Seizure-Like Activities during Head-Up Tilt Test-Induced Syncope

Purpose

Some patients with neurally mediated reflex syncope may be misdiagnosed as epilepsy because myoclonic jerky movements are observed during syncope. The seizure-like activities during the head-up tilt test (HUT) have been rarely reported. The purpose of this study was to assess the characteristics of these seizure-like activities and evaluate whether there are differences in the clinical characteristics and hemodynamic parameters of patients with neurally mediated reflex syncope with and without seizure-like activities during HUT-induced syncope.

Materials and Methods

The medical records of 1,383 consecutive patients with a positive HUT were retrospectively reviewed, and 226 patients were included in this study.

Results

Of 226 patients, 13 (5.75%) showed seizure-like activities, with 5 of these (2.21%) having multifocal myoclonic jerky movements, 5 (2.21%) having focal seizure-like activity involving one extremity, and 3 (1.33%) having upward deviation of eye ball. Comparison of patients with and without seizure-like activities revealed no significant differences in terms of clinical variables and hemodynamic parameters during HUT.

Conclusion

Seizure-like activities occurred occasionally during HUT-induced syncope in patients with neurally mediated reflex syncope. The seizure-like activities during HUT might not be related to the severity of the syncopal episodes or hemodynamic changes during HUT.     

Diagnostic patterns in the evaluation of patients presenting with syncope at the emergency or outpatient department

Purpose

Patterns of syncope evaluation vary widely among physicians and hospitals. The aim of this study was to assess current diagnostic patterns and medical costs in the evaluation of patients presenting with syncope at the emergency department (ED) or the outpatient department (OPD) of a referral hospital.

Materials and Methods

This study included 171 consecutive patients with syncope, who visited the ED or OPD between January 2009 and July 2009.

Results

The ED group had fewer episodes of syncope [2 (1-2) vs. 2 (1-5), p=0.014] and fewer prodromal symptoms (81.5% vs. 93.3%, p=0.018) than the OPD group. Diagnostic tests were more frequently performed in the ED group than in the OPD group (6.2±1.7 vs. 5.3±2.0; p=0.012). In addition, tests with low diagnostic yields were more frequently used in the ED group than in the OPD group. The total cost of syncope evaluation per patient was higher in the ED group than in the OPD group [823000 (440000-1408000) won vs. 420000 (186000-766000) won, p<0.001].

Conclusion

There were some differences in the clinical characteristics of patients and diagnostic patterns in the evaluation of syncope between the ED and the OPD groups. Therefore, a selective diagnostic approach according to the presentation site is needed to improve diagnostic yields and to reduce the time and costs of evaluation of syncope.     

A close association of body cell mass loss with disease activity and disability in Chinese patients with rheumatoid arthritis

OBJECTIVES:

To investigate the association of body cell mass loss with disease activity and disability in rheumatoid arthritis patients.

INTRODUCTION:

Rheumatoid cachexia, defined as the loss of body cell mass, is important but under-recognized and contributes to morbidity and mortality in patients with rheumatoid arthritis.

METHODS:

One hundred forty-nine rheumatoid arthritis patients and 53 healthy, non-rheumatoid arthritis control subjects underwent anthropometric measurements of body mass index and waist and hip circumferences. Bioelectrical impedance analysis was used to determine the subjects'' body compositions, including fat mass, skeletal lean mass, and body cell mass. The disease activity of rheumatoid arthritis was assessed using C-reactive protein serum, the erythrocyte sedimentation rate and the 28-joint disease activity score, while disability was evaluated using a health assessment questionnaire.

RESULTS:

Rheumatoid arthritis patients had lower waist-to-hip ratio (0.86±0.07 vs. 0.95±0.06; p<0.001) and lower skeletal lean mass indexes (14.44±1.52 vs. 15.18±1.35; p = 0.002) than those in the healthy control group. Compared with rheumatoid arthritis patients with higher body cell masses, those with body cell masses lower than median had higher erythrocyte sedimentation rates (40.10±27.33 vs. 25.09±14.85; p<0.001), higher disease activity scores (5.36±3.79 vs. 4.23±1.21; p = 0.022) and greater disability as measured by health assessment questionnaire scores (1.26±0.79 vs. 0.87±0.79; p = 0.004).

CONCLUSIONS:

The loss of body cell mass is associated with higher disease activity and greater disability in rheumatoid arthritis patients. Body composition determined by bioelectrical impedance analysis can provide valuable information for a rheumatologist to more rapidly recognize rheumatoid cachexia in rheumatoid arthritis patients.     

Removal of kidney stones by extracorporeal shock wave lithotripsy is associated with delayed progression of chronic kidney disease

Purpose

This study aimed to elucidate whether stone removal by extracorporeal shock wave lithotripsy (ESWL) is associated with delayed chronic kidney disease (CKD) progression.

Materials and Methods

We conducted a retrospective analysis of 131 nephrolithiasis patients with stage 3 and 4 CKD. We collected baseline clinical and laboratory data, kidney stone characteristics, and history of receiving ESWL. We classified study patients into two groups according to whether they underwent ESWL or not (Non-ESWL group vs. ESWL group). We initially compared annual estimated glomerular filtration rate (eGFR) changes of Non-ESWL group with those of ESWL group before undergoing ESWL. In the next step, we sought to compare annual eGFR changes in the same patients before and after ESWL. Finally, we compared annual eGFR changes between success and failure groups among patients undergoing ESWL.

Results

The mean age of the patients was 62 years and 72.5% were male. The mean observation period was 3.2 years. Non-ESWL group and ESWL group before undergoing ESWL showed similar annual eGFR changes (-1.75±6.5 vs. -1.63±7.2 mL/min/1.73 m²/year, p=0.425). However, eGFR declined slower after undergoing ESWL than before ESWL (annual eGFR changes, -0.29±6.1 vs. -1.63±7.2 mL/min/1.73 m²/year, p<0.05). In addition, among patients in ESWL group, eGFR declined faster in the failure group than in the success group (annual eGFR change, -1.01±4.7 vs. -0.05±5.2 mL/min/1.73 m²/year, p<0.05).

Conclusion

Our results suggest that stone removal by ESWL is associated with delayed deterioration of renal function in CKD patients with nephrolithiasis.     

Taiwanese female vegetarians have lower lipoprotein-associated phospholipase A2 compared with omnivores

Purpose

Many studies supported that vegetarians have a lower risk of cardiac diseases and mortality, partly due to better blood pressure and serum cholesterol profiles. However, the inflammatory markers, especially lipoprotein-associated phospholipase A2 (Lp-PLA2), have not been well-studied. This study aimed to compare inflammatory markers and conventional risk factors between vegetarians and omnivores.

Materials and Methods

One hundred and seventy-three vegetarians and 190 omnivores were studied. Fasting blood samples were obtained to compare levels of glucose, total cholesterol, triacylglycerol, high density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol, homocysteine, Lp-PLA2 activity, and high-sensitivity C-reactive protein (hs-CRP).

Results

Vegetarians had higher serum levels of the following markers: hs-CRP (1.8 ± 3.4 vs. 1.2 1.8 mg/L, respectively; p = 0.05), homocysteine (9.39 ± 3.22 vs. 7.62 ± 2.41 µmol/L, respectively; p < 0.01), and triacylglycerol (96.91 ± 59.56 vs. 84.66 ± 43.24 mg/dL, respectively; p < 0.05). Vegetarians also had lower levels of Lp-PLA2 (18.32 ± 7.19 10-3 µmol/min/mL vs. 20.22 8.13 10-3 µmol/min/mL; p < 0.05), total cholesterol (180.62 ± 36.55 mg/dL vs. 192.73 ± 36.57 mg/dL; p < 0.01), LDL cholesterol (118.15 ± 32.8 vs. 126.41 ± 34.28 mg/dL; p < 0.05), and HDL cholesterol (55.59 ± 13.30 vs. 62.09 ± 14.52 mg/dL, p < 0.01). Multivariate analyses demonstrated that a vegetarian diet increases the chances for high serum hs-CRP and low Lp-PLA2 activity.

Conclusion

In addition to lower total cholesterol, LDL-cholesterol, and HDL-cholesterol, Taiwanese female vegetarians have lower serum Lp-PLA2 activity but higher levels of hs-CRP, homocysteine, and triacylglyerol. It might be due to geographic differences of vegetarian diets, and further studies are needed.     

Comparison of optical coherence tomographic assessment between first- and second-generation drug-eluting stents

Purpose

There is a lack of sufficient data in comparison of optical coherence tomographic (OCT) findings between first- and second-generation drug-eluting stents (DES). Compared to first-generation (i.e., sirolimus- or paclitaxel-eluting stents), second-generation DESs (i.e., everolimus- or biolinx-based zotarolimus-eluting stents) might have more favorable neointimal coverage.

Materials and Methods

Follow-up OCT findings of 103 patients (119 lesions) treated with second-generation DESs were compared with those of 139 patients (149 lesions) treated with first-generation DESs. The percentage of uncovered or malapposed struts, calculated as the ratio of uncovered or malapposed struts to total struts in all OCT cross-sections, respectively, was compared between the two groups.

Results

Both DES groups showed similar suppression of neointimal hyperplasia (NIH) on OCT (mean NIH cross-sectional area; second- vs. first-generation=1.1±0.5 versus 1.2±1.0 mm², respectively, p=0.547). However, the percentage of uncovered struts of second-generation DESs was significantly smaller than that of first-generation DESs (3.8±4.8% vs.7.5±11.1%, respectively, p<0.001). The percentage of malapposed struts was also significantly smaller in second-generation DESs than in first-generation DESs (0.4±1.6% vs.1.4±3.7%, respectively, p=0.005). In addition, intra-stent thrombi were less frequently detected in second-generations DESs than in first-generation DESs (8% vs. 20%, respectively, p=0.004).

Conclusion

This follow-up OCT study showed that second-generation DESs characteristically had greater neointimal coverage than first-generation DESs.     

Incidence of Venous Air Embolism during Myomectomy: The Effect of Patient Position

Purpose

Venous air embolism (VAE) is characterized by the entrainment of air or exogenous gases from broken venous vasculature into the central venous system. No study exists regarding the effect of patient positioning on the incidence of VAE during abdominal myomectomy. The purpose of this study was to assess the incidence and grade of VAE during abdominal myomectomy in the supine position in comparison to those in the head-up tilt position using transesophageal echocardiography.

Materials and Methods

In this study, 84 female patients of American Society of Anesthesiologist physical status I or II who were scheduled for myomectomy under general anesthesia were included. Patients were randomly divided into two groups: supine group and head-up tilt group. Transesophageal echocardiography images were videotaped throughout the surgery. The tapes were then reviewed for VAE grading.

Results

In the supine group, 10% of the patients showed no VAE. Moreover, 10% of the patients were classified as grade I VAE, while 50% were categorized as grade II, 22.5% as grade III, and 7.5% as grade IV. In the head-up tilt group, no VAE was detected in 43.2% of the patients. In addition, 18.2% of the patients were classified as grade I VAE, 31.8% as grade II, and 6.8% as grade III; no patients showed grade IV. VAE grade in the head-up tilt group was significantly lower than that in the supine group (p<0.001).

Conclusion

The incidence and grade of VAE in the head-up tilt group were significantly lower than those in the supine group during abdominal myomectomy.     

Effect of charcoal filter on the emergence from sevoflurane anesthesia in a semi-closed rebreathing circuit

Purpose

A charcoal filter attached within the anesthetic circuit has been shown to efficiently adsorb halothane or isoflurane, thus hastening anesthetic recovery in low or minimal flow system. This study was intended to demonstrate whether the charcoal filter enhances the recovery time from sevoflurane anesthesia using a semi-closed circuit system.

Materials and Methods

Thirty healthy patients scheduled for elective surgery under sevoflurane anesthesia were randomly assigned to the charcoal filter or control group. Upon completion of surgery, the end-tidal concentration of sevoflurane was maintained at 2.0 vol%. A charcoal filter was attached to the expiratory limb of the breathing circuit of charcoal filter group subjects. After sevoflurane was discontinued, ventilation was controlled with the same minute volume as the intra-operative period at a fresh gas flow rate of 5 L·min^-1 with 100% O₂. The elimination kinetics of sevoflurane from end-tidal concentration, Bispectral index and times of eye opening and extubation were obtained.

Results

The exponential time constant (τ) of alveolar sevoflurane concentration in the charcoal filter group was significantly shorter than that in the control group (1.7±0.5 vs. 2.5±1.1 min, p=0.008). The charcoal filter hastened rapid eye opening (11.1±3.8 vs. 14.8±3.0 min, p=0.007) and extubation (11.9±3.9 vs. 15.3±3.2 min, p=0.014), compared to the control group.

Conclusion

A charcoal filter enhances the recovery from sevoflurane anesthesia with a semi-closed rebreathing circuit.     

Clinical and echocardiographic findings of newly diagnosed acute decompensated heart failure in elderly patients

Purpose

Elderly patients (pts) (EPs; ≥ 65 years old) with newly diagnosed-acute decompensated heart failure (ND-ADHF) have not yet been studied. The aim of the present study was to investigate clinical characteristics, including echocardiographic findings and prognosis, for EPs with ND-ADHF and to compare those with non-elderly pts (NEPs).

Materials and Methods

We retrospectively investigated 256 pts (144 males, 63.0 ± 14.8 years old) who were admitted to our hospital between January 2005 and March 2009 with ND-ADHF. Clinical characteristics and echocardiographic parameters were analyzed in EPs (n = 135, 58 males) and NEPs (n = 121, 86 males).

Results

In intergroup comparison, female gender, diabetes mellitus, previous stroke and hypertension were more common in EPs. Body mass index (22.3 ± 4.5 vs. 24.0 ± 4.4 kg/m²), estimated glomerular filtration rate (54.8 ± 24.3 vs. 69.2 ± 30.7 mL/min/m²), C-reactive protein (28.5 ± 46.9 vs. 7.6 ± 11.6 mg/dL), hemoglobin (12.3 ± 2.1 vs. 13.6 ± 2.3 g/dL) and N-terminal pro-brain natriuretic peptide level (10,538.2 ± 10,942.3 vs. 6,771.0 ± 8,964.7 pg/mL) were significantly different (p < 0.05 for all). Early mitral inflow velocity to early diastolic mitral annular velocity (E/E'') was significantly higher in EPs than in NEPs (21.2 ± 9.4 vs. 18.0 ± 8.9, p < 0.05). During follow-up (44.7 ± 14.5 months), there were no significant differences in in-hospital mortality, re-hospitalization and cardiovascular mortality between EPs and NEPs (p = NS for all).

Conclusion

EPs with ND-ADHF have different clinical characteristics and higher LV filling pressure when compared with NEPs. However, the clinical outcomes for NEPs with ND-ADHF are not necessarily more favorable than those for EPs.     

Eccentric Strength and Endurance in Patients with Unilateral Intermittent Claudication

OBJECTIVE:

To analyze concentric and eccentric strength and endurance in patients with unilateral intermittent claudication.

INTRODUCTION:

Basic motor tasks are composed of concentric, isometric, and eccentric actions, which are related and contribute to physical performance. In previous studies of patients with intermittent claudication, the disease-related reduction in concentric and isometric muscular strength and endurance resulted in poorer walking performance. To date, no study has evaluated eccentric muscle action in patients with intermittent claudication.

METHODS:

Eleven patients with unilateral intermittent claudication performed isokinetic concentric and eccentric actions at the ankle joints to assess peak torque and total work in both symptomatic and asymptomatic legs.

RESULTS:

Concentric peak torque and total work were lower in the symptomatic than in the asymptomatic leg (80 ± 32 vs. 95 ± 41 N/m, P = 0.01; 1479 ± 667 vs. 1709 ± 879 J, P = 0.03, respectively). There were no differences in eccentric peak torque and total work between symptomatic and asymptomatic legs (96 ± 30 vs. 108 ± 48 N/m; 1852 ± 879 vs. 1891 ± 755 J, respectively).

CONCLUSION:

Strength and endurance in the symptomatic leg were lower during concentric compared to eccentric action. Future studies are recommended to investigate the mechanisms underlying these responses and to analyze the effects of interventions to improve concentric strength and endurance on functional limitations in patients with intermittent claudication.     

Arg389Gly β1-adrenergic receptor polymorphism and susceptibility to syncope during tilt test

Introduction

Numerous hormones, neurotransmitters, and other stimuli exert their biological effect on cellular functioning through heptahelical receptors coupled to G proteins (GPCR – G protein-coupled receptors). Adrenergic receptors that belong to this superfamily of receptors are components of the sympathetic nervous system. They play a pivotal role in blood pressure regulation and myocardial contractility. Alterations of the adrenergic receptor pathway have been suggested to be involved in the pathophysiology of vasovagal syncope (VVS). The aim of the present study was to evaluate the distribution of Arg389Gly polymorphism within the ADRB1 gene among patients with recurrent syncope.

Material and methods

Arg389Gly single nucleotide polymorphism was analyzed in 205 patients with recurrent syncope. Ninety-five patients (46%) had a positive head-up tilt test (HUT) result. The control group comprised 143 non-fainting subjects. Genotyping was performed by restriction fragment length polymorphism (RFLP) with BstNI enzyme.

Results

Both analyzed groups had similar distribution of the 389Gly allele. Sixty percent of polymorphic 389Gly carriers belong to the group of syncopal patients, while 40% belong to the control group of healthy subjects.

Conclusions

An association between syncopal incidence and Arg389Gly polymorphism within the ADRB1 gene was not found. The analyzed polymorphism affecting sympathetic activity does not influence vasovagal syncope in Polish patients.     

Early hemodynamic response to the tilt test in patients with syncope

Introduction

Our aim was to evaluate the differences in the early hemodynamic response to the tilt test (HUTT) in patients with and without syncope using impedance cardiography (ICG).

Material and methods

One hundred twenty-six patients (72 female/48 male; 37 ±17 years) were divided into a group with syncope (HUTT(+), n = 45 patients) and a group without syncope (HUTT(–), n = 81 patients). ECG and ICG signals were continuously recorded during the whole examination, allowing the calculation of heart rate (HR), stroke volume (SV), and cardiac output (CO) for every beat. The hemodynamic parameters (averaged over 1 min) were analyzed at the following points of the HUTT: the last minute of resting, the period immediately after the tilt (0 min), 1 min and 5 min after the maneuver. The absolute changes of HR, SV and CO were calculated for 0, 1, and 5 min after the maneuver in relation to the values at rest (ΔHR, ΔSV, ΔCO). Also, the percentage changes were calculated (HRi, SVi, COi).

Results

There were no differences between the groups in absolute and percentage changes of hemodynamic parameters immediately after and 1 min after tilting. Significant differences between the HUTT(+) and HUTT(–) groups were observed in the 5^th min of tilting: for ΔSV (–27.2 ±21.2 ml vs. –9.7 ±27.2 ml; p = 0.03), ΔCO (–1.78 ±1.62 l/min vs. –0.34 ±2.48 l/min; p = 0.032), COi (–30 ±28% vs. –0.2 ±58%; p = 0.034).

Conclusions

In the 5^th min the decrease of hemodynamic parameters (ΔSV, ΔCO, COi) was significantly more pronounced in HUTT(+) patients in comparison to the HUTT(–) group.     

Association of lipoprotein-associated phospholipase A₂ with characteristics of vulnerable coronary atherosclerotic plaques

Purpose

Lipoprotein-associated phospholipase A₂ (Lp-PLA₂) is an inflammatory enzyme expressed in atherosclerotic plaques. We investigated the association of circulating Lp-PLA₂ with characteristics of vulnerable coronary atherosclerotic plaques.

Materials and Methods

We recruited 113 patients with either unstable angina (UA, n=59) and stable angina (SA, n=54) by coronary angiography. Thirty-six healthy subjects served as controls. Intravascular ultrasound (IVUS) was used to evaluate the characteristics of coronary atherosclerotic plaque, and serum Lp-PLA2 concentration was measured as well.

Results

Lp-PLA₂ concentration was significantly higher in both UA and SA patients [(396±36) µg/L and (321±39) µg/L, respectively] compared with the controls [(127±49) µg/L, p<0.01], and higher in UA than SA group. IVUS findings showed that remodeling index (RI) (0.91±0.15 vs. 0.85±0.11, p=0.005) and eccentricity index (EI) (0.73±0.16 vs. 0.65±0.22, p=0.039) were larger in UA than in SA group, and fibrous caps were thicker in SA than UA group [(0.91±0.23) mm vs. (0.63±0.21) mm, p=0.032]. Moreover, Lp-PLA₂ correlated positively with EI (r=0.439, p<0.01) and RI (r=0.592, p<0.05) in UA group. There was an inverse relationship between Lp-PLA₂ and fibrous cap thickness in both UA (r=-0.587, p<0.001) and SA (r=-0.318, p<0.05) groups. The independent risk factors in UA group were Lp-PLA₂ (OR=1.055, 95% CI: 1.03-1.08, p=0.013), LDL-cholesterol (OR=0.032, 95% CI: 0.00-0.05, p=0.041) and fibrous cap thickness (OR=0.008, 95% CI: 0.00-0.45, p=0.019). Lp-PLA₂ was strongly associated with both EI and fibrous cap thickness in both groups.

Conclusion

Serum level of Lp-PLA₂ is associated with both eccentricity index and fibrous cap thickness in both UA and SA groups. Elevated levels of circulating Lp-PLA₂ might to be a strong risk factor and more serious for unstable angina than stable angina.     

Adjunctive Cilostazol versus High Maintenance Dose of Clopidogrel in Patients with Hyporesponsiveness to Chronic Clopidogrel Therapy

Purpose

Whether addition of cilostazol is superior to increasing dose of clopidogrel in patients with hyporesponsiveness to chronic clopidogrel therapy is unknown.

Materials and Methods

We studied 73 patients with hyporesponsiveness to clopidogrel on standard dual antiplatelet therapy for more than 2 weeks. Clopidogrel hyporesponsiveness was defined as percent inhibition of P2Y12 reaction units (PRU) <30% on VerifyNow P2Y12 assay. Patients were randomly assigned to increased dose of clopidogrel (aspirin 100 mg+clopidogrel 150 mg daily: group A, n=38) or to receiving additional cilostazol (aspirin 100 mg+clopidogrel 75 mg+cilostazol 100 mg bid daily: group B, n=35).

Results

Baseline percent inhibition of PRU and PRU was similar between 2 groups (13.0±10.2% versus 11.8±9.7%, p=0.61, and 286.3±54.7 versus 295.7±53.7, p=0.44, respectively). At follow-up, percent inhibition of PRU was higher and PRU was lower significantly in group B than in group A (38.5±17.9% versus 28.3±16.6%, p=0.02, and 207.3±68.2 versus 241.3±76.7, p=0.050, respectively). Among those still showing hyporesponsiveness to clopidogrel at follow-up (21 patients in group A, 10 patients in group B), 12 patients completed further crossover study. Compared to the baseline, magnitude of change in percent inhibition of PRU and PRU showed an improved tendency after the crossover (from 2.7±8.7% to 15.8±18.4%, p=0.08, and from -18.6±58.0 to -61.9±84.3, p=0.08).

Conclusion

Adjunctive cilostazol improved clopidogrel responsiveness better than the higher maintenance dose of clopidogrel in hyporesponsive patients with chronic clopidogrel therapy.     

Diffusion Tensor Imaging of Heterotopia: Changes of Fractional Anisotropy during Radial Migration of Neurons

Purpose

Diffusion tensor imaging provides better understanding of pathophysiology of congenital anomalies, involving central nervous system. This study was aimed to specify the pathogenetic mechanism of heterotopia, proved by diffusion tensor imaging, and establish new findings of heterotopia on fractional anisotropy maps.

Materials and Methods

Diffusion-weighted imaging data from 11 patients (M : F = 7 : 4, aged from 1 to 22 years, mean = 12.3 years) who visited the epilepsy clinic and received a routine seizure protocol MRI exam were retrospectively analyzed. Fractional anisotropy (FA) maps were generated from diffusion tensor imaging of 11 patients with heterotopia. Regions of interests (ROI) were placed in cerebral cortex, heterotopic gray matter and deep gray matter, including putamen. ANOVA analysis was performed for comparison of different gray matter tissues.

Results

Heterotopic gray matter showed signal intensities similar to normal gray matter on T1 and T2 weighted MRI. The measured FA of heterotopic gray matter was higher than that of cortical gray matter (0.236 ± 0.011 vs. 0.169 ± 0.015, p < 0.01, one way ANOVA), and slightly lower than that of deep gray matter (0.236 ± 0.011 vs. 0.259 ± 0.016, p < 0.01).

Conclusion

Increased FA of heterotopic gray matter suggests arrested neuron during radial migration and provides better understanding of neurodevelopment.     

Clinical Implications and Risk Factors of Acute Pancreatitis after Cardiac Valve Surgery

Purpose

Acute pancreatitis is one of the potentially lethal complications that occurs after cardiac surgery. We tried to identify risk factors for and the prognosis of acute pancreatitis after cardiac valve surgery with cardiopulmonary bypass.

Materials and Methods

We retrospectively analyzed a database of consecutive patients who underwent cardiac valve surgery with cardiopulmonary bypass between January 2005 and April 2010 at our institution. Patients were classified as having acute pancreatitis based on serum lipase concentration and clinical symptoms (lipase ≥180 U/L or ≥60 U/L with relevant symptoms).

Results

Of the 986 patients who underwent cardiac valve surgery with cardiopulmonary bypass, 58 (5.9%) patients developed post-operative pancreatitis. Post-operative hospital stay was significantly longer (29.7±45.6 days vs. 12.4±10.7 days, p=0.005) and in-hospital mortality rate was higher (15.5% vs. 2.0%, p<0.001) in patients with post-operative pancreatitis than those without. Hypertension, chronic kidney disease, and peri-operative use of norepinephrine were identified as independent risk factors for developing pancreatitis after cardiac valve surgery.

Conclusion

We found that acute pancreatitis after cardiac valve surgery requires longer hospitalization and increases the in-hospital mortality rate. Clinicians should be aware that patients could develop pancreatitis after cardiac valve surgery, especially in patients with hypertension and chronic kidney disease treated with norepinephrine.     

The Influence of the Severity of Chronic Virus-Related Liver Disease on Propofol Requirements during Propofol-Remifentanil Anesthesia

Purpose

The purpose of this study was to investigate the influence of chronic virus-related liver disease severity on propofol requirements.

Materials and Methods

In this study, 48 male patients with chronic hepatitis B infection were divided into three groups according to Child-Turcotte-Pugh classification of liver function (groups A, B, and C with mild, moderate and severe liver disease, respectively). After intubation, propofol concentration was adjusted by ±0.3 µg/mL increments to maintain bispectral index in the range of 40-60. Target propofol concentrations at anesthesia initiation, pre-intubation and pre-incision were recorded.

Results

The initial concentration used in group C was significantly lower than that used in group A or B (p<0.05), whereas no difference was observed between groups A and B. At pre-intubation, the actual required concentration of propofol increased significantly (3.2 µg/mL) in group A (p<0.05), which lead to significant differences between the groups (p<0.05). At pre-incision, the requirements for propofol decreased significantly in both groups A and B (3.0 µg/mL and 2.7 µg/mL, respectively) compared with those at pre-intubation (p<0.05), and were significantly different for all three groups (p<0.05), with group C demonstrating the lowest requirement (2.2 µg/mL). The required concentrations of propofol at pre-incision were similar to those at induction.

Conclusion

In this study, propofol requirements administered by target-controlled infusion to maintain similar depths of hypnosis were shown to depend on the severity of chronic virus-related liver dysfunction. In other words, patients with the most severe liver dysfunction required the least amount of propofol.     

Remote preconditioning,perconditioning, and postconditioning: a comparative study of their cardioprotective properties in rat models

OBJECTIVE:

Ischemia reperfusion injury is partly responsible for the high mortality associated with induced myocardial injury and the reduction in the full benefit of myocardial reperfusion. Remote ischemic preconditioning, perconditioning, and postconditioning have all been shown to be cardioprotective. However, it is still unknown which one is the most beneficial. To examine this issue, we used adult male Wistar rat ischemia reperfusion models to compare the cardioprotective effect of these three approaches applied on double-sided hind limbs.

METHODS:

The rats were randomly distributed to the following five groups: sham, ischemia reperfusion, remote preconditioning, remote perconditioning, and remote post-conditioning. The ischemia/reperfusion model was established by sternotomy followed by a 30-min ligation of the left coronary artery and a subsequent 3-h reperfusion. Remote conditioning was induced with three 5-min ischemia/5-min reperfusion cycles of the double-sided hind limbs using a tourniquet.

RESULTS:

A lower early reperfusion arrhythmia score (1.50±0.97) was found in the rats treated with remote perconditioning compared to those in the ischemia reperfusion group (2.33±0.71). Meanwhile, reduced infarct size was also observed (15.27±5.19% in remote perconditioning, 14.53±3.45% in remote preconditioning, and 19.84±5.85% in remote post-conditioning vs. 34.47±7.13% in ischemia reperfusion, p<0.05), as well as higher expression levels of the apoptosis-relevant protein Bcl-2/Bax following global (ischemia/reperfusion) injury in in vivo rat heart models (1.255±0.053 in remote perconditioning, 1.463±0.290 in remote preconditioning, and 1.461±0.541 in remote post-conditioning vs. 1.003±0.159 in ischemia reperfusion, p<0.05).

CONCLUSION:

Three remote conditioning strategies implemented with episodes of double-sided hind limb ischemia/reperfusion have similar therapeutic potential for cardiac ischemia/reperfusion injury, and remote perconditioning has a greater ability to prevent reperfusion arrhythmia.     

Long-Term Clinical Outcomes according to Initial Management and Thrombolysis In Myocardial Infarction Risk Score in Patients with Acute Non-ST-Segment Elevation Myocardial Infarction

Purpose

There is still debate about the timing of revascularization in patients with acute non-ST-segment elevation myocardial infarction (NSTEMI). We analyzed the long-term clinical outcomes of the timing of revascularization in patients with acute NSTEMI obtained from the Korea Acute Myocardial Infarction Registry (KAMIR).

Materials and Methods

2,845 patients with acute NSTEMI (65.6 ± 12.5 years, 1,836 males) who were enrolled in KAMIR were included in the present study. The therapeutic strategy of NSTEMI was categorized into early invasive (within 48 hours, 65.8 ± 12.6 years, 856 males) and late invasive treatment (65.3 ± 12.1 years, 979 males). The initial- and long-term clinical outcomes were compared between two groups according to the level of Thrombolysis In Myocardial Infarction (TIMI) risk score.

Results

There were significant differences in-hospital mortality and the incidence of major adverse cardiac events during one-year clinical follow-up between two groups (2.1% vs. 4.8%, p < 0.001, 10.0% vs. 13.5%, p = 0.004, respectively). According to the TIMI risk score, there was no significant difference of long-term clinical outcomes in patients with low to moderate TIMI risk score, but significant difference in patients with high TIMI risk score (≥ 5 points).

Conclusions

The old age, high Killip class, low ejection fraction, high TIMI risk score, and late invasive treatment strategy are the independent predictors for the long-term clinical outcomes in patients with NSTEMI.     

Plasma adiponectin concentration and its association with metabolic syndrome in patients with heart failure

Purpose

Plasma adiponectin concentrations are inversely related with metabolic syndrome (MetS), and MetS is associated with increased risk for heart failure (HF). However, the relationship between adiponectin and MetS in HF remains undetermined. Therefore, we tested whether MetS was associated with the degree of plasma adiponectin concentrations in HF patients.

Materials and Methods

One hundred twenty eight ambulatory HF patients with left ventricular ejection fraction of <50% (80 males, 61.8±11.9 years old) were enrolled for this cross-sectional study. Echocardiographic measurements were performed, and plasma concentrations of adiponectin, lipoproteins, apolipoproteins (apoB, apoA1) and high sensitive C-reactive protein (hsCRP) were measured.

Results

Adiponectin concentrations in HF patients with MetS (n=43) were significantly lower than those without MetS (n=85) (9.7±7.0 vs. 15.8±10.9 µg/mL, p=0.001). Higher concentrations of apoB (p=0.017), apoB/A1 ratio (p<0.001), blood urea nitrogen (p=0.034), creatinine (p=0.003), and fasting insulin (p=0.004) were observed in HF patients with MetS compared with those without MetS. In HF patients with MetS, adiponectin concentrations were negatively correlated with hsCRP (r=-0.388, p=0.015) and positively correlated with the ratio of early mitral inflow velocity to early diastolic mitral annular velocity, E/E'' (r=0.399, p=0.015). There was a significant trend towards decreased adiponectin concentrations with an increasing number of components of MetS (p for trend=0.012).

Conclusion

Our study demonstrated that adiponectin concentrations decreased in HF patients with MetS, and that relationship between adiponectin, inflammation and abnormal diastolic function, possibly leading to the progression of HF.