This is the third reported case of valsartan-induced angioedema and the first thought to be dose dependent. Practitioners should be aware of this potential adverse effect of valsartan, although the underlying cause is still not known.
Morphological variations of the sternocleidomastoid (SCM) muscle assume relevance during attempted surgical interventions in the cervical region. The present study reports bipartite clavicular attachment of the SCM in the neck of an adult male cadaver during performance of a routine anatomy demonstration. The anomaly was unilaterally observed on the left side of the neck. The clavicular head of the muscle exhibited two bellies, one medial and one lateral. While the medial belly was fused with the sternal head, the lateral belly appeared to blend with the medial. Cranially, the SCM attached to the mastoid process and superior nuchal line. We have attempted to elucidate the embryological basis of the above muscular variant. Additionally, we discuss its clinical relevance, highlighting the utility of the SCM in various reconstructive procedures. We assert that detailed anatomical knowledge of such SCM variants is of utility not only to the gross anatomist, but also for neck and orthopaedic surgeons and anaesthetists. Moreover, radiologists require familiarity with such aberrations to decipher magnetic resonance imaging scans of the cervical region.
The overall incidence of heart failure increases with age, affecting up to 10% of people >65 years of age. Diastolic heart failure is also age-dependent, increasing from <15% in middle-aged patients to >40% in patients > or =70 years of age. Elderly patients usually have other co-morbid conditions such as hypertension, diabetes mellitus, coronary artery disease and atrial fibrillation that can adversely affect the diastolic properties of the heart. The clinical manifestations of diastolic heart failure are similar to those of systolic heart failure. In practice, the diagnosis is generally based on the finding of typical symptoms and signs of heart failure with preserved left ventricular ejection fraction and no valvular abnormalities on echocardiography. Altered ventricular relaxation and abnormal ventricular filling are the hallmarks of diastolic heart failure. Cardiac fibrosis and cellular disarray lead to the alterations in the diastolic properties of the heart. Diffuse foci of fibrosis in the myocardium have been reported with advancing age. Aldosterone has been shown to play a crucial role in the development of cardiac fibrosis via a direct effect on the mineralocorticoid receptors within the myocardium. Unlike the situation with treatment of systolic heart failure, few clinical trials are available to guide the management of patients with diastolic heart failure. In the absence of controlled clinical trials, patient management is based on control of the physiological factors (blood pressure, heart rate, blood volume and myocardial ischaemia) that are known to exert important effects on ventricular relaxation. Aldosterone antagonists inhibit the deposition of collagen matrix in the myocardium, thereby targeting the basic pathophysiological mechanism of diastolic dysfunction. Thus, they appear to represent a promising therapeutic approach for this condition. Currently, only small clinical trials supporting this therapy are available and large clinical trials evaluating long-term outcomes in diastolic dysfunction are therefore needed.
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