Etanercept can induce resolution of renal deterioration in patients with amyloid A amyloidosis secondary to rheumatoid arthritis

The benefit of biological therapies in rheumatoid arthritis (RA) treatment is well known, but their role in amyloid A (AA) amyloidosis secondary to RA is unclear. The aim of this study was to clarify the clinical benefit of etanercept in RA patients with AA amyloidosis. We treated 14 RA patients who had serum amyloid A protein (SAA) 1.3 allele, with biopsy-confirmed AA amyloidosis with etanercept and investigated the efficacy of etanercept treatment, focusing on renal function retrospectively. The AA amyloidosis improved and stabilized after 89.1 ± 27.2 weeks. Proteinuria decreased from 2.24 ± 0.81 to 0.57 ± 0.41 g/day (P < 0.01) and SAA fell from 250 ± 129 to 26 ± 15μg/ml (P < 0.01), respectively. Diarrhea secondary to gastrointestinal AA amyloidosis was less. Overall, the serum creatinine levels did not benefit with treatment, but in those with a creatinine values <2.0 mg/dl the creatinine level continued to fall (P = 0.021). Serum albumin increased following 96 weeks of etanercept treatment (P = 0.003). Etanercept treatment led to clinical improvement in proteinuria and serum albumin levels accompanied by a fall in SAA levels.     

Prevention of contrast-induced nephropathy with haemofiltration in high-risk patients after percutaneous coronary intervention

Background: The incidence of contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) is increasing. The aim of the study is to assess the benefits of prophylactic haemofiltration (PHF) in patients with high risk of developing CIN after PCI. Methods: 20 patients who underwent PHF after PCI in the context of acute coronary syndrome were selected retrospectively and compared with 20 matched controls with similar risk characteristics. The main variable analysed was the appearance of CIN and the secondary variables were the development of acute clinical kidney failure, heart failure, therapeutic HF and mortality.Results: The baseline characteristics were similar in both groups, with reference creatinine of 2.4 ± 1.3 mg/dl, contrast used 392±213 cc and Mehran score of 21.9±5.2 in the PHF group, as opposed to values of 2.0±0.6 mg/dl, 368±126 cc and 20.2±6.9 respectively in controls. The incidence of CIN was of 6 patients (30%) in the PHF group and 13 patients (65%) in the control group (P=0.03). There were no significant differences in the rest of the variables studied.Conclusion: Haemofiltration after PCI may be an effective strategy for the prevention of CIN in patients at high risk of developing it.     

A randomized trial of intravenous N‐acetylcysteine to prevent contrast induced nephropathy in acute coronary syndromes

Background : Pharmacokinetic data suggests that the intravenous form of n‐acetylcysteine (NAC) may be more effective than the oral formulation in preventing contrast induced nephropathy (CIN). NAC owing to its anti‐oxidant properties might be beneficial for patients with acute coronary syndromes (ACS) who are at increased risk for CIN. The aim of this prospective randomized, single‐center, double‐blind, placebo controlled trial (NCT00939913) was to assess the effect of high‐dose intravenous NAC on CIN in ACS patients undergoing coronary angiography and/or percutaneous coronary intervention (PCI). Methods : We randomized 398 ACS patients scheduled for diagnostic angiography ± PCI to an intravenous regimen of high‐dose NAC (1,200 mg bolus followed by 200 mg/hr for 24 hr; n = 206) or placebo (n = 192). The primary end‐point was incidence of CIN defined as an increase in serum creatinine concentration ≥25% above the baseline level within 72 hr of the administration of intravenous contrast. Results : There was no difference found for the primary end point with CIN in 16% of the NAC group and in 13% of the placebo group (p = 0.40). Change in serum cystatin‐C, a sensitive marker for renal function, was 0.046 ± 0.204 in the NAC group and 0.002 ± 0.260 in the control group (p = 0.07). Conclusion : In ACS patients undergoing angiography ± PCI, high‐dose intravenous NAC failed to reduce the incidence of CIN. © 2011 Wiley Periodicals, Inc.     

Serum creatinine ratio: A novel predictor of mortality after percutaneous coronary intervention in patients with normal and abnormal renal function

The occurrence of contrast induced nephropathy (CIN) is associated with increased mortality after percutaneous revascularization procedures. However, the exact correlation between various levels of creatinine elevation relative to the baseline and subsequent mortality in patients with chronic renal insufficiency (CRI) is not well established. In addition, the relationship between elevated postprocedural creatinine and ensuing mortality in patients with normal baseline renal function needs to be investigated. Methods : All percutaneous coronary intervention (PCI) patients (n = 12,997) were analyzed for any rise in serum creatinine (SCr): CRI group (BSC ≥ 1.5 mg/dl) (n = 1,853) and normal baseline renal function (NBR BSC < 1.5 mg/dl) group (n = 11,144). Patients in each group were analyzed for any elevation in SCr postprocedure and subdivided based on the SCr ratio [peak SCr/Baseline creatinine (BSC)] of <1.25, 1.25–1.5, and >1.5. The overall incidence of CIN (defined as an increment of 25% over baseline creatinine) was 5.9%: 11.3% in the CRI group versus 5.1% in normal BSC group (P < 0.01). Recursive partitioning and Cox hazard modeling were used to assess significant variables associated with mortality within 1 year. Only serum creatinine ratio (SCrR) > 1.5 correlated with increased mortality in both CRI group as well as normal BSC group. Conclusions : SCrR > 1.5 predicts mortality at 1 year after PCI. The association between SCrR > 1.5 and increased mortality at follow‐up is observed in patients with CRI as well as normal baseline renal function. SCrR may thus serve as a useful clinical tool for risk stratification and prognostication of patients after PCI. © 2009 Wiley‐Liss, Inc.     

Ischemia heart disease and greater waist circumference are risk factors of renal function deterioration in male gout patients

We examined the incidence of renal function deterioration (RFD) in a population of male gout patients and to identify associated risk factors. Subjects who had been regularly followed up for more than 2 years and had visited Chang Gung Memorial Hospital-Kaohsiung Medical Center Rheumatology Clinic between June 1, 2006 and January 31, 2007 were enrolled. Four subjects were excluded as secondary gout was suspected. Group I (Gr I) comprised subjects without RFD and group II (Gr II) comprised subjects with RFD during the follow-up period. RFD was defined as absolute increment in creatinine (Cr) levels over 0.4 mg/dl for subjects with baseline Cr levels ≤1.4 mg/dl or as more than 50% increment of baseline Cr level per 12-month interval in average for subjects with baseline Cr levels >1.4 mg/dl. Clinical parameters were analyzed to study the potential risk factors of RFD. Of 318 male gout patients, 296 (93.1%) were categorized as Gr I, and 22 (6.9%) were categorized as Gr II. The observation periods for Gr I and Gr II were 81.20 ± 53.29 and 92.41 ± 46.72 months, respectively (p = 0.338). Initial Cr levels are similar between the two groups (1.25 ± 0.51 vs 1.25 ± 0.61, p = 0.963). Multiple logistic regression analysis revealed that current age, age at disease onset, disease duration, treatment duration, body weight, height, family history of gout, tophi, urolithiasis, tobacco use, alcohol consumption, history of cerebral vascular accident, hypertension, diabetes mellitus, dyslipidemia, base-line and final Cr, blood urea nitrogen level, serum uric acid level, and body-mass index were not independent risk factors. However, history of ischemic heart disease [IHD; odds ratio (OR) 7.68, 95% confidence interval (CI) 1.99–29.70] and greater waist circumference (WC; OR 1.06, 95% CI 1.01–1.11) were two independent risk factors of RFD. Additionally, the Cox multivariable analysis disclosed that IHD (p < 0.001) and greater WC (p = 0.011) deteriorated kidney function in these patients. The incidence of RFD in male gout patients is 6.9%. History of IHD and greater WC are two independent risk factors for developing RFD.     

Gadolinium-based coronary angiography in patients with contraindication for iodinated x-ray contrast medium: a word of caution

BACKGROUND: In coronary angiography, the use of contrast agents containing iodine still defines the gold standard. In patients with contraindications for iodine exposition, gadolinium has been considered to be a safe alternative to standard iodinated contrast medium for coronary angiography. The aim of the present study was to assess the safety and technical quality of gadolinium-based coronary angiography. METHODS: Nineteen consecutive patients with contraindication to iodinated contrast medium underwent gadolinium-based coronary angiography. Contraindications included previous anaphylactic shock or severe allergic reaction to iodinated contrast medium (n = 13) or thyrotoxicosis (n = 6). Gadolinium was diluted 1:1 with sodium chloride before application. Patients were clinically observed for potential side effects, and renal function was assessed by determination of creatinine values and calculation of creatinine clearance in pre- and postprocedural blood samples. Image quality was evaluated by two independent observers, and classified into three different categories (grade 1, high diagnostic quality; grade 2, moderate diagnostic quality; and grade 3, poor quality). RESULTS: During angiography, a mean of 32.6 +/- 10.9 mL (range 10-45 mL) gadolinium was used. No patient developed a significant impairment of renal function within 24 hours after the examination (mean creatinine value preprocedural: 1.12 +/- 0.15 mg/dL, postprocedural: 6 hours 1.15 +/- 0.18 mg/dL, 24 hours 1.13 +/- 0.16 mg/dL) (baseline vs. 6 hours P = 0.23, baseline vs. 24 hours P = 0.66, 6 hours vs. 24 hours P = 0.12) (mean creatinine clearance preprocedural: 73.8 +/- 18 mg/dL, postprocedural: 6 hours 71.7 +/- 16.8 mg/dL, 24 hours 73.2 +/- 17.8 mg/dL) (baseline vs. 6 hours P = 0.2, baseline vs. 24 hours P = 0.71, 6 hours vs. 24 hours P = 0.21). Four patients (21%) suffered severe complications due to gadolinium application, such as malignant cardiac arrhythmias (n = 3) and hemodynamic decompensation (n = 1). Image quality was generally reduced in comparison to iodine contrast coronary angiography, but was adequate for diagnostic purposes (13 patients [68.4%] had reasonably good picture contrast [grade 2.1 +/- 0.3]; in 6 patients [31.6%], image quality was satisfactory [grade 2.6 +/- 0.13]). Opacification of distal vessels as compared to proximal segments was remarkably reduced. CONCLUSIONS: Gadolinium-based coronary angiography is a potential alternative technique in patients with allergy to iodinated contrast medium or thyrotoxicosis with reduced, but acceptable, image quality for diagnostic purposes. Nevertheless, possible life-threatening side effects and complications have to be considered.     

Does Nebivolol Prevent Contrast‐Induced Nephropathy in Humans?

Background:

An experimental study showed that nebivolol is an effective agent in contrast‐induced nephropathy (CIN) prophylaxis.

Hypothesis:

We hypothesized that prophylactic nebivolol use had protective effects on renal function in human beings subjected to iodinated contrast agent since it has vasodilatory effect and antioxidant properties.

Methods:

The present study enrolled 120 patients scheduled for coronary angiography and ventriculography. All patients were hydrated with intravenous isotonic saline. The patients in group I received 600 mg N‐acetylcysteine every 12 hours for 4 days. The patients in group II received 5 mg nebivolol every 24 hours for 4 days. The patients in group III were only hydrated. The primary endpoint was the occurrence of CIN. The secondary endpoint was the change in serum creatinine (Cr) levels at 2 days and 5 days after the contrast exposure.

Results:

Nine (22.5%) patients in group I developed CIN, as did 8 patients (20.0%) in group II and 11 patients (27.5%) in group III (P = 0.72). Changes in mean Cr level from baseline to day 2 were not statistically significant in all groups. However, we detected a statistically significant increase in mean Cr levels at day 5 compared with baseline levels in group I and group III (from 1.42 ± 0.13 to 1.52 ± 0.26, p2 = 0.02; and from 1.43 ± 0.14 to 1.55 ± 0.30, p2 = 0.01, respectively). Although an increase was detected in mean Cr level from baseline to the 5‐day Cr level in group II, this did not reach statistical significance (from 1.40 ± 0.12 to 1.48 ± 0.23, P = 0.06).

Conclusions:

Pretreatment with nebivolol is protective against nephrotoxic effects of contrast media. © 2012 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Effectiveness of theophylline prophylaxis of renal impairment after coronary angiography in patients with chronic renal insufficiency

Contrast media can lead to renal impairment that results in longer hospitalization and increased mortality. Adenosine is a crucial mediator of contrast-induced nephropathy (CIN; an increase in serum creatinine of >or=0.5 mg/dl within 48 hours). Therefore, it was the purpose of our study to investigate whether the adenosine antagonist theophylline reduces the incidence of CIN after coronary angiography. We also characterized risk factors for CIN after coronary angiography. One hundred patients with serum creatinine concentrations of >or=1.3 mg/dl randomly received 200 mg IV theophylline or placebo 30 minutes before coronary angiography (amount of contrast medium >or=100 ml). Patients who received theophylline and the controls were comparable with regard to baseline creatinine levels (means +/- SD) (1.65 +/- 0.41 vs 1.72 +/- 0.69 mg/dl) and the amount of contrast medium received (235 +/- 89 vs 261 +/- 139 ml). Theophylline significantly reduced the incidence of CIN (4% vs 20%, p = 0.0138). With placebo, creatinine significantly increased at 12 (1.82 +/- 0.79 mg/dl, p = 0.0057), 24 (1.90 +/- 0.86 mg/dl, p = 0.0001), and 48 hours (1.90 +/- 0.89 mg/dl, p = 0.0007) after administration of contrast medium. With pretreatment with theophylline, mean creatinine only increased 24 hours after contrast medium administration (1.70 +/- 0.40 mg/dl, p = 0.029), but was stable 12 hours (1.65 +/- 0.43 mg/dl, p = 0.99) and 48 hours after contrast medium administration (1.65 +/- 0.41 mg/dl, p = 0.99). The following parameters were significantly associated with contrast-induced renal impairment: Cigarroa quotient >5 (contrast medium [milliters] x serum creatinine/body weight [kg]), elevated troponin T, >300 ml of contrast medium, and emergency angiography. In conclusion, theophylline reduces the incidence of CIN in patients with chronic renal insufficiency undergoing coronary angiography. It should be used especially in patients receiving large amounts of contrast medium, and in patients with a Cigarroa quotient of >5 and/or elevated troponin T levels.     

Clinical impact of nephropathy induced by contrast medium in patients with acute myocardial infarction undergoing emergent coronary angiography

OBJECTIVES: The incidence of contrast-induced nephropathy (CIN) after coronary angiography and the prognostic value in patients with acute myocardial infarction remains to be determined. This study investigated the frequency, predictors of CIN, and the prognostic significance of CIN in acute myocardial infarction patients undergoing emergent coronary angiography. METHODS: This study included 132 consecutive acute myocardial infarction patients undergoing emergent coronary angiography within 24 hr after the onset between January 1999 and June 2001. The serum creatinine concentration was measured on admission and at 48 hr after contrast medium exposure. CIN was defined as an increase in serum creatinine from the baseline > or = 0.5 mg/dl or > or = 25% at 48 hr after emergent coronary angiography. The patient characteristics, and in-hospital and long-term mortality were compared between the CIN and non-CIN groups. RESULTS: CIN occurred in 15 patients (11.4%) after emergent coronary angiography. The predictor of CIN development was preexisting renal impairment (serum creatinine concentration > or = 1.2 mg/dl on presentation; 21.9% vs 8.0%, odds ratio 3.22, 95% confidence interval 1.07-9.74, p = 0.04). In-hospital mortality was significantly higher in the CIN group than in the non-CIN group (13.3% vs 1.7%; odds ratio 8.85, 95% confidence interval 1.15-68.2, p = 0.01). The long-term mortality (mean follow-up period of 40 months) was also higher in the CIN group (26.7% vs 8.6%; hazard ratio 3.91, 95% confidence interval 1.21-12.5, p = 0.02). CONCLUSIONS: CIN was an independent predictor of both in-hospital and long-term mortality in acute myocardial infarction patients undergoing emergent coronary angiography. Preexisting renal insufficiency was associated with subsequent CIN.     

Mizoribine intermittent pulse protocol for induction therapy for systemic lupus erythematosus in children: an open-label pilot study with five newly diagnosed patients

The objective of the current work is to report our preliminary experience with the mizoribine (MZR) intermittent pulse protocol for induction therapy for newly diagnosed pediatric-onset systemic lupus erythematosus (SLE). Five consecutive patients who were newly diagnosed as having SLE with biopsy-proven lupus nephritis were recruited for an open-label trial of prednisolone (PDN) and MZR intermittent pulse therapy (10 mg/kg for 2 days of the week for 12 months). Data on the renal response and serologic lupus activity were collected prospectively. The baseline characteristics of the patients were: mean age, 11 years; urinary protein/creatinine ratio (U-prot./cre.), 0.99 ± 0.91; serum complement hemolytic activity (CH50), 10.6 ± 1.3 (normal, 23–46 U/ml); serum anti-dsDNA antibody titer, 258.6 ± 125.5 IU/ml (normal, <12.0 IU/ml); serum creatinine, 0.5 ± 0.1 mg/dl; European Consensus Lupus Activity Measurement index (ECLAM), 7.4 ± 1.1. The primary endpoint was the interval until the development of a flare of SLE. Despite gradual tapering of the PDN dose, significant improvement as compared to the baseline values was observed in all the parameters examined at 3, 6, and 12 months of treatment. After 12 months therapy, complete response was achieved in all of the patients, except for 1 patient who showed poor drug compliance. In two patients who had severe lupus nephritis at the first renal biopsy, marked histologic improvement was confirmed at the second renal biopsy. No serious adverse effects were observed. We believe that the MZR pulse protocol combined with PDN for induction therapy may be the treatment of choice in selected young patients with SLE. Further studies to confirm the long-term efficacy and safety of our current protocol in larger numbers of patients are, however, needed.     

Comparison of the usefulness of gadodiamide and iodine mixture versus iodinated contrast alone for prevention of contrast-induced nephropathy in patients with chronic kidney disease undergoing coronary angiography

Contrast-induced nephropathy (CIN) is a common cause of hospital-acquired renal failure. Gadolinium-based contrast agents have been proposed as alternatives to iodinated contrast in patients at high risk for CIN. The use of high-dose intraarterial gadolinium chelates in the catheterization laboratory has been investigated in only a small number of patients. We compared patients with a creatinine clearance <60 ml/min/1.73 m2 who received intravenous hydration (> or =1,500 ml) and oral n-acetylcysteine prophylaxis with those who received a gadodiamide-iodine mixture (n = 90) or iodinated contrast alone (n = 79) in the cardiac catheterization laboratory. CIN was defined as an increase of 0.5 mg/dl in serum creatine from baseline. The 2 groups were similar with respect to demographics and risk factors. Although less iodinated contrast was used in the gadolinium mixture group, there was no difference in the incidence of CIN between the 2 groups. However, the initiation of dialysis (n = 7) and death (n = 8) only occurred in the diluted gadolinium contrast group. A stepdown multivariate analysis found diabetes mellitus to be the only independent predictor of CIN (p = 0.02, odds ratio 3.35, 95% confidence interval 1.21 to 9.29, c-statistic 0.66). In conclusion, the incidence of CIN was not decreased in high-risk patients receiving a gadolinium-iodinated contrast mixture versus iodinated contrast alone.     

Earlier Eradication of Intra-Anal Warts with Argon Plasma Coagulator Combined with Imiquimod Cream Compared with Argon Plasma Coagulator Alone: A Prospective,Randomized Trial

Purpose Despite the increasing incidence of condylomata acuminate, optimal treatment of anal warts is still undecided. This prospective, randomized study was designed to compare the efficacy of combined argon plasma coagulation and imiquimod cream vs. argon plasma coagulation alone in the management of intra-anal warts. Methods From October 2002 to March 2005, 49 patients with intra-anal warts were randomly assigned to argon plasma coagulation plus imiquimod cream (n = 24) vs. argon plasma coagulation alone (n = 25). Therapeutic sessions were repeated until the elimination of the warts. Efficacy of therapy was defined as the time needed for eradication. All patients were followed up for a mean period of 12 months for signs of recurrence. Results Elimination of warts was achieved earlier in patients receiving combination therapy compared with those receiving monotherapy with argon plasma coagulation (62.5 ± 5.4 days vs. 91.2 ± 6.4 days; P = 0.0016). A subgroup analysis performed in HIV-positive patients showed similar results (combination therapy 95 ± 22.6 days; monotherapy 124.3 ± 20.7 days; P = 0.033); however, in HIV-positive patients warts were eradicated later compared with HIV-negative patients (110.8 ± 25.7 days vs. 65 ± 25.4 days; P < 0.0001). No major complications were observed in our study population. After the follow-up period, recurrence of warts was evident in 22.7 percent of patients in the combination group compared with 34.7 percent of patients in the monotherapy group (P = 0.51). Recurrence was significantly higher in HIV-positive patients compared with HIV-negative patients (P = 0.0039). Conclusions Combination therapy with argon plasma coagulator plus imiquimod cream results in earlier clearance of intra-anal warts in both immunocompetent and immunocompromised patients; however, it does not affect the rate of recurrence. Reprints are not available.     

The significance of platelet activation in rheumatoid arthritis

We evaluated the significance of platelet activation in patients with rheumatoid arthritis (RA). The expression of CD62P and CD63 by platelets was determined using flow cytometry in 18 active RA patients, 10 remission RA and 15 normal controls. Meanwhile, the erythrocyte sedimentation rate (ESR) and C-reactive protein was also determined in all groups. The expression of CD62P in active RA patients (11.88 ± 2.47%) was significantly higher than that in remission RA group (2.85 ± 1.60%; P < 0.01) and control group (2.78 ± 1.04%; P < 0.01). The expression of CD63 in active RA patients (9.90 ± 3.02%) was significantly higher than that in remission RA group (4.11 ± 2.00%; P < 0.01) and control group (4.13 ± 1.85%; P < 0.01). The level of CRP (54.33 ± 23.35 mg/l) and ESR (86.06 ± 33.67 mm/h) in active RA patients was higher than that in remission RA group (2.55 ± 1.01 mg/l, 14.70 ± 4.57 mm/h; P < 0.01 for both) and normal control group (3.21 ± 2.18 mg/l, 12.25 ± 5.05 mm/h; P < 0.01 for both). There was a positive correlation between CD62P and ESR (r = 0.5224, P < 0.01) and also a positive correlation between CD62P and CRP (r = 0.7048, P < 0.01) as well as between CD63 and ESR (r = 0.4476, P < 0.05) but no correlation between CD63 and CRP. Platelet activation may be a sign of RA exacerbation.     

Inflammatory markers in a 2-year follow-up of coronary artery disease

Our study was designed in an attempt to determine the dynamics of changes in serum tumor necrosis factor (TNF)-α, soluble forms of its receptors (sTNFR 1, sTNFR 2), and adhesion molecules (sE-selectin, sP-selectin, sVCAM-1, sICAM-1) over a 2-year follow-up of patients with coronary artery disease (CAD). The study involved 70 patients with stable CAD (stable angina class II/III according to the Canadian Cardiovascular Society) and 20 apparently healthy subjects. Over the follow-up period a marked attenuation of angina (P < 0.001) was observed. Interventional treatment (percutaneous coronary intervention, coronary artery bypass grafting) was used in 53 CAD patients. Laboratory analysis revealed a significant decrease of serum TNF-α and sTNFR1 at 2 years (TNF-α: 12.1 ± 0.7 pg/ml; sTNFR 1: 1306 ± 46 pg/ml) as compared to baseline levels (16.5 ± 0.7 pg/ml, P = 0.030; 1551 ± 82 pg/ml, P = 0.048, respectively). The levels of sP-selectin (159 ± 7 vs 201 ± 14 ng/ml, P < 0.01) and sICAM-1 (133 ± 4 vs 153 ± 6 ng/ml, P < 0.05) were found to be significantly increased as compared to the baseline. Interventional procedures resulted in suppression of both cytokine (TNF-α, sTNFR 2) and adhesion molecule (sE-selectin, sP-selectin) activation in the CAD group. The baseline and post-follow-up TNF-α and sTNFR 1 levels showed persistent elevation in CAD patients as compared to the controls (9.0, 956.3 pg/ml, respectively; P < 0.01). There were no differences between baseline and final cytokines and adhesion molecules in healthy subjects. The course of CAD as modified by a clinically effective therapy is characterized by changes of immune markers activation. Revascularization seems to be an important factor suppressing both cytokine and adhesion molecule activation in CAD patients.     

Deferasirox (Exjade®) significantly improves cardiac T2* in heavily iron-overloaded patients with β-thalassemia major

Noninvasive measurement of tissue iron levels can be assessed using T2* magnetic resonance imaging (MRI) to identify and monitor patients with iron overload. This study monitored cardiac siderosis using T2* MRI in a cohort of 19 heavily iron-overloaded patients with β-thalassemia major receiving iron chelation therapy with deferasirox over an 18-month period. Overall, deferasirox therapy significantly improved mean ± standard deviation cardiac T2* from a baseline of 17.2 ± 10.8 to 21.5 ± 12.8 ms (+25.0%; P = 0.02). A concomitant reduction in median serum ferritin from a baseline of 5,497 to 4,235 ng/mL (−23.0%; P = 0.001), and mean liver iron concentration from 24.2 ± 9.0 to 17.6 ± 12.9 mg Fe/g dry weight (−27.1%; P = 0.01) was also seen. Improvements were seen in patients with various degrees of cardiac siderosis, including those patients with a baseline cardiac T2* of <10 ms, indicative of high cardiac iron burden. These findings therefore support previous observations that deferasirox is effective in the removal of myocardial iron with concomitant reduction in total body iron.     

Insulin resistance and acute coronary syndrome in the young Japanese population have a strong association

There are few data regarding acute coronary syndrome (ACS) in young Japanese patients. We examined the risk factors for ACS in young Japanese patients, especially impaired glucose metabolism. From a database of 789 consecutive patients admitted to our hospital with ACS between 2000 and 2005, we compared risk factors of patients divided into two age categories: ≤45 years (group Y, n = 41) and ≥46 years (group O, n = 748). All patients in group Y were male. Overt diabetes, hypertension, and a family history of ischemic heart disease were not so important to group Y. Higher triglyceride (160.5 ± 86.0 vs 133.9 ± 75.2 mg/dl, P = 0.0296) and lower high-density lipoprotein cholesterol (43.9 ± 12.1 vs 48.7 ± 13.5 mg/dl, P = 0.027) concentrations were present in group Y. We obtained data concerning insulin resistance in 326 of 789 patients. Although the incidence of impaired glucose tolerance was similar between the groups (31% vs 31%, not significant), a higher homeostasis model assessment insulin resistance index (2.26 ± 2.03), indicating insulin resistance, was present in group Y. Insulin resistance might be correlated with the development of ACS in the young adult Japanese population.     

Safety and efficacy of catheter ablation of atrial fibrillation in patients with diabetes mellitus—single center experience

Background and objective Little is known about the outcome of catheter ablation of atrial fibrillation (AF) in patients with diabetes mellitus (DM). We investigated the safety and efficacy of catheter ablation of AF in patients with DM. Materials and methods Thirty one patients with DM from a group of 263 consecutive patients undergoing a first-time catheter ablation of AF procedure were enrolled in a prospective study. The ablation protocol (guided by CARTO system) consisted in two continuous circular lesions around ipsilateral pulmonary veins. Results The following clinical characteristics differed between DM and no-DM patients: age (62.0 ± 10.8 vs. 56.1 ± 10.6 years, P = 0.004), longer AF history (9.6 ± 9.3 vs. 6.7 ± 6.3 years, P = 0.024), significantly larger left atrium size (41.1 ± 7.8 vs. 38.3 ± 5.8 mm, P = 0.021), hypertension (58.1 vs. 35.8%, P = 0.018) and structural heart disease (67.7 vs. 43.5%, P = 0.011). Despite a similar AF recurrence rate in DM and no-DM patients (32.3 vs. 22.4%, P = 0.240), the ablation procedure was complicated in 28 patients (11 hematomas, three cardiac tamponades and three strokes) and the incidence of complications was significantly higher in DM than in no-DM patients (29.0 vs. 8.2%, respectively, P = 0.002). Multivariate analysis showed that DM was an independent risk factor for complications occurrence (odd ratio 5.936, 95% confidence interval 2.059 to 17.112, P = 0.001). Conclusions First catheter ablation of AF procedure in DM patients was equally efficacious than in no-DM patients. However, DM patients had a higher incidence of complications, mostly thrombotic or hemorrhagic.     

Laparoscopic Ileal Pouch-Anal Anastomosis in Patients with Chronic Ulcerative Colitis and Primary Sclerosing Cholangitis: A Case-Matched Study

Purpose This study was designed to compare short-term outcomes after laparoscopic ileal pouch-anal anastomosis with those of open ileal pouch-anal anastomosis in patients with both sclerosing cholangitis and ulcerative colitis. Methods Sixteen patients with sclerosing cholangitis and ulcerative colitis undergoing laparoscopic ileal pouch-anal anastomosis were matched with 16 open ileal pouch control subjects by sex, American Society of Anesthesiologists’ score, age, and body mass index. Results Operative mortality was zero. Operative time was longer in the laparoscopic group (500 ± 125.8 vs. 381.8 ± 60.9 minutes, P = 0.03). Thirty-day complications were not significantly different between groups (laparoscopic 25 percent vs. open 43.7 percent, P = 0.26). Length of stay was significantly shorter in the laparoscopic group (5.3 ± 1.3 days vs. 9.9 ± 3.3 days open, P < 0.001). Average return of gastrointestinal function was 2.5 days in the laparoscopic group and 4.8 days in the open group (P = 0.001). Time to soft diet was three days in the laparoscopic group and six days in the open group (P < 0.001). All patients were alive and all pouches were intact at last follow-up. Conclusions Laparoscopic ileal pouch-anal anastomosis is feasible with apparent safety in patients with primary sclerosing cholangitis, resulting in shorter duration of hospital stay and quicker return of gastrointestinal function compared with the open procedure with no difference in perioperative complications, reoperations, and readmissions.     

Predictors of hemodynamic compromise with propofol during defibrillator implantation: a single center experience

Background  Intra-operative hypotension has been reported in cardiac resynchronization therapy defibrillator (CRT-D) clinical trials but this phenomenon is not well characterized. The purpose of this study was to understand the frequency and determinants of intra-operative hypotension in patients undergoing defibrillator implantations. Methods  We retrospectively reviewed clinical data of all CRT-D implantations over a 21-month period. We compared a randomly selected contemporaneous group undergoing implantable cardiac defibrillator (ICD) implantations as a reference group. Procedure protocol involved intra-arterial blood pressure monitoring throughout the case. Lidocaine (1%) was routinely used along with propofol for sedation in all patients. Procedure time was defined as the time from initial administration of lidocaine for arterial line access, to completion of defibrillator pocket closure. Cumulative dose of propofol was calculated in each patient. Hypotension was defined as a fall in the systolic blood pressure of ≥30% from baseline or a systolic blood pressure of ≤80 mm Hg for >3 min. CRT-D and ICD patients were divided into hypotensive and non-hypotensive subsets. Results  The incidence of hypotension in the CRT-D group (N  = 100) was 56%, as compared to 40% in the ICD group (N = 97). The mean duration of procedure in the CRT-D group was 114 ± 95 min in the hypotensive subset versus 69 ± 31.9 min in the non-hypotensive subset (p = 0.0015). The mean NYHA class in the hypotensive subset of the CRT-D group was 2.85 ± 1.2 vs 2.2 ± 1.5 in the non-hypotensive subset (p = 0.0179). Cumulative dose of propofol in the hypotensive subset of the CRT-D group was 386 ± 22 mg, while that in the non hypotensive subset was 238.3 ± 17 mg (p < 0.0001). Creatinine clearance in the hypotensive subset of the CRT-D group was 63.8 ± 12.8 ml/min, while that in the non-hypotensive subset was 78.7 ± 23.5 ml/min (p = 0.003). Patients in the CRT-D group who developed hypotension had a lower left ventricular ejection fraction of 21.1 ± 10.2% versus 29 ± 14.8% in the non-hypotensive subset (p = 0.0035). Conclusions  Hypotension is a common occurrence during defibrillator implantation under conscious sedation. Risk factors for significant hypotension include: higher NYHA class, lower left ventricular ejection fraction, lower creatinine clearance, higher doses of propofol and longer procedure times.     

The significance of platelet activation in ankylosing spondylitis

The objective of this study was to explore the significance of platelet activation in patients with ankylosing spondylitis (AS). Thirty-five AS patients and 15 normal controls were selected from November 2005 to October 2006. The number of CD62P- and CD63-positive cells were detected by flow cytometry. At the same time, the erythrocyte sedimentation rate (ESR), platelet count (PLT) and C-reactive protein (CRP) were determined in both groups. The percentage of CD62P-positive cell in AS patients (13.60 ± 7.64%) was significantly higher than that in control group (2.78 ± 1.04%; P < 0.01). The percentage of CD63-positive cell in AS patients (6.92 ± 4.16%) was significantly higher than that in control group (4.13 ± 1.85%; P < 0.05). The levels of CRP (20.18 ± 23.17 mg/l), PLT (259.54 ± 102.59 × 10⁹/l) and ESR (36.86 ± 31.23 mm/h) in AS patients were higher than those in normal controls, respectively (3.21 ± 2.18 mg/l, P < 0.01; 197.00 ± 55.70 × 10⁹/l, P < 0.01; 12.25 ± 5.05 mm/h, P < 0.05). Platelet activation may be a sign of AS exacerbation.