Treatment with peg-interferon-alpha of patients with chronic hepatitis C

AIM: To investigate a comparative efficacy of treatment with different types of interferon. MATERIAL AND METHODS: We studied comparative effectiveness of alpha-interferon vs pegilated interferon. In both cases alpha-interferon was administered in combination with ribavirin. 98 patients (age 16-65 years) with chronic HCV infection have undergone serological, virological, biochemical and histological tests for diagnosis and characterization of HCV infection. HCV genotyping was done by sequencing-based technology. RESULTS: It is shown that treatment with pegilated interferon-alpha in combination with ribavirin resulted in a higher rate of sustained viral response. Adverse reactions were less frequent with peg-interferon vs conventional interferon therapy. CONCLUSION: Treatment with peg-interferon-alpha in combination with ribavirin is more effective than conventional interferon therapy.     

Electrophysiological abnormalities occur prior to the development of clinical episodes of atrial fibrillation: observations from human epicardial mapping

Background: Atrial fibrillation (AF) is characterized by irregular atrial activation maintained by an arrhythmogenic substrate. We addressed the hypothesis that the substrate of human AF includes changes in atrial conduction properties. Methods: Patients in sinus rhythm (SR) and permanent AF undergoing cardiac surgery underwent right atrial epicardial mapping. AF was induced by burst pacing in patients in SR and was defined as sustained at >30 seconds. Epicardial maps were analyzed to determine conduction properties, AF activation patterns, and refractoriness. Patients in SR underwent postoperative Holter monitoring. Results: Thirty‐seven subjects were recruited. (27 in SR and 10 in permanent AF). Sustained AF was induced in 17 patients in SR. Only patients with sustained AF developed any episodes of postoperative AF (P < 0.05), indicating the preexistence of an arrhythmogenic substrate, which was characterized by prolonged unipolar electrograms (37.0 ± 9.4 ms vs 27.5 ± 6.4 ms, P = 0.03), particularly in the region of the crista terminalis (41.2 ms ± 12.1 vs 26.7 ms ± 5.8, P = 0.004) compared with the nonsustaining group. However, these differences in electrogram characteristics were not associated with changes in wavefront propagation velocity (WPV) during SR or pacing. Activation mapping of acutely induced AF was compared with permanent AF and although there were shorter mean fibrillation intervals in permanent AF (171 ± 16 ms vs 229 ± 51 ms, P < 0.001), there was no difference in fibrillatory activation pattern (complexity scores: 2.21 ± 0.52 vs 2.02 ± 0.61) or WPV (46.9 ± 15.4 cm/s vs 53.5 ± 17.6 cm/s, P = 0.37). Fibrillatory activation pattern was associated with both WPV (P = 0.03) and wavelength (P = 0.03) in both pacing‐induced and permanent AF. Conclusions: Patients in SR capable of sustaining pacing‐induced AF have differences in electrogram duration, which are apparent before clinical episodes of AF. Although patients with permanent AF had shortening of refractoriness, there was no evidence of further changes in fibrillatory activation pattern or macroscopic wavefront propagation velocity in permanent AF. These results imply that changes occur before the onset of AF and indicate the presence of a substrate capable of maintaining AF with only alterations in refractoriness required for the development of permanent AF.     

Sleep study–guided multidisciplinary therapy (SGMT) for patients with acute coronary syndrome: Trial rationale and design

Obstructive sleep apnea (OSA) is an emerging risk marker for acute coronary syndrome (ACS). This randomized trial aims to determine the effects of sleep study–guided multidisciplinary therapy (SGMT) comprising overnight sleep study, continuous positive airway pressure, and behavioral therapy for OSA during the subacute phase of ACS. We hypothesize that SGMT will reduce (1) the plasma levels of N‐terminal pro brain natriuretic peptide and suppression of tumorigenicity 2; (2) the estimated 10‐year risk of cardiovascular mortality as measured by the European Systematic Coronary Risk Evaluation (SCORE) algorithm; and (3) the cardiovascular event rate during a 3‐year follow‐up, compared with standard therapy. In the SGMT trial, 180 patients presenting with ACS will be randomly assigned to SGMT (n = 90) and standard therapy (n = 90) groups. Both groups will receive guideline‐mandated treatment for ACS. Those assigned to SGMT will additionally undergo a sleep study and, if OSA is diagnosed, attend a multidisciplinary OSA clinic where they will receive personalized treatment including continuous positive airway pressure and behavioral/lifestyle counseling. The primary endpoint is the plasma N‐terminal pro brain natriuretic peptide concentration at 7‐month follow‐up. This report presents the baseline characteristics of 117 patients (SGMT group: n =54; standard therapy group: n =63) who had been enrolled into the study as of August 31, 2017. The results of this trial will help us to understand whether active OSA diagnosis and treatment will improve the physiologic and clinical cardiovascular outcomes of this group of patients.     

The effects of carbenoxolone on human myocardial conduction: a tool to investigate the role of gap junctional uncoupling in human arrhythmogenesis.

OBJECTIVES: This study assessed the effects of carbenoxolone on human myocardial conduction and refractoriness. BACKGROUND: Carbenoxolone, an antipeptic ulcer drug, has been shown to reduce gap junctional coupling without affecting cellular ion channels. Gap junctions (GJ) are considered to be determinants of cardiac action potential propagation. The effects of GJ uncoupling in the human heart are unknown. METHODS: Right atrial (RA) and ventricular (RV) activation mapping (Carto, Biosense Webster Inc., Diamond Bar, California) was performed during sinus rhythm. Right atrial and RV wavefront propagation velocity (WPV), specifically in the direction of propagation, was determined from these maps using a triangulation method. Refractoriness at multiple RA and RV sites, sinus rhythm cycle length, and AH, PR, QRS, and QT intervals were measured. The protocol was repeated 1 h after oral administration of 100 mg of carbenoxolone. RESULTS: In 11 patients, WPV was reduced from 79.6 +/- 13.3 cm/s to 57.2 +/- 9.1 cm/s (-27.1 +/- 12.8%, p < 0.001) in RA and from 98.7 +/- 19.8 cm/s to 76.5 +/- 21.7 cm/s (-22.7 +/- 14.1%, p < 0.01) in RV after carbenoxolone. Conduction slowing was more marked in 6 older patients with ischemic heart disease compared with younger subjects with normal hearts (RA -35.1 +/- 5.5% vs. -17.5 +/- 12.7%, p = 0.03; RV -33.8 +/- 5.1% vs. -9.3 +/- 7.7%, p < 0.001). Refractoriness and electrocardiogram parameters remained unchanged. CONCLUSIONS: Carbenoxolone causes a 27% reduction in human RA WPV and 23% in the RV without affecting refractoriness. The slowing of myocardial conduction by carbenoxolone demonstrates the significance of GJ in regulating human myocardial conduction and provides a tool for investigating the effects of GJ uncoupling on human arrhythmogenesis.     

Indonesian registry on atrial fibrillation (OneAF)

Background:Data on the optimal therapeutic international normalized ratio (INR) for non-valvular and valvular atrial fibrillation (AF) in Indonesia is currently unavailable. Therefore, we designed the Indonesian Registry on Atrial Fibrillation (OneAF) registry in order to seek a safe and beneficial range of INR in Indonesian patients with non-valvular and valvular AF.Methods/design:The OneAF registry is a nationwide collaboration of the Indonesian Heart Rhythm Society (InaHRS) enrolling all hospitals with cardiac electrophysiologists in Indonesia. It is a prospective, multicentre, nationwide, observational study aiming to recruit non-valvular and valvular AF patients in Indonesia. The registry was started in January 2020 with a planned 2 years of recruitment. There are 2 respondents for this registry: non-cohort and cohort respondents. Non-cohort registry respondents are AF patients at hospitals who fulfill inclusion and exclusion criteria but did not consent for a 24 month follow up. Whereas patients who consented for a 24 month follow up were included as cohort registry respondents. Key data collected includes basic sociodemographic information, symptoms and signs, medical history, results of physical examination and laboratory test, details of diagnostics and treatment measures and events.Results:Currently, a total of 1568 respondents have been enrolled in the non-cohort registry, including 1065 respondents with non-valvular AF (67.8%) and 503 respondents with valvular AF (32.2%). We believe that the OneAF registry will provide insight into the regional variability of anticoagulant treatment for AF, the implementation of rhythm/rate control approaches, and the clinical outcomes concerning cardiocerebrovascular events.Trial registration:Registered at clinicaltrials.gov ({"type":"clinical-trial","attrs":{"text":"NCT04222868","term_id":"NCT04222868"}}NCT04222868).     

Short and long-term outcome of pancreatic surgery in a district general hospital

Pancreatic surgery is a formidable undertaking with historically high mortality and poor prognosis for periampullary lesions. This has led to recommendations that all pancreatic surgery should be performed in specialist centres. There is no doubt from large series that a low mortality can be achieved in these centres, but there has been no direct comparison between results from these specialist centres and district general hospitals with an interest in pancreatic disease. We present a retrospective, seven-year experience with a 3% 30 day mortality, 39% morbidity and 14 month median survival for malignant disease. Comparison with the UK survey of specialist pancreatic units shows that pancreatic surgery can be safely performed in the setting of a district general hospital with low morbidity and mortality, and good long-term outcome.     

An unusual case of dysphonia and dysphagia

A 68-year-old man presented with a six-month history of painless dysphagia, malnutrition, anorexia and vocal hoarseness. Signs of severe mitral regurgitation and preserved left atrial dimensions were discovered on transthoracic echocardiography. However, electrocardiography and chest radiography were strongly suggestive of left atrial enlargement. Further investigations confirmed extrinsic compression of the oesophagus, which caused the dysphagia. Computed tomography of the throrax revealed a giant left atrium that was not appreciated on echocardiography. Hoarseness was found to be caused by right recurrent laryngeal nerve palsy. Ortner''s syndrome, which describes the occurrence of vocal hoarseness due to a cardiopulmonary disease that results in the compression of the left recurrent laryngeal nerve, is usually associated with severe mitral stenosis. Herein, we report an unusual case of Ortner''s syndrome caused by a giant left atrium, which resulted from severe mitral regurgitation, causing extrinsic oesophageal compression and right recurrent laryngeal nerve palsy. Physicians should remain cognisant of cardiovascular disorders as uncommon causes of painless dysphagia or vocal hoarseness.