Well-controlled Hypertension Research Articles

Atypical Presentation of Pre-excited Atrial Fibrillation in an Elderly Patient: A Case Report

Pre-excited atrial fibrillation (AF) is a significant clinical condition associated with Wolff-Parkinson-White (WPW) syndrome, characterized by an accessory pathway that enables rapid conduction of atrial fibrillatory waves to the ventricles, leading to dangerously elevated ventricular rates. While WPW syndrome is typically diagnosed in younger individuals, its occurrence in elderly patients is rare and often underreported. This case report discusses a 79-year-old male with well-controlled hypertension who was admitted for poorly tolerated irregular tachycardia with broad QRS complexes, indicative of pre-excited atrial fibrillation (AF). Urgent synchronized electrical cardioversion successfully restored sinus rhythm. Although catheter ablation was proposed as a definitive treatment, the patient chose to postpone the procedure, with close monitoring implemented afterward. This case underscores the challenges of diagnosing WPW syndrome in elderly patients, the potential dangers of pre-excited AF, and the importance of individualized management strategies tailored to patient preferences and comorbidities.

Relationship between triglyceride-glucose index and carotid artery plaques in ischemic stroke patients: Based on blood pressure status, sex, and age

BackgroundNumerous studies have shown that the triglyceride-glucose (TyG) index is a reliable substitute marker for insulin resistance. Nevertheless, its correlation with carotid artery plaques (CAPs) among patients with ischemic stroke (IS) remains to be elucidated. Methods9248 IS patients hospitalized at the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine were grouped according to the quartiles of TyG index. Patients were further stratified by blood pressure status, sex, age and hypertension control status. Employing logistic regression to examine the connection between the TyG index and CAPs.Additionally, analyzing the receiver operating characteristic (ROC) curve to evaluate the predictive value of the TyG index for CAPs. ResultsParticipants with an elevated TyG index had an increased prevalence of CAPs. The TyG index was positively correlated with CAPs (OR: 1.26, CI: 1.14-1.40, P<0.001). Compared with normal blood pressure and prehypertensive patients, the TyG index was markedly correlated with CAPs among hypertensive patients (OR: 1.29, 95% CI: 1.15-1.44, P<0.001). Females had a higher OR value than males(OR: 1.31, 95% CI: 1.11-1.54, P=0.001 versus OR: 1.24, 95% CI: 1.09-1.41, P=0.001). Older patients (>60 years) had a higher OR value than their middle-aged counterparts (≤60 years) (OR: 1.35; 95% CI: 1.16-1.58, P<0.001 versus OR: 1.20; 95% CI: 1.05-1.37, P=0.007). Patients with poorly-controlled hypertension had a higher OR value than patients with well-controlled hypertension(OR: 1.36; 95% CI: 1.14-1.63, P=0.001 versus OR: 1.24; 95% CI: 1.07-1.44, P=0.003). After adjusting for potential confounding factors, the area under the ROC curve (AUC) value in the overall population, sex-stratified group, hypertensive patients and hypertension control status-stratified group were all above 0.7 (P<0.01), demonstrating good forecasting capability. ConclusionsIn IS patients, the TyG index was significantly associated with CAPs. Additionally, this correlation was more pronounced in hypertensive patients, females, older individuals and patients with poorly-controlled hypertension.

Heterotopic Splenic Tissue Mimicking Metastases on Magnetic Resonance Imaging.

Heterotopic splenic tissue can occur following splenectomy and is typically asymptomatic, often discovered incidentally during imaging for other conditions. This benign condition may mimic malignant processes, posing diagnostic challenges especially in patients with a history of cancer or concurrent malignancy. We report the case of a 60-year-old male with a history of well-controlled hypertension and a splenectomy following a traumatic injury at age 7. The patient underwent routine screening which revealed elevated prostate-specific antigen (PSA) levels. Subsequent magnetic resonance imaging (MRI) identified suspicious lesions in the prostate and a left lower quadrant mass. Prostate biopsy confirmed an adenocarcinoma with a Gleason score of 6, while biopsy of the abdominal mass revealed heterotopic splenic tissue. The management strategy included active surveillance for prostate cancer, considering the tumour's low aggressiveness and the benign nature of the splenic tissue. This case highlights the importance of considering heterotopic splenic tissue in differential diagnosis when evaluating abdominal masses in patients with a history of splenectomy. Accurate diagnosis through careful imaging and biopsy is crucial to avoid misdiagnosis and unnecessary treatments, particularly in patients with concurrent malignancies. In patients who have had a prior splenectomy for trauma, heterotopic splenic tissue may be mistaken for metastases on MRI.

Long-term blood pressure variability and risk of cardiovascular diseases in populations with different blood pressure status: an ambispective cohort study.

We aimed to investigate the correlation between long-term blood pressure variability (BPV) and the risk of cardiovascular diseases (CVDs) among population with different blood pressure statuses (normotension, well-controlled hypertension, and uncontrolled hypertension). In this ambispective cohort study, CVD-free residents aged over 50 years were consecutively enrolled from two community health service centers (CHCs) in Tianjin, China from April 2017 to May 2017. Information on blood pressure was retrospectively extracted from electronic medical records of CHCs between January 2010 and May 2017, and the occurrence of new-onset CVDs was prospectively observed during follow-up until September 2019. Long-term variation of SBP and DBP was assessed using four indicators: SD, coefficient of variation (CV), average successive variability (ASV), and average real variability (ARV). Cox proportional hazards regression model was developed to identify the potential impact of BPV on the incidence of CVDs. The receiver operating characteristic curve (ROC) was utilized to evaluate the predictive value of BPV indicators for the occurrence of CVDs. Of 1275 participants included, 412 (32.3%) experienced new CVD events during the median 7.7 years of follow-up, with an incidence density of 499/10 000 person-year in the whole cohort. Cox regression analysis revealed that almost all SBP and DBP variability indicators (except for SBP-SD) were significantly related to the risk of CVDs, especially among individuals with well-controlled hypertension. A trend toward an increased risk of CVDs across BPV quartiles was also observed. Moderate predictive abilities of BPV were observed, with the area under ROC curves ranging between 0.649 and 0.736. For SBP variability, SD had the lowest predictive ability, whereas for DBP variability, ARV had the lowest predictive ability. No significant association of CVDs with SBP-SD was found in all analyses, no matter as a continuous or categorical variable. Elevated long-term BPV is associated with an increased risk of CVDs, especially among individuals with well-controlled hypertension. CV and ASV had higher predictive values than SD and ARV.

Patients with uncontrolled hypertension subjected to cardiopulmonary bypass have altered coronary vasomotor responses to serotonin

BackgroundWe previously found that cardioplegic arrest and cardiopulmonary bypass are associated with altered coronary arteriolar response to serotonin in patients undergoing cardiac surgery. In this study, we investigated the effects of hypertension on coronary microvascular vasomotor tone in response to serotonin and alterations in serotonin receptor protein expression in the setting of cardioplegic arrest and cardiopulmonary bypass. MethodsCoronary arterioles were dissected from harvested pre– and post–cardioplegic arrest and cardiopulmonary bypass right atrial tissue samples of patients undergoing cardiac surgery with normotension, well-controlled hypertension, and uncontrolled hypertension. Vasomotor tone was assessed by video-myography, and protein expression was measured with immunoblotting. ResultsPre–cardioplegic arrest and cardiopulmonary bypass, serotonin induced moderate relaxation responses of coronary arterioles in normotension and well-controlled hypertension patients, whereas serotonin caused moderate contractile responses in uncontrolled hypertension patients. Post–cardioplegic arrest and cardiopulmonary bypass, serotonin caused contractile responses of coronary arterioles in all 3 groups. The post–cardioplegic arrest and cardiopulmonary bypass contractile response to serotonin was significantly higher in the uncontrolled hypertension group compared with the normotension or well-controlled hypertension groups (P < .05). Pre–cardioplegic arrest and cardiopulmonary bypass, expression of the serotonin 1A receptor was significantly lower in the uncontrolled hypertension group compared with the well-controlled hypertension and normotension groups (P = .01 and P < .001). Serotonin 1B receptor expression was higher in the uncontrolled hypertension group compared with the normotension or well-controlled hypertension groups post–cardioplegic arrest and cardiopulmonary bypass (P = .03 and P = .046). ConclusionUncontrolled hypertension is associated with an increased coronary contractile response of coronary microvessels to serotonin and altered serotonin receptor protein expression after cardioplegic arrest and cardiopulmonary bypass. These findings may contribute to a worse postoperative coronary spasm and worsened recovery of coronary perfusion in patients with uncontrolled hypertension after cardioplegic arrest and cardiopulmonary bypass and cardiac surgery.

Leukocyte-Platelet-Rich Fibrin in Bone Regeneration after Periapical Surgery: A 30-Month Follow-Up Clinical Report

Aim and background: Periapical lesions, which occur due to the infection and necrosis of dental pulp, are a significant dental pathology that poses risks to oral and systemic health. These lesions often require interventions such as root canal treatment or periapical surgery. Recent research has focused on the effectiveness of biocompatible materials, including mineral trioxide aggregate, bioceramics, and leukocyte-platelet-rich fibrin (L’PRF), in improving healing outcomes. This report presents the application of leukocyte-platelet-rich fibrin (L’PRF) derived from the patient’s autologous blood to enhance bone healing. Case description: A 61-year-old woman with well-controlled hypertension and good oral hygiene visited the dental clinic due to a painless swelling near her upper left central incisor. After examination, it was determined that she had a periapical granuloma. The patient underwent successful root canal retreatment and apical surgery, during which leukocyte-platelet-rich fibrin was applied. After 30 months, she experienced significant improvement with no symptoms and substantial bone regeneration. Conclusion: Clinical evidence and this case study indicate that leukocyte-platelet-rich fibrin (L’PRF) may enhance healing post periapical surgery. Further research, including more extensive and longer-term randomized trials, must confirm L’PRF’s effectiveness and refine treatment protocols. Clinical significance: L’PRF enhances bone healing post periapical surgery. Clinicians should consider integrating L’PRF in periapical surgeries, ensure diligent follow-up, and inform patients of its long-term advantages. Further randomized trials are needed to refine L’PRF clinical guidelines.

Superior oblique palsy as the initial manifestation of anti-contactin-1 IgG4 autoimmune nodopathy: A case report

Autoimmune nodopathy (AN) is a group of peripheral neuropathies caused by antibodies targeting the nodes of Ranvier or paranodes. It typically presents with sensory ataxia, distal limb weakness, and tremor, and often has a subacute onset, with limited response to immunoglobulin or corticosteroids. We report a case of anti-contactin-1 neuropathy initially manifesting as isolated superior oblique palsy, aiming to broaden the clinical spectrum of the disease. A 68-year-old male with well-controlled diabetes, hypertension, and hyperlipidemia developed acute binocular vertical diplopia, progressing over two months to include distal paresthesia, sensory ataxia, ageusia, and dysarthria. Concurrent nephrotic syndrome was identified. Nerve conduction studies supported demyelination. Despite treatment with intravenous methylprednisolone followed by long-term immunosuppression, some disability persisted. Serum archived during his admission tested positive for anti-contactin-1 IgG, with IgG4 as the predominant subclass, in the flow cytometry assay for AN. This case extends the clinical spectrum of AN. Some cases of isolated cranial nerve palsies, especially in the relevant context like nephrotic syndrome, may be attributed to AN. Prompt initiation of more effective therapies, such as rituximab, could significantly improve outcomes.

Spontaneous spinal epidural hematoma leading to acute paraplegia: a case report

BackgroundSpontaneous spinal epidural hematoma is an infrequent yet potentially debilitating condition characterized by blood accumulation in the epidural space, with only 300 documented cases globally. Although the exact etiology of spontaneous spinal epidural hematoma remains poorly understood, theories suggest arteriovenous malformations, rupture of epidural vessels, or epidural veins as possible causes.Case presentationThis study presents a 58-year-old Malay woman patient from Singapore with well-controlled hypertension, hyperlipidemia, type II diabetes mellitus, and microscopic hematuria. Despite a prior cystoscopy revealing no abnormalities, she presented to the emergency department with sudden-onset back pain, weakness, and numbness in both lower limbs. Rapidly progressing symptoms prompted imaging, leading to the diagnosis of a spinal epidural hematoma from thoracic (T) 9 to lumbar (L) 1. Prompt decompressive surgery was performed, and the patient is currently undergoing postoperative rehabilitation for paralysis.ConclusionThis case emphasizes the severity and life-altering consequences of spontaneous spinal epidural hematomas. Despite various proposed causative factors, a definitive consensus remains elusive in current literature. Consequently, maintaining a low threshold of suspicion for patients with similar presentations is crucial. The findings underscore the urgent need for swift evaluation and surgical intervention in cases of acute paraplegia.

Abstract 17167: Uncontrolled Hypertension Increases Endothelin-1-Induced Contractile Response of Coronary Microvasculature Both Before and After Cardioplegia and Cardiopulmonary Bypass

Introduction: Hypertensive patients undergoing cardiopulmonary bypass (CPB) have worse clinical outcomes, and coronary microvascular dysfunction may play a role. Endothelin-1 (ET-1), a vasoactive biopeptide, is increased in cardiomyocytes during the hypertrophic response to hypertension and in patients following CPB. Differential effects of hypertension on coronary microvascular reactivity and molecular signaling pathways following CPB have yet to be elucidated. Aims: This study investigated the effects of well-controlled and uncontrolled hypertension on CPB-induced changes in coronary microvascular vasoconstriction to ET-1 and associated signaling using unique in vitro microvascular reactivity studies, RNA deep sequencing, and established molecular methods. Methods: Coronary microvessels (&lt;200um) were harvested from atrial samples from patients with no hypertension (NH), well-controlled hypertension (CH), and uncontrolled hypertension (UH) before and after CPB. In vitro contractile response to ET-1 was assessed using video microscopy. Protein expression and receptor localization were measured using immunoblotting and immunohistochemistry, respectively. Enzyme-linked immunosorbent assay was used to quantify plasma concentration of ET-1. Results: Pre-CPB contractile response of coronary microvessels to ET-1 in UH was increased compared to NH or CH (p &lt;0.05). Post-CPB contractile response was impaired overall (p &lt;0.05). Between groups, contractile response in CH and NH was comparable while response in UH was higher (p &lt;0.05). Plasma ET-1 increased post-CPB (p = 0.18). Total protein levels and localization of ET A R and ET B R were unchanged post-CPB. Conclusions: While CPB overall blunted vasomotor contractile response of coronary microvessels to ET-1, UH was associated with relatively increased vasoconstriction compared to CH and NH. Changes in plasma ET-1, ET A R and ET B R levels or localization did not contribute to these effects.

Abstract 17883: Subacute Native Aortic and Mitral Valve Endocarditis Manifesting as Embolic ST-Elevation Myocardial Infarction

Case description: A 54-year-old male presented with one day of substernal chest pain. He also reported two months of malaise, myalgias, chills, and intermittent fevers. Medical history was notable for well-controlled hypertension and negative for dyslipidemia, diabetes, or drug and tobacco use. Family history was negative for premature coronary artery disease. Vitals were notable for fever of 103F, blood pressure of 108/56 mmHg, and heart rate of 88 beats per minute. Physical exam showed bounding pulses and a soft diastolic murmur at the left lower sternal border. Electrocardiogram showed inferior lead ST-elevations. He was taken for cardiac catheterization and found to have a totally occlusive thrombus in the distal right coronary artery with minimal disease in the remaining vessels. He underwent aspiration thrombectomy and placement of drug eluting stent with normal flow. He was transferred to the coronary intensive care unit. Labs showed mild leukocytosis, normal serum creatinine, and unremarkable urinalysis. Echocardiogram showed a 1.7 x 0.5 cm mobile echodensity on the aortic valve with severe aortic regurgitation and a small echodensity on the anterior mitral leaflet. Blood cultures grew Enterococcus faecalis. A CT scan of the head, chest, abdomen, and pelvis revealed no embolic disease. He underwent urgent surgery due to concern for infective endocarditis with coronary embolism. Purulence was found at the stent site and the posterior descending artery was obliterated by necrotic tissue. A bypass graft was placed distal to the stent site and infected territory was unroofed and irrigated. Mitral and aortic valve replacement was performed. He tolerated surgery and was discharged with 6 weeks of intravenous antibiotics. Discussion: This case was unique in the subacute chronicity of endocarditis and lack of other systemic emboli. Clinically relevant coronary embolism was reported in only 1.5% of cases of infective endocarditis but microemboli were found in 60% postmortem. Embolization is more common with mitral valve involvement, &gt;10 mm vegetation, and fungal or staphylococcal disease. Angiographic evidence of heavy thrombus burden or lack of significant atherosclerosis after myocardial infarction may prompt evaluation for coronary embolism.

Increased Coronary Contraction to Thromboxane A2 in Cardiac Surgery Patients With Poorly Controlled Hypertension

IntroductionCardioplegia and cardiopulmonary bypass (CP/CPB) alters coronary arteriolar response to thromboxane A2 (TXA2) in patients undergoing cardiac surgery. Comorbidities, including hypertension (HTN), can further alter coronary vasomotor tone. This study investigates the effects of HTN on coronary arteriolar response to TXA2 pre and post-CP/CPB and cardiac surgery. Materials and methodsCoronary arterioles pre and post-CP/CPB were dissected from atrial tissue samples in patients with no HTN (NH, n = 9), well-controlled HTN (WC, n = 12), or uncontrolled HTN (UC, n = 12). In-vitro coronary microvascular reactivity was examined in the presence of TXA2 analog U46619 (10−9-10−4M). Protein expression of TXA2 receptor in the harvested right atrial tissue samples were measured by immunoblotting. ResultsTXA2 analog U46619 induced dose-dependent contractile responses of coronary arterioles in all groups. Pre-CPB contractile responses to U46619 were significantly increased in microvessels in the UC group compared to the NH group (P < 0.05). The pre-CP/CPB contractile responses of coronary arterioles were significantly diminished post-CP/CPB among the three groups (P < 0.05), but there remained an increased contractile response in the microvessels of the UC group compared to the WC and NH groups (P < 0.05). There were no significant differences in U46619-induced vasomotor tone between patients in the NH and WC groups (P > 0.05). There were no differences in expression of TXA2R among groups. ConclusionsPoorly controlled HTN is associated with increased contractile response of coronary arterioles to TXA2. This alteration may contribute to worsened recovery of coronary microvascular function in patients with poorly controlled HTN after CP/CPB and cardiac surgery.

Redefining primary hyperaldosteronism as "The Syndrome of Inappropriate Aldosterone Secretion (SIALDS)": A common but unrecognized cause of hypertension.

The current screening and diagnostic recommendations for detecting Primary Hyperaldosteronism (PHA) focus on diagnosing the more severe and overt instances of renin-independent aldosterone production. However, milder forms of autonomous aldosterone secretion have been demonstrated to exist below the diagnostic thresholds of current PHA guidelines, and associate with clinically relevant cardiovascular risk. PHAencompasses a spectrum of renin independent aldosterone production, progressing from a subclinical state in normotensives to a full-blown clinical syndrome representing the resistant hypertension population. The authors propose the Syndrome of Inappropriately Elevated Aldosterone Secretion (SIALDS) concept as a potential new paradigm for understanding and diagnosing PHA and expanded diagnostic approach to improve early detection even in well-controlled hypertension. The authors also delve into the impact of treatments, including mineralocorticoid receptor antagonists and emerging aldosterone synthase inhibitors. Furthermore, The authors outline future research directions, proposing clinical trials to investigate the long-term identification and treatment outcomes of SIALDS.

Myocardial Work Appraisal in Transthyretin Cardiac Amyloidosis and Nonobstructive Hypertrophic Cardiomyopathy

Global left ventricular (LV) myocardial work (MW) indexes can be recognized at ultrasound imaging from the LV pressure/global longitudinal strain (GLS) loop analysis. A total of 4 indexes, global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE), have been demonstrated to overcome the methodological limitations of GLS and provide useful information on myocardial dysfunction in some clinical settings. Although impaired MW indexes have been demonstrated in patients with transthyretin cardiac amyloidosis (ATTR) or with nonobstructive hypertrophic cardiomyopathy (HCM), there are no comparative studies at present. This study aimed to describe the characteristics of MW in both these clinical settings compared with patients with well-controlled hypertension (HTN). A total of 83 patients, 32 with ATTR (aged 70 ± 11years, 32% mutated, 68% wild-type, 72% men), 29 with HCM (aged 57 ± 17years), and 22 HTN controls (aged 56 ± 5.6years, 59% men) were prospectively enrolled at 2 clinical centers. All participants had New York Heart Association class I or II. Overall, the LV mass index was greater in both study groups than in HTN, whereas the LV ejection fraction (EF) was significantly lower in ATTR compared with other groups. Based on this finding, patients with ATTR were further divided into 2 subgroups: ATTR1 (LVEF ≤0.50), n=14 (44%) and ATTR2 (LVEF >0.50), n=18 (56%). Overall, the GWI and GCW were lower in all ATTR patients (mostly in ATTR1) than in the other groups (p <0.001), whereas only small differences in GWE and none in GWW were found among the groups. Of interest, the pairwise comparison and receiver operating characteristic analysis in preserved LVEF patients showed that GWI was a better discriminator of ATTR2 from HCM patients than GLS, with the cut-off value ≤1,419 mm Hg% (89% sensitivity; 55% specificity; p=0.013). In conclusion, MW analysis was confirmed to be a modern way to investigate myocardial function in patients with hypertrophic phenocopies. GWI and GCW were more impaired in patients with ATTR compared with HCM and HTN controls. Furthermore, this study likely revealed an additional discriminative value of GWI over GLS alone in preserved LVEF settings.

FRI371 Serum Androstenedione As An Additive Biomarker In Ectopic Cushing’s Syndrome Evaluation

Abstract Disclosure: S. Zhang: None. J.C. Lo: None. M.G. Jaffe: None. H. Arzumanyan: None. Background: Ectopic Cushing’s syndrome (ECS) results from glucocorticoid excess secondary to ectopic ACTH or CRH producing tumors. Although ECS identification can be challenging when presentation lacks classic Cushing’s features, ectopic ACTH secretion can result in a key constellation of findings that facilitate early clinical recognition. We describe a case of ECS from an ACTH-producing carcinoid tumor of the lung presenting with resistant hypertension, severe hypokalemia, and muscle weakness. In addition to significant hypercortisolism, laboratory findings were notable for high androstenedione levels without concomitant increase in DHEAS and testosterone levels. Case: A 59-year-old female athlete with history of well-controlled hypertension developed difficult to control hypertension, requiring escalation to triple antihypertensive therapy within 3 months. During this time, she had multiple emergency department visits for progressive muscle weakness, hypertension, and persistent hypokalemia despite potassium supplementation. She was hospitalized for further evaluation. Physical examination was notable for bruising, muscle wasting, thin extremities, facial fullness, and disproportionate abdominal adiposity. Workup for Cushing’s syndrome demonstrated ACTH-dependent hypercortisolism and markedly elevated androstenedione 398 ng/dL (normal 20-75 ng/dL) despite normal DHEAS 48 mcg/dL (normal &amp;lt;430 mcg/dL) and total testosterone 11 ng/dL (normal &amp;lt;45 ng/dL) levels. A chest CT identified a 3.8 cm right lower lobe lung mass and transbronchial biopsy confirmed atypical carcinoid tumor. She underwent a right middle and lower lobe bilobectomy with complete tumor resection. Cortisol, androstenedione, and potassium levels rapidly normalized postoperatively, and blood pressure returned to baseline, well-controlled on monotherapy. The patient only required 3 days of hydrocortisone therapy for transient steroid withdrawal symptoms. Conclusions: Our case illustrates a difficult to diagnose uncommon disease presenting with resistant hypertension, hypokalemia and marked androstenedione elevation despite normal DHEAS and testosterone levels. This steroidogenic profile has been reported in other ECS cases and attributed to differential effects of ectopic ACTH production on adrenal androgen biosynthesis (1). Although ECS is rare and the primary lesion can be difficult to identify, disproportionate elevation in androstenedione may prompt recognition of ECS and support early detection and management. Reference: (1) Barbetta L, Dall’Asta C, Re T, Colombo P, Travaglini P, Ambrosi B. Androgen secretion in ectopic ACTH syndrome and in Cushing’s disease: modifications before and after surgery. Horm Metab Res Horm Stoffwechselforschung Horm Metab. 2001;33(10):596-601 Presentation: Friday, June 16, 2023

Strangulated Hernia with Appendicitis: A Rare Case of Amyand’s Hernia in a 72-Year-Old Man

Introduction: Amyand’s hernia is an extremely rare and atypical hernia that is difficult to diagnose clinically characterised by engagement of the appendix in the inguinal sac. The aim of this report is to describe a case of Amyand’s hernia in a 72-year-old man with a history of hypertension on well-controlled calcium channel blockers, and to highlight the importance of surgical exploration in the diagnosis and management of this condition. Case Report: We present a rare case of a 72-year-old man with a history of well-controlled calcium channel blocker hypertension presenting with intermittent right inguinal pain. The patient was admitted to the hospital’s surgical emergency department and was deemed in need of surgical exploration due to suspected strangulated hernia or irreducible hernial engorgement. Preoperative examination revealed no signs of appendicitis. During surgery, an Amyand’s hernia was discovered with an inflamed appendix. Intraoperative work-up was otherwise normal. Discussion: Amyand’s hernia is an extremely rare condition, accounting for less than 1% of all adult inguinal hernias. Acute appendicitis in the context of Amyand’s hernia is even rarer, accounting for only 0.1% of all cases of acute appendicitis. This hernia may remain asymptomatic until inflammation of the appendix leads to incarceration, strangulation, necrosis, perforation or rupture. Early symptoms include inguinal tenderness and swelling. CT scanning is essential for accurate and early diagnosis of Amyand’s hernia, which can help avoid the complications of delayed surgery. Conclusion: This case highlights the importance of early CT scanning for accurate diagnosis of Amyand’s hernia with appendicitis. Management of this rare condition requires appendectomy combined with repair of the hernia, depending on the degree of inflammation of the appendix and the anatomical features of the patient.

Holistic Hypertension Management.

Hypertension (HTN) is a major health care problem affecting nearly half of American's adult population. HTN is one of the costliest diagnoses among cardiovascular disease and leads to other major cardiovascular complications, which increase overall morbidity and mortality. Of those diagnosed with HTN in America, only one-fourth of patients are living with well-controlled HTN. This evidenced-based HTN management practice innovation was conducted to explore evidenced-based, holistic nursing practice of a low-sodium dietary approach to stop hypertension (DASH) diet, and exercise alongside antihypertensive medication management in decreasing systolic blood pressure (SBP) and diastolic blood pressure (DBP) in adult patients diagnosed with HTN. This community-based holistic care initiative supports data previously published, which suggests a low-sodium DASH diet, exercise, and antihypertensive medication management are effective in decreasing SBP and DBP. This project supported clinicians seeking to integrate a complementary holistic and traditional approach to HTN management in patients diagnosed with HTN.

Hepatoid adenocarcinoma masquerading as adrenocortical carcinoma in an elderly male

Background: Hepatoid adenocarcinoma is a malignant lesion arising from an anatomic site other than the liver with histological features similar to hepatocellular carcinoma. Hepatoid adenocarcinoma has been reported from various anatomical sites, but adrenal hepatoid adenocarcinomas are extremely rare.Case Description: A 70-year-old male with well-controlled hypertension presented with chronic abdominal pain and was found to have a large left-sided supra renal mass. The lesion showed radiological features suggestive of malignancy with local invasion. There was biochemical evidence of primary aldosteronism and a non-suppressed overnight dexamethasone suppression test. He underwent open left-sided adrenalectomy: histologically the tumour demonstrated features typical of a hepatoid carcinoma with bile production and immunohistochemical staining for Hep Par-1 and CD10 demonstrating a hepatic canalicular pattern. Adrenocortical-specific immunohistochemical markers (Inhibin and melan A) and neuroendocrine markers (synaptophysin and chromogranin) were negative. He did not have clinical or biochemical evidence of cirrhosis, Hepatitis B or C infection. Triple-phase CT scanning of the abdomen before resection of the adrenal lesion and five months following surgery did not show any significant lesion in the liver suggestive of primary hepatocellular carcinoma, except an 8 mm non enhancing benign-appearing cystic lesion.Conclusion: Most hepatoid adenocarcinomas originate from the gastro-intestinal tract. We present a patient with hepatoid adenocarcinoma masquerading as adrenocortical carcinoma due to misleading imaging and biochemical evidence. Very little is known about their pathogenesis, especially those with an atypical site of origin such as the adrenal gland.

Effect of Preoperative Antianxiety Medications on Blood Pressure and Blood Loss in Total Knee Arthroplasty: A Case-Control Study.

The increasing number of canceled operations in patients undergoing total knee arthroplasty (TKA) due to high blood pressure readings has put a considerable burden on surgeons. In this study, we aim to assess the effect of giving antianxiety drugs preoperatively on maintaining blood pressure (BP) and blood loss for patients undergoing TKA surgery. This retrospective case-control study included patients who underwent total knee arthroplasty and divided them into two main groups: those who had taken a 3 mg bromazepam oral tablet at the night preoperatively and the control group. The blood pressure of patients was then measured preoperatively (baseline), in the morning of surgery, in the operating room before anesthesia, and during the surgery. The percentage of measured BP was calculated by dividing the measured BP by the baseline, then multiplying by 100. 301 patients were included in our study: 137 received bromazepam and 164 as a control group. The ratio of systolic BP (SBP) in the morning of surgery to the baseline (percentage of morning SBP) decreased significantly in the bromazepam group compared with the controls. The ratio of SBP, in the operating room before anesthesia (percentage of preanesthesia SBP) also decreased significantly in the bromazepam group. However, the percentage of SBP in the middle of surgery did not change significantly. In addition, there was a significant difference change from the baseline in diastolic BP and mean arterial BP between the two groups in the morning of surgery, inside the theatre, and in the middle of the operation. The bromazepam group also showed a significant decrease in blood loss. Preoperative oral antianxiety drugs (bromazepam) helps in controlling hemodynamic changes associated with anxiety, including maintaining BP in well-controlled hypertensive and healthy patients undergoing TKA, and it plays a role in decreasing the total blood loss.

Menopausal treatment in women with diabetes and hypertension

Menopausal transition is associated with increased risk of hypertension and metabolic changes predisposing for type 2 diabetes. Moreover, hypertension and type 2 diabetes are independent risk factors for cardiovascular disease, which is the leading cause of morbidity and mortality in women. It is well-known that endogenous estrogen protects against cardiovascular disease by vasodilatation through mechanisms including increased nitric oxid synthesis and reduced angiotensin receptor activity leading to reduced blood pressure. What about menopausal hormone treatment (MHT), could MHT be beneficial and prevent from development of diabetes and cardiovascular disease? Furthermore, is MHT safe in women with pre-existing diabetes and hypertension? Well-controlled diabetes and/or hypertension are not contraindications for MHT. Vasomotor symptoms should be indication for treatment also in these women with special consideration of cardiovascular risk. In fact, MHT can improve diabetic control. However, there is no clear evidence to support that MHT can prevent from developing diabetes. The oral route of MHT can affect blood pressure by liver induction of plasma proteins, which may increase blood pressure and aggravate hypertension. Furthermore, oral estrogen increaes coagulation factors and therby increases the risk of thrombosis. In women with hypertension, transdermal estrogen might be the most appropriate MHT. Transdermal estrogen does not increase blood pressure and is preferable for women with moderate risk for cardiovascular disease. Progestogens with neutral effect on metabolic parameters could also be recommended. The risk benefit balance of using MHT for healthy women is favorable if introduced early in relation to menopause, but the timing hypothesis for primary prevention of cardiovascular disease is still under debate. These questions and the management of menopausal symptoms in women with diabetes and hypertension will be illustrated by a patient case.

CHIOS MASTIC IMPROVES NIGHT-TIME DIASTOLIC PRESSURE IN WELL-CONTROLLED PATIENTS WITH HYPERTENSION; PRELIMINARY RESULTS OF THE HYPER-MASTIC CLINICAL TRIAL

Objective: Chios mastic is a natural nutritional supplement consisting of several bioactive compounds and it possesses antioxidant and anti-inflammatory activities. Preliminary recent evidence suggests an anti-hypertensive effect of mastic. HYPER-MASTIC is a double-blind, randomized and controlled clinical trial, with the aim of investigating the additional effect of a three-month supplementation with Chios mastic on arterial hypertension of Greek patients with well-managed cardiovascular risk factors. Design and method: Patients with well controlled hypertension are being consecutively recruited and randomly allocated into three groups of supplements: 1500mg of mastic, 2800 mg of mastic and placebo in this ongoing study. For the current analyses, the two mastic groups were merged. Blood pressure measurements, using both office and 24h blood pressure measurement, and blood tests were performed at baseline and at 3 months. Flow-mediated dilatation (FMD) at the level of the brachial artery was measured in all patients as a measure of endothelial function. Patients reported no recent history of acute myocardial infarction or stroke and no history of heart failure. Herein, the preliminary results of the study are presented. Results: At the time of analysis, twenty one patients [48% females, age: 62 (14)] were consecutively recruited and randomized, with available data at 3 months. Thirteen volunteers were allocated to mastic and eight to placebo. No difference was found regarding age, sex distribution, BMI levels, personal or family history of hyperlipidemia and hypertension, diabetes mellitus type 2 and coronary artery disease between the two groups. Patients in the mastic group reduced their night-time diastolic blood pressure compared to placebo [-5 (10) vs -2.5 (16.3) mmHg | p = 0.025, respectively]. No other differences from placebo were observed on the effect of mastic on BP parameters. FMD dropped with time in the placebo group, whereas in the mastic group it was preserved [-1.2 (2.7) vs -0.2 (0.8) | pinteraction = 0.010]. Conclusions: Chios mastic supplementation leads to improved night-time diastolic blood pressure and preserved endothelial function in patients with well-controlled hypertension, suggesting that it may incrementally exert anti-hypertensive and vasculoprotective properties over anti-hypertensive medication.