Stress-induced cardiomyopathy

В кардиологична клиника постъпва 70-годишна жена с гръдна болка. Ангинозният характер на болката, наличните ЕКГ промени и дискинезия на сърдечния връх насочват към остър коронарен синдром. Проведената коронарна ангиография не установява промени в епикардните съдове. След няколко дни настъпва пълно възстановяване на кинетиката. Приета е диагноза стрес-индуцирана кардиомиопатия.А 70-year-old woman is admitted to the Cardiology Department because of retrosternal pain. The typical angina, ECG changes and apical dyskinesia lead to the diagnosis of acute coronary syndrome. The coronary angiography does not show any significant lesions. The kinetics of left ventricle is fully restored in few days. The final diagnosis is stress-induced cardiomyopathy

Endoscopic imaging of the human laryngeal complex in an experimental setting - methodology and clinical significance

AIM: The human laryngeal complex has been an endoscopic sight since the late 19th century, however despite the technological advances little has changed in the standard observational methodology, with optical distortion of the image being a major setback in all endoscopic studies. The aim of this study is to evaluate different endoscopes and image correction algorithms in the endoscopic imaging of the laryngeal complex.METHODS AND MATERIALS: Conventional rigid 00, 300, 700 and 900 endoscopes and a flexible otorhinolaryngoscope with two-dimensional imaging capabilities, a digital camera and a direct laryngoscope were used together with an intubation mannequin to obtain endoscopic images of the laryngeal complex. Images of a custom made lens distortion grid were taken to compare the different optical systems and used as a benchmark for image correction. Both sets of images were superimposed in order to digitally correct for angle and lens distortion and to show the true size and proportions of the human laryngeal complex, so far seen only during an intubation or autopsy.RESULTS: After comparing the fiber optic and rigid endoscope obtained images, the rigid endoscopes proved to have better imaging qualities and therefore a better potential for future in depth study of laryngeal anatomy. The rigid 700 endoscope, compared to other rigid systems, allowed for an atraumatic perpendicular to the glottis view of the laryngeal complex, best suited for the study, despite the higher image distortion.CONCLUSION: Based on the collected data the 700 rigid otorhinolaryngoscope together with a standard software correction is an affordable, atraumatic and reliable method for anatomical and proportionate measuring of the human laryngeal complex in a model study

Total testosterone levels in men with acute coronary syndrome

Introduction:When acute systemic illness occurs due to stress, dysfunction of some of the endocrine axes often occurs. However, the specific mechanisms have not been elucidated. Acute coronary syndrome (ACS) is one model of acute physiological stress in which the hypothalamic-pituitary-gonadal axis is also affected.Aim:The aim of this study was to investigate the difference in total testosterone (T) levels in men with ACS compared to controls.Results:In 72 patients with ACS, the level of total testosterone was studied until the 48th hour after its onset. Thirty-five controls were also included in the study. After statistical processing of the data, we found that total T in the ACS group was statistically significantly lower compared to the controls group (t = -3.20, p = 0.001) There was also a statistically significant difference in the incidence of hypotestosteronemia between the two groups with 52.8% (n = 38) in the ACS group and 28.6% (n = 10) in the control group. (χ2(1) = 4.705, p = .030).Conclusion:Low levels of total T are common in patients with ACS. However, T values in the acute period after the onset of ACS should be interpreted with caution because of the changes occurring in the regulation of gonadal function

Cabbage and fermented vegetables : From death rate heterogeneity in countries to candidates for mitigation strategies of severe COVID-19

Large differences in COVID-19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe, or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage have been associated with low death rates in European countries. SARS-CoV-2 binds to its receptor, the angiotensin-converting enzyme 2 (ACE2). As a result of SARS-CoV-2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT(1)R) axis associated with oxidative stress. This leads to insulin resistance as well as lung and endothelial damage, two severe outcomes of COVID-19. The nuclear factor (erythroid-derived 2)-like 2 (Nrf2) is the most potent antioxidant in humans and can block in particular the AT(1)R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are: kimchi in Korea, westernized foods, and the slum paradox. It is proposed that fermented cabbage is a proof-of-concept of dietary manipulations that may enhance Nrf2-associated antioxidant effects, helpful in mitigating COVID-19 severity.Peer reviewe

Nrf2-interacting nutrients and COVID-19 : time for research to develop adaptation strategies

There are large between- and within-country variations in COVID-19 death rates. Some very low death rate settings such as Eastern Asia, Central Europe, the Balkans and Africa have a common feature of eating large quantities of fermented foods whose intake is associated with the activation of the Nrf2 (Nuclear factor (erythroid-derived 2)-like 2) anti-oxidant transcription factor. There are many Nrf2-interacting nutrients (berberine, curcumin, epigallocatechin gallate, genistein, quercetin, resveratrol, sulforaphane) that all act similarly to reduce insulin resistance, endothelial damage, lung injury and cytokine storm. They also act on the same mechanisms (mTOR: Mammalian target of rapamycin, PPAR gamma:Peroxisome proliferator-activated receptor, NF kappa B: Nuclear factor kappa B, ERK: Extracellular signal-regulated kinases and eIF2 alpha:Elongation initiation factor 2 alpha). They may as a result be important in mitigating the severity of COVID-19, acting through the endoplasmic reticulum stress or ACE-Angiotensin-II-AT(1)R axis (AT(1)R) pathway. Many Nrf2-interacting nutrients are also interacting with TRPA1 and/or TRPV1. Interestingly, geographical areas with very low COVID-19 mortality are those with the lowest prevalence of obesity (Sub-Saharan Africa and Asia). It is tempting to propose that Nrf2-interacting foods and nutrients can re-balance insulin resistance and have a significant effect on COVID-19 severity. It is therefore possible that the intake of these foods may restore an optimal natural balance for the Nrf2 pathway and may be of interest in the mitigation of COVID-19 severity

Testosterone and cardiovascular disease - a literature review

The effects of testosterone on the cardiovascular (CV) system make it a matter of scientific interest. Disturbances in endogenous steroid concentrations are some of the factors involved in the pathogenesis of atherosclerosis and ischemic heart disease. The aim of this article is to summarize the role of hypogonadism in the context of ischemic heart disease development and to review the current evidence on the CV benefits of testosterone replacement. Its low endogenous level is associated with worsened lipid profile, accelerated development of atherosclerotic plaques, high body mass index, metabolic syndrome and, type 2 diabetes mellitus. In light of these facts, some studies look into the benefits of exogenous testosterone replacement in patients with coronary heart disease and heart failure. The results are divergent and a large randomized trial is required to define the link between testosterone replacement therapy and CV risk. New clues present the recent data on the possible adaptive role of hypogonadism in acute coronary syndrome. This has the potential to expand the knowledge on the link between the CV system and gonadal function in men. The role of sex steroids in the pathogenesis of atherosclerotic heart disease and adaptation to acute coronary syndrome is a subject of increasing scientific interest as a result of accumulating evidence in this field

Androgen Levels in Men with Acute and Chronic Coronary Syndrome // Андрогенни нива при мъже с остър и хроничен коронарен синдром

The problem of androgens in men with acute (ACS) and chronic coronary syndrome (CCS) is relevant to clarify the pathogenesis and prevention of CHD. There is evidence of a beneficial effect of androgens on the cardiac muscle and vascularization and an increased risk with substitution. In this regard, we aim to investigate the role of androgens in adaptation to ACS as well as in the development of CHD. We studied 105 patients, 72 with ACS, 32 with CCS and 35 controls. We found lower values of all testosterone (T) fractions and a higher incidence of hypotestosteronemia in patients with ACS. T fractions and aromatization index were the lowest in the group of patients with ST-elevation compared to non-ST-elevation ACS. In the CCS group, the aromatization index correlates with some lipid parameters. Lower SHBG levels were associated with a worse metabolic profile in the CCS group, whereas in the OCS group, higher SHBG levels were a parameter reflecting and complementing the risk characteristic. The main determinants of DHEA-S were age and glomerular filtration rate in the IHD and ACS groups, whereas for the CCS group, it was only age. A higher value of the cortisol/DHEA-S ratio was associated with a worse risk characteristic of ACS patients. The results of this study provide the basis for studies that could elucidate important aspects in regulating gonadal function and the extragonadal effects of steroid hormones in the context of CHD.Актуалността на проблема за андрогените при мъже с остър (ОКС)и хроничен коронарен синдром (ХКС) е свързана изясняване патогенезата и профилактика на ИБС. Налице са данни за благоприятен ефект на андрогените върху сърдечната мускулатура и васкуларизация, но и повишен риск при субституция. В тази връзка си поставихме за цел да изследваме ролята на андрогените при адаптацията към ОКС както и за развитието на ИБС при мъже със остър и ХКС. Изследвани са 105 пациенти - 72 с ОКС, 32 с ХКС и 35 контроли. Установихме по-ниски стойности на всички фракции на тестостерона (Т), по-висока честота на хипотестостеронемията при пациенти с ОКС . Най- ниски са посочените фракции на Т и ароматизационния индекс в групата на пациентите със ST-елевация, спрямо ОКС без ST-елевация. В групата на ХКС ароматизационния индекс корелира с някои липидни показатели. По-ниските нива на SHBG се свързват с по-лош метаболитен профил в групата ХКС, докато в ОКС по-високите нива на SHBG са параметър отразяващ и допълващ рисковата характеристика. Основни детерминанти на DHEA-S са възрастта и гломерулната филтрация в групите ОКС и АКБ, докато за групата на ХКС това е само възрастта. По-високата стойност на отношението кортизол/DHEA-S се свързва с по-лоша рискова характеристика на пациентите с ОКС. Резултатите от изследването дават основата за провеждане на проучвания, които биха могли да изяснят важни аспекти в регулацията на гонадната функция и екстрагонадните ефекти на стероидните хормони в контекста на ИБС

Physiological and pathophysiological role of dehydroepiandrosterone in cardiovascular disease

Dehydroepiandrosterone (DHEA) and its sulfated forma (DHEA-S) are the endogenous steroids with the highest concentrations, fulfilling the role of androgen precursors. This review discusses the current understanding of the physiological role of DHEA-S in different stages of life, as well as the biological effects of its metabolites. Accent is put on the role of DHEA-S in the context of cardiovascular disease as a factor influencing the pathogenesis of ischemic heart disease and the cardiovascular risk factors. The studies reviewed outline DHEA-S as one of the possible factors influencing atherogenesis, turning it into a likely subject of future research

Case of Euglycemic Ketoacidosis Induced by SGLT2 Inhibitors (Sodium-Glucose Cotransporter 2) in a Diabetic Patient

Introduction: Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a new class of hypoglycemic antidiabetic medications indicated for the treatment of type 2 diabetes by inhibiting the SGLT2 protein in the proximal renal tubule to prevent reabsorption of glucose and facilitate its removal by the kidneys.Materials and Methods: We report case of a 38-year-old woman with unrecognized type 1 diabetes, who developed severe ketoacidosis caused by a sodium-glucose cotransporter 2 inhibitor - Forxiga (dapagliflozin).Results: The patient was misdiagnosed with diabetes type 2 a month and a half before the hospital admission with initial complaints of polydipsia, polyuria, genital pruritus and insignificant weight reduction (1 kg). Family history revealed a mother and an aunt with type 2 diabetes. In this period, she received gliclazide (30 mg/day), metformin (3 x 850 mg/day) and dapagliflozin (10 mg/day). Four days before hospitalization, the woman complained of nausea, tachydyspnea with gradual deterioration of her general condition. At the hospital admission, the laboratory results showed severe metabolic acidosis (pH: 6.91), positive urinary ketones (+++) and blood glucose level: 11.7 mmol/L. The patient was admitted at the Clinic of Anesthesiology and Intensive Care with severe acidosis and impaired consciousness. The treatment included intravenous insulin, infusions and correction of the electrolytes and acid-base disorders followed by subcutaneous insulin treatment in a basal bolus regimen. An examination of a panel of antibodies revealed positive GAD 65 (+) with low C-peptide.Conclusion: Diabetic ketoacidosis (DKA) is an acute complication of type 1 diabetes. Glucosuria, insulinopenia and hyperglucagonemia induced by SGLT2 inhibitors are the mechanisms behind normoglycemic ketoacidosis

A Case of Congenital Hypopituitarism

Introduction: Congenital hypopituitarism is a condition, presenting with partial or total loss of a single or multiple hormones, secreted by the anterior and/or posterior part of the pituitary gland. Patients have damaged hormone sequences and certain deficits depending on the hormone/s that is absent. Studies point the etiology of the condition as multi-sided - abnormal development, molecular and recently found genetic patterns.  Materials and Methods: We present a case of a 21-year-old male patient, first diagnosed with bilateral cryptorchidism 10 years ago. Later on, he developed fatigue, nausea, vertigo and dry scaly skin. The further endocrinology tests showed low levels of adrenocorticotrophic hormones, glucocorticoids, thyrotrophic hormone and gonadotrophins, including low testosterone levels. Physical examination revealed metatarsal bone abnormalities and no signs of puberty development. The family history of the patient also shows a relation between his parents (distant cousins) and another present relative - an older brother with normal development.Results: In this case these four pituitary hormones are absent: corticotrophic, thyrothophic, somatotrophic and gonadotrophic hormone and the results from the MRI study point out hypoplasia of the anterior pituitary gland, enlargement of the posterior part and an absent infundibulum. X-ray results of the hand show retardation of the bone age (consistent with the one of a 12- or 13-year-old boy).Conclusion: Results of the diagnostic tests and procedures lead to the suspicion that in the present case there is a genetic abnormality in the SOX3 gene consistent with the anterior pituitary hypoplasia and an ectopic posterior part