Decrease in bispectral index prior to cardiovascular collapse during Caesarean sections

We report a case of significant reduction in bispectral index (BIS) associated with suspected amniotic fluid embolism (AFE) that occurred prior to change in haemodynamic variables. The patient was a 29‐year‐old nulliparous, who was admitted for Caesarean section under general anaesthesia in the 33rd week of pregnancy. After the baby was born, the BIS value suddenly decreased to 0, with suppression ratio of 100. One minute later, saturation decreased abruptly to 85%, end‐tidal carbon dioxide (EtCO₂) decreased to 5 mmHg, peak inspiratory pressure increased to 35 cm H₂O, and non‐invasive blood pressure (BP) failed to obtain a reading. After administration of vasoactive drugs, the systolic BP was maintained at 100 mmHg or higher, the BIS value rose to 10–20, and the EtCO₂ increased to 24–33 mmHg. In this case, the BIS monitoring may provide an earlier warning of impending cardiovascular collapse in the case of AFE.     

Low‐Dose Heparin for Elective Percutaneous Coronary Intervention

Objectives

We evaluated the safety and efficacy of low‐dose heparin (40 IU/kg) for elective percutaneous coronary intervention (PCI).

Background

Current guidelines recommend a 70–100 IU/kg bolus of heparin for elective PCI, but this dose may be associated with increased bleeding risk. Low‐dose heparin may have an advantage in this regard, but has not been well studied.

Methods

From January 2008 to October 2012, 300 patients underwent elective transfemoral PCI and were treated with an initial bolus of 40 IU/kg of heparin at the UCLA Medical Center. Dual antiplatelet therapy with clopidogrel and aspirin was administered prior to or just after diagnostic coronary angiography. The primary end‐point was the composite of cardiac death, myocardial infarction, urgent target vessel revascularization for ischemia, or major bleeding within 30 days after PCI.

Results

The mean activating clotting time was 233 ± 28 seconds. The primary end‐point occurred in 2.3%. The cardiac death rate was 0.3% but was not related to the PCI. The myocardial infarction rate was 1.3%. Urgent target vessel revascularization occurred in 1 patient (0.3%). The major bleeding rate was 0.3%. No stent thrombosis occurred.

Conclusion

Using a lower dose of heparin with dual antiplatelet therapy is safe and is associated with a low bleeding risk after transfemoral PCI while providing suppression of ischemic events. This may also represent a cost savings compared with other antithrombotic strategies. A randomized clinical trial comparing low‐dose heparin with bivalirudin in patients is required to determine the optimal anticoagulation strategy. (J Interven Cardiol 2014;27:58–62)

     

Effects of a problem‐solving counseling program to facilitate intensified walking on Koreans with type 2 diabetes

Aim: This study aimed to evaluate the immediate and long‐term effects of a 12 week problem‐solving (PS) counseling program to facilitate intensified walking with machinery monitoring on persons with type 2 diabetes mellitus in Korea. Methods: The study used a quasi‐experimental design. The participants were 57 patients with diabetes from three endocrinology or internal medicine clinics in an urban city of South Korea. Moderate‐intensity walking and PS counseling were recommended to both groups. The difference between the two groups was whether the intensity of the exercise was monitored by an ambulatory heart rate monitor (experimental group) or was self‐regulated (comparison group). Those programs were evaluated in relation to BMI, glycemic control (blood glucose level, glycosylated hemoglobin [HbA1c]), a vascular complication index (total cholesterol, high‐density lipoprotein cholesterol, low‐density lipoprotein cholesterol, triglycerides, tissue plasminogen activator [t‐PA], plasminogen activator inhibitor‐1 [PAI‐1], Parma Cardiovascular Risk Index), and coping strategies at 3 and 6 months. Results: The experimental group members showed dramatic decreases in their glucose and HbA1c levels at 3 months. The values of t‐PA decreased significantly at baseline, compared to at 3 months. The levels of PAI‐1 continuously declined and the Parma Cardiovascular Risk Index score did not change significantly from baseline to at 3 months, but showed significant effects at 6 months. Conclusion: A combined program of intensified walking, using a heart rate monitor, with PS counseling is more helpful to prevent complications than self‐regulated exercise for persons with type 2 diabetes in Korea.     

The effects of an orally administered probiotic on sulfasalazine metabolism in individuals with rheumatoid arthritis: a preliminary study

Aim: To carry out a pilot study to investigate the effect of short‐term oral probiotic administration on the metabolism of sulfasalazine (SSZ) in patients with rheumatoid arthritis (RA) stabilized on SSZ. Methods: Twelve subjects with RA taking stable doses of SSZ for a minimum of 3 months prior to the study, received a probiotic preparation contained three strains of bacteria (1.8 × 10⁹ CFU/day) twice daily for 1 week. Single point blood and 12‐h urine samples were taken before and after probiotic treatment and 3 weeks following discontinuation of probiotics, for determination of SSZ and its metabolites. The presence of the probiotic bacteria in the feces of patients was investigated by denaturing gradient gel electrophoresis (DGGE). Results: Adverse events recorded were three instances of gastrointestinal disturbance and one flare of RA. Plasma and urinary levels of SSZ and its metabolites showed no statistically significant changes after probiotic administration and the incidence of gastrointestinal disturbance did not appear to be ascribed to higher sulfapyridine plasma levels. Probiotic‐specific DGGE bands were detected in the feces of some patients after the treatment period. Conclusions: Short‐term treatment of RA patients with a multi‐strain probiotic did not significantly influence SSZ metabolism as has been demonstrated in animal models.     

In vitro metabolism of the new insecticide flupyrazofos by rat liver microsomes

1. The in vitro metabolism of the new insecticide flupyrazofos was studied using rat liver microsomes. Two metabolites were produced and identified as O, O -diethyl O -(1- phenyl-3-trifluoromethyl-5-pyrazoyl) phosphoric acid ester (flupyrazofos oxon) and 1- phenyl-3-trifluoromethyl-5-hydroxypyrazole (PTMHP) based on UV and mass spectral analysis. 2. Cytochrome P450 oxidatively converted flupyrazofos to flupyrazofos oxon, a major metabolite and phenobarbital-induced microsomes increased this desulphuration by 8- fold. 3. Flupyrazofos oxon was converted to PTMHP with a half-life of 47 8?min by chemical hydrolysis and this conversion also proceeded non-enzymatically under our microsomal incubation conditions.     

Prophylactic control of post‐operative nausea and vomiting using ondansetron and ramosetron after cardiac surgery

Background: The aim of this study was to evaluate the efficacy of ondansetron and ramosetron in the reduction of post‐operative nausea and vomiting (PONV) associated with patient‐controlled analgesia (PCA) after cardiac surgery. Methods: A total of 320 patients scheduled for elective cardiac surgery were enrolled. Patients were randomly assigned to one of four treatment regimens (n=80 in each group): no prophylactic antiemetics (group P); intravenous (i.v.) ondansetron 4 mg at the end of surgery and 12 mg added to PCA (group O); i.v. ramosetron 0.3 mg at the end of surgery and no antiemetics added to PCA (group R1); and i.v. ramosetron 0.3 mg at the end of surgery and 0.6 mg added to PCA (group R2). Results: The incidence of PONV during the 48‐h post‐operative period was lower in groups O (46%), R1 (54%), and R2 (35%) compared with group P (71%, P<0.001). The incidence and severity of nausea were lower in groups O, R1, and R2 than in group P during the 24‐h post‐operative period, whereas the incidence and severity of nausea during 24–48 h after surgery were lower in groups O and R2, but not in group R1, than in group P. Compared with group P (53%), the frequency of rescue antiemetic usage was significantly lower in groups O (34%) and R2 (29%), but not in group R1 (43%). Conclusion: The addition of either ondansetron or ramosetron to PCA can reduce the incidence of PONV during 48 h after cardiac surgery.