Do ACE inhibitors or ARBs help prevent kidney disease in patients with diabetes and normal BP?

Q: Do ACE inhibitors or ARBs help prevent kidney disease in patients with diabetes and normal BP? Evidence-based answer: Yes for angiotensin-converting enzyme (ACE) inhibitors, no for angiotensin receptor blockers (ARBs). In normotensive patients with type 1 and type 2 diabetes, ACE inhibitor therapy reduces the risk of developing diabetic kidney disease, defined as new-onset microalbuminuria or macroalbuminuria, by 18% (strength of recommendation [SOR]: C, meta-analysis of randomized controlled trials [RCTs], disease-oriented evidence). ACE inhibitor treatment improves all-cause mortality by 16% in patients with diabetes, including patients with and without hypertension. Patients on ACE inhibitor therapy are at increased risk of cough (SOR: A, meta-analysis of RCTs). ARB therapy doesn't lower the risk of developing kidney disease in normotensive patients with type 2 diabetes (SOR: C, meta-analysis of RCTs, disease-oriented evidence); nor does it reduce all-cause mortality in patients with or without hypertension (SOR: A, meta-analysis of RCTs). ARBs aren't associated with significant adverse events (SOR: A, meta-analysis of RCTs)

Association of major depression with blood pressure and vascular complications of type 2 diabetes mellitus

Background: The WHO estimates the diabetic population to increase to 366 million by 2030 worldwide, with maximum 79.4 million Indians. Depression is an undiagnosed co-morbidity leading to significant disability, non-compliance and postulated to cause poorer glycemic control leading to early disease complications. We aimed to detect depression and study its correlation with vascular complications among type 2 diabetes mellitus (T2DM) patients.Methods: In an observational study, 312 randomly selected T2DM patients were evaluated at tertiary care center in Northern India. Socio-demographic, clinical and laboratory data was collected. Montgomery Asberg depression rating scale (MADRS) was used to detect depression. Groups with and without major depression were compared for various diabetes variables. Statistical analysis was carried out using the SPSS version 14.0.Results: One third T2DM patients (32.05%) suffered from major depression. Depression was significantly associated with diabetic patients having cardiac (p 0.01), ophthalmic (p 0.04), nephropathy (p 0.01), cerebrovascular (p 0.001) complications and diabetic foot (p 0.04). However, depression showed no significant association with systolic blood pressure, neuropathic and infectious complications.Conclusions: Identification of depression and its appropriate management may go a long way in delaying diabetic vascular complications by improving treatment adherence and subsequently glycemic control.

Dengue: multicentre clinical profile of patients admitted in intensive care unit

Background: Dengue with 2.5 billion people at risk and 50 million new cases every year is one of the most rapidly spreading vectors borne disease in world. We aimed to analyse the clinical profile of dengue patients requiring ICU admission.Methods: In a cross-sectional, observational, multicenter case study 105randomly selected laboratory positive dengue subjects were randomly selected from four tertiary care centers ICU’s. Socio-demographical, clinical, therapeutic & laboratory parameters were evaluated. Statistical analysis was done using SPSS version 14.0.Results: The main cause of ICU admission was shock or hypotension due to sepsis (20%). Most patients presenting complaint was fever (93.33%), bodyache (84.76%) and retro-orbital pain (34.3%). Most prevalent warning sign indicating severe dengue was abdominal pain (37.4%). Mucosal bleed (20.9%) was the most common haemorrhagic manifestation. 37.14% with warning signs and 62.86% patients with severe dengue required ICU care.Conclusions: A rapid assessment of clinical profile, presenting symptoms and warning signs can aid in early decision for requirement of ICU admission & may go a long way in decreasing mortality

A study to investigate the prevalence of metabolic syndrome in Chronic Obstructive Pulmonary Disease patients from North India

Background: Worldwide, Chronic obstructive pulmonary disease (COPD) is the one of the leading cause of chronic morbidity and mortality. COPD is one of the diseases in which smoking is the common and important risk factor when it is associated with Metabolic syndrome (MetS). The individual components of MetS, i.e., obesity, dyslipidemia, fasting hyperglycaemia, and hypertension were independently associated with impairment of lung function too. The objective of this study is to find out the prevalence of metabolic syndrome among COPD patients.Methods: This was a cross-sectional study conducted in department of Respiratory Diseases and a total of 70 COPD patients were included in the study, which were enrolled for treatment from July 2016 to July 2017. The severity level in patients with COPD were determined according to GOLD (Global Initiative for Chronic Obstructive Lung Disease), 2015 guideline. International Diabetes Federation (IDF) guideline; (2005) was used in diagnosis of metabolic syndrome.Results: Seventy patients with COPD were enrolled during the study period. There were 45 males (64.2%) and 25(35.7%) females. Mean age of male patients was 58.67±9.87 years, while mean age of female patients was 57.23±10.4 years (35-87 years). Mean BMI of male was 24.33±6.64 kg/m2, while in case of female it was 30.07±6.95 kg/m2 and overall mean BMI of study population was 26.22±7.22 kg/m2. The mean   waist circumference of male was 86.91±13.31 cm while in female it was 87.18±14.51 cm. The Overall prevalence of metabolic syndrome was 31.34% and most common in GOLD stage-3 (47.06%), followed by stage-2 (40%), followed by stage-4 (25.71%) and 7.4 % in GOLD stage -1.Conclusions: The presence of metabolic syndrome is common in patients with COPD and, all COPD patients should be considered for screening for it

Relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit

Aim The anastomosis technique used following right-sided colonic resection is widely variable and may affect patient outcome. This study aimed to assess the association between leak and anastomosis technique (stapled vs handsewn). Method This was a prospective, multicentre, international audit including patients undergoing elective or emergency right hemicolectomy or ileo-caecal resection operations over a 2-month period in early 2015. The primary outcome measure was the presence of anastomotic leak within 30 days of surgery, determined using a prespecified definition. Mixed effects logistic regression models were used to assess the association between leak and anastomosis method, adjusting for patient, disease and operative cofactors, with centre included as a random-effect variable. Results This study included 3208 patients, of whom 78.4% (n = 2515) underwent surgery for malignancy and 11.7% (n = 375) underwent surgery for Crohn's disease. An anastomosis was performed in 94.8% (n = 3041) of patients, which was handsewn in 38.9% (n = 1183) and stapled in 61.1% (n = 1858). Patients undergoing hand-sewn anastomosis were more likely to be emergency admissions (20.5% handsewn vs 12.9% stapled) and to undergo open surgery (54.7% handsewn vs 36.6% stapled). The overall anastomotic leak rate was 8.1% (245/3041), which was similar following handsewn (7.4%) and stapled (8.5%) techniques (P = 0.3). After adjustment for cofactors, the odds of a leak were higher for stapled anastomosis (adjusted OR = 1.43; 95% CI: 1.04-1.95; P = 0.03). Conclusion Despite being used in lower-risk patients, stapled anastomosis was associated with an increased anastomotic leak rate in this observational study. Further research is needed to define patient groups in whom a stapled anastomosis is safe.This is the peer-reviewed version of the article: Pinkney, T.; Battersby, N.; Bhangu, A.; Chaudhri, S.; El-Hussuna, A.; Frasson, M.; Nepogodiev, D.; Singh, B.; Kovačević, B.; Autora), (i Jos Puno. Relationship between Method of Anastomosis and Anastomotic Failure after Right Hemicolectomy and Ileo-Caecal Resection: An International Snapshot Audit. Colorectal Disease 2017, 19 (8), O296–O311. [https://doi.org/10.1111/codi.13646

In vitro modeling of endothelial interaction with macrophages and pericytes demonstrates Notch signaling function in the vascular microenvironment.

Angiogenesis is regulated by complex interactions between endothelial cells and support cells of the vascular microenvironment, such as tissue myeloid cells and vascular mural cells. Multicellular interactions during angiogenesis are difficult to study in animals and challenging in a reductive setting. We incorporated stromal cells into an established bead-based capillary sprouting assay to develop assays that faithfully reproduce major steps of vessel sprouting and maturation. We observed that macrophages enhance angiogenesis, increasing the number and length of endothelial sprouts, a property we have dubbed "angiotrophism." We found that polarizing macrophages toward a pro-inflammatory profile further increased their angiotrophic stimulation of vessel sprouting, and this increase was dependent on macrophage Notch signaling. To study endothelial/pericyte interactions, we added vascular pericytes directly to the bead-bound endothelial monolayer. These pericytes formed close associations with the endothelial sprouts, causing increased sprout number and vessel caliber. We found that Jagged1 expression and Notch signaling are essential for the growth of both endothelial cells and pericytes and may function in their interaction. We observed that combining endothelial cells with both macrophages and pericytes in the same sprouting assay has multiplicative effects on sprouting. These results significantly improve bead-capillary sprouting assays and provide an enhanced method for modeling interactions between the endothelium and the vascular microenvironment. Achieving this in a reductive in vitro setting represents a significant step toward a better understanding of the cellular elements that contribute to the formation of mature vasculature.S

The WOMAN trial: clinical and contextual factors surrounding the deaths of 483 women following post-partum haemorrhage in developing countries.

BACKGROUND: Post-partum haemorrhage (PPH) is a leading cause of maternal death worldwide. The WOMAN trial assessed the effects of tranexamic acid (TXA) on death and surgical morbidity in women with PPH. The trial recorded 483 maternal deaths. We report the circumstances of the women who died. METHODS: The WOMAN trial recruited 20,060 women with a clinical diagnosis of PPH after a vaginal birth or caesarean section. We randomly allocated women to receive TXA or placebo. When a woman died, we asked participating clinicians to report the cause of death and to provide a short narrative of the events surrounding the death. We collated and edited for clarity the narrative data. RESULTS: Case fatality rates were 3.0% in Africa and 1.7% in Asia. Nearly three quarters of deaths were within 3 h of delivery and 91% of these deaths were from bleeding. Women who delivered outside a participating hospital (12%) were three times more likely to die (OR = 3.12, 95%CI 2.55-3.81) than those who delivered in hospital. Blood was often unavailable due to shortages or because relatives could not afford to buy it. Clinicians highlighted late presentation, maternal anaemia and poor infrastructure as key contributory factors. CONCLUSIONS: Although TXA use reduces bleeding deaths by almost one third, mortality rates similar to those in high income countries will not be achieved without tackling late presentation, maternal anaemia, availability of blood for transfusion and poor infrastructure