A prospective randomised comparative study of endoscopic band ligation versus injection sclerotherapy of bleeding internal haemorrhoids in patients with liver cirrhosis

Background and study aimsBleeding internal haemorrhoids are common and used to be treated surgically with too many complications. Endoscopic therapy is trying to take the lead. Sclerotherapy and rubber band ligation are the candidates to replace surgical therapy especially in patients with liver cirrhosis. The aim of this study was to compare endoscopic injection sclerotherapy (EIS) to endoscopic rubber band ligation (EBL) regarding effectiveness and complications in the treatment of bleeding internal haemorrhoids in Egyptian patients with liver cirrhosis.Patients and methodsOne hundred and twenty adult patients with liver cirrhosis and bleeding internal haemorrhoids were randomised into two equal groups; the first treated with EBL using Saeed multiband ligator, and the second with EIS using either ethanolamine oleate 5% or N-butyl cyanoacrylate. All groups were matched as regards age, sex, Child score and pre-procedure Doppler values. Patients were followed up clinically and with abdominal ultrasound/Doppler for 6 months. Endoscopic and endosonography/Doppler was done before and one month after the procedure. Pre and post-procedure data were recorded and analysed.ResultsBoth techniques were highly effective in the control of bleeding from internal haemorrhoids with a low rebleeding [10% in the EBL group and 13.33% in the EIS group] and recurrence [20% in the EBL group 20% in the EIS group] rates. Child score had a positive correlation with rebleeding and recurrence in EIS group only.Pain score and need for analgesia were significantly higher while patient satisfaction was significantly lower in EIS compared to EBL [p < 0.05]. No significant difference between ethanolamine and cyanoacrylate subgroups was found [p > 0.05].ConclusionsBoth EBL and EIS were effective in the treatment of bleeding internal haemorrhoids in patients with liver cirrhosis. EBL had significantly less pain and higher patient satisfaction than EIS. EBL was also safer in patients with advanced cirrhosis.     

Echocardiographic variables associated with mitral regurgitation after aortic valve replacement for aortic valve stenosis

BackgroundMitral regurgitation (MR) is frequently associated with aortic stenosis. Previous reports have shown that coexisting mitral insufficiency can regress after aortic valve replacement (AVR) while others recommend dealing with examination.AimThe study aimed to assess the severity of MR before and after aortic valve replacement for aortic stenosis and to define the determinants of its postoperative evolution.MethodsFor this purpose, 30 adult patients referred for aortic valve surgery underwent pre- and 1 month postoperative transthoracic echocardiography including 2D, MM, PW, CW and color Doppler examination.ResultsPostoperative MR improved in 68.4% of the 19 patients (63.3%) who had preoperative moderate MR (p = 0.002). The effect of the valve size on the postoperative MR was statistically insignificant (0.059) but was significant on regression of the mass (p = 0.001) and drop in mean PG (p = 0.04) across AV. Patients with persistent moderate MR after surgery were all in AF and had significantly larger left atrial size (45 ± 26 mm), compared to none and a smaller left atrial (37 ± 19 mm) in patients in whom MR regressed or disappeared after surgery; respectively, p < 0.05. The postoperative variables associated with moderate MR were peak PG across AV (29.4 ± 5.1 vs 38.0 ± 5.7 p = 0.004), mean PG (15.04 ± 4.4 vs 22.8 ± 5.8 p = 0.009) and LVMI (124.7 ± 19.3 vs 147.2 ± 31.6 p = 0.065).ConclusionPreoperative predictors of residual postoperative MR were large LA and AF while the postoperative variables were high peak and mean pressure gradient across the aortic valve and high LVMI.     

Evaluation of spleen stiffness in healthy volunteers using point shear wave elastography

Introduction and ObjectivesThis study aims to measure the values of spleen stiffness (SS) in healthy subjects, the inter-operator agreement in SS measurement, and to detect statistically significant correlations between SS and age, sex, weight, BMI, portal vein dynamics and splenic dimensions.Materials and methodsThe study included 100 healthy volunteers who had no substantial alcohol intake (<30 g/daily for man, <20 g/daily women), were negative on hepatitis B, hepatitis C, HIV blood serology, and had any history of lymphoproliferative disorders. Abdominal ultrasound, liver and spleen elastography were performed on each patient to search for focal splenic lesions, bile tract or portal vein dilatation, moderate/severe liver steatosis, and to measure liver and spleen stiffness.ResultsThe mean value was 18.14 (±3.08) kPa. In the group of men (n = 49), the mean was 17.73 (±2.91) kPa, whereas in the group of women (n = 51) it was 16.72 (±3.32) kPa. Statistical analyses showed no correlation between spleen stiffness and sex, age, weight, and BMI. Regarding their splenoportal axis, statistically significant differences in SS were found in the means of the two subgroups of subjects stratified by their portal flow velocity (p = 0.003) and spleen area (p < 0.001).Spearman's rank showed a weak association between SS and portal flow velocty (r = 0.271) and splenic area (r = −0.237). ICC showed excellent (0.96) inter-operator agreement and Bland–Altman plot demonstrated no systematic over/under-estimation of spleen stiffness values.ConclusionsOur results may serve as a reference point in the evaluation of SS especially in patients affected by advanced liver disease.     

Osteoprotegerin (OPG) and Matrix Gla protein (MGP) in rheumatoid arthritis patients: Relation to disease activity

BackgroundImbalanced Matrix Gla protein (MGP) and Osteoprotegerin (OPG) levels occur in inflammatory diseases.Aim of the workThe aim of the present study was to evaluate serum MGP and OPG levels in Rheumatoid Arthritis (RA) patients and study their relation to the disease activity.Patients and methodsForty-five female RA patients and 45 age and sex-matched healthy controls were included in this study. Disease activity score 28-C-reactive protein (DAS28-CRP) was used for the assessment of disease activity. High-sensitivity C-reactive protein (hs-CRP), erythrocyte sedimentation rate (ESR), MGP and OPG were measured in patients and controls. The associations of MGP and OPG with DAS28-CRP and the other laboratory and clinical variables were analyzed.ResultsRA patients had significantly higher serum OPG levels (408.3 ± 520.9 pg/ml) and hs-CRP (2.8 ± 1.9 mg/l) than the control (92.5 ± 86.3 pg/ml and 0.9 ± 1.5 mg/l respectively) (p < 0.001 each). There was no significant difference in MGP levels between the patients and control (p = 0.3). The correlation of OPG and MGP with DAS28-CRP in the patients was insignificant (p = 0.4 and p = 0.8 respectively). Age positively correlated with OPG (r = 0.32, p = 0.02), but not with MGP concentration (r = 0.05, p = 0.64) in the RA patients.ConclusionsThe significant elevation of the OPG level in RA patients may through light on its possible role in the pathogenesis of this disease and could be considered as a future therapeutic target. The significant correlation with age suggests that OPG may be an important mediator especially in elderly RA cases.     

Angiopoietin-2 as a biomarker for metabolic syndrome and disease activity in rheumatoid arthritis patients

BackgroundThe incidence of metabolic syndrome (MetS) increases in rheumatoid arthritis (RA) patients which increases the risk of cardiovascular disease (CVD). Angiopoietin-2 levels increase in RA and were reported to predict CVD.Aim of the workTo assess the level of angiopoietin-2 in RA patients and study its relation to disease activity and its role in those with MetS.Patients and methodsThe study included 80 RA patients (67 females and 13 males) and 20 healthy age and sex matched controls. The patients were divided into Group 1 (n = 40) with MetS and Group 2 (n = 40) without. Data were collected throughout history, basic clinical examination and investigation. Disease activity score (DAS-28) was assessed in all patients. Enzyme linked immunosorbent assay was used for the estimation of angiopoietin-2.ResultsThe age and disease duration of those with MetS (40.7 ± 7.23 years and 9.63 ± 6.73 years respectively) and those without (38.6 ± 9.2 and 8.65 ± 5.52 years respectively) were comparable (p = 0.26 and p = 0.48 respectively). The disease activity (DAS-28) was also similar in both groups (5.12 ± 0.77 and 5.01 ± 0.96 respectively; p = 0.56). There was a significant increase in the angiopoietin-2 levels in RA patients with MetS (5.31 ± 0.56 ng/ml) than those without (4.93 ± 0.44 ng/ml) (p < 0.001). The levels were significantly higher than those of the control (4.44 ± 0.29 ng/ml) (p < 0.001). The angiopoietin-2 level significantly correlated with the DAS-28 (r = 0.23, p = 0.045), systolic (r = 0.36, p = 0.001) and diastolic blood pressure (r = 0.35, p = 0.001), fasting blood sugar (r = 0.29, p = 0.009) and triglycerides (r = 0.24, p = 0.03).ConclusionsAngiopoietin-2 can be used as a biomarker of MetS and disease activity in RA patients. This could point to those RA patients at risk of developing CVDs.     

Serum adipokine profile in Indian men with nonalcoholic steatohepatitis: Serum adiponectin is paradoxically decreased in lean vs. obese patients

BackgroundAsian Indians are known to be more insulin resistant for the same degree of weight gain. It is therefore likely that the adipokine profile in nonalcoholic fatty liver disease (NAFLD) in Asian Indian population could be different from the Western subjects.AimsTo study the serum adiponectin, resistin, leptin and TNF-α profile in NAFLD and cryptogenic cirrhosis patients.Subjects and methodsBody mass indices, insulin resistance and serum adipokine levels were studied in 56 patients; 10 with fatty liver, 30 with nonalcoholic steatohepatitis (NASH) and 16 with cryptogenic cirrhosis. Eighteen healthy controls were also included.ResultsPatients in general were obese compared to controls (mean BMI 26.9 ± 4.5 vs. 22.6 ± 2.5, respectively, p < 0.0001). In patients with NASH, adiponectin levels were lower than controls (5.4 ± 3 μg/ml vs.7.2 ± 2.9 μg/ml, p = 0.037). Insulin Resistance as assessed by homeostasis model assessment (HOMA) was higher in obese than lean, NAFLD patients (HOMA IR obese, median = 2.8, range = 0.8–16.3 and lean: median = 1.05, range = 0.51–2.75, p = 0.003). Lean NAFLD patients had adiponectin levels lower than obese patients (3 ± 1 μg/ml vs.6.7 ± 3.8 μg/ml respectively, p = 0.003). Serum resistin levels were higher in NAFLD patients (3.7 ± 3 ng/ml) than controls (2.1 ± 1.7 ng/ml, p = 0.007). This difference was significant even when cirrhotic patients were excluded (3.4 ± 2.7 ng/ml, p = 0.036). Serum leptin levels were raised in cryptogentic cirrhosis compared to NASH (p = 0.03). All adipokines tested were raised in cirrhotic patients compared to NAFLD and controls.ConclusionsA significant reduction in serum adiponectin and increase in serum resistin levels were observed in NAFLD patients, more so in lean than obese NAFLD. This paradoxical decrease of serum adiponectin as well as low frequency of insulin resistance in lean NAFLD suggests a possible different etiology for this subset of patients.     

Hypoglycemia symptoms are reduced in hospitalized patients with diabetes

AimsHospitalized patients with diabetes are have an impaired ability to detect hypoglycemia events. The purpose of this study was to compare hypoglycemia symptom scores (HSS) in hospitalized patients with diabetes after a documented blood glucose (BG) <70 mg/dl with recalled HSS with outpatient hypoglycemia events.MethodsNon-critically ill hospitalized patients with diabetes grouped as symptomatic (n = 23) or asymptomatic (n = 32) at time of index hypoglycemia completed a standardized HSS-Questionnaires (HSS-Q) related to the inpatient event and to recall of symptoms with outpatient hypoglycemia.ResultsAfter controlling for BG at time of index hypoglycemia (49.8 ± 11.4 vs. 57.4 ± 6.8 mg/dl, p = 0.02), symptomatic patients reported higher HSS than asymptomatic patients with the inpatient event (11.6 ± 7.3 vs. 1.5 ± 3.4, p < 0.001) and in the outpatient setting (13.9 ± 8.6 vs. 10.1 ± 10.6, p < 0.01). Recurrent hypoglycemia was more frequent in asymptomatic patients (13% vs. 44%, p = 0.015) during the hospitalization.ConclusionsCompared to symptomatic patients, asymptomatic patients had lower inpatient and outpatient HSS and more frequent recurrent hypoglycemia events. These results suggest modification of glycemic management strategies in high risk patients to reduce risk for hypoglycemia events.     

Evaluation of the liver condition in chronic hepatitis C virus patients with and without vasculitis

Aim of the workThe association between hepatitis C virus (HCV)-related vasculitis and severe hepatic fibrosis is a controversial issue. In this study, we aimed to evaluate the liver affection in a group of patients with HCV-related vasculitis and a control group with chronic HCV infection without vasculitis.Patients and methodsTwenty-six HCV associated vasculitis patients (22 females, 4 males) with a mean age of 51.9 ± 8.5 years (range 36–72 years) and a control group including 20 age- and sex matched HCV infected patients without any extra-hepatic autoimmune manifestations were recruited in this study. All patients and controls were evaluated by routine biochemical tests, conventional ultrasonography and Fibroscan.ResultsThe mean disease duration in patients with vasculitis and the control group was 7.5 ± 7.3 and 4.1 ± 3.6 years, respectively (p = 0.062). Mean aspartate aminotransferase, bilirubin and international normalized ratio (INR) values were higher in the control group (p = 0.036, 0.041 and 0.017, respectively). Hepatomegaly was found in 11 (42.3%) vasculitis patients and 17 (85%) controls (p = 0.006), while portal hypertension was found in 4 (15.4%) vasculitis patients and 9 (45%) controls (p = 0.046). On Fibroscan, eleven vasculitis patients (42.3%) had mild to moderate liver fibrosis (F1–2), and 10 (38.5%) had severe liver fibrosis (F3–4), while only one patient (5%) of the control group had mild, and 17 (85%) had severe liver fibrosis (p = 0.002).ConclusionPatients with chronic HCV infection without vasculitis have worse liver functions and more advanced liver fibrosis than those with HCV related vasculitis.     

Intestinal permeability is increased in children with non-alcoholic fatty liver disease,and correlates with liver disease severity

BackgroundIncreased intestinal permeability seems to play a major role in non-alcoholic liver disease development and progression.AimTo investigate the prevalence of altered intestinal permeability in children with non-alcoholic fatty liver disease, and to study its potential association with the stage of liver disease.MethodsWe performed a case–control study examining intestinal permeability in children using the lactulose–mannitol bowel permeability test.ResultsOverall, 39 consecutive patients (30 males, median age 12 years) and 21 controls (14 males, median age 11.8 years) were included. The lactulose/mannitol ratio resulted impaired in 12/39 patients (31%) and none of the controls. Intestinal permeability was higher in children with non-alcoholic fatty liver disease (lactulose/mannitol ratios: 0.038 ± 0.037 vs. 0.008 ± 0.007, p < 0.05). Within the non-alcoholic fatty liver disease group, intestinal permeability was increased in children with steatohepatitis compared to those with steatosis only (0.05 ± 0.04 vs. 0.03 vs. 0.03, p < 0.05). Pathological lactulose/mannitol ratio correlated with portal inflammation (p = 0.02), fibrosis (p = 0.0002), and ballooning of hepatocytes (p = 0.003). Blood lipopolysaccharides levels were higher in children with steatohepatitis (2.27 ± 0.68 vs. 2.80 ± 0.35, p < 0.05).ConclusionsIntestinal permeability is increased in children with non-alcoholic fatty liver disease, and correlates with the severity of the disease.     

Levels of plasma cell-free DNA and its correlation with disease activity in rheumatoid arthritis and systemic lupus erythematosus patients

BackgroundCell free deoxyribonucleic acid (cf-DNA) is now emerging as a useful tool for non-invasive diagnostic methods related to a wide range of clinical conditions including autoimmune diseases.Aim of the workTo estimate the concentration of plasma cf-DNA in rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) patients compared with healthy subjects and to correlate the results with clinical and laboratory parameters of disease activity.Patients and methodsThe study included 30 RA patients, 35 SLE patients and 25 matched control. Plasma cf-DNA was estimated by real-time quantitative PCR. Disease activity parameters for each disease were assessed; Disease Activity Score-28 (DAS28) was used for RA and SLE disease activity index 2000 (SLEDAI-2K) for SLE patients.ResultsThe RA patients (F:M 4:1) had a mean age of 36.8 ± 9.6 years and disease duration of 8.3 ± 1.1 years while the SLE patients (F:M 7.75:1) had a mean age of 35.6 ± 8.8 years and disease duration of 8.1 ± 0.87 years. There was a highly significant increase in the cf-DNA level in SLE patients (17.33 ± 2.4 ng/ml) and RA patients (11.15 ± 2.3 ng/ml) compared to the level in the control (4.15 ± 1.4 ng/ml) (p = 0.0005). The cf-DNA significantly correlated with the erythrocyte sedimentation rate (ESR) (p = 0.04), C-reactive protein (p = 0.04) and the DAS28 (p = 0.005) in the RA patients and with the ESR (p = 0.03), anti-ds-DNA (p = 0.008), complement-4 (p = 0.04) and SLEDAI-2K (p = 0.002).ConclusionThe increased cf-DNA implicates a possible role in the pathogenesis of both RA and SLE and appears to be a useful marker of disease activity in addition to other laboratory tests.     

Hypoadiponectinemia in lipodystrophic HIV individuals: A metabolic marker of subclinical cardiac damage

Background and aimTo evaluate cardiovascular abnormalities in highly active antiretroviral therapy (HAART) treated HIV patients with no signs or symptoms of cardiovascular impairment, and to assess the relative role of multiple concomitant risk factors.Methods and resultsForty-four consecutive HIV subjects (mean age 41 ± 6 yrs) were enrolled. Inclusion criteria were HIV infection, CD4 + cell count > 150/ml, HAART treatment for at least 4 years. Metabolic serum levels, morphological and functional echocardiographic parameters were assessed in all subjects. Sixteen healthy age and sex matched subjects with no cardiovascular risk factors were recruited as controls.HIV patients showed increased left ventricular mass index with reduced mid-wall fractional shortening (mFS) when compared to controls (50.2 ± 10.5 vs. 38.6 ± 14.4, p = 0.05 and 18.3 ± 0.6 vs. 21.9 ± 0.7, p < 0.05, respectively). Twenty-nine patients were lipodystrophic (LD) and showed a longer HAART period (p = 0.0004) and greater use of protease inhibitors (PI) (p = 0.001). Coronary flow reserve (CFR) was significantly reduced in HIV patients as compared to controls (p < 0.0001), as it was in LD subjects when compared to non-lipodystrophic ones (NLD) (p < 0.001). Adiponectin concentrations were found to be significantly lower in LD subjects than in NLD ones (7.8 ± 0.8 vs. 13.8 ± 1.2 μg/ml, p = 0.01), and showed a direct correlation with CFR. In multiple regression analysis, insulin, HDL and adiponectin accounted for 63% of CFR variations.ConclusionsLeft ventricular hypertrophy, depressed mFS and reduced CFR represent the main signs of subclinical cardiac damage in HIV subjects treated with HAART. Hypoadiponectinemia in these subjects seems to be a metabolic risk factor of cardiovascular impairment.     

Impact of pre-excitation syndrome on left ventricular systolic function and cardiac synchronization assessed by tissue Doppler imaging and speckle tracking techniques

BackgroundThe pathogenic mechanism for the development of left ventricular (LV) dysfunction in patients with asymptomatic pre-excitation syndrome has not yet been fully elucidated. We sought to assess the impact of pre-excitation on LV systolic function and whether the use of tissue Doppler imaging (TDI) and speckle tracking is more helpful in detection of the LV dyssynchrony than conventional echo parameters in these patients.MethodsThis observational case control study was carried out on adults with manifest pre-excitation syndromes. A detailed echocardiographic assessment was performed including TDI and speckle tracking examination.ResultsOur study patients were divided into two groups, group 1: with lateral accessory pathways (AP) (23 patients aged 31.65 ± 6.5 years), group 2: with septal AP (25 patients, 34.84 ± 10.8 years). Echocardiography showed a lower ejection fraction (EF) in group 2 than in group 1 (0.60 ± 0.07% in group 1 vs. 0.50 ± 0.08% in group 2, p = 0.000). The radial strain dyssynchrony index was higher in group 2 than in group 1 (58.78 ± 33.47 vs. 139.52 ± 21.14 ms; p < 0.0001) with a significant negative correlation with EF (r = −0.8, p = 0.000). Dyssynchrony detection was higher using speckle tracking technique than M mode/Doppler methods (p = 0.006).ConclusionPatients with pre-excitation syndrome may have depressed LV function unrelated to tachyarrhythmia, especially if the AP has a septal location. This dysfunction may be associated with the LV dyssynchronus contraction caused by pre-excitation. The use of TDI and speckle tracking echocardiographic techniques may be associated with an increase in the identification of manifest pre-excitation patients with significant LV dyssynchrony.     

The correlation between sclerostin and bone mineral density in renal transplant recipients

IntroductionSclerostin is an anti-anabolic protein synthesized by osteocytes that may cause osteoporosis by inhibiting bone formation. The aim of our study was to investigate the correlation between sclerostin and bone mineral density (BMD) reduction in renal transplant recipients (RTRs) with more than 1 year after transplantation.Material and methodsThis cross-sectional study was conducted on 80 patients (38 (47.5%) male/42 (52.5%) female) RTRs with a mean age of 44.68 ± 10.39 years. Patients were compared with an age and sex-matched control group of 40 healthy individuals. BMD was measured by dual-energy X-ray absorptiometry. The levels of sclerostin were determined using enzyme-linked immunosorbent assay.ResultsThe mean sclerostin was 3.77 ± 0.3 pg/mL in patients and 3.81 ± 0.21 pg/mL in healthy individuals. The mean T score of femoral trochanter (FT) (FT-T), femoral neck (FN) (FN-T), lumbar vertebrae (L1-4) (L1-4-T) were −0.81 ± 0.86, −1.08 ± 1.09 and −0.8 ± 1.2, respectively. The mean Z score of FT (FT-Z), FN (FN-Z), L1-4 (L1-4-Z) were −0.6 ± 0.73, −0.32 ± 0.9 and −0.54 ± 1.13, respectively. FT-Z and L1-4-Z were lower in patients than healthy subjects (p = 0.009, p = 0.021 respectively). Serum creatinine (p < 0.001), intact parathyroid hormone (p < 0.001) were higher and phosphate (p < 0.001), was lower in patients than healthy subjects. Patients with a log₁₀ sclerostin of >3.84 pg/mL had higher FT-T (p = 0.040), FT-Z, FN-T (p = 0.018), FN-Z (p = 0.006) than those with a log₁₀ sclerostin of ≤3.84 pg/mL. There was a significant correlation between log₁₀ sclerostin and FN-T (r = −0.296, p = 0.009) and FN-Z (r = −0.269, p = 0.019). In linear regression analysis, high sclerostin was found to be correlated with male gender, lower FN-T and lower FN-Z independently of other risk factors.ConclusionThe levels of sclerostin can predict reduction of proximal femur BMD and development of mineral and bone disorder in RTRs. There was no difference in sclerostin levels between RTRs and healthy individuals.     

Assessment of the acute impact of normobaric hypoxia as a part of an intermittent hypoxic training on heart rate variability

AimTo assess the dynamics of ANS by means of heart rate variability (HRV) during and after acute exposure to normobaric hypoxia, representing a single session of an intermittent hypoxic training protocol.Material and methodsTwenty four healthy males aged 28.0 ± 7.2 (mean ± SD) breathed hypoxic air (FIO2 = 12.3 ± 1.5%) for one hour delivered via hypoxicator (AltiPro 8850 Summit+, Altitude Tech, Canada). Pulse oximetry and HRV were measured before, during and after the hypoxic exposure.ResultsAt the end of the hypoxic session all of the tested subjects had higher low frequency (lnLF) (6.9 ± 1.1 ms² vs. 7.5 ± 1.1 ms²; p = 0.042), LF/HF (1.5 ± 0.8 vs. 3.3 ± 2.8; p = 0.007) and standard deviation 2 of the Poincaré plot (SD2) (92.8 ± 140.0 ms vs. 120.2 ± 54.2 ms; p = 0.005) as well as increase in the Total power (7.7 ± 1.1 ms² vs. 8.1 ± 1.2 ms²; p = 0.032) and the Standard deviation of normal-to-normal interbeat intervals (SDNN) (57.3 ± 31.0 ms vs. 72.3 ± 41.1 ms; p = 0.024) but lower Sample entropy (SampEn) (1.6 ± 0.2 vs. 1.4 ± 0.2; p = 0.010). Immediately after the hypoxic exposure LF/HF lowered (3.3 ± 2.8 vs. 2.2 ± 1.8; p = 0.001) but lnHF significantly increased (6.6 ± 1.4 ms² vs. 7.1 ± 1.3 ms²; p = 0.020).ConclusionAcute normobaric hypoxia as a part of a single session of an intermittent hypoxic training protocol leads to changes in the activity of the ANS. The sympathetic tone prevails during hypoxic exposure and parasympathetic tone increases immediately after the hypoxic factor is withdrawn.     

Increased maximum p wave duration in smoking patients with ST-elevation acute myocardial infarction and its relationship with inflammatory markers

IntroductionElectrocardiographic markers for atrial fibrillation and the relationship with inflammatory markers have not been evaluated in smoker patients with acute myocardial infarction.Material and methodsThis is a cross-sectional study developed between January 2012 and July 2014 at Hospital Universitario Celestino Hernández Robau from Santa Clara, Cuba. One hundred fifteen patients were included finally. The sample was divided into two groups (smokers and non-smokers). We obtained clinical and laboratory data and compared electrocardiographic markers for atrial fibrillation in both groups and with inflammatory markers.ResultsMaximum p wave duration was significantly higher in smoker than non-smoker patients (102 ± 12 vs. 97 ± 9; p = 0,020). Minimum p wave duration and p wave dispersion also are higher in smoker patients but not significantly (61 ± 10 vs. 60 ± 7; p = 0,476 and 41 ± 10 vs. 37 ± 9; p = 0,050). There is a positive and significant linear correlation between neutrophils count and maximum p wave duration in smokers (r = 0,45; p = 0,004), but not in non-smokers patients (r = 0,09; p = 0,49). There is a negative correlation between lymphocyte count and maximum p wave duration in smokers (r = -0,44; p = 0,004) and in non-smoker patients (r = -0,07; p = 0,62).ConclusionMaximum p wave duration is higher in smoker patients than non-smoker patients during ST-elevation acute myocardial infarction. Neutrophil count is positively associated with maximum p wave duration in smoker patients. Lymphocyte count has a negative association with maximum p wave duration.     

Magnesium administration may improve heart rate variability in patients with heart failure

Background and aimIntracellular magnesium (icMg) depletion may coexist with normomagnesemia. Mg deficiency (serum and/or intracellular) and decreased heart rate variability (HRV) are common in heart failure (HF). Since both are predictors of poor prognosis, it was of interest to evaluate the effect of Mg supplementation on HRV in patients with HF.Methods and resultsWe investigated the effect of Mg administration on HRV in normomagnesemic patients with systolic HF. HRV, serum Mg and icMg were determined before and after 5-week 300 mg/day Mg citrate treatment in 16 patients (group 1). The control group included 16 Mg-non-treated HF patients (group 2). HRV was determined by a non-linear dynamics analysis, derived from the chaos theory, which calculates HRV–correlation dimension (HRV–CD). After 5 weeks, serum Mg (mmol/l) increased more significantly in group 1 (from 0.78 ± 0.04 to 0.89 ± 0.06, p < 0.001), than in group 2 (from 0.79 ± 0.07 to 0.84 ± 0.06, p = 0.042). IcMg and HRV–CD increased significantly only in group 1 (from 59 ± 7 to 66 ± 9 mmol/g cell protein, p = 0.025, and from 3.47 ± 0.42 to 3.94 ± 0.36, p < 0.001, respectively). In group 2, the differences in the respective parameters were 63 ± 12 to 66 ± 9 mmol/g cell protein (p = 0.7) and 3.59 ± 0.42 to 3.55 ± 0.4 (p = 0.8).ConclusionMg administration to normomagnesemic patients with systolic HF increases serum Mg, icMg and HRV–CD. Increasing of HRV by Mg supplementation may prove beneficial to HF patients.     

Albuminuria and VEGF as early markers of cardiovascular disturbances in young type 1 diabetic patients

AimsThe aim of the study was to assess myocardial perfusion by means of non-invasive diagnostic methods and measurement of the plasma concentration of vascular endothelial growth factor (VEGF) in patients with long-lasting type 1 diabetes.Methods and resultsThe study was performed on 41 Type 1 diabetic patients (23 females, 18 males), aged 30 ± 7.6 with a duration of disease 15.2 ± 5.5 years. 17 patients exhibited microalbuminuria (10 females, 7 males) and 24 subjects were without microalbuminuria (13 females, 11 males). The methods used included a 24-h ECG tape, an exercise treadmill test, echocardiological evaluation with dobutamine and atropine challenge and single photon emission computer tomography (SPECT) at rest, and after dipyridamol induction of ischemia. All the exercise and stress echocardiography tests were negative. There were significant differences between microalbuminuric and normoalbuminuric subjects in the duration of their exercise tests (586.9 ± 110.5 vs. 664.9 ± 133.2 s, p = 0.027), performed work (11.4 ± 1.6.vs. 12.6 ± 1.8 METs, p = 0.045), achieved pulse limit (89.1 ± 3.6 vs. 92.6 ± 5.2%, p = 0.037), rest ejection fraction (55.8 ± 8.7 vs. 62.0 ± 4.4%, p = 0.040), abnormal changes in SPECT (53 vs. 21%, p = 0.047) and VEGF concentration (101.5 ± 7.8 vs. 75.15 ± 16.5 pg/ml, p < 0.05). The presence of retinopathy increased 12-fold the probability of significant changes in the SPECT (OR 12.1, 95% CI 1.38–105.64, p = 0.02) and nephropathy (OR 4.27; 95%CI 1.09–16.83, p = 0.03).ConclusionAsymptomatic patients with long lasting type 1 diabetes may have disturbances in myocardial perfusion, especially these with microalbuminuria.     

Lung Function,Radiological Findings and Biomarkers of Fibrogenesis in a Cohort of COVID-19 Patients Six Months After Hospital Discharge

IntroductionImpairment in pulmonary function tests and radiological abnormalities are a major concern in COVID-19 survivors. Our aim is to evaluate functional respiratory parameters, changes in chest CT, and correlation with peripheral blood biomarkers involved in lung fibrosis at two and six months after SARS-CoV-2 pneumonia.MethodsCOVID-FIBROTIC (clinicaltrials.gov NCT04409275) is a multicenter prospective observational cohort study aimed to evaluate discharged patients. Pulmonary function tests, circulating serum biomarkers, chest radiography and chest CT were performed at outpatient visits.ResultsIn total, 313, aged 61.12 ± 12.26 years, out of 481 included patients were available. The proportion of patients with DLCO < 80% was 54.6% and 47% at 60 and 180 days. Associated factors with diffusion impairment at 6 months were female sex (OR: 2.97, 95%CI 1.74–5.06, p = 0.001), age (OR: 1.03, 95% CI: 1.01–1.05, p = 0.005), and peak RALE score (OR: 1.22, 95% CI 1.06–1.40, p = 0.005). Patients with altered lung diffusion showed higher levels of MMP-7 (11.54 ± 8.96 vs 6.71 ± 4.25, p = 0.001), and periostin (1.11 ± 0.07 vs 0.84 ± 0.40, p = 0.001). 226 patients underwent CT scan, of whom 149 (66%) had radiological sequelae of COVID-19. In severe patients, 68.35% had ground glass opacities and 38.46% had parenchymal bands. Early fibrotic changes were associated with higher levels of MMP7 (13.20 ± 9.20 vs 7.92 ± 6.32, p = 0.001), MMP1 (10.40 ± 8.21 vs 6.97 ± 8.89, p = 0.023), and periostin (1.36 ± 0.93 vs 0.87 ± 0.39, p = 0.001).ConclusionAlmost half of patients with moderate or severe COVID-19 pneumonia had impaired pulmonary diffusion six months after discharge. Severe patients showed fibrotic lesions in CT scan and elevated serum biomarkers involved in pulmonary fibrosis.     

Tiotropium induced bronchodilation and protection from dynamic hyperinflation is independent of extent of emphysema in COPD

BackgroundThe magnitude of tiotropium (1) induced bronchodilation and (2) protection against dynamic hyperinflation in COPD phenotypes has not been studied.MethodsWe studied moderate to severe COPD patients with varying extent of emphysema as evaluated by high-resolution thin-section lung CT. Spirometry including inspiratory capacity (IC) was measured before and immediately after metronome paced hyperventilation (MPH) at 2 times resting respiratory rate for 20 s to induce dynamic hyperinflation. Spirometry was obtained at baseline and pre- and 1.5 h post-18 μg tiotropium via HandiHaler after 30 day tiotropium treatment period in a single blind, open label intervention.ResultsIn 29 COPD patients (15 M), age 70 ± 9 years (mean ± SD) with smoking history of 53 ± 37 pack years, baseline forced expiratory volume in 1 s (FEV₁) post-180 μg albuterol MDI was 1.6 ± 0.4 L (61 ± 8% predicted) and FEV₁/FVC 59 ± 6%. Lung CT emphysema score (LCTES) was 23 ± 20 (mean ± SD) on a scale of 0–100 (none to most severe emphysema). After 30-day tiotropium, FEV₁ increased 101 ± 124 mL (mean ± SD) (p < 0.001) and Spearman correlation (r) = ?0.04, p = 0.8 with LCTES; IC increased 163 ± 232 mL (p < 0.001), and r = ?0.2, p = 0.3 with LCTES. Results following MPH induced DH before and after 30-day tiotropium were significant (p < 0.001) and similar: IC decreased 340 ± 280 mL before and 337 ± 270 mL after tiotropium, and r = ?0.3, p = 0.9 with LCTES.ConclusionTiotropium significantly increased FEV₁ (L) and inspiratory capacity in moderate-severe COPD, independent of extent of lung CT emphysema score. Despite bronchodilation and lower resting lung volume, tiotropium did not abbreviate induced dynamic hyperinflation, which was also independent of underlying emphysema.     

Impact of coronary artery calcification on percutaneous coronary intervention and postprocedural complications

BackgroundExcessive coronary calcification can lead to adverse outcomes after percutaneous coronary intervention (PCI). We therefore evaluated the impact of coronary calcium score (CCS) measured by multidetector computed tomography (MDCT) on immediate complications of PCI and rate of restenosis.MethodsWe performed a single-center retrospective analysis of 84 patients with coronary stenosis diagnosed by MDCT who underwent PCI. The Agatston method was used to measure total, target-vessel, and segmental (stent deployment site) CCS.ResultsIn 108 PCI procedures, 32 lesions (29.5%) were American College of Cardiology/American Heart Association type A, 60 (55.5%) were type B, and 16 (15%) were type C. ANOVA showed significantly higher segmental CCS in type C than in type A lesions (29 ± 51 vs. 214 ± 162; p = 0.03). Six patients (7.1%) had periprocedural complications and seven (8.3%) had in-stent restenosis and angina. Mean total, target-vessel, and segmental CCS was significantly higher in complicated than in successful PCI (199 ± 325 vs. 816 ± 624, p = 0.001; 92 ± 207 vs. 337 ± 157, p = 0.001; and 79 ± 158 vs. 256 ± 142, p = 0.003, respectively), but there was no significant difference in CCS between successful PCI and PCI complicated by late restenosis.ConclusionsCCS measured by MDCT has an important role in predicting early, but not late, complications from PCI.