Posterior reversible encephalopathy syndrome in HIV-positive patients: a case report and literature review.

We are reporting the case of a woman who was admitted acutely to our intensive care unit without any collateral history. She was diagnosed with posterior reversible encephalopathy syndrome (PRES) as a consequence of poor adherence to anti-hypertensive, anti-diabetic and anti-retroviral medications. PRES is a rare condition, which may cause cortical blindness; contrary to its name it is not always reversible. Rapid diagnosis and aggressive management of underlying causes facilitate reversibility of PRES. We also summarise the literature on patients with HIV and PRES.

Acute coronary syndromes: an old age problem.

The increasing population in older age will lead to greater numbers of them presenting with acute coronary syndromes (ACS). This has implications on global healthcare resources and necessitates better management and selection for evidenced-based therapies. The elderly are a high risk group with more significant treatment benefits than younger ACS. Nevertheless, age related inequalities in ACS care are recognised and persist. This discrepancy in care, to some extent, is explained by the higher frequency of atypical and delayed presentations in the elderly, and less diagnostic electrocardiograms at presentation, potentiating a delay in ACS diagnosis. Under estimation of mortality risk in the elderly due to limited consideration for physiological frailty, co-morbidity, cognitive/psychological impairment and physical disability, less input by cardiology specialists and lack of randomised, controlled trials data to guide management in the elderly may further confound the inequality of care. While these inequalities exist, there remains a substantial opportunity to improve age related ACS outcomes. The selection of elderly patients for specific therapies and medication regimens are unanswered. There is a growing need for randomised, controlled trial data to be more representative of the population and enroll those of advanced age with co-morbidity. A lack of reporting of adverse events, such as renal impairment post coronary angiography, in the elderly further limit risk benefit decisions. Substantial improvements in care of elderly ACS patients are required and should be advocated. Ultimately, these improvements are likely to lead to better outcomes post ACS. However, the improvement in outcome is not infinite and will be limited by non-modifiable factors of age-related risk.

Predicting mortality and hospital admission in patients with COPD: significance of NT pro-BNP, clinical and echocardiographic assessment.

AIMS: To quantify the ability of N-terminal pro-brain natriuretic peptide (NT pro-BNP) to predict mortality and hospitalization in patients with chronic obstructive airways disease (COPD). METHODS: Prospective single-centre observational study of 140 consecutive patients aged at least 18 years with COPD between 27 March 2004 and 28 February 2008 (median follow-up 3.9 years). RESULTS: Sixty-five (46%) men, 26 (19%) O2 therapy, 115 (82%) smokers, 38 (27%) patients receiving diuretics, 15 (11%) left-ventricular ejection fraction less than 45%. Median [interquartile range (IQR)] NT pro-BNP concentration 16.2 (25.4) pmol/l. NT pro-BNP was higher in those with a dilated left atrium (P<0.001), aortic stenosis (P=0.02), left-ventricular systolic dysfunction (P=0.027), right ventricular impairment (P=0.011), atrial fibrillation (P<0.001), patients receiving diuretics (P=0.010) and angiotensin-converting enzyme (ACE) inhibitors (P=0.006). One-year mortality and hospitalization rates were 2.9 and 25.4%. The median (IQR) time to hospitalization and length of first hospital stay: 383.5 (605) and 4.0 (7.0) days. NT pro-BNP was an excellent discriminator of right-ventricular impairment (C statistic=0.90) and predicted survival (highest quartile versus lowest quartile relative risk=3.02, P=0.001), but not hospital admission. After adjustment this association was not significant. CONCLUSION: NT pro-BNP predicts survival, but not hospital admission in patients with COPD. The ability of NT pro-BNP to independently predict death or hospitalization is superseded by the presence of a dilated left atrium, aortic stenosis and left-ventricular systolic dysfunction.

Premature coronary artery disease shows no evidence of linkage to loci encoding for tissue inhibitors of matrix metalloproteinases.

Tissue inhibitors of metalloproteinases (TIMP1, TIMP2, TIMP3) are naturally occurring inhibitors of matrix metalloproteinases (MMPs). It has been proposed that MMPs have a role in weakening the fibrous cap and subsequent plaque rupture. We hypothesized that TIMP polymorphisms could predispose to premature coronary artery disease. As a first step, we examined the relevant loci using a linkage approach. Sibling pairs recruited for the British Heart Foundation (BHF) Family Heart Study with premature coronary artery disease were examined. Two to three microsatellite markers were examined per TIMP gene. These markers were either intragenic or very close to the locus encoding for the gene. Products were analyzed by capillary gel electrophoresis. Single and multipoint linkage analysis based on the likelihood ratio test was performed using SPLINK and Mapmaker/Sibs software; 417 families were genotyped consisting of 385 sibling pairs, 27 trios, and five sets of four siblings. We were unable to detect linkage of premature coronary artery disease to loci encoding for TIMP1-3. Polymorphisms of the tissue inhibitors of MMP genes do not predispose to premature coronary artery disease in an epidemiologically significant way.