephroprotection. Dapagliflozin, canagliflozin, and empagliflozin are SGLT2i drugs, useful in reducing hyperglycemia and in their potential renoprotective mechanisms, which include blood pressure control, body weight loss, intraglomerular pressure reduction, and a decrease in urinary proximal tubular injury biomarkers. In this review we have discussed the potential synergistic and/or additive effects of GLP 1 RA and SGLT2 inhibitors on the primary onset and progression of kidney disease, and the potential implications on current guidelines of diabetes type 2 management.

Parameters to Be Measured during Exercise

The chapter Parameters to be Measured During Exercise reviews the physiologic changes with exercise which indicate health and disease. Key parameters include blood pressure, heart rate, electrocardiographic changes, exercise duration, maximum oxygen uptake (VO2max), and anaerobic threshold. An in-depth review and consensus estimate is provided to estimate metabolic equivalents (METs) achieved based on exercise duration on the Bruce and Ellestad protocols. Use of bipolar leads for detection of exercise induced myocardial ischemia is discussed, typified by CM5 which captures up to 90% of patients with an electrocardiographic manifestation of ischemia. Changes in murmurs that occur with exercise are reviewed; walk-through angina and chronotropic incompetence.

Riwayat Hipertensi Keluarga Sebagai Faktor Dominan Hipertensi pada Remaja Kelas XI SMA Sejahtera 1 Depok Tahun 2017

Nutritional status changes, diet, and lifestyle are risk factors adolescent’s hypertension. This study isa cross sectional research to determine the most dominant factor of hypertension among adolescentsat SMA Sejahtera 1 Depok 2017. Collected data include blood pressure, nutritional status (BMI forage), intake nutrients (sodium, potassium, calcium, fat, fruits and vegetables consumption), lifestyle(sleep duration, stress, and physical activity), and adolescent characteristics (sex and family historyof hypertension). Blood pressure was measured using mercury sphygmomanometer, nutritional statuswith anthropometry, nutrient intake with Semi Quantitative FFQ, lifestyle and characteristics withquestionnaire. The study showed that 42.4% of adolescents had hypertension (≥95 percentile). Factorsassociated with hypertension were BMI for age and family history of hypertension. The most dominantfactor associated with hypertension was family history of hypertension. Education on genetic relatedrisk factors of hypertension such as genetic counseling through Health School Program was needed forprevent adolescent’s hypertension, so that students with a family history of hypertension may be moreconcerned about other risk factors such as nutritional status.Keywords : adolescent, family history of hypertension, hypertension AbstrakPerubahan status gizi, pola makan dan gaya hidup pada remaja merupakan faktor risiko hipertensi remaja.Penelitian ini merupakan penelitian cross sectional untuk mengetahui faktor dominan hipertensi padaremaja di SMA Sejahtera 1 Depok tahun 2017. Data yang dikumpulkan meliputi tekanan darah, statusgizi (IMT/U), asupan zat gizi (natrium, kalium, kalsium, lemak, konsumsi buah dan sayur), pola hidup(durasi tidur, stres, aktivitas fisik), dan karakteristik remaja (jenis kelamin dan riwayat hipertensi keluarga).Tekanan darah diukur menggunakan sfigmomanometer air raksa, status gizi dengan antropometri,asupan zat gizidengan Semi Quantitative FFQ, pola hidup dan karakteristik dengan kuesioner. Hasilpenelitian menunjukkan bahwa sebanyak 42,4% remaja SMA Sejahtera 1 Depok mengalami hipertensi(≥95 persentil). Terdapat hubungan IMT/U dan riwayat hipertensi keluarga pada hipertensi remajanya.Faktor dominan yang paling berhubungan dengan hipertensi pada remaja di SMA Sejahtera 1 Depoktahun 2017 adalah riwayat hipertensi keluarga. Diperlukan edukasi seperti kegiatan konseling genetikmelalui UKS (Usaha Kesehatan Sekolah) tentang faktor risiko riwayat hipertensi keluarga sebagaipencegahan hipertensi remaja, sehingga bagi siswa yang memiliki riwayat hipertensi keluarga dapat lebihmemperhatikan faktor risiko lainnya seperti status gizi.Kata kunci: hipertensi, remaja, riwayat hipertensi keluarga

Cardiovascular complications of novel kinase inhibitors

Tyrosine and serine kinase inhibitors are new cancer therapies which have revolutionized the field of modern oncology and have transformed previously fatal conditions such as chronic myeloid leukaemia into treatable chronic diseases. The cardiovascular complications related to kinase inhibitor treatments have emerged and the importance of effective cardiovascular management is becoming clear. Precise cardiovascular toxicity profiles vary among different classes of kinase inhibitors and between different specific agents. The most important cardiovascular complications of these kinase inhibitors include hypertension, heart failure, arterial thromboembolic disease, QT prolongation, and pulmonary hypertension. The aim of effective cardiovascular management in this setting should be to minimize the impact of toxicities to facilitate the continuation of these highly effective cancer treatments. It is key to perform a thorough baseline cardiovascular risk assessment prior to commencing treatment so that reversible risk factors are identified and addressed appropriately. Preliminary assessment should, at a minimum, include blood pressure measurement, serum creatinine, lipid profile and fasting glucose, and a resting electrocardiogram. Additionally, in selected high-risk patients or those starting high-risk kinase inhibitors, baseline assessment of left ventricular function can also be helpful. Effective risk stratification will allow appropriate, individualized surveillance to be arranged for each patient in order to identify complications early and manage them effectively. When significant cardiovascular complications occur, decisions regarding the need to suspend or discontinue potentially life-prolonging treatments are exceptionally challenging and the input of the multidisciplinary team in this setting and communication between the cardiologists and the oncologists or haemato-oncologists is invaluable.

Ambulance-delivered transdermal glyceryl trinitrate versus sham for ultra-acute stroke: Rationale, design and protocol for the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) trial (ISRCTN26986053)

Rationale Vascular nitric oxide levels are low in acute stroke and donors such as glyceryl trinitrate have shown promise when administered very early after stroke. Potential mechanisms of action include augmentation of cerebral reperfusion, thrombolysis and thrombectomy, lowering blood pressure, and cytoprotection. Aim To test the safety and efficacy of four days of transdermal glyceryl trinitrate (5 mg/day) versus sham in patients with ultra-acute presumed stroke who are recruited by paramedics prior to hospital presentation. Sample size estimates The sample size of 850 patients will allow a shift in the modified Rankin Scale with odds ratio 0.70 (glyceryl trinitrate versus sham, ordinal logistic regression) to be detected with 90% power at 5% significance (two-sided). Design The Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) is a multicentre UK prospective randomized sham-controlled outcome-blinded parallel-group trial in 850 patients with ultra-acute (≤4 h of onset) FAST-positive presumed stroke and systolic blood pressure ≥120 mmHg who present to the ambulance service following a 999 emergency call. Data collection is performed via a secure internet site with real-time data validation. Study outcomes The primary outcome is the modified Rankin Scale measured centrally by telephone at 90 days and masked to treatment. Secondary outcomes include: blood pressure, impairment, recurrence, dysphagia, neuroimaging markers of the acute lesion including vessel patency, discharge disposition, length of stay, death, cognition, quality of life, and mood. Neuroimaging and serious adverse events are adjudicated blinded to treatment. Discussion RIGHT-2 has recruited more than 500 participants from seven UK ambulance services. Status Trial is ongoing. Funding British Heart Foundation. Registration ISRCTN26986053.

Evolution of patients with heart disease after cardiopulmonary rehabilitation program: case report

Introduction: Recovery and maintenance of patients suffering from heart and respiratory diseases using the cardiopulmonary rehabilitation program (CPRP) help maintain their functionality and improve the activities of daily living (ADLs) carried out according to their functional limitations. Objective: To investigate the efficacy of a CPRP in a patient with cardiopulmonary disease, following a 5-month training program. Methods: A 66-year-old female patient, body weight 78 kg, height 1.55 m, diagnosed with acute myocardial infarction and bronchial asthma underwent a six-minute walk test (6MWT) to measure exercise tolerance; the Wells Bench was used to measure the flexibility of the posterior chain and lower limbs (LL), and a hand-held dynamometer (HHD) was used to measure upper limb strength (ULS).Vital sign measurements include blood pressure (BP), heart rate (HR), respiratory rate (RR), oxygen saturation (SpO2) as well as dyspnea and LL fatigue (modified Borg scale) at rest, during and after 5-month CPRP. Results: An increase of 145 meters during the cardiopulmonary rehabilitation program i.e. 30% of walk distance (WD) in the 6MWT (pre = 345, post = 490m). There was an increase of 32% in flexibility (pre = 13, post = 19cm); in right upper limb (pre = 26, post = 60 kgf) and left lower limb strength (pre = 28, post = 72kgf), there was an increase of 57% and 61%, respectively. Conclusion: The CPRP proved to be effective in increasing exercise capacity, upper limb strength and flexibility of the posterior chain and lower limbs.

Evaluation of the Tolerability of Intermittent Intravenous Sildenafil in Pediatric Patients With Pulmonary Hypertension

OBJECTIVES: The primary purpose of this study was to determine the tolerability of intermittent intravenous (IV) sildenafil for the treatment of pulmonary hypertension in pediatric patients. Secondary objectives were to evaluate parameters related to efficacy. METHODS: This was a retrospective chart review from January 2013 to August 2014 of pediatric patients under age 18 years treated with intermittent doses of IV sildenafil for pulmonary hypertension. Patients were excluded if they were over age 18 years or received sildenafil for other indications. Measures collected to assess tolerability include blood pressure and heart rate before and after the administration of IV sildenafil, as well as adverse events. RESULTS: Thirty-seven patients (21 females and 16 males) were identified meeting inclusion criteria, and 21 (56.8%) were on oral sildenafil prior to the initial IV dose. The mean decrease in blood pressure after the first dose of IV sildenafil was 7.16/2.74 mmHg. The decrease in systolic blood pressure was statistically significant. During the study period, 5 patients experienced medication related adverse events, primarily hypotension. Despite this, none of the patients had the medication discontinued due to these events. For secondary objectives, a statistically significant difference was not found between other clinical measures before and after intermittent IV sildenafil dosing. CONCLUSIONS: Sildenafil, when administered as intermittent IV doses, was tolerated by the majority of patients evaluated in this study. For pediatric patients with pulmonary hypertension in whom enteral or continuous IV sildenafil cannot be administered, intermittent IV sildenafil may be considered as an alternative administration option.

Patient Outcome in Pregnancy Requiring Dialysis: A Case Series

The optimal management of pregnant dialysis patients remains a great challenge for nephrologists, end-stage renal disease being a predictor of adverse outcomes in this condition. We report a single-center experience of four patients requiring dialysis during pregnancy, all of which resulted in successful delivery of viable infants. Our success rate may reflect an overall improvement in management of this population, with special attention paid to multiple risk factors. These include blood pressure and volume control, anemia management with erythropoietin analogues, nutritional intake and total dose of dialysis.