Inhibition of neprilysin with sacubitril without RAS blockage aggravates renal disease in Dahl SS rats

Salt-sensitive (SS) hypertension is accompanied with severe cardiorenal complications. In this condition, elevated blood pressure (BP) resulting from salt retention is associated with counterintuitively lower levels of atrial natriuretic peptide (ANP). In plasma, ANP is degraded by the neprilysin; therefore, pharmacological inhibition of this metalloprotease (i.e., with sacubitril) can be employed to increase ANP level. We have shown earlier that sacubitril in combination with valsartan (75 μg/day each) had beneficial effects on renal function in Dahl SS rats. The goal of this study was to evaluate the effects of a higher dose of sacubitril on renal damage in this model. To induce hypertension, male Dahl SS rats were fed a 4% NaCl diet (HS) for 21 days, and were administered sacubitril (125 μg/day) or vehicle via s.c. osmotic pumps. At the end of the HS challenge, both groups exhibited similar outcomes for GFR, heart weight, plasma electrolytes, BUN, and creatinine. Sacubitril exacerbated kidney hypertrophy, but did not affect levels of renal fibrosis. We also observed aggravated glomerular lesions and increased formation of protein casts in the sacubitril-treated animals compared to controls. Thus, in Dahl SS rats, administration of sacubitril without renin-angiotensin-system blockage had adverse effects on renal disease progression, particularly in regards to glomerular damage and protein cast formation. We can speculate that while ANP levels are increased because of neprilysin inhibition, there are off-target effects of sacubitril, which are detrimental to renal function in the SS hypertensive state.

Infection control and human immunodeficiency virus: perceptions of risk among nurses and hospital domestic workers

In December 1993 the first case of patient-to-patient transmission of human immunodeficiency virus (HIV), at a doctor's surgery in New South Wales, was documented. In an environment of heightened anxiety about HIV transmission and the adequacy of infection-control measures taken by health providers, it is important to explore perceptions of occupational risk of exposure to infection among hospital workers, reasons why hospital domestic workers sometimes depart from standard procedure in infection control, and how they regard the patients who have infectious diseases. In this study, at an infectious diseases hospital where there is an acute awareness of such issues, nurses had accurate knowledge about control of infection, including HIV, but had limited trust of that knowledge. They gave rationales for why they sometimes departed from infection-control procedures. They had low levels of fear of homosexuals and of acquired immune deficiency syndrome. The hospital domestic workers had lower levels of accurate knowledge about infection control, including HIV, and less trust of that knowledge and of protection by health provider from occupational exposure to infection. They had low levels of fear of homosexuals and HIV. Both groups sought regular, small-group, interactive education programs on infection control and HIV to allow them to discuss their concerns. Participatory education of workers should include eliciting concerns of participants, and should discuss concerns regarding administrators' and educators' interests in their safety and wellbeing.

Malignant fibrous histiocytoma of the heart presenting as hemoptysis. Association with pseudothrombocytopenia

A 24-year-old patient presented with hemoptysis. Pulmonary evaluation was unrevealing. After being lost to follow-up, he again presented with worsening symptoms and physical findings of severe pulmonary hypertension. A large left atrial mass was found on echocardiogram. This was subsequently found to be a malignant fibrous histiocytoma. He also had pseudothrombocytopenia due to platelet cold agglutinins. Left atrial masses must be considered in unexplained hemoptysis.

The value of obtaining renal images following brain scintigraphy with technetium-99m glucoheptonate

The value of adding an extra view of the kidneys immediately following brain imaging with Tc-99m glucoheptonate was investigated in a two-year retrospective study at our institution. Between October 1982 and October 1984, 561 individuals underwent Tc-99m glucoheptonate brain imaging with the added renal view. Twenty-nine of these individuals (5.2%) demonstrated renal abnormalities. The abnormal renal findings were clinically correlated in 24 of these persons. Sixteen (67%) of these 24 individuals were unaware of any renal abnormality. Useful information can be obtained from renal images incidental to brain imaging at no added expense or radiation exposure to the patient, and at a minimal cost in time to the imaging clinic.

Painless giant cell thyroiditis diagnosed by fine needle aspiration and associated with intense thyroidal uptake of gallium

A 52-year-old woman presented with fever, goiter, and no evidence of pain or tenderness in the thyroid. A diagnosis of silent thyroiditis was made after obtaining evidence of biochemical thyrotoxicosis, intense gallium-67 citrate thyroidal localization, and cytologic thyroiditis. Fine needle aspiration biopsy of the thyroid revealed numerous giant cells in all areas of the thyroid, typical of subacute thyroiditis. This is believed to be the first time painless thyroiditis is reported with the classic cytologic feature of painful subacute thyroiditis.

Gallium-67 citrate scintigraphy in pulmonary embolism

Eight cases of pulmonary embolism were evaluated with Ga-67 citrate scintigraphy. Of the eight patients, all but one showed evidence of abnormal Ga-67 citrate localization within involved regions of the lung as demonstrated by ventilation-perfusion lung scintigraphy. The sole patient who did not demonstrate Ga-67 localization within the lung had marked breast accumulation of the radiotracer which may have obscured lung parenchymal uptake. Since Ga-67 citrate is known to accumulate within inflammatory lung processes, this radiotracer would not have a specific role in differentiating pulmonary embolism from these conditions. This study disagrees with the results of other studies in the medical literature that describe such a role.

Splenic rotation as demonstrated by 99mTc SCOL

The spleen is free to move around on its pedicle, since it is not fixed in the abdomen. We describe the case of a woman who demonstrated a temporary rotation of the spleen 90 degrees from its usual axis as shown by liver-spleen scintigraphy using technetium Tc-99m sulfur colloid (99mTc SCOL). The reason for this rotation is discussed. Other previously reported causes of splenic displacement are also reviewed.

Myositis ossificans with Ga-67 citrate positivity

A 16 year-old boy presented with a firm mass within the left thigh. Ga-6 7 citrate and bone scintigraphy revealed soft tissue radiotracer accumulation within the mass lesion. Radiographs and xerography of the left thigh revealed calcification within the soft tissue mass typical of myositis ossificans. The patient's clinical course was uneventful.

Cholelithiasis demonstrated on hepatobiliary scintigraphy as a photopenic defect within the inferior portion of the liver

A 47-year-old man presented with the clinical findings of acute cholecystitis. During hepatobiliary scintigraphy using Tc-99m DISIDA, a persistent photopenic defect was noted within the inferior portion of the liver in the region of the gallbladder. Abdominal ultrasonography revealed large gallstones with acoustic shadowing within a normal-sized gallbladder. Eleven large gallstones were found within a normal-sized intrahepatic gallbladder at surgery.

Scintigraphic and radiographic findings in Caroli's disease

In recent years, noninvasive evaluation of Caroli's disease has been demonstrated by computed tomography, ultrasonography, and nuclear scintigraphy. Confirmation of Caroli's disease requires invasive procedures such as percutaneous transhepatic cholangiography or endoscopic retrograde cholangiography. All of the techniques give valuable information making it easier to diagnose Caroli's disease and to determine its extent. In addition, associated abnormalities in organs outside of the biliary system may be revealed. Two cases are presented to illustrate the radiographic and scintigraphic findings of Caroli's disease.

Gallium-67 citrate localization in the heart secondary to constrictive pericarditis with myocardial fibrosis

Scintigraphy has demonstrated gallium-67 accumulation within the heart in pericarditis and cardiomyopathies of various kinds. We present a case report of a 63-yr-old man with multisystem disease who showed extensive myocardial uptake of Ga-67 by scintigraphy. At autopsy, constrictive pericarditis with myocardial fibrosis was found. Gallium-67 localization has not been documented previously in myocardial fibrosis accompanying constrictive pericarditis.

Ruptured abdominal aortic aneurysm identified incidental to bone scintigraphy

A report is presented of a man who had a ruptured abdominal aortic aneurysm identified incidental to bone scintigraphy. The bone scan revealed displacement of the left kidney to nearly a horizontal axis and indicated the need for more definitive evaluation. Renal scintigraphy and computed tomography correctly demonstrated a ruptured, but contained abdominal aortic aneurysm.

Total anomalous systemic venous return

We have described an 18-year-old boy who is asymptomatic nine years after surgical correction of total anomalous systemic venous return. His clinical course and anatomy are compared to the eight previously reported patients.

Single injection thallium-201 stress and redistribution myocardial perfusion imaging: comparison with stress electrocardiography and coronary arteriography

The efficacy of single injection thallium-201 exercise stress and rest redistribution imaging in the evaluation of myocardiacl ischemia was compared with stress electrocardiography and coronary arteriography. Thallium-201 imaging was interpreted at two levels of sensitivity in order to define the circumstances under which it best serves as a screening modality for coronary arteriography. With the prevalence of coronary disease usually found in patients referred for coronary arteriography (75%), unprocessed thallium-201 imaging is as good as stress electrocardiography in identifying patients apt to show coronary artery abnormalities, but not much better than stress electrocardiography in delineating those patients unlikely to show coronary artery disease. In contrast, processed lesion enhanced images showing normal results virtually eliminate the possibility of significant arteriographic findings. With this screening technique, many patients may be spared unnecessary coronary arteriography.

Cardiac complications of protein-sparing modified fasting

Cardiovascular abnormalities developed in a patient during a protein-sparing modified fasting diet. Syncope was the complaint at the time of examination. Hypotension, persistent QTc interval prolongation, and a low QRS voltage were observed before the development of refractory ventricular tachycardia. At autopsy, antemortem thrombi were attached to the left ventricular endocardium and a fenestrated aortic valvule. Strick protein-sparing modified fasting is not without risk of sudden death even with close medical supervision.

Starr-Edwards mitral valve failure ten years after replacement surgery: chronic fibrous obstruction of the prosthesis frustrum area. Report of a case

A case of malfunction of a Starr-Edwards caged-ball mitral prosthesis occurring ten years after implantation is presented. The possibility of late malfunction must be suspected in any patient who redevelops symptoms after valve replacement. Preservation of normal prosthetic opening and closing clicks does not prove that the device is functioning normally. The diagnosis is difficult, with cardiac catheterization and demonstration of mitral obstruction providing the most valuable information. Once the diagnosis of prosthesis obstruction is made, reoperation and replacement is mandatory.

This clinical pattern will be seen with increasing frequency as patients with artificial valves are followed over longer periods of time.