Short- and long-term cardiovascular outcomes in insulin-treated versus non-insulin-treated diabetes mellitus patients after percutaneous coronary intervention: A systematic review and meta-analysis

Aims: This study aims to assess differences in severity of short-term (<1 year) and long-term (_x005F_x0001_1 year) adverse CV outcomes after PCI in insulin-treated vs. non-insulin-treated diabetes mellitus (DM) patients. Methods: A systematic search on Pubmed and Embase led to the incorporation of 29 studies that compared post-percutaneous coronary interventional outcomes in insulin-treated and non-insulintreated diabetes mellitus. Diabetes mellitus (type 2) was defined as fasting blood glucose (FBG) level of >7.0 mmol/L or with an oral glucose tolerance test (OGTT) level of >11.1 mmol/L at least on two separate occasions. Adverse CV outcomes were assessed in insulin-treated and non-insulin-treated DM after the PCI procedure considered for the analyses were mortality, MACE, TLR, TVR, MI, stent thrombosis, target lesion failure (TLF), and need for-post PCI CABG. Data were pooled and analyzed using Review Manager 5.3, and risk ratios (RR) with respective 95% confidence intervals (CI) were calculated.The statistical analyses were carried out by Review Manager v.5.3, and the data were pooled using a random-effects model. Risk ratios (RRs) with 95% confidence intervals (CI) were reported along with forest plots. The chi-square test was performed to assess for differences between the subgroups. Heterogeneity across studies was evaluated using Higgins I2 statistics. Visual inspection of the funnel plot and Begg's regression test were used to assess publication bias. Results: A total of 40,527 patients (11742 in the Insulin-treated diabetes mellitus group and 28785 in the non-insulin-treated DM group) who underwent PCI were included. The pooled analysis of short-term follow up outcomes preceding PCI demonstrated a significantly higher risk of mortality (RR ¼ 1.75 [1.24,2.47]; p ¼ 0.002), MI (RR ¼ 1.81[1.14,2.87]; p ¼ 0.01], stent thrombosis (RR ¼ 1.63[1.13, 2.35]; p ¼ 0.009) and target lesion revascularization (TLR) (RR ¼ 1.29[1.02,1.63]; p ¼ 0.03) in insulin-treated DM patients. Similarly, analysis of long-term follow-up studies depicted a significantly higher risk mortality (RR ¼ 1.55 [1.22, 1.97]; p ¼ 0.0003), MI (RR ¼ 1.63 [1.35, 1.97]; p¼<0.00001), MACE (R ¼ 1.47 [1.31, 1.65]; p¼<0.00001), stent thrombosis (RR ¼ 1.54 [1.19,1.99]; p ¼ 0.001), TLR (RR ¼ 1.40 [1.18, 1.66]; p ¼ 0.0001), target vessel revascularization (TVR) (RR ¼ 1.35 [1.11, 1.64]; p ¼ 0.003) in insulin-treated DM group after PCI versus non-insulin-treated DM patients. Conclusion: Despite a tremendous technical success rate of multi-vessel stenting, people living with diabetes who were being treated with insulin had higher long-term, and short-term mortality rates, MI, TLR, TVR, and stroke compared to people living with diabetes who were being treated with means other than insulin and are more prone to detrimental cardiovascular outcomes.

Left paraduodenal hernia

Left paraduodenal hernia is a rare cause of small bowel obstruction. A sixty-five-year-old Indian male presented with a history of recurrent vomiting for a couple of days. CT scan was performed and the diagnosis was suspected but not confirmed. Laparoscopic repair was performed with uneventful postoperative course

Timing of Levothyroxine in the Treatment of Primary Hypothyroidism.

Aim: Timing of levothyroxine (L-thyroxine) administration seems beneficial for early obtaining thyroid state. The present study aimed at investigating the best time of L-thyroxine administration that can achieve earlier normalization of thyroid stimulating hormone (TSH) and free thyroxine (FT4) levels in patients with primary hypothyroidism. Study Design: Eighty two patients with primary hypothyroidism were recruited between November 2012 and July 2013 during their consultation to Al-Faiha Specialized Diabetes, Endocrine and Metabolism Center, Basrah, Iraq. The patients were divided into two equal groups; group A were receiving L-thyroxine daily, one hour before breakfast, group B: the dose of L-thyroxine was given at the evening. TSH, FT4, Body mass index (BMI), blood pressure, lipid profile were measured before, 30, 60 and 90 days after treatment with L-thyroxine. Results: The mean reduction in TSH from baseline for the evening treatment was 13.6±22.2 mIU/ml which was slightly and insignificantly higher than the value of the morning treatment (11.3±22.5 mIU/ml), P = .63, df = 80, 95% CI: -12.17, 7.5). The mean increase in FT4 from baseline for the evening treatment was 5.7±4.9 pmol/l which was lower than 7.6±6 pmol/l in the morning treatment, (P = .12, df = 80, 95% CI: - 0.5, 4.3). There was no effect of treatment timing on lipid profile, blood pressure, and BMI. Conclusions: There were no differences between the morning and evening treatment with L-thyroxine on early normalization of TSH and FT4.

A study of the effect of Nigella sativa (black seeds) on methotrexateinduced hepatotoxicity in rabbits.

Background: To evaluate the effectiveness of Nigella sativa (NS) in the prevention of hepatotoxicity of large doses of methotrexate (MTX) (IP) in rabbits. Methods: Three groups of male rabbits, six in each were used. Oral dosing was administered as a paste; formula 1 was prepared by mixing 2 g fl our with water; formula 2 contained fl our and NS and water. Group 1 was fed with formula 1 daily and injected with 2 ml/kg normal saline IP. Group 2 was given formula 1 daily with 20 mg/kg MTX IP. Group 3 was fed with formula 2 daily + MTX 20 mg/kg IP. Injections were given weekly for 5 weeks, and then the animals were sacrifi ced at day 39. Liver enzymes, malondialdehyde (MDA), glutathione (GSH), and histopathology of the liver were evaluated. Results: Liver enzymes, serum, and liver MDA were signifi cantly increased by MTX. MTX + NS treatment signifi cantly reduced the rise in liver enzymes, MDA in serum with little effect on liver MDA. Serum aspartate aminotransferase, alkaline phosphatase, and bilirubin were reduced from 82.8±18.04 U/L, 4.9±2.0 kind and king unit/100 ml and 0.74±0.1 mg/dl to 56.1±7.5, 2.0±0.6 and 0.27±0.1 respectively. Unexpectedly, serum and liver GSH were slightly increased by MTX. Treatment with MTX + NS further increased these levels. Histologically, portal and lobular sinusoidal dilatation, lymphocytic infi ltration, and hepatocyte hydropic degeneration were seen in all rabbits on MTX, which disappeared in three rabbits on NS + MTX. Conclusion: NS is hepatoprotective against MTX induced hepatotoxicity.

A significant hepatotoxicity associated with paracetamol overdose in the absence of kidney injury in rabbits.

Background: Overdose of paracetamol (PCM) is reported to cause hepatotoxicity and nephrotoxicity, or nephrotoxicity in absence of hepatotoxicity. This study was planned to investigate hepatotoxicity or nephrotoxicity induced by PCM. Methods: Two groups of rabbits, six rabbits in each were used; control group were treated with normal saline, the second group was treated with PCM 1 g/kg/day orally for 9 days. Results: PCM lead to a significant rise in serum liver enzymes, aspartate aminotransferase, alanine transaminase, alkaline phosphatase and total bilirubin with an increase in serum level of malondialdehyde (MDA) and reduction in serum glutathione (GSH). MDA level in liver homogenate was also significantly increased. These findings were further confirmed by histopathological changes suggestive of severe liver damage. On the contrary, PCM slightly increased serum creatinine, without changing MDA and GSH in kidney homogenate. Lack of PCM nephrotoxicity was further confirmed by histopathological examination. Conclusion: PCM overdose produced severe hepatotoxicity without affecting the kidneys of the rabbits.

Quantitative comparison of calcium hydroxide removal by EndoActivator, ultrasonic and ProTaper file agitation techniques: an in vitro study / 华中科技大学学报（医学）（英德文版）

Calcium hydroxide (CH) dressing residues can compromise endodontic sealing. This study aimed to evaluate the amount of remaining CH in root canals after mechanical removal by four groups of irrigation techniques including needle irrigation only, ProTaper file, EndoActivator, and ultrasonic file. Fifteen extracted single-rooted teeth were collected and used for all four groups. The samples were firstly prepared by ProTaper rotary instruments, and then sectioned longitudinally through the long axis of the root canals, followed by final reassembling by wires. CH was kept in the canals for 7 days setting. The removal procedure began with 5 mL of 2.5% sodium hypochlorite (NaOCl) followed by 1 mL of 17% ethylenediaminetetraacetic acid and a final irrigation with 5 mL of 2.5% NaOCl solution for all groups. No additional agitation of the irrigant was performed in group 1, while agitation for 20 s between irrigants was done with F2 ProTaper rotary file in group 2, EndoActivator with tip size 25/.04 in group 3 and by an ultrasonic file 25/.02 in group 4. The total activation time was 60 s. The roots were then disassembled and captured by digital camera. The ratio of CH coated surface area to the surface area of the whole canal as well as each third of the canal was calculated. The data were statistically analyzed by one-way ANOVA using post hoc Tukey test. Results showed that none of the four techniques could remove all CH. No significant difference was found between EndoActivator and ultrasonic techniques. However, they both removed significantly more CH than ProTaper and needle irrigation (P=0.0001). In conclusion, the sonic and ultrasonic agitation techniques were more effective in removing intracanal medicaments than the ProTaper rotary file and needle irrigation in all thirds of the canal.

Quantitative comparison of calcium hydroxide removal by EndoActivator, ultrasonic and ProTaper file agitation techniques: an in vitro study / 华中科技大学学报（医学）（英德文版）

Calcium hydroxide (CH) dressing residues can compromise endodontic sealing. This study aimed to evaluate the amount of remaining CH in root canals after mechanical removal by four groups of irrigation techniques including needle irrigation only, ProTaper file, EndoActivator, and ultrasonic file. Fifteen extracted single-rooted teeth were collected and used for all four groups. The samples were firstly prepared by ProTaper rotary instruments, and then sectioned longitudinally through the long axis of the root canals, followed by final reassembling by wires. CH was kept in the canals for 7 days setting. The removal procedure began with 5 mL of 2.5% sodium hypochlorite (NaOCl) followed by 1 mL of 17% ethylenediaminetetraacetic acid and a final irrigation with 5 mL of 2.5% NaOCl solution for all groups. No additional agitation of the irrigant was performed in group 1, while agitation for 20 s between irrigants was done with F2 ProTaper rotary file in group 2, EndoActivator with tip size 25/.04 in group 3 and by an ultrasonic file 25/.02 in group 4. The total activation time was 60 s. The roots were then disassembled and captured by digital camera. The ratio of CH coated surface area to the surface area of the whole canal as well as each third of the canal was calculated. The data were statistically analyzed by one-way ANOVA using post hoc Tukey test. Results showed that none of the four techniques could remove all CH. No significant difference was found between EndoActivator and ultrasonic techniques. However, they both removed significantly more CH than ProTaper and needle irrigation (P=0.0001). In conclusion, the sonic and ultrasonic agitation techniques were more effective in removing intracanal medicaments than the ProTaper rotary file and needle irrigation in all thirds of the canal.

Unusual outcome of Ludwig's angina

This is a report of 2 cases of Ludwig's angina. An Indonesian young female patient developed severe stridor after oral examination. Then she underwent tracheostomy and developed post decannulation dyspnea due to huge surgical emphysema. The second case regards an Indian young male who developed disseminated intravascular coagulation and died from hemorrhage. The objectives of our cases presentation are to avoid mouth examination of Ludwig's angina if we are not ready for performing tracheotomy and to be aware of the possible development of disseminated intravascular coagulation and post decannulation emphysema

Small bowel obstruction due to gallstones [gallstone ileus]

Eigthy one years old male,presented with history of abdominal pain, vomiting, and abdominal distension. Abdominal radiographies revealed pneumobilia, small bowel obstruction, and aberrantly located gallstone. He underwent laparatomy and simple enterolithotomy after stabilization. Subsequently, the patient improved clinically and was discharged