This document appears to be a collection of citations and snippets of text from various medical journal articles and publications. The articles discuss topics related to renal physiology including potassium regulation and excretion, mechanisms of hypertension, genetic disorders involving ion transporters, and case studies of patients presenting with hypokalemia, metabolic alkalosis, and other electrolyte abnormalities. Copyright information is provided for most entries.
Tabaquismo factor de riesgo cardiovascular y disfuncion endotelial Ricardo Mora MD
Tabaquismo como factor de riesgo endotelial y disfuncion endotelial; Dr. Ricardo Mora Moreno R2C; IMSS UMAE T1; León, Guanajuato, Mexico; 09 de Noviembre del 2017
This study examined autonomic remodeling in the left atrium and pulmonary veins that contributes to atrial fibrillation (AF) substrate in congestive heart failure (CHF). The following key findings were reported:
1. Autonomic and electrophysiological remodeling was observed in CHF dogs, particularly in the posterior left atrium and pulmonary veins, involving both sympathetic and parasympathetic systems.
2. Sympathetic hyperinnervation was seen with increases in nerve fibers, cardiac ganglia, and beta-adrenergic receptors. Parasympathetic remodeling was more complex with increased acetylcholinesterase activity.
3. Both parasympathetic and sympathetic signaling contributed significantly to AF maintenance in
1) Felicita Andreotti presents an update on atrial fibrillation and the prevention of thromboembolic complications.
2) The document reviews several studies comparing novel direct oral anticoagulants (NOACs) to warfarin for stroke prevention in nonvalvular atrial fibrillation. The studies show that NOACs are equally or more effective at reducing stroke and systemic embolism compared to warfarin, and have consistent reductions in intracranial hemorrhage and major bleeding.
3) In aggregate, NOACs are considered life-saving and safer alternatives to warfarin for stroke prevention in nonvalvular atrial fibrillation based on
ueda2012 do we still need high doses-d.mohammedueda2015
This document discusses hypertension and the need for high doses of antihypertensive medications. It provides data showing that over half of adults with hypertension still have uncontrolled blood pressure despite improvements. It also summarizes trials showing residual cardiovascular risk even when blood pressure is controlled. The document advocates for early use of combination antihypertensive therapy, especially those targeting the renin-angiotensin-aldosterone system, to improve control and reduce organ damage. It highlights valsartan specifically as a well-studied angiotensin receptor blocker with strong evidence from numerous trials across cardiovascular conditions.
Causes for syncope are multifaceted. Hormonal etiology, specifically hypothyroidism, is associated with cardiac arrhythmias [1]. Sinus bradycardia, low voltage, nonspecific T-wave changes and dissociative atrioventricular (AV) abnormalities are some of descriptive electrocardiographic features [2]. In the majority of well know clinical presentations complete AV block requires the insertion of a permanent pacemaker. However hypothyroidism related bradycardia and consequential symptomatic AV blocks could be reversible with timely and proper management.
We report a case of severe hypothyroidism resulting in insertion of transient pacemaker with favorable clinical course and fully reversible complete AV block after accordant pharmacological hormonal substitution.
Importance of iron deficiency in asian patients with heart failuredrucsamal
- Iron deficiency is highly prevalent in Asian patients with heart failure, ranging from 37-61% in different regions. It is associated with increased risk of death and poorer outcomes.
- A study of over 750 heart failure patients and 600 controls in Singapore found iron deficiency to be common, even in controls without heart failure. Concomitant iron deficiency and anemia predicted the worst prognosis.
- Contributing factors to iron deficiency in Asians may include dietary differences like vegetarianism and black tea consumption, as well as possible genetic differences in iron regulation. Future research includes randomized trials of intravenous iron replacement in Asian heart failure patients.
The document discusses cardiovascular risk factors and management. It summarizes that most heart attacks are caused by low-grade coronary artery blockages rupturing and triggering blood clots. Several risk factors can make plaques more vulnerable to rupture, such as inflammation, thin fibrous caps, and lipid-rich cores. Lifestyle changes and statin drugs are effective at reducing cardiovascular risks by lowering cholesterol levels and having additional anti-inflammatory effects. More aggressive lowering of LDL cholesterol is associated with greater reduction in heart attack risk.
1. Heart failure is a major public health problem, affecting over 5 million Americans. It is primarily a condition of the elderly and costs Medicare billions of dollars annually.
2. The VALIANT trial compared the ARB valsartan to the ACE inhibitor captopril and their combination in over 14,000 patients with heart failure or left ventricular dysfunction following a myocardial infarction. It found valsartan to be noninferior to captopril in reducing cardiovascular mortality and morbidity.
3. The presentation discusses the role of the renin-angiotensin system in cardiovascular disease and how ARBs like valsartan can provide beneficial blockade of this system in heart failure and post-myocardial infarction
Tabaquismo factor de riesgo cardiovascular y disfuncion endotelial Ricardo Mora MD
Tabaquismo como factor de riesgo endotelial y disfuncion endotelial; Dr. Ricardo Mora Moreno R2C; IMSS UMAE T1; León, Guanajuato, Mexico; 09 de Noviembre del 2017
This study examined autonomic remodeling in the left atrium and pulmonary veins that contributes to atrial fibrillation (AF) substrate in congestive heart failure (CHF). The following key findings were reported:
1. Autonomic and electrophysiological remodeling was observed in CHF dogs, particularly in the posterior left atrium and pulmonary veins, involving both sympathetic and parasympathetic systems.
2. Sympathetic hyperinnervation was seen with increases in nerve fibers, cardiac ganglia, and beta-adrenergic receptors. Parasympathetic remodeling was more complex with increased acetylcholinesterase activity.
3. Both parasympathetic and sympathetic signaling contributed significantly to AF maintenance in
1) Felicita Andreotti presents an update on atrial fibrillation and the prevention of thromboembolic complications.
2) The document reviews several studies comparing novel direct oral anticoagulants (NOACs) to warfarin for stroke prevention in nonvalvular atrial fibrillation. The studies show that NOACs are equally or more effective at reducing stroke and systemic embolism compared to warfarin, and have consistent reductions in intracranial hemorrhage and major bleeding.
3) In aggregate, NOACs are considered life-saving and safer alternatives to warfarin for stroke prevention in nonvalvular atrial fibrillation based on
ueda2012 do we still need high doses-d.mohammedueda2015
This document discusses hypertension and the need for high doses of antihypertensive medications. It provides data showing that over half of adults with hypertension still have uncontrolled blood pressure despite improvements. It also summarizes trials showing residual cardiovascular risk even when blood pressure is controlled. The document advocates for early use of combination antihypertensive therapy, especially those targeting the renin-angiotensin-aldosterone system, to improve control and reduce organ damage. It highlights valsartan specifically as a well-studied angiotensin receptor blocker with strong evidence from numerous trials across cardiovascular conditions.
Causes for syncope are multifaceted. Hormonal etiology, specifically hypothyroidism, is associated with cardiac arrhythmias [1]. Sinus bradycardia, low voltage, nonspecific T-wave changes and dissociative atrioventricular (AV) abnormalities are some of descriptive electrocardiographic features [2]. In the majority of well know clinical presentations complete AV block requires the insertion of a permanent pacemaker. However hypothyroidism related bradycardia and consequential symptomatic AV blocks could be reversible with timely and proper management.
We report a case of severe hypothyroidism resulting in insertion of transient pacemaker with favorable clinical course and fully reversible complete AV block after accordant pharmacological hormonal substitution.
Importance of iron deficiency in asian patients with heart failuredrucsamal
- Iron deficiency is highly prevalent in Asian patients with heart failure, ranging from 37-61% in different regions. It is associated with increased risk of death and poorer outcomes.
- A study of over 750 heart failure patients and 600 controls in Singapore found iron deficiency to be common, even in controls without heart failure. Concomitant iron deficiency and anemia predicted the worst prognosis.
- Contributing factors to iron deficiency in Asians may include dietary differences like vegetarianism and black tea consumption, as well as possible genetic differences in iron regulation. Future research includes randomized trials of intravenous iron replacement in Asian heart failure patients.
The document discusses cardiovascular risk factors and management. It summarizes that most heart attacks are caused by low-grade coronary artery blockages rupturing and triggering blood clots. Several risk factors can make plaques more vulnerable to rupture, such as inflammation, thin fibrous caps, and lipid-rich cores. Lifestyle changes and statin drugs are effective at reducing cardiovascular risks by lowering cholesterol levels and having additional anti-inflammatory effects. More aggressive lowering of LDL cholesterol is associated with greater reduction in heart attack risk.
1. Heart failure is a major public health problem, affecting over 5 million Americans. It is primarily a condition of the elderly and costs Medicare billions of dollars annually.
2. The VALIANT trial compared the ARB valsartan to the ACE inhibitor captopril and their combination in over 14,000 patients with heart failure or left ventricular dysfunction following a myocardial infarction. It found valsartan to be noninferior to captopril in reducing cardiovascular mortality and morbidity.
3. The presentation discusses the role of the renin-angiotensin system in cardiovascular disease and how ARBs like valsartan can provide beneficial blockade of this system in heart failure and post-myocardial infarction
Did you know that the right kind of salt actually HELPS your heart? How about that blood pressure drugs slow down the heart which decreases oxygen to the brain. Does that sound like a good idea to you? Did you also know that cholesterol is critical for hormone production in the body? It's time for some common sense! You are built to be healthy!
Reducing Perioperative Cardiac Risk: Do Beta blockers Help?Terry Shaneyfelt
Review of the effect of beta blockers on perioperative cardiac events including updated recommendations by the ACC/AHA (August 2014. Watch my YouTube video (http://youtu.be/WPLXDm9Nzoc) describing these slides.
A review of the existing evidence that supports the current practice in perioperative medicine regarding Renin-angiotensin-aldosterone system antagonists, mainly ACE inhibitors and Angiotensin type 1 receptor blockers (ARB's).
Presented as the Cleveland Clinic Hospital Medicine Grand Rounds on April 1, 2009. CME AMA Category 1 - 1 hour.
There is a Primary Prevent Indication in Diabetes | Mubashar A ChoudryMubashar A Choudry MD
Dr. Mubashar A Choudry, MD, is proud to serve patients at Washington Vascular Specialists, the first outpatient vascular treatment center in the mid-Atlantic region, with locations in Takoma Park, Largo, and Frederick, Maryland. He is a specialist in cardiology medical field.
This document summarizes research on myeloid cells and cardiovascular health conducted by Matthias Nahrendorf, a professor of radiology. It discusses how myeloid cells like monocytes and macrophages play roles in processes like atherosclerosis, acute myocardial infarction, and infarct healing. The document also explores how the bone marrow and spleen contribute monocytes during inflammation and injury. It summarizes research showing how stress, exercise, and other factors can impact hematopoiesis and myeloid cell production/phenotypes in the bone marrow.
El jueves y viernes 18 y 19 de enero del 2018 se organizó en la Fundación Ramón Areces un Simposio Internacional: Patología del Sueño: de la Neurobiología a las manifestaciones sistémicas. En colaboración con la Sociedad Española de Sueño.
This document summarizes evidence from major clinical trials supporting current pharmacological treatments for chronic heart failure (CHF). It discusses trials that demonstrated mortality benefits of ACE inhibitors, beta-blockers, aldosterone receptor antagonists, and hydralazine/isosorbide dinitrate combinations. Together, these trials established the current neurohormonal model of CHF and shifted focus to treatments targeting the renin-angiotensin-aldosterone system and sympathetic nervous system overactivation in CHF.
Eplerenone in Patients with Systolic Heart Failure and Mild Symptoms.
Presented at AHA by: Faiez Zannad, M.D., Ph.D., John J.V. McMurray, M.D., Henry Krum, M.B., PhD., Dirk J. van Veldhuisen, M.D.,Ph.D., Karl Swedberg, M.D., Ph.D, Harry Shi, M.S., John Vincent, M.B., PhD., Stuart J Pocock, Ph.D. and Bertram Pitt, M.D. for the EMPHASIS-HF Study Group * Eplerenone in Mild Patients Hospitalization And SurvIval Study in Heart Failure
Courtesy of http://www.cardiovascularbusiness.com
This document summarizes a study reviewing 26 cases of inhibitory motor seizures, including two new cases. The authors found that inhibitory motor seizures most commonly arose from lesions in the frontoparietal motor cortex (64% of adult cases) or mesial temporal lobe (23% of adult cases). Seizures from frontoparietal lesions tended to cause paralysis lasting over 2-3 minutes, while those from the temporal lobe caused paralysis under 1.5 minutes. The EEG was abnormal in 88% of cases. Most adult patients had an identifiable brain lesion, while pediatric patients did not. Intravenous diazepam or oral clobazam resolved prolonged inhibitory motor seizures in the two new cases reported.
Early repolarization (ER) is an ECG pattern characterized by J-point elevation. While historically considered a benign variant, recent studies have linked ER to an increased risk of arrhythmia. ER syndrome describes those with both ER on ECG and symptomatic arrhythmias like ventricular fibrillation. Diagnosis requires excluding other causes through testing of survivors of sudden cardiac death. While the ER pattern itself usually requires no treatment, an implantable cardioverter-defibrillator is recommended for secondary prevention in ER syndrome patients with a history of resuscitated sudden cardiac death.
The document discusses guidelines for selecting candidates for catheter ablation to treat atrial fibrillation (AF). It notes that ablation is recommended for symptomatic patients with recurrent AF despite medication. Ablation success depends on properly selecting patients with high likelihood of symptom improvement and success but low risk of complications. Long-standing and persistent AF as well as certain medical conditions like obstructive sleep apnea predict lower success rates.
Iron Deficiency : An Overlooked Aspect of Heart Failure Managementmagdy elmasry
Iron deficiency: a comorbidity that goes unnoticed in heart failure.Optimization of heart failure treatment.
Types of iron deficiency.Absolute ID &Functional ID.Iron Deficiency in Heart Failure :
A Therapeutic Target
Iron therapy for the treatment of iron deficiency
in chronic heart failure: intravenous or oral?
The HYVET trial provides the first clear evidence that treating hypertension in patients aged 80 or older reduces health risks. The trial found that treating very elderly hypertensive patients with the drug Natrilix SR plus Coversyl reduced total mortality by 21%, all strokes by 30%, and heart failure by 64% compared to a placebo. The treatment was also well-tolerated with few side effects reported. The results indicate that blood pressure lowering therapy should be offered to hypertensive patients over age 80 to improve health outcomes.
Early repolarization syndrome is defined by J-point elevation in the ECG. While prevalence is 1-9% depending on factors, the arrhythmic risk is generally low though higher for those with horizontal or downward sloping ST segments. The mechanism involves enhanced outward potassium currents leading to transmural voltage gradients. Genetic variants have been linked to severe cases. Clinical manifestations range from asymptomatic findings to cardiac arrest. Diagnosis requires exclusion of other causes in survivors of sudden cardiac death. Prognosis depends on location and morphology of early repolarization pattern. Therapies include beta-agonists and antiarrhythmic drugs while ICDs are for high-risk patients. Familial inheritance is seen though screening asymptomatic family
Management of severe heart failure in japan heart transplantation and lvaddrucsamal
This document provides information about a joint symposium between the European Society of Cardiology and the Japanese Heart Failure Society on the treatment of severe heart failure in Japan. It discusses heart failure epidemiology and causes of death from cardiovascular disease in Japan compared to Europe. It also reviews heart failure etiology, management, and outcomes including survival rates and the use of heart transplantation and left ventricular assist devices in Japan.
Fabry disease affects many parts of the heart and blood vessels. It can cause high blood pressure, an enlarged heart, heart rhythm problems, valve disease, blood vessel damage, heart attack, and sudden cardiac death. These complications are now the leading cause of death in Fabry patients. Advanced imaging techniques like echocardiograms, cardiac MRI, and T1 mapping can detect early heart changes before symptoms appear. Comprehensive screening and treatment of cardiovascular involvement in Fabry disease may allow earlier intervention and reduce morbidity and mortality.
1. Atrial fibrillation (AF) is an irregular heartbeat that can lead to blood clots, stroke, heart failure, and other complications. It is the most common arrhythmia and its prevalence increases with age.
2. AF occurs due to uncoordinated electrical signals in the atria that cause rapid and irregular beating. Risk factors include heart disease, high blood pressure, diabetes, sleep apnea, and thyroid problems.
3. Diagnosis involves an electrocardiogram to detect the irregular rhythm. Treatment depends on symptoms and includes rate or rhythm control medications, lifestyle changes, and sometimes procedures like ablation to restore normal rhythm.
Quantifying Cardiovascular and Behavioral Correlates of Fear in Mice: Implica...InsideScientific
This document summarizes research on quantifying cardiovascular and behavioral correlates of fear in mice, with implications for PTSD and cardiovascular disease risk. The research pairs behavioral and cardiovascular responses to cued fear learning in mice. It demonstrates that fear-based disorders like PTSD can contribute to increased cardiovascular disease risk by causing physiological hyperarousal and impaired fear processing. The researchers developed methods to remotely trigger conditioned stimuli based on a mouse's cardiovascular state, allowing measurement of cardiovascular responses to learned fear in the home cage environment. This integrated approach provides insights into mechanisms linking PTSD and cardiovascular dysfunction.
This document provides guidance for a 90-day weight management program called ageLOC TR90. The program consists of ageLOC products, a simple eating plan, and complete exercise programs. It instructs participants to download an app, create a profile, identify motivation goals, take before photos, record measurements, follow product and plan guidelines, track progress daily, share goals with an accountability partner, and write a transformation story. The goal is to help people look leaner and healthier in 90 days through these three clinically-proven program components: products, eating, and exercise.
This curriculum vitae summarizes Preeti Prakash's professional experience and qualifications. She has over 5 years of experience in accounts and finance roles for Johnson & Johnson and Deloitte & Touche in Dubai. She is currently pursuing her ACCA and has a BBA from Symbiosis Center for Management Studies in India. Her experience includes accounts payable, financial reporting, analysis, and system implementation. She is proficient in ERP systems like SAP and seeks to further her career in accounting.
Did you know that the right kind of salt actually HELPS your heart? How about that blood pressure drugs slow down the heart which decreases oxygen to the brain. Does that sound like a good idea to you? Did you also know that cholesterol is critical for hormone production in the body? It's time for some common sense! You are built to be healthy!
Reducing Perioperative Cardiac Risk: Do Beta blockers Help?Terry Shaneyfelt
Review of the effect of beta blockers on perioperative cardiac events including updated recommendations by the ACC/AHA (August 2014. Watch my YouTube video (http://youtu.be/WPLXDm9Nzoc) describing these slides.
A review of the existing evidence that supports the current practice in perioperative medicine regarding Renin-angiotensin-aldosterone system antagonists, mainly ACE inhibitors and Angiotensin type 1 receptor blockers (ARB's).
Presented as the Cleveland Clinic Hospital Medicine Grand Rounds on April 1, 2009. CME AMA Category 1 - 1 hour.
There is a Primary Prevent Indication in Diabetes | Mubashar A ChoudryMubashar A Choudry MD
Dr. Mubashar A Choudry, MD, is proud to serve patients at Washington Vascular Specialists, the first outpatient vascular treatment center in the mid-Atlantic region, with locations in Takoma Park, Largo, and Frederick, Maryland. He is a specialist in cardiology medical field.
This document summarizes research on myeloid cells and cardiovascular health conducted by Matthias Nahrendorf, a professor of radiology. It discusses how myeloid cells like monocytes and macrophages play roles in processes like atherosclerosis, acute myocardial infarction, and infarct healing. The document also explores how the bone marrow and spleen contribute monocytes during inflammation and injury. It summarizes research showing how stress, exercise, and other factors can impact hematopoiesis and myeloid cell production/phenotypes in the bone marrow.
El jueves y viernes 18 y 19 de enero del 2018 se organizó en la Fundación Ramón Areces un Simposio Internacional: Patología del Sueño: de la Neurobiología a las manifestaciones sistémicas. En colaboración con la Sociedad Española de Sueño.
This document summarizes evidence from major clinical trials supporting current pharmacological treatments for chronic heart failure (CHF). It discusses trials that demonstrated mortality benefits of ACE inhibitors, beta-blockers, aldosterone receptor antagonists, and hydralazine/isosorbide dinitrate combinations. Together, these trials established the current neurohormonal model of CHF and shifted focus to treatments targeting the renin-angiotensin-aldosterone system and sympathetic nervous system overactivation in CHF.
Eplerenone in Patients with Systolic Heart Failure and Mild Symptoms.
Presented at AHA by: Faiez Zannad, M.D., Ph.D., John J.V. McMurray, M.D., Henry Krum, M.B., PhD., Dirk J. van Veldhuisen, M.D.,Ph.D., Karl Swedberg, M.D., Ph.D, Harry Shi, M.S., John Vincent, M.B., PhD., Stuart J Pocock, Ph.D. and Bertram Pitt, M.D. for the EMPHASIS-HF Study Group * Eplerenone in Mild Patients Hospitalization And SurvIval Study in Heart Failure
Courtesy of http://www.cardiovascularbusiness.com
This document summarizes a study reviewing 26 cases of inhibitory motor seizures, including two new cases. The authors found that inhibitory motor seizures most commonly arose from lesions in the frontoparietal motor cortex (64% of adult cases) or mesial temporal lobe (23% of adult cases). Seizures from frontoparietal lesions tended to cause paralysis lasting over 2-3 minutes, while those from the temporal lobe caused paralysis under 1.5 minutes. The EEG was abnormal in 88% of cases. Most adult patients had an identifiable brain lesion, while pediatric patients did not. Intravenous diazepam or oral clobazam resolved prolonged inhibitory motor seizures in the two new cases reported.
Early repolarization (ER) is an ECG pattern characterized by J-point elevation. While historically considered a benign variant, recent studies have linked ER to an increased risk of arrhythmia. ER syndrome describes those with both ER on ECG and symptomatic arrhythmias like ventricular fibrillation. Diagnosis requires excluding other causes through testing of survivors of sudden cardiac death. While the ER pattern itself usually requires no treatment, an implantable cardioverter-defibrillator is recommended for secondary prevention in ER syndrome patients with a history of resuscitated sudden cardiac death.
The document discusses guidelines for selecting candidates for catheter ablation to treat atrial fibrillation (AF). It notes that ablation is recommended for symptomatic patients with recurrent AF despite medication. Ablation success depends on properly selecting patients with high likelihood of symptom improvement and success but low risk of complications. Long-standing and persistent AF as well as certain medical conditions like obstructive sleep apnea predict lower success rates.
Iron Deficiency : An Overlooked Aspect of Heart Failure Managementmagdy elmasry
Iron deficiency: a comorbidity that goes unnoticed in heart failure.Optimization of heart failure treatment.
Types of iron deficiency.Absolute ID &Functional ID.Iron Deficiency in Heart Failure :
A Therapeutic Target
Iron therapy for the treatment of iron deficiency
in chronic heart failure: intravenous or oral?
The HYVET trial provides the first clear evidence that treating hypertension in patients aged 80 or older reduces health risks. The trial found that treating very elderly hypertensive patients with the drug Natrilix SR plus Coversyl reduced total mortality by 21%, all strokes by 30%, and heart failure by 64% compared to a placebo. The treatment was also well-tolerated with few side effects reported. The results indicate that blood pressure lowering therapy should be offered to hypertensive patients over age 80 to improve health outcomes.
Early repolarization syndrome is defined by J-point elevation in the ECG. While prevalence is 1-9% depending on factors, the arrhythmic risk is generally low though higher for those with horizontal or downward sloping ST segments. The mechanism involves enhanced outward potassium currents leading to transmural voltage gradients. Genetic variants have been linked to severe cases. Clinical manifestations range from asymptomatic findings to cardiac arrest. Diagnosis requires exclusion of other causes in survivors of sudden cardiac death. Prognosis depends on location and morphology of early repolarization pattern. Therapies include beta-agonists and antiarrhythmic drugs while ICDs are for high-risk patients. Familial inheritance is seen though screening asymptomatic family
Management of severe heart failure in japan heart transplantation and lvaddrucsamal
This document provides information about a joint symposium between the European Society of Cardiology and the Japanese Heart Failure Society on the treatment of severe heart failure in Japan. It discusses heart failure epidemiology and causes of death from cardiovascular disease in Japan compared to Europe. It also reviews heart failure etiology, management, and outcomes including survival rates and the use of heart transplantation and left ventricular assist devices in Japan.
Fabry disease affects many parts of the heart and blood vessels. It can cause high blood pressure, an enlarged heart, heart rhythm problems, valve disease, blood vessel damage, heart attack, and sudden cardiac death. These complications are now the leading cause of death in Fabry patients. Advanced imaging techniques like echocardiograms, cardiac MRI, and T1 mapping can detect early heart changes before symptoms appear. Comprehensive screening and treatment of cardiovascular involvement in Fabry disease may allow earlier intervention and reduce morbidity and mortality.
1. Atrial fibrillation (AF) is an irregular heartbeat that can lead to blood clots, stroke, heart failure, and other complications. It is the most common arrhythmia and its prevalence increases with age.
2. AF occurs due to uncoordinated electrical signals in the atria that cause rapid and irregular beating. Risk factors include heart disease, high blood pressure, diabetes, sleep apnea, and thyroid problems.
3. Diagnosis involves an electrocardiogram to detect the irregular rhythm. Treatment depends on symptoms and includes rate or rhythm control medications, lifestyle changes, and sometimes procedures like ablation to restore normal rhythm.
Quantifying Cardiovascular and Behavioral Correlates of Fear in Mice: Implica...InsideScientific
This document summarizes research on quantifying cardiovascular and behavioral correlates of fear in mice, with implications for PTSD and cardiovascular disease risk. The research pairs behavioral and cardiovascular responses to cued fear learning in mice. It demonstrates that fear-based disorders like PTSD can contribute to increased cardiovascular disease risk by causing physiological hyperarousal and impaired fear processing. The researchers developed methods to remotely trigger conditioned stimuli based on a mouse's cardiovascular state, allowing measurement of cardiovascular responses to learned fear in the home cage environment. This integrated approach provides insights into mechanisms linking PTSD and cardiovascular dysfunction.
This document provides guidance for a 90-day weight management program called ageLOC TR90. The program consists of ageLOC products, a simple eating plan, and complete exercise programs. It instructs participants to download an app, create a profile, identify motivation goals, take before photos, record measurements, follow product and plan guidelines, track progress daily, share goals with an accountability partner, and write a transformation story. The goal is to help people look leaner and healthier in 90 days through these three clinically-proven program components: products, eating, and exercise.
This curriculum vitae summarizes Preeti Prakash's professional experience and qualifications. She has over 5 years of experience in accounts and finance roles for Johnson & Johnson and Deloitte & Touche in Dubai. She is currently pursuing her ACCA and has a BBA from Symbiosis Center for Management Studies in India. Her experience includes accounts payable, financial reporting, analysis, and system implementation. She is proficient in ERP systems like SAP and seeks to further her career in accounting.
almost all the types of math are included here..if you learn these maths ,feel these maths i can assure you that you will find almost all the maths easy and simple.
The music video for "Sound of the Underground" by Girls Aloud contains several conventions of the pop genre, including choreographed dancing, close-ups emphasizing the stars' images, and bright costumes reflecting a playful, lively style. There are direct connections between the lyrics and visuals, such as a crab walk movement matching a lyric. The video also establishes the group's identity through coordinated outfits while highlighting each member's individual style. Shots emphasize notions of the male gaze, with focus on women's bodies.
The music video for "Still Dre" contains many hip hop conventions, such as an LA setting, hip hop clothing, luxury cars, and partying atmosphere. There are links between lyrics and visual
Viyellatex Spinning Ltd produces high quality yarn through ring and rotor spinning. It has over 40,000 spindles and produces 700 tons of yarn per month through ring spinning and 200 tons through rotor spinning. The company has a quality assurance lab equipped with modern machinery to test raw materials and finished yarns. It produces both combed and carded yarns through different processes and machinery. The quality department works to maintain standards and reduce wastage at each production stage.
This document provides information about starting a business opportunity with Nu Skin, a direct selling company. It outlines the benefits of becoming a distributor such as purchasing products at wholesale prices, earning commissions, and generating income through building a team. The document shares average annual incomes earned by distributors at different levels and highlights Nu Skin's growth, $1.5 billion in annual revenues, and $7 billion paid in commissions to date. It encourages readers to get involved in the next wave of opportunity.
Siyao Qian has a Master's degree in Accountancy from Simon Business School, University of Rochester and a Bachelor's degree in Accounting and Financial Management from Shanghai University of Finance and Economics. She has work experience as an intern at Jaguar Land Rover, Ruihua Certified Public Accountants, and Citibank. Qian also has leadership experience volunteering with various organizations and participating in business competitions. She is fluent in English and proficient in Microsoft Office, accounting software, and Photoshop.
This document is a resume for Muhammad Zeeshan Saleem from Pakistan. It summarizes his objective to seek an advancement opportunity utilizing his work experience and education. It details his educational background including a BSc in Agricultural Economics and FSc and Matriculation degrees. It describes his internship with Punjab Rural Support Programme where he executed projects, managed supervisors, and worked efficiently. It lists his attributes such as meeting deadlines, analytical skills, teamwork experience, and computer and language proficiencies. It provides his personal details and availability of references.
Rizwan Ali Shah is a lecturer in telecommunications seeking a managerial position. He has 6 years experience as a core network engineer for Mobilink and taught telecommunications courses. His experience includes operations and maintenance of mobile network equipment, database implementation, software upgrades, and analyzing and troubleshooting subscriber issues. He has an engineering degree in telecommunications, an MBA, and law degree and is pursuing a master's in engineering.
The document is a business plan for the Welsh Institute for Minimal Access Therapy (WIMAT) that aims to enhance efficiency and sustainability while identifying opportunities for growth. It proposes offering free mandatory surgical training for NHS Wales delegates to recruit and retain surgeons. This would cost £75,000 for the 2016/17 academic year. The plan also stresses the need to improve WIMAT's marketing to increase attendance levels and promote its reputation as a world-class surgical training center.
Implicacion de los padres de familia en la educacion de sus hijos III-11 ENMPNNegocio Propio
Propuesta de Innovación Educativa – 2011: La Implicación de los Padres en el Proceso Enseñanza - Aprendizaje de sus Hijos. con el enfoque de la Investigación - Acción.
III-11 de Magisterio de la Escuela Normal Mixta "Pedro Nufio" Tegucigalpa M.D.C. Honduras.
Prof. Xavier Canales
The document discusses erectile dysfunction (ED), including its association with other medical conditions, risk factors, diagnosis, and management. It notes that ED screening can detect underlying diseases like diabetes and cardiovascular issues. Treatment includes lifestyle changes, medications like PDE5 inhibitors, counseling, and other therapies to help improve patients' quality of life and sexual functioning.
This document discusses acute kidney injury (AKI) in perioperative patients. It notes that AKI is associated with high mortality rates, even mild cases. Biomarkers like NGAL can detect AKI earlier than creatinine, allowing for potential intervention. However, biomarkers have limitations and more research is needed. Fluid overload is associated with worse outcomes and can cause tissue edema. The document emphasizes optimizing fluid balance and considering earlier interventions like diuretics or intensive care to manage AKI risks.
Atrial fibrillation and increased mortality: causation or association? Mexico...Antonio Raviele
AF is associated with increased mortality, but it is unclear if this is directly caused by AF or associated conditions. Studies show AF patients have 1.5-2x higher risk of death than controls (1). While some evidence suggests AF directly increases mortality risk through stroke and heart failure worsening, randomized trials found rhythm control did not reduce mortality compared to rate control (2). It is likely AF directly increases mortality in some patients and is also a marker for worsening of linked conditions. Understanding the AF-mortality relationship could guide new treatments to lower premature death risk.
Apresentação realizada em Julho/2017 durante a Residencia Médica no módulo de Cardiologia , fundamentado no artigo Differences in Clinical and Functional Outcomes of Atrial Fibrillation in Women and Men .
Diferença no desfecho clinico e funcional em Homens e Mulheres com Fibrilação Atrial .
Fibrilação Atrial é uma patologia frequente e de alto custo para saúde pública por causa dos sintomas e por afetar a qualidade de vida e em virtude disso, muitos estudos têm sido realizados para conhecer melhor os efeitos trombolíticos.
Poucos estudos focam a diferença da doença entre sexos e poucos clínicos sabem a diferença de reação ao tratamento em cada sexo.
Foi então realizado um estudo de observação dos pacientes e o Dr. Piccini observou que mulheres com Fibrilação Atrial apresentavam sintomas mais evidentes e era cabível levar aos clínicos essa observação para consideração de que as mulheres são sintomáticas a patologia.
Dando continuidade ao estudo com o Dr. Passman que observou a diferença dos sintomas de Mulheres para Homens em avaliação dos Registros dos Pacientes, mas não explorou as questões do porque dessas diferenças, por ser um estudo inicial e que necessitava de um aprofundamento.
De acordo com a Pesquisa concluiu-se que as mulheres com FA têm mais sintomas e pior qualidade de vida. Apesar de maior risco, as mulheres têm menor risco-ajustado por todas as causas e de morte cardiovascular em comparação com os homens, mas com maior acidente vascular cerebral taxas. Estudos futuros devem se concentrar em como o tratamento e intervenções afetam especificamente AF-relacionados a qualidade de vida e sistema circulatório resultados em mulheres.
Hypokalemia in Emergency Medicine is an article that discusses potassium levels in the body and defines hypokalemia as a potassium level below 3.5 mEq/L. It notes that nearly 98% of the body's potassium is intracellular and plays an important role in cellular membrane potential. Hypokalemia can result from renal or GI losses, inadequate diet, medications, or a transcellular shift of potassium into cells. As many as 20% of hospitalized patients and 14% of outpatients undergoing testing may have mild hypokalemia, though it is clinically significant in only 4-5% of cases. Approximately 80% of patients on diuretics become hypokalemic.
Severe Hyponatremia, SIADH, and Pericardiac Effusion as Initial Presenting Fe...Jayanth Hiremagalur
A 56-year-old female presented with headache, dysarthria, and unsteady gait. Imaging revealed a moderate to large pericardial effusion. Labs showed hyponatremia consistent with SIADH. A pericardial window drained fluid and symptoms improved. Further imaging found metastatic non-Hodgkin's lymphoma to the pericardium and lung, explaining the presentation. The patient's citalopram use and pericardial effusion both likely contributed to her SIADH. Management included fluid restriction, hypertonic saline, and pericardial drainage.
This summarizes a journal club discussion on a clinical trial examining the effects of allopurinol treatment in patients with chronic kidney disease (CKD). The trial found that allopurinol attenuated the decline in glomerular filtration rate compared to controls and reduced cardiovascular events and inflammatory markers. However, the study had some limitations as an open-label, single-center trial with a small sample size. While allopurinol showed potential benefits, larger and more robust studies are still needed before strongly recommending its use to attenuate CKD progression.
This document summarizes information on anemia in heart failure patients. Some key points:
1. The prevalence of anemia in heart failure patients ranges from 20-30% for outpatients to 30-40% for inpatients, depending on the definition and study.
2. Anemia is associated with worse prognosis and increased risk of hospitalization and mortality in heart failure patients.
3. Potential treatment options for anemia in heart failure include blood transfusions, erythropoietin-stimulating proteins (ESPs), and iron therapy. However, clinical trials of ESPs like darbepoetin alfa have not shown clear benefits.
4. The FAIR-HF trial found
The document discusses heart failure (HF), its epidemiology, pathophysiology, and management. Some key points:
- HF is a major public health problem costing $29.6 billion annually in the US. Hospitalizations are a major driver of costs, and rates are increasing.
- Over 90% of acute decompensated HF hospitalizations are due to fluid overload. Diuretics are standard first-line treatment but resistance limits their effectiveness in many patients.
- Even mild reductions in renal function correlate with increased HF morbidity and mortality. Diuretics can further impair renal function, worsening outcomes.
- Ultrafiltration is an alternative fluid removal method that may benefit patients where diure
1) Early humans engaged in strenuous morning hunting activities which increased stress hormones like cortisol and catecholamines, establishing a circadian rhythm of higher cardiovascular risk in the morning.
2) This early morning activity aligned the peak in male testosterone levels with mating opportunities, another factor selecting for increased cardiovascular responses in the morning.
3) Modern disruptions to circadian rhythms from late eating or sleeping can increase cardiometabolic risk by disturbing the established morning peak in stress and sex hormones linked to cardiovascular events.
This document discusses the case of a 31-year-old female presenting with stage 2 hypertension. Laboratory tests found her aldosterone level to be elevated at 76 and her plasma renin activity to be less than 0.5, suggesting primary aldosteronism. A CT scan showed a left adrenal adenoma. Adrenal vein sampling found a cortisol corrected aldosterone ratio from the left adrenal vein greater than 4:1, confirming unilateral primary aldosteronism from a left adrenal adenoma. The patient was referred for a laparoscopic left adrenalectomy.
Gregg L. Semenza discusses hypoxia-inducible factors (HIFs) and their role in physiology and medicine. HIFs control oxygen homeostasis by regulating erythropoietin production and red blood cell production. They also play a role in cardiovascular disease by mediating vascularization and in cancer by promoting tumor growth and metastasis. HIFs activate genes involved in angiogenesis, cancer stem cell maintenance, immune evasion, and premetastatic niche formation. Inhibiting HIF activity has been shown to reduce tumor growth and improve outcomes for cancer and cardiovascular disease.
Edelman-derived quantification of dyselectrolytemias.
Equation-based monitoring of hyponatremia therapy with a focus on safely and predictably increasing sodium as per guideline advice using a strategy involving desmopressin administration in severe hyponatremias, especially those patients at risk of becoming overcorrectors. Explanation of risk factors responsible for overshooting when correcting hyponatremia. Adrogue-Madias, Barsoum, Nguyen-Kurtz equations are explained and proven to be of help at least conceptually when attempting to have a desmopressin-guided therapy in hyponatremia. All recommendations are done in accordance with European and American guidelines published in 2013 and 2014.
Hepatic encephalopathy is a syndrome characterized by personality changes, impaired intellect, and depressed consciousness that occurs in patients with cirrhosis of the liver. An important prerequisite is the diversion of portal blood into systemic circulation through portosystemic shunts. Subtle signs are seen in 70% of cirrhosis patients, with symptoms debilitating in 24-53% of those with portosystemic shunt surgery. Triphasic waves seen on EEGs are nonspecific but classic for hepatic encephalopathy. While commonly caused by hepatic or renal failure, triphasic waves can result from various toxic, metabolic, or structural abnormalities.
Journal Presentation , After the party’s overআহমেদ শাহেদ
A 35-year-old woman presented to the emergency department with vomiting, diarrhea and abdominal pain after drinking vodka and tonic at an office party. She was diagnosed with acute gastroenteritis and discharged. She returned two days later with worsening kidney function and symptoms. Further evaluation revealed thrombotic microangiopathy (TMA). A prior similar illness 16 months ago was reviewed, suggesting quinine-induced TMA from the tonic component of the vodka and tonic drink. The patient was treated with plasma exchange, hemodialysis and steroids.
Commercial products and compounded options for the treatment of erectile dysfunction. Brief overview regarding the pathophysiology, medical, and physical causes behind these disorders as well as epidemiology and prevalence of the disease.
This case report describes a 5-year-old boy with nephrotic syndrome who presented with sudden loss of vision. His blood pressure was elevated and imaging showed abnormalities in the parietal lobe white matter. After his blood pressure was normalized, his vision returned within 48 hours and follow-up imaging showed resolution of the abnormalities, leading to a diagnosis of posterior reversible encephalopathy syndrome (PRES). PRES is characterized by neurological symptoms including visual disturbances that are reversible if blood pressure is controlled. The report discusses the clinical features and imaging findings of PRES.
This document discusses inotropes and vasopressors used in cardiogenic shock. It defines cardiogenic shock as ineffective cardiac output caused by a primary cardiac alteration resulting in clinical and biochemical signs of inadequate tissue perfusion. Common clinical characteristics include hypotension that does not respond to volume. The document discusses drugs commonly used including dobutamine, milrinone, levosimendan, and norepinephrine. It provides details on the pharmacokinetics, effects, dosing, and risks of each drug. The goal of treatment is to increase cardiac output and blood pressure through increasing contractility, heart rate, and vascular tone.
Denervacion renal en hipertension resistenteDaniel Meneses
This document summarizes research on renal denervation for treatment of resistant hypertension. It describes activation of the renal sympathetic nervous system in hypertensive patients and the renal denervation technique. The Symplicity clinical trial program is outlined, including Symplicity HTN-1 and HTN-2 trials showing reductions in blood pressure out to 3 years with the renal denervation procedure. The document concludes that resistant hypertension poses high risk, but renal denervation safely and effectively eliminates renal sympathetic nerves to lower blood pressure in these difficult to treat patients.
Power Spectral Analysis of Heart Rate Variability In HypothyroidismMatiaAhmed
This document summarizes a study that assessed cardiac autonomic nervous activity through power spectral analysis of heart rate variability in patients with hypothyroidism. The study found:
1) Untreated hypothyroid patients had significantly higher levels of TSH and lower levels of FT4 compared to healthy controls and treated patients.
2) Untreated hypothyroid patients had significantly lower values of total power, HF power, and HF nu, indicating reduced vagal modulation of the heart, compared to controls and treated patients.
3) Untreated hypothyroid patients had significantly higher values of LF/HF ratio and LF nu, indicating higher sympathetic activity and altered sympathovagal balance, compared to controls and treated
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
10. Creation of a more negative voltage in cells.
J.H.M. Groeneveld et al. QJM 2005;98:305-316
The Author 2005. Published by Oxford University Press on behalf of the Association of
Physicians. All rights reserved. For Permissions, please email:
journals.permissions@oupjournals.org
11. Approach to the patient with low K+ excretion.
J.H.M. Groeneveld et al. QJM 2005;98:305-316
The Author 2005. Published by Oxford University Press on behalf of the Association of
Physicians. All rights reserved. For Permissions, please email:
journals.permissions@oupjournals.org
12. Approach to the patient with high K+ excretion.
J.H.M. Groeneveld et al. QJM 2005;98:305-316
The Author 2005. Published by Oxford University Press on behalf of the Association of
Physicians. All rights reserved. For Permissions, please email:
journals.permissions@oupjournals.org
13. Plasma renin and aldosterone in the syndromes of mineralocorticoid excess.
J.H.M. Groeneveld et al. QJM 2005;98:305-316
The Author 2005. Published by Oxford University Press on behalf of the Association of
Physicians. All rights reserved. For Permissions, please email:
journals.permissions@oupjournals.org
15. trastornos asociados con mutaciones en el SCN4A.
Lehmann-Horn F, Jurkat-Rott K, Rüdel R. Diagnostics and Therapy of Muscle Channelopathies –
Guidelines of the Ulm Muscle Centre. Acta Myologica. 2008;27(3):98-113.
17. Syed K. Haque et al. Nephrol. Dial. Transplant.
2012;27:4273-4287
18. Vieira H, Mendes L, Mendes P, da Silva JE. Classic Bartter syndrome: a rare cause o
f failure to thrive in a child. BMJ Case Reports. 2012;2012:bcr0220125888. doi:10.1136/bcr.02.2012.5888.
CASO CLINICO
19. Israel Zelikovic Nephrol.
Dial. Transplant. 2003;18:1696-1700
European Renal Association–European Dialysis and Transplant Association
Nephron Physiol 2006;104:p73–p80
(DOI:10.1159/000094001)
20. Kidney International (1998) 54, 1396–1410;
doi:10.1046/j.1523-1755.1998.00124.x
• Polihidramnios
• Anormalidad bioquímica del
líquido amniótico
• Hipostenuria
• Alcalosis metabólica
con hipopotasemia
• Nefrocalcinosis,hipercalciuria
• Retardo del crecimiento
• Potasio urinario alto
• Niveles elevados de RA
21. Niño de 8 años de edad, desarrolló una convulsión generalizada que se prolongó durante 5 min y se produjo mientras jugaba . fue
admitido en urgencias , estaba consciente y sin fiebre . Su altura del cuerpo era de 120 cm, el peso corporal 21,3 kg, la presión
arterial 96/42 mmHg, frecuencia cardíaca 92 / min, y SpO 2 100%. Su historia pasada no tenía nada especial, excepto por quejarse
de debilidad muscular después de jugar al fútbol. Su historia familiar reveló que su hermano mayor fue tratado con un
anticonvulsivo causa de trastorno de hiperactividad y déficit de atención. Fue diagnosticado con convulsiones de causa
desconocida,se le prescribio potasio L-aspartato (300 mg, dos tab / día) para la hipopotasemia y la carbamazepina (220 mg / día,
dividida en dos tomas) asintomatico por un año . Sin embargo, un año después del ingreso en el hospital, presento alcalosis
metabólica, hipopotasemia, hipomagnesemia.
CASO CLINICO
G. Graziani, C. Fedeli, L. Moroni, L. Cosmai, S. Badalamenti, C. Ponticelli 2010
The cell model illustrates β2-adrenergic and insulin-mediated regulatory pathways for K+uptake. β2-Adrenergic and insulin both lead to K+ uptake by stimulating the activity of the Na+-K+-ATPase pump primarily in skeletal muscle, but they do so through different signaling pathways. β2-Adrenergic stimulation leads to increased pump activity through a cAMP- and protein kinase A (PKA)–dependent pathway. Insulin binding to its receptor leads to phosphorylation of the insulin receptor substrate protein (IRS-1), which, in turn, binds to phosphatidylinositide 3-kinase (PI3-K). The IRS-1–PI3-K interaction leads to activation of 3-phosphoinositide–dependent protein kinase-1 (PDK1). The stimulatory effect of insulin on glucose uptake and K+ uptake diverge at this point. An Akt-dependent pathway is responsible for membrane insertion of the glucose transporter GLUT4, whereas activation of atypical protein kinase C (aPKC) leads to membrane insertion of the Na+-K+-ATPase pump (reviewed in ref. 3).
A cell model for K+transport in the proximal tubule. K+ reabsorption in the proximal tubule primarily occurs through the paracellular pathway. Active Na+ reabsorption drives net fluid reabsorption across the proximal tubule, which in turn, drives K+ reabsorption through a solvent drag mechanism. As fluid flows down the proximal tubule, the luminal voltage shifts from slightly negative to slightly positive. The shift in transepithelial voltage provides an additional driving force favoring K+ diffusion through the low-resistance paracellular pathway. Experimental studies suggest that there may be a small component of transcellular K+ transport; however, the significance of this pathway is not known. K+ uptake through the Na+-K+-ATPase pump can exit the basolateral membrane through a conductive pathway or coupled to Cl−. An apically located K+ channel functions to stabilize the cell negative potential, particularly in the setting of Na+-coupled cotransport of glucose and amino acids, which has a depolarizing effect on cell voltage.
A cell model for K+transport in the distal convoluted tubule (DCT). In the early DCT, luminal Na+ uptake is mediated by the apically located thiazide-sensitive Na+-Cl− cotransporter. The transporter is energized by the basolateral Na+-K+-ATPase, which maintains intracellular Na+ concentration low, thus providing a favorable gradient for Na+ entry into the cell through secondary active transport. The cotransporter is abundantly expressed in the DCT1 but progressively declines along the DCT2. ROMK is expressed throughout the DCT and into the cortical collecting duct. Expression of the epithelial Na+ channel (ENaC), which mediates amiloride-sensitive Na+ absorption, begins in the DCT2 and is robustly expressed throughout the downstream connecting tubule and cortical collecting duct. The DCT2 is the beginning of the aldosterone-sensitive distal nephron (ASDN) as identified by the presence of both the mineralocorticoid receptor and the enzyme 11β-hydroxysteroid dehydrogenase II. This enzyme maintains the mineralocorticoid receptor free to only bind aldosterone by metabolizing cortisol to cortisone, the latter of which has no affinity for the receptor. Electrogenic-mediated K+ transport begins in the DCT2 with the combined presence of ROMK, ENaC, and aldosterone sensitivity. Electroneutral K+-Cl− cotransport is present in the DCT and collecting duct. Conditions that cause a low luminal Cl− concentration increase K+ secretion through this mechanism, which occurs with delivery of poorly reabsorbable anions, such as sulfate, phosphate, or bicarbonate.
Role of magnesium in ROMK potassium channel function. Potassium is the most abundant intracellular cation, creating a large chemical gradient that favors the outward flow of K+ through ROMK. (Left panel) Normally, magnesium binds to a cytosol-exposed site in ROMK to limit this outward flow. (Right panel) During hypomagnesemia, fewer Mg2+ ions can bind to this site, and K+ is secreted more freely. Thus, magnesium deficiency causes K+ wasting. This likely explains why magnesium repletion is required to efficiently restore potassium concentrations to normal during concomitant hypomagnesemia and hypokalemia.
Under normal circumstances, delivery of Na+to the distal nephron is inversely associated with serum aldosterone levels. For this reason, renal K+ excretion is kept independent of changes in extracellular fluid volume. Hypokalemia caused by renal K+ wasting can be explained by pathophysiologic changes that lead to coupling of increased distal Na+ delivery and aldosterone or aldosterone-like effects. When approaching the hypokalemia caused by renal K+ wasting, one must determine whether the primary disorder is an increase in mineralocorticoid activity or an increase in distal Na+ delivery. EABV, effective arterial blood volume.
Model of the “aldosterone paradox.” Two pathophysiological settings are depicted: hypovolemia (left) and hyperkalemia (right). Aldosterone acts as a sodium retaining hormone during hypovolemia, leading to a low urinary Na+ excretion (left). Conversely, aldosterone acts as a K+-secreting hormone during hyperkalemia, leading to a high urinary K+ excretion (right). Hypovolemia stimulates angiotensin II (Ang II), which in turn increases aldosterone (Aldo). Both contribute to renal Na+ retention. Ang II stimulates Na+ transport in the proximal tubule by activating the NHE3. Ang II also increases the activity of the NCC in the early DCT1. Aldo activates both NCC and the ENaC in the late DCT (DCT2), CNT, and CD. Note that because Na+ transport is stimulated at three locations, the distal delivery of Na+ decreases, contributing to the low Na+ excretion. The effects of Ang II and Aldo are primarily mediated via a WNK–SPAK pathway, whereas the effects of Aldo on ENaC primarily involves SGK1. Unknown factors increase the WNK1–KS–WNK1 ratio, leading to inhibition of the ROMK, helping to conserve potassium during hypovolemia. In the setting of hyperkalemia, the opposite occurs, because direct effects of a high serum K+ level decrease the WNK1–KS-WNK1 ratio (right). This leads to an activation of ROMK, stimulating potassium secretion. The lower WNK1–KS-WNK1 ratio also increases WNK4, preventing Aldo from activating NCC (dashed line). However, Aldo is still capable of activating ENaC, which stimulates Na+ exchange for K+ in the collecting duct.
Creation of a more negative voltage in cells. The circle depicts the cell membrane. The Na-K-ATPase pumps positive voltage out of cells, causing a large inside negative voltage (−60 to −90 mV). This ion pump is activated by β2-adrenergics. Insulin, by activating the Na+/H+ exchanger (NHE), causes the electroneutral entry of Na+ into cells, and thereby more positive voltage exit from cells via the Na-K-ATPase. K+ exits cells through ion channels that are in a sufficiently open configuration to approach, but not reach, the electrochemical equilibrium for K+.
Approach to the patient with low K+ excretion.
Approach to the patient with high K+ excretion.
Plasma renin and aldosterone in the syndromes of mineralocorticoid excess. For details, see text. AME, apparent mineralocorticoid excess syndrome; BP, blood pressure; ENaC, epithelial Na channel.
Mechanism of TTP. (A) A traditional pathogenesis of TPP. An increased Na+–K+ ATPase activity directly induced by thyroid hormone and indirectly induced by hyperadrenergic activity, hyperinsulinemia, and androgen is mostly involved. The open circle denotes the skeletal muscle cells and Na+/H+ exchanger (NHE). (B) Reduced K+ channel efflux in TPP. The enhanced Na+–K+ ATPase activity causes initial hypokalemia, and the reduced outward Kir current caused by hypokalemia, loss of function mutation, or hormone (adrenalin or insulin) -mediated inhibition on Kir channels can potentially inhibits total K+ efflux, leading to the trapping of K+ in the cell; a vicious cycle of hypokalemia-induced paradoxical depolarization and an inactivation of Na+ channel with muscle inexcitability and paralysis can result.
Developmental features are critical in the assessment of patients with PP and the LQT syndrome to make the appropriate diagnosis and include: hypertelorism, small mandible, low set ears (A and B) and clinodactyly (C and D). Mankodi A, Tawil R. PP and related disorders. In: Gilman S, editor. MedLink Neurology. San Diego: MedLink Corporation. Available at www.medlink.com. Accessed February 9, 2005.
Transport pathways in the thick ascending limb of the loop of Henle (A) and the distal convoluted tubule (B). (A) Cl– reabsorption across the luminal membrane occurs via the Na+–K+–2Cl– co-transporter (NKCC2). This co-transporter is driven by the low intracellular Na+ and Cl– concentrations generated by the basolateral Na+–K+-ATPase and ClC-Kb, respectively. In addition, ROMK enables functioning of NKCC2 by recycling K+ back to the lumen. The lumen-positive electrical potential, which is generated by Cl– entry into the cell and K+ exit from the cell, drives paracellular Ca2+ and Mg2+ transport from lumen to blood. Activation of the basolateral calcium-sensing receptor (CaSR) inhibits the luminal ROMK channel which, in turn, results in decreased NaCl reabsorption and (secondary to the reduction in the intraluminal positive potential) increased urinary Ca2+ and Mg2+ excretion. (B) Cl– transport occurs via the luminal, thiazide-sensitive NaCl co-transporter (TSC). Cl– exit to blood is mediated by basolateral Cl– channels. Ca2+ and Mg2+ enter the cell via luminal voltage-activated Ca2+ and Mg2+ channels and exit the cell via basolateral Na+/Ca2+ and Na+/Mg2+ exchangers. The depicted apical Mg2+ channel and basolateral Na+/Mg2+ exchanger are putative. Variants of Bartter syndrome caused by defects in these transport mechanisms are depicted. BSND, Bartter syndrome with deafness; ADH, autosomal dominant hypocalcaemia.
Model of NCC regulation by WNK kinases. NCC is trafficked as a monomer from the cytosol to the apical plasma membrane to become an inactive dimer (lower half of figure). Activation of the NCC dimer is achieved by phosphorylation through SPAK, stimulating NaCl transport (left). This process is regulated by WNK kinases. WNK4 (green symbol) inhibits the trafficking step of NCC by diverting it to the lysosome, a process that is mediated by sortilin and adaptin 3 (AP3). Conversely, WNK3 (red symbol) stimulates trafficking. WNK3 and WNK4 inhibit each other's activities. WNK4 is inhibited by WNK1 (red symbol), which in turn is inhibited by KS-WNK1 (blue and red symbol). WNK1 and WNK3 are also thought to influence the activity of SPAK, thereby controlling the phosphorylation and thus activation step of NCC. At present, it is unknown how the endocytic retrieval of NCC is regulated (question mark symbol). See text for details and abbreviations.
A model of WNK-SPAK/OSR1 regulation of NCC and its role in the pathogenesis of Familial Hyperkalemic Hypertension (FHHt). (A) In the baseline inactive state, WNK4 suppresses NCC trafficking to the plasma membrane, holding the cotransporter in an intracellular storage pool. The kinase active form of WNK1 can reverse this process. The Kelch-like 3/Cullin-3 (KLHL3/CUL3) E3 ubiquitin ligase complex constitutively degrades the WNKs. (B) FHHt-associated mutations in WNK4 reduce binding to KLHL3, increasing WNK4 abundance and triggering NCC activation through the WNK effector kinases SPAK and OSR1. Additionally, FHHt-causing mutations in WNK4 reduce its inhibitory effect on NCC traffic (represented by the hatched bar-headed line), which releases NCC from its intracellular compartment, increasing its trafficking to the cell surface. Thus, FHHt mutations in WNK4 convert it into an NCC stimulator. (C) WNK1 gene mutations increase kinase-active WNK1 expression, which overcomes constitutive degradation by KLHL3/CUL3. Because kinase active WNK1 can inhibit wild-type WNK4 and activate SPAK/OSR1, increased WNK1 expression stimulates NCC surface delivery and phosphorylation. (D) Mutations in KLHL3 either reduce binding of KLHL3/CUL3 to WNK1 and WNK4 or disconnect CUL3 from KLHL3; in either case, the CUL3 E3 ligase is unable to mark WNK signaling complexes for degradation. Increased WNK1 and WNK4 abundance stimulates NCC trafficking to the surface and triggers NCC phosphorylation. FHHt-causing mutations in CUL3 also likely reduce its activity to WNKs, although the mechanism by which this occurs remains unknown. WNK, With-No-Lysine [amino acid=K] kinase.