Diagnostic value of B-natriuretic peptide, ankle brachial index and carotid doppler in detection of sub-clinical cardiovascular disease in type 2 diabetic patients

Diabetes is important as a cause of cardiovascular disease [CVD], ranging from asymptomatic ischemia to clinically evident heart failure. Therefore, early identification of sub-clinical CVD in diabetic patients may be particularly important in leading to early initiation of treatment. The aim of the present study was to identify role of BNP [Brain natriuretic Peptide]. Ankle Brachial Index [ABI] and carotid Doppler in detection of sub-clinical CVD in type 2 diabetic patients. BNP was measured in 60 consecutive diabetic patients [patients group] whom were attended internal medicine outpatient clinics or admitted at endocrinology unit of Assiut university hospital. Another 40 patients; were chosen as [control group] their age and sex matched with patients. Echocardiography examinations were performed to all participants. ABI measurements were eonducted on all study participants. Carotid intima Media Thickness [CIMT] and carotid Plaque were evaluated by Carotid Doppler Ultrasonography, along with the determination of anthropometric parameters, HbAlc, lipid profile, assessment of diabetic retinopathy, nephropathy, and neuropathy, in patients with type 2 diabetes mellitus [T2DM]. Our study revealed 11 patients had Left ventricular hypertrophy [LVH], 20 patients had Left Ventricular Diastolic Dysfunction [LVDD], and no systolic dysfunction were detected. BNP were independent determinants of mild to moderate LVDD. Prevalence of a low ABI [<0.9] was 18.3%. Patients with low ABI had significant increased mean ages [P=0.038] duration of DM [P=0.004], concentration of HbAlc [P=0.044], BNP [P=0.013] and microalbuminurea [P-0.007].Patients with low ABI significantly associated with nephropathy [P=0.001], retinopathy [P=0:007], LVH [P=0.010] LVDD [P=0.018] and carotid artery atherosclerosis [P=0.018]. 20 patients [33.3%] were found to have evidence of carotid artery disease of them 5 patients [8.3%] had increased CIMT and 15 patients [25%] had carotid artery plaques, patients with carotid plaque were significantly smoker [P=0.008], male gender [P=0.013], had low HDL [P-0.008] and higher concentration of HbAlc [P=0.001]. Also patients with carotid artery atherosclerosis were significantly associated with nephropathy [P=0.000], neuropathy [P=0.050], Peripheral Arterial Disease [PAD] [P=0.018], LVDD [0.002].Conclusion: Our study showed that BNP discriminated patients at high risk for mild to moderate LVDD. A low ABI were prevalent in our study and associated with age, duration of diabetes, high HbAlc, microalbuminurea and chronic complication of DM, also carotid atherosclerosis high prevalent in our study especially carotid plaques which significantly associated with male gender, smoking, high HbAlc, low HDL, LVDD, PAD, and diabetic microangiopathy

Hypertension; ecological factors, control and complication in Urban Sohag, Upper Egypt

Because of the associated morbidity, mortality and the cost to societies, hypertension is an important public health challenge being the most common worldwide disease-affecting human. To study the clinical characteristics, therapeutic regimens, compliance with treatment, risk factors and target organ damage of hypertensive patients among people > 35 years old. A cross sectional study; conducted in Sohag city; it involved 520 patients; males [45.7%] and females [54.3%]. Their ages were 35 to 85 years. Hypertension presented more between non-smokers [72.55%], females [54.3%], educated patients [50.99%] and patients with low SES [54.9%]. ECG of hypertensive patients showed that ischemia presented in [51.63%] of patients, while their laboratory investigations showed that hyperglycemia presented in [28.7%], anemia in [18.3%], high serum creatinine level presented in [8.49%] and proteinuria in [10.45%] of patient. Adequate BP control was found to be achieved in [49.67%]; older patients had lower adequacy of BP control in spite of the extensive use of multiple-drug therapy and of appropriate drug choice. This is probably due to high prevalence of a difficult to control form of hypertension and poor compliance with the multiple-drug regimen. Most hypertensive patients had more than one coexistent CV risk factor. Aging, being a female [54.3%], diabetes, family history of hypertension [28.7%], smoking [27.45%], family history of coronary heart disease [25.4%], and obesity [10%] were of the contributing risk factors .About 72% had target organ damage. Heart involvement was the most frequent finding [63.39%]; coronary heart disease was the most common heart damage [51.63%]. ACE-inhibitors were prescribed in [58.16%]; mostly capotril and zestril. Beta-blockers were used in [34.64%] of the patients, Ateno is the drug mostly used in this group. Monotherapy was prescribed for [41.17%] only of the patients. Fortunately [75.81%] of patients showed regular use of their drug regimens. It was observed that [49.67%] only of patients had their condition under control, the number of drugs was inversely related to BP control. Hypertensive patients in Sohag city had a profile of high CV risks, target organs damage and poor blood pressure control particularly in the elderly. Great efforts towards improving the compliance of both service providers with guidelines and patients with treatment must be done. A multidisciplinary approach for routine clinical check up, follow-up, training, prescribing simple once-daily regimens and encourage life style modifications; all to optimize patient outcomes and prevent disease

Alternative technique for posterior exposure of the distal humeral shaft

The common approach for the distal humeral shaft is the posterior one, and in treating fractures at the distal third this approach includes exploration of the radial nerve through the triceps muscle. In this study an alternative approach avoiding triceps splitting is experienced. This approach has been experienced in twenty one patients with fracture at the distal third of the humeral shaft treated by open reduction and internal fixation using plates and screws. All the fractures have united with very good functional results. Two cases developed postoperative radial nerve neuropraxia, and both have recovered within ten weeks. This approach was found satisfactory as it allows good exposure of an adequate part of the humerus as well as starting early postoperative rehabilitation

Revision endonasal endoscopic dacrocystorhinostomy [REEDCR] with adjunctive intraoperative Mitomycin-C application

The aim of this study was to determine the efficacy of the adjunctive use of Mitomycin C in revision endonasal endoscopic dacrocystorhinostomy. A prospective randomized controlled study included 36 patients who underwent 44 endoscopic dacrocystorhinostomy [DCR] procedures. A total of 44 surgeries were divided into 2 equal groups, a traditional group [group I] underwent revision endonasal endoscopic dacrocystorhinostomy [REEDCR] and a Mitomycin-C adjunct to REEDCR group [group II]. In group I, the male to female ratio was 7:11 with mean age 36 years [range 25-56], while in group II the male to female ratio was 4:5 with mean age 37 years [range 23-58].The surgical procedures in both groups were exactly the same. The submucosal fibrosis from prior surgery was sharply dissected with removal of any scar tissue to enter the sac's interior. The sac opening was enlarged to a diameter of at least 20 mm. U - shaped intubation of the superior and inferior canaliculi was performed with a thin silicone tube. A piece of neurosurgical cottonoid saturated with 0.5 mg/ml Mitomycin-C was placed over osteotomy site for 5 minutes in group II surgeries. The silicone tubes were removed at 6 months after surgeries in all patients. The REEDCR results were assessed subjectively and objectively at the end of 1[st] week after surgery and during the follow up period at 3[rd], 6[th] and 9[th] postoperative months. Subjective assessment was based on the patients symptom of epiphora. The objective assessment of anatomical and functional outcomes included irrigation test, functional endoscopic dye test [FEDT] as well as nasal endoscopic assessment of rhinostomy site [nasolacrimal ostium size and pathological conditions]. Surgery was considered successful when the patient had no or minimal conditional epiphora and the fluid passed freely without reflux on lacrimal irrigation. In group II [Mitomycin group], 86% [19/22] eyes got significant improvement of the epiphora symptom compared to 77% [17/22] in group I [conventional group]. The higher subjective improvement in group II was associated with a higher objective improvement based on positive irrigation test in 86% and positive FEDT in 82% of patients compared to group I [77% irrigation test positive and 73% FEDT test positive]. Endoscopic nasal examination of rhinostomy site in group I failed cases revealed scar tissue formation in 3 cases [14%] and granulation tissue formation in 2 cases [9%]. In group II, assessment of rhinostomy site revealed scar tissue formation in 9% of cases [2 out of 22] while no granulation tissue formation was detected in this group. In group II, the mean rhinostomy diameter decreased from 14 +/- 1.2 mm on the first postoperative week to 10.3 +/- 2.1mm at the 3rd. month, 8.2 +/- 2.3mm at the 6th.month and 5.7 +/- 1.8mm at the 9th.month. This diameter change was significantly less than that in group I. By the end of follow up period the mean rhinostomy diameter in group II [5.7 +/- 1.8mm] was significantly greater than that in group I [3.6 +/- 1.4mm]. The adjunctive intra-operative Mitomycin-C local application increases the success rate of revision endonasal endoscopic DCR with a high safety profile, we suggest that Mitomycin-C reduces the fibrous adhesion, scarring and granulation tissue formation at the ostium area preventing further shrinkage of the final ostium. Large scale-study with long follow up period and different Mitomycin-C concentrations and exposure time is needed

QT dispersion in type 2 diabetic patients

Diabetes mellitus is one of the most common causes of patient contact with a physician, and is a major cause of premature disability and mortality. Several studies have described a poor survival prognosis in type 2 diabetic patients compared with non-diabetic populations. It has been postulated that QT prolongation and QT dispersion [QTd]. predispose to cardiac arrhythmias and sudden death. The aim of our study was to detect the relationship between [QT corrected] QTc and QTd with type 2 diabetes mellitus. This study included eighty subjects divided into two groups; Group I: included sixty patients with type 2 diabetes and group II: included twenty healthy controls. All subjects were subjected to the following: Careful history taking and clinical examination, assessment of BMI, assessment of cardiovascular autonomic function tests and laboratory investigations including fasting and postprandial blood glucose levels, blood urea and serum creatinine levels, lipid profile, serum electrolytes [Na, K and Ca levels] and electrocardiography [ECG] for measurement of QT interval and calculation of QTc and QTd. The results of our study revealed that QTc and QTd was significantly increased in diabetic patients compared to non-diabetic controls. QTd was significantly related to QTc. QTc and QTd have no relation to the patient's gender. QTc was significantly related to BMI, type of therapy, fasting blood glucose and triglycerides. QTd was significantly related to the patients age, fasting and posiprandial blood glucose levels, triglycerides, HDL-c, type of therapy, presence of cardiac autonomic neuropathy and smoking. QT dispersion should now, be used as a screening test, and those with high QTd should undergo extensive cardiac examinations to identify reversible contributors to future cardiac death, with particular emphasis on examination designed to detect underlying cardiac ischemia. Recommendations: We recommend extending this study to be done on a wider scale and a big number of diabetic patients with different diabetic complications in order to study the correlation of QTc and QTd with diabetic complications

Relation of microalbuminuria to the left ventricular mass and cardiovascular risk factors in hypertension and type 2 diabetes mellitus

The presence of microalbuminuria was associated with a relative risk of all cause mortality 2-8 times higher than that in similar individuals without microalbuminuria and the cardiovascular mortality and morbidity was 2-4 times higher than in persons without microalbuminuria and left ventricular hypertrophy [LVH] represents a risk factor of cardiovascular disease, independent of systolic blood pressure, as well as of age, smoking and cholesterol. We aimed in this study to find out relation of microalbuminuria to left ventricular mass [LVM] and cardiovascular risk factors among hypertensive patients with or without type 2 diabetes mellitus. This study included 10 healthy volunteers [group I] as a control group with age ranged from 20-60 years and 40 hypertensive patients with or without type 2 diabetes mellitus and were classified into; Group II: included 10 patients with isolated hypertension with age ranged 35-74 years and duration of hypertension ranged from 1- 15 years, 6 patients with positive microalbuminuria. Group III: included 10 hypertensive patients with type 2 diabetes mellitus without microalbuminuria with age ranged from 35-62 years and duration of both hypertension and D. M. ranged from 1-15 and 1-10 years respectively. Group IV: Included 10 hypertensive patients with type 2 diabetes mellitus associated with microalbuminuria with age ranged from 36-70 years and duration of hypertension ranged from 1-10 years and duration of D. M. ranged from 2-17 years. All individuals were subjected to the following:-Complete history taking and thorough clinical examination, routine laboratory tests [CBC, urine analysis, renal function tests, LFT, FBS and PPBS, Lipogram and detection of microalbuminuria], resting 12 leads electrocardiography and plain chest X-ray, body weight, height and body surface area [BSA] and finally echocardiographic study. The mean values of left ventricular mass index [LVMI] in different groups were: 74.8 +/- 21.1, 131.9 +/- 43.2, 118.5 +/- 48.2 and 121.0 +/- 26.9 respectively with a highly significant difference [F = 4.72 and P <0.01] between different groups. LVMI was significantly higher in groups II, III, and IV in comparison to group I [P <0.05], also there was a significantly higher value in group II in comparison to both group III and II [P <0.05], there was no significant difference between group III and IV. The mean values of microalbuminuria [UAE] in different groups were: 8.4 +/- 4.0, 73.3 +/- 32.2, 8.4 +/- 4.0 and 150.0 +/- 52.7 mg/L respectively with a highly significant difference [F = 35.88 and P <0.01] between the different groups. Microalbuminuria was significantly higher in both group II and IV in comparison to both group I and III [P <0.05], also there was significantly higher value in group IV in comparison to group 11 [P <0.05], there was no significant difference between group I and III. There was a highly significant positive correlation between microalbuminuria and systolic blood pressure[r=0.678, P < 0.01], there was no significant correlation between microalbuminuria and diastolic blood pressure [r=0.133], Also there was a significant positive correlation between microalbuminuria and both FBS [r-0.201, P < 0.05] and PPBS [r=0.218, P < 0.05]. In correlating microalbuminuria and the lipid profile, we found a significant positive correlation between microalbuminuria and total cholesterol [r=0.443, P < 0.05], a significant negative correlation between micaoalbuminuria and HDL-C [r=-.319, P < 0.05], while there was no significant correlation between microalbuminuria and both triglyceride and LDL-C [r= 0.179 and 0.134 respectively]. There was a significant correlation between LVMI and microalbuminuria in the patients with positive microalbuminuria [r = 0.462, P <0.05]. We concluded that the presence of microalbuminuria related closely to the LVMI in both hypertensive and hypertensive diabetic patients, and its presence associated with various potentially reversible risk factors including systolic hypertension, altered lipid profile and poor glucose control. So, increased attention has been given to the role of microalbuminuria as a cardiovascular risk indicator, particularly in patients with diabetes and hypertension

Curative effects of n-acetylcysteine against methanol- induced retinal toxicity

Methanol toxicity produces toxic injuries to the retina and optic nerve results in blindness. Formic acid [the toxic metabolite responsible for these toxic effects] is a mitochondrial toxin that increases the production of Reactive Oxygen Species resulting in oxidative stress cell injury. In the retina, glutathione acts as a vital defense mechanism against oxidative stress. N-acetylcysteine [NAC] is a glutathione precursor and acts as a free radical scavenger. In this study the role of NAC against methanol-induced retinal toxicity was evaluated in adult male albino rats. Group [I] [control: received normal saline], group [IIa]: [received daily oral toxic dose of methanol 3gmlkg for 72 hrs], group [IIb] [follow up group]: [received daily oral toxic dose of methanol 3gmlkg for 72 hrs then saved for follow up for 24 hrs], group [IIc]: [received daily oral toxic dose of methanol 3gm/kg for 72 hrs and single oral therapeutic dose of NAC 800mg/kg 24 hrs after the last dose of methanol], group [III]: [received single oral therapeutic dose of NAC 800mg/kg]. After the period of each group, the rats were sacrificed and were investigated by assessment of glutathione, glutathione peroxidase activity, histopathological and ultrastructural examination of retinal tissue. Methanol-toxicity induced a significant decrease in glutathione and glutathione peroxidase activity, with retinal edema and vaculation of photoreceptors inner segment and enlarged irregularly stained nuclei, and profound mitochondrial swelling with severely disrupted cristae, as compared with control. Follow up group showed a significant decrease in glutathione and glutathione peroxidase, as compared with control, and a significant increase in its activity as compared with methanol-toxicity, with mild alterations in photoreceptor mitochondria. NAC-treated group revealed a significant increase in glutathione and glutathione peroxidase, as compared with methanol toxicity, and a non significant difference in comparison with control and NAC groups, with normal retinal structures. It is concluded that methanol induced severe retinal toxicity that could be reversed by N-acetylcysteine administration through its action as a glutathione precursor and a free radical scavenger

Using computerized dynamic posturography in myopathy and neuropathy

This study included 40 cases [20 cases were diagnosed as myopathy and 20 cases were diagnosed as neuropathy]. Computerized dynamic posturography [CDP] including sensory organization test [SOT], motor control test [MCT] and posture-evoked response [EMG] test were done. The study showed that the equilibrium scores [SOT] in the 40 cases were significantly declined in conditions SOT1, SOT2, SOT3 and SOT6. The MCT revealed bilateral prolongation in latencies in the 40 patients. The EMG revealed short latency component delays and long latency component delays in neuropathy and myopathy. The results revealed that CPD is a quantitative method for the diagnoses and follow up of sensory, motor and biochemical component contributing in myopathies and neuropathies patients

Role of circulating fosciola antigens and IgG4 isotype in assessment of cure from fascioliasis

Sixty-eight individuals were included in this study; 30 of them were presented with Fasciola infection, 20 were infected with other parasites [infected control group] and 18 individuals were parasite- free [normal control group]. For all groups, stool analysis by modified formol-ether technique and Kato thick smears for egg counts and the circulating Fasciola antigens [CFAgs] and anti-Fasciola IgG4 isotype were estimated by ELISA technique. Complete blood count, liver functions tests and abdominal ultrasonography were performed for all Fasciola-infected patients. Patients with fascioliasis received a myrrh-derived drug [mirazid] in a dose of 10 mg/kg b. Wt., one hour before breakfast for six consecutive days. Re-measuring of the above parameters was performed one and three months after therapy. The detection of CFAgs was found to be a useful marker for the assessment of core. No cross-reaction was observed between Fasciola and other parasites using CFAg [100% specificity]. The level of these antigens was positively correlated with the signs of cure, parasitologically, clinically or ultrasonographically. The detection of IgG4 isotype was found to be a more sensitive and accurate immunodiagnostic tool for fascioliasis, but it was not a useful marker for the assessment of cure. Mirazid drug possesses a high therapeutic efficacy [100% cure rate] on fascioliasis without remarkable side effects

Cervical paragangliomas: diagnosis, management, and complications [personal experience]

Sixteen patients were diagnosed to have cervical paragangliomas. Eleven patients [68.75%] had twelve carotid paragangliomas [C.P]], and five patients [31.25%] had six vagal paragangliomas [V.P]. Only one C.P [8.33%] originated from paraganglia around the C.C.A. Three case reports of multiple paragangliomas were presented [18.75%]. In 80% [4/5] of V.P patients, there was widening of the carotid bifurcation similar to that of C.P. Transcervical approach with cutting the digastric muscles and the stylo id process with the attached ligaments and muscles, and dislocation of the mandible was sufficient for excision of most V.P. Vascular injuries occurred in 12.5% [2/16] of patients. Superior laryngeal nerve paralysis occured in 18.18% [2/11] of patients with C.P, hypoglossal nerve paralysis occured in 9.09% [1/11] of patients with C.P., and vagal paralysis occurred in all patients with V.P. Cerebrovascular accidents occurred in one patient [6.26%]. Post-operative mortality occurred in one patient [6.26%]

Laryngoceles associated with laryngeal carcinoma

Laryngoceles and large saccules were found in 3.07% and 5.12% of patients with laryngeal carcinomas. CT proved to be very accurate more than endoscopy in detection of asymptomatic laryngocele associated with cancer larynx. However both endoscopy and CT are recommended in cases presented primarily with laryngoceles to rule out any underlying malignancy. Laryngoceles were bilateral in 50% of cases. Large saccules were ipsilateral in 60% [6/10], bilateral in 10% [1/10], and contralateral in 30% [3/10] of cases. Four patients with supraglottic tumors [4.54%] were associated with two bilateral symptomatic and two asymptomatic ipsilateral laryngoceles. Two patients with transglottic tumors [3.44%] showed asymptomatic ipsilateral internal and bilateral mixed laryngoceles. All asymptomatic laryngoceles were diagnosed by CT and postoperative examination of the specimens as patients presented usually with symptoms related to the tumor. Large saccules were found in 5.68% of supraglottic tumors, 4.76% of glottic tumors, and 5.17% of transglottic tumors. 60% [6/10] of large saccules were ipsilateral, 30% [3/10] were contralateral, and 10% [1/10] was bilateral

Pitfalls in the surgical management of cancer larynx and hypopharynx

One hundred and eighty patients presented with cancer of the larynx and hypopharynx form the basis of this report. Positive margins were found in 12.2% [22/180] of all cases, 12.5% [8/64] of supraglottic tumors, 16% [4/26] of tronsglottic tumors, 5.3% [2/38] of glottic tumors, 11.1% [2/18] of pyriform fossa tumor, 50% [3/6] of posterior pharyngeal wall tumors, and 10.6% [3/29] of postcricoid tumors. The relationship between the inadequate surgical margins of the specimens, tumor spread, the preoperative computerized tomography [CT] findings, and the surgical procedure performed have been correlated

Saccular disorders in cancer larynx

Abnormal saccular dilatations like laryngoceles, laryngomucoceles, large dilated saccules, and saccular cysts have been reported to occur secondary to laryngeal tumors. These disorders occurred in 11.5% [15/130] of our cases of cancer larynx. Laryngoceles, large saccules, and saccular cysts were found in 3.1%, 4.6%, and 3.8% of cases respectively. CT proved to be very accurate more than endoscopy in detection of symptomatic or asymptomatic saccular disorders associated with cancer larynx. However both endoscopy and CT are recommended in cases presented with laryngoceles or saccular cysts to rule out any underlying malignancy

parathyroid glands identification during neck surgery: a microsurgical perspective

Parathyroid gland identification using the operative microscope was attempted in twenty patients operated upon for thyroidectomy and other neck surgeries. Histopathological examination of an incisional biopsy confirmed the identification in twenty four out of twenty five identified glands [i. e accuracy rate of 92%]. The point of intersection of the recurrent laryngeal nerve with the inferior thyroid artery. The cricothyroid joint and the paratracheal pad of fat were all found to be valuable landmarks for parathyroid gland identification

Endoscopy and computed tomography [CT] in lower respiratory tract scleroma

Out of fifty two patients with scleroma, twenty patients with laryngotracheal scleroma [38.5%] were examined by CT and endoscopy. Tracheal involvement was found in 65% [13/20] of cases, whereas bronchial affection was found in 15% [3/20] of cases with laryngeal scleroma and in 23.1% [3/31] of cases with tracheal scleroma. Two patients were presented with supraglottic scleroma. The first one showed supraglotric granulomata, and the second one showed bilateral lateral saccular cysts. Culture of the cyst contents showed klebsiella rhinoscleromatis. Endoscopy was very efficient in diagnosis, staging, and management of these patients. Although diagnosis could not be made on the basis of CT only, CT was useful in determining the extent of the disease as well as the response to therapy

Hyoid Bone Syndrome [H.B.S.] and Styloid Process Syndrome [St P.S.] clinical presentation, diagnosis, and management

Both St.P.S. and H.B.S. involve pain in the anterolateral part of the upper neck radiating to the ear. In this study, fourteen patients were presented with St.P.S. and 74 patients were presented with H.B.S. The key for diagnosis of these syndromes was the palpating finger for a tender tip of the hyoid bone in H.B.S. or an elongated styloid process in St.P.S. Radiology had a confirmatory role in diagnosis of St.P.S, and a limited role in diagnosis of H.B.S. Both syndromes occurred in recurrent acute or chronic persistent forms. Conservative management was the treatment of choice in H.B.S., whereas surgery was the treatment of choice in St P.S. Clinical presentation, pathogenesis, and management plans of both syndromes were discussed