OBJECTIVEGlycemic variability is emerging as a measure of glycemic control, which may be a reliable predictor of complications. This systematic review and meta-analysis evaluates the association between HbA 1c variability and micro-and macrovascular complications and mortality in type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODSMedline and Embase were searched (2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015) for studies describing associations between HbA 1c variability and adverse outcomes in patients with type 1 and type 2 diabetes. Data extraction was performed independently by two reviewers. Random-effects meta-analysis was performed with stratification according to the measure of HbA 1c variability, method of analysis, and diabetes type. RESULTS

There is an association between influenza-like illness and cardiovascular events, but the relationship is less clear with serologically diagnosed influenza. We recommend renewed efforts to apply current clinical guidelines and maximise the uptake of annual influenza immunisation among patients with cardiovascular diseases, to decrease their risks of MI and stroke.

Abstract. Crimean-Congo hemorrhagic fever (CCHF) is a vector-borne viral disease, widely distributed in different regions of the world. The fever is caused by the CCHF virus (CCHFV), which belongs to the Nairovirus genus and Bunyaviridae family. The virus is clustered in seven genotypes, which are Africa-1, Africa-2, Africa-3, Europe-1, Europe-2, Asia-1 and Asia-2. The virus is highly pathogenic in nature, easily transmissible and has a high case fatality rate of 10-40%. The reservoir and vector of CCHFV are the ticks of the Hyalomma genus. Therefore, the circulation of this virus depends upon the distribution of the ticks. The virus can be transmitted from tick to animal, animal to human and human to human. The major symptoms include headache, high fever, abdominal pain, myalgia, hypotension and flushed face. As the disease progresses, severe symptoms start appearing, which include petechiae, ecchymosis, epistaxis, bleeding gums and emesis. Enzyme-linked immunosorbent assay, quantitative polymerase chain reaction, antigen detection, serum neutralization and isolation of the virus by cell culture are the diagnostic techniques used for this viral infection. There is no specific antiviral therapy available thus far. However, ribavirin has been approved by the World Health Organization for the treatment of CCHFV infection. Awareness campaigns regarding the risk factors and control measures can aid in reducing the spread of this disease to a greater extent, particularly in developing countries.

Adenosine is a commonly used drug in myocardial perfusion imaging. Its action is mediated via stimulation of A 2 receptors leading to vasodilatation while A 1 receptor counteracts this effect. CASE REPORTA 52-year-old lady presented with a 6-month history of angina. She had a background of Takayasu's arteritis and hypertension; her medications included prednisolone, atenolol, and nifedipine. A Rubidium PET myocardial perfusion scan with adenosine was performed. Within 3 minutes of commencing the adenosine infusion, the patient developed severe chest pain. The electrocardiogram showed significant ST depression in the antero-lateral leads ( Figure 1) which settled alongside the chest pain within 15 minutes after stopping the adenosine infusion. No hemodynamic changes were demonstrated during this episode. Furthermore, no perfusion defects were evident on relative perfusion images; however, on quantitative measurement, myocardial perfusion reserve was globally impaired raising the possibility of balanced ischemia (Figures 2, 3). Coronary angiography showed normal epicardial coronary arteries; therefore coronary vasospasm was considered (Figure 4). She was commenced on diltiazem after discontinuing nifedipine and atenolol. This resulted in dramatic improvement of her symptoms. DISCUSSIONPreviously published reports of adenosine-induced vasospasm occurred during recovery, probably due to overdrive of A 1 receptors following withdrawal of A 2 stimulation. 1 In our patient, it occurred during infusion that suggests that different underlying mechanisms were responsible. Patients with Takayasu's arteritis have raised levels of circulating endothelin-1 irrespective of disease activity including patients with a normal ESR. 2,3 Endothelin-1 is a potent vasoconstrictor 2 and regulates arterial tone at rest. 4,5 However, during exercise, endothelin-1 levels decrease facilitating coronary vasodilatation. Work in animals has suggested that high circulating endothelin-1 reduces adenosine-induced coronary vasodilatation. 3 We postulate that endothelin-1 may have modified the response to adenosine contributing to vasospasm with an overdrive of A 1 receptors and probably beta-blocker treatment. During exertion, adrenergic stimulation promotes coronary vasodilatation mainly via the activity of the beta-1 receptors. The use of beta blockers blunts this coronary vasodilatation.