Two-dimensional speckle tracking echocardiography demonstrates no effect of active acromegaly on left ventricular strain

Background

Speckle tracking echocardiography (STE) allows for the study of myocardial strain (ε), a marker of early and subclinical ventricular systolic dysfunction. Cardiac disease may be present in patients with acromegaly; however, STE has never been used to evaluate these patients.

Objective

To evaluate left ventricular (LV) global longitudinal strain in patients with active acromegaly with normal LV systolic function.

Design

Cross-sectional clinical study.

Methods

Patients with active acromegaly with no detectable heart disease and a control group were matched for age, gender, arterial hypertension and diabetes mellitus underwent STE. Global LV longitudinal ε (GLS), left ventricular mass index (LVMi), left ventricular ejection fraction (LVEF) and relative wall thickness (RWT) were obtained via two-dimensional (2D) echocardiography using STE.

Results

Thirty-seven patients with active acromegaly (mean age 45.6?±?13.8; 48.6% were males) and 48 controls were included. The mean GLS was not significantly different between the acromegaly group and the control group (in %, ?20.1?±?3.1 vs. ?19.4?±?2.2, p?=?0.256). Mean LVMi was increased in the acromegaly group (in g/m², 101.6?±?27.1 vs. 73.2?±?18.6, p?<?0.01). There was a negative correlation between LVMi and GLS (r?=??0.39, p?=?0.01).

Conclusions

Acromegaly patients, despite presenting with a higher LVMi when analyzed by 2D echocardiography, did not present with impairment in the strain when compared to a control group; this finding indicates a low chance of evolution to systolic dysfunction and agrees with recent studies that show a lower frequency of cardiac disease in these patients.

     

Sedation with Propofol for Bronchoscopy in Cystic Fibrosis Lung Transplant Recipients

Introduction

Flexible fiberoptic bronchoscopy (FFB) plays an important role in the surveillance of cystic fibrosis (CF) patients after lung transplantation (LTx). With rapid onset and clearance, propofol provides a safe and efficient method for sedation during FFB, yet sedation requirements for CF patients are not well described.

Objectives

Due to pharmacokinetic differences for other classes of drugs in CF patients, this study was performed to examine propofol requirements for sedation during bronchoscopy in lung transplant recipients with CF.

Methods

A single-center retrospective cohort study was performed to examine propofol sedation requirements during outpatient surveillance. FFB procedures with transbronchial biopsy (TBB) in post-LTx recipients between 2009 and 2014 were conducted.

Results

A total of 40 FFB procedures with TBB were performed 20 CF (11 females), 20 non-CF (11 females). Mean (±?SD) age was 25.6?±?9.2 (range 13–42) years and 22.2?±?10.8 (range 11–39) years for the CF and non-CF groups, respectively. Propofol requirements were significantly higher in the CF patients compared to the non-CF patients. Mean (±?SD) propofol dose for CF patients was 334?±?86 versus 214?±?88 mg for non-CF patients (p?<?0.001). Mean (±?SD) propofol dose per weight (mg/kg) was 6.5?±?2.1 for CF patients versus 3.8?±?1.6 for non-CF patients (p?<?0.001).

Conclusions

Compared to a non-CF cohort, CF lung transplant recipients required higher dosages of propofol for sedation during FFB with TBB.

     

Pneumothorax in Patients with Pulmonary Langerhans Cell Histiocytosis

Introduction

Pneumothorax often develops in pulmonary Langerhans cell histiocytosis (PLCH), but some patients take a long time to be correctly diagnosed.

Objectives

This study assessed the frequency of pneumothorax in PLCH and analysed the role of chest computed tomography (CT) in the prompt diagnosis.

Patients and material

Of the 90 patients with PLCH seen from 2000 to 2015, 29 (32%) had pneumothorax as the initial finding. In this group, 18 (62%) patients were diagnosed within 1 month, whereas the diagnosis was delayed for 4–120 months in 11 (38%) patients.

Results

Patients who had pneumothorax as the initial sign of PLCH tended to be younger (mean age 27.7?±?7.92 vs. 39.9?±?13.21 years; P?=?0.0001), male (69% vs. 43%; P?=?0.028), smoked less (mean pack/years 8.4?±?6.85 vs. 19?±?17.16; P?=?0.003), and had a significantly lower mean FVC (77.96?±?19.62 vs. 89.47?±?21.86% pred.; P?=?0.015) and FEV₁ (68.6?±?19.93 vs. 79.4?±?21.48% pred.; P?=?0.03 than patients who had no pneumothorax. Recurrent pneumothorax was diagnosed more frequently in the group with a delayed diagnosis (82% vs. 39%; P?=?0.02). CT was performed in all of the patients who were diagnosed promptly, but in none of the patients with a delayed diagnosis.

Conclusions

Patients who had pneumothorax as the initial sign of PLCH were younger, more frequently men, and had greater respiratory impairment than those who had no pneumothorax. CT in patients with pneumothorax led to a correct diagnosis of this disease.

     

Treatment of gastroesophageal reflux disease using radiofrequency ablation (Stretta procedure): An interim analysis of a randomized trial

Background

Gastroesophageal reflux disease (GERD) is the most common chronic gastrointestinal disorder, affecting one third of the population worldwide. Recently, there has been a renewed interest in Stretta therapy in view of potential long-term side effects of PPIs and the durability of relief with fundoplication.

Method

Prospective randomized study comparing the Stretta treatment with controls receiving PPIs. Patient (>?18 years, n = 20) with symptoms of heartburn, regurgitation, abnormal esophageal acid exposure (≥?4%), and endoscopically confirmed esophagitis were included into the study. The primary measure was improvement in quality of life (QOL) and decrease in the frequency and severity of GERD symptoms.

Results

The mean age of the patients was 39 (±?15) years and controls were 34 (±?11) years. Three months after Stretta, 80% reported improvement in QOL compared to 40% in the control group. At the end of 3 months, significant (p < 0.05) improvement in GERD symptom score for heartburn, regurgitation, chest pain, and cough compared with the control group was observed. After Stretta treatment, 60% of the patients were free of PPIs whereas there was no change in the control group. Almost 80% of the patients on Stretta treatment were satisfied with the treatment compared to 30% of the patients in the control group.

Conclusion

Stretta was effective in the short-term for the management of GERD.

     

Electrical isolation of the superior vena cava by laser balloon ablation in patients with atrial fibrillation

Purpose

The aim of the present study is to evaluate the feasibility and safety of SVC electrical isolation by LB ablation in patients with atrial fibrillation (AF) referred for pulmonary vein isolation (PVI).

Methods

Electrical disconnection of the SVC was attempted by LB in 13 consecutive patients (59?±?10.5 years, 11 male) with AF following PVI. PVI was successfully achieved by standard LB in all before attempting SVC isolation.

Results

A laser beam was delivered with 6.3?±?2.3 W and 8.4?±?2.7 W (P?=?0.001) during 5.38?±?2.4 min and 9.75?±?1.6 min (P?=?0.024) to achieve SVC and PV, respectively. Isolation of the SVC by LB was accomplished in 8 patients (61%) without complications. Phrenic nerve palsy developed in 3 patients (23%), which resulted in early procedure termination before isolation. Technical problems or interposition of a pacemaker lead to prevented SVC isolation in the remaining 2 patients. After a mean follow-up of 19?±?3 months, no patient recovered from phrenic nerve palsy.

Conclusions

SVC isolation by LB is feasible but associated with a high risk of phrenic nerve palsy. Limitation of laser delivery time and power appears insufficient to prevent this complication.

     

Type 1 diabetic patients with peripheral neuropathy have pan-enteric prolongation of gastrointestinal transit times and an altered caecal pH profile

Aims/hypothesis

We hypothesised that type 1 diabetic patients with established diabetic sensorimotor polyneuropathy (DSPN) would have segmental and/or pan-enteric dysmotility in comparison to healthy age-matched controls. We aimed to investigate the co-relationships between gastrointestinal function, degree of DSPN and clinical symptoms.

Methods

An observational comparison was made between 48 patients with DSPN (39 men, mean age 50 years, range 29–71 years), representing the baseline data of an ongoing clinical trial (representing a secondary analysis of baseline data collected from an ongoing double-blind randomised controlled trial investigating the neuroprotective effects of liraglutide) and 41 healthy participants (16 men, mean age 49 years, range 30–78) who underwent a standardised wireless motility capsule test to assess gastrointestinal transit. In patients, vibration thresholds, the Michigan Neuropathy Screening Instrument and Patient Assessment of Upper Gastrointestinal Symptom questionnaires were recorded.

Results

Compared with healthy controls, patients showed prolonged gastric emptying (299?±?289 vs 179?±?49 min; p?=?0.01), small bowel transit (289?±?107 vs 224?±?63 min; p?=?0.001), colonic transit (2140, interquartile range [IQR] 1149–2799 min vs 1087, IQR 882–1650 min; p?=?0.0001) and whole-gut transit time (2721, IQR 1196–3541 min vs 1475 (IQR 1278–2214) min; p?<?0.0001). Patients also showed an increased fall in pH across the ileocaecal junction (?1.8?±?0.4 vs ?1.3?±?0.4 pH; p?<?0.0001), which was associated with prolonged colonic transit (r?=?0.3, p?=?0.001). Multivariable regression, controlling for sex, disease duration and glycaemic control, demonstrated an association between whole-gut transit time and total GCSI (p?=?0.02).

Conclusions/interpretation

Pan-enteric prolongation of gastrointestinal transit times and a more acidic caecal pH, which may represent heightened caecal fermentation, are present in patients with type 1 diabetes. The potential implication of delayed gastrointestinal transit on the bioavailability of nutrition and on pharmacotherapeutic and glycaemic control warrants further investigation.

Trial registration

EUDRA CT: 2013-004375-12

     

Surgical results of laparoscopic Toupet fundoplication for gastroesophageal reflux disease with special reference to recurrence

Background

Surgical results of GERD have mainly been reported from the Western countries, with a few reports found in Japan. We examined the surgical results of laparoscopic Toupet fundoplication and clarify the characteristics of recurrent cases.

Methods

The subjects included 375 patients who underwent laparoscopic Toupet fundoplication from June 1997 to December 2016 as the initial surgery. Patient characteristics, pathophysiology, and surgical results were examined. In addition, we compared the patient characteristics and pathophysiology of recurrent cases in comparison with non-recurrent cases.

Results

Age 59 (43–70) and male 211 (56.3%). The operation time was 141 min (113–180) and intraoperative complications were found to have onset in 13 subjects (3.5%). Dysphagia after surgery was found in 18 cases (4.8%). The A factor (the degree of hiatal hernia), P factor (the degree of esophagitis), and pH?<?4 holding time significantly improved after surgery compared with prior to surgery (p?<?0.001 for all), while the LES lengths and abdominal LES lengths were extended (p?<?0.001 for each). Recurrence was found in 48 patients (15.1%) among the 318 patients for whom we could confirm the presence or absence of recurrence. The A factor, P factor, and pH?<?4 holding time prior to surgery were, respectively, higher in the recurrence group (p?=?0.031, p?<?0.001, p?<?0.001).

Conclusions

Laparoscopic Toupet fundoplication for GERD could be performed safely, with a response rate as good as 85%. Compared with non-recurrent cases, preoperative clinical conditions such as esophageal hiatal hernia, reflux esophagitis, and acid reflux time were all advanced in recurrent cases.

     

Effects of surgically assisted rapid maxillary expansion on obstructive sleep apnea and daytime sleepiness

Purpose

The aim of the study was to evaluate the effects of surgically assisted rapid maxillary expansion (SARME) on obstructive sleep events and daytime sleepiness in adults with obstructive sleep apnea syndrome (OSAS).

Methods

Sixteen individuals (7 women/9 men) aged 40.2?±?10.2 (range, 24.4 to 62.2 years) with maxillary transverse deficiency and OSAS (respiratory disturbance index [RDI] greater than 5) confirmed with full-night polysomnography (PSG) underwent SARME to evaluate its efficiency for OSAS treatment.

Results

Several PSG parameters and the Epworth Sleepiness Scale (ESS) results were compared in selected individuals before and after they underwent SARME. An RDI reduction from 35.4?±?38.5 to 16.0?±?19.7 was found, corresponding to a mean decrease of 54.6 % (p?=?0.0013). A 56.2 % (33.23?±?39.5 to 14.5?±?19.4, p?=?0.001) decrease was found in the apnea-hypopnea index (AHI), in addition to decreases in the desaturation and microarousal rates, among other parameters. The ESS scores improved from 12.5?±?5.3 to 7.2?±?3.5 (p?<?0.001).

Conclusions

SARME promotes an improvement in OSAS symptoms; decreases the rates of respiratory disturbances; microarousal, and desaturation; and reduces daytime sleepiness.

     

Electrogram characteristics of the coronary sinus in cases requiring epicardial ablation within the coronary sinus for creating a conduction block at the left lateral mitral isthmus

Purpose

We aimed to evaluate the late clinical outcomes of percutaneous LAA closure in patients with atrial fibrillation (AF) and contraindication to oral anticoagulation.

Methods

Consecutive AF patients with contraindications to oral anticoagulation who underwent successful LAA closure between December 2008 and March 2013 at four centers were included.

Results

A total of 101 patients (median age 76 [IQR 69–80] years, 48% women, mean CHA₂DS₂-VASc 5?±?2; HAS-BLED 4?±?1) were included. Eighty-six (85.1%) patients received an Amplatzer Cardiac Plug/Amulet device and 15 (14.9%) patients a Watchman device. The mean follow-up period was 4?±?1 years. During 358.6 patient-years of follow-up, 7 (6.9%) patients suffered a major stroke (2 cases per 100 person-years; expected rate: 6.2 cases per 100 person-years), and 20 (19.8%) patients experienced at least one episode of major bleeding (6.4 cases per 100 person-years; expected rate: 9.0 cases per 100 person-years). There were no cases of late adverse events related to the device. A total of 34 (33.7%) patients died during follow-up (9.5 cases per 100 person-years). Older age, male sex, low ejection fraction, and chronic kidney disease were identified as predictive factors of late mortality.

Conclusions

Percutaneous LAA closure is safe and effective in the long term in patients with AF with contraindications to anticoagulation. However, a high long-term mortality rate was observed in this high-risk population. Comprehensive patient assessment prior to undergoing LAA closure should identify patients in whose comorbidities limit their overall prognosis.

     

Communication Skills Training for Physicians Improves Patient Satisfaction

BACKGROUND

Skilled physician communication is a key component of patient experience. Large-scale studies of exposure to communication skills training and its impact on patient satisfaction have not been conducted.

OBJECTIVE

We aimed to examine the impact of experiential relationship-centered physician communication skills training on patient satisfaction and physician experience.

DESIGN

This was an observational study.

SETTING

The study was conducted at a large, multispecialty academic medical center.

PARTICIPANTS

Participants included 1537 attending physicians who participated in, and 1951 physicians who did not participate in, communication skills training between 1 August 2013 and 30 April 2014.

INTERVENTION

An 8-h block of interactive didactics, live or video skill demonstrations, and small group and large group skills practice sessions using a relationship-centered model.

MAIN MEASURES

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS), Jefferson Scale of Empathy (JSE), Maslach Burnout Inventory (MBI), self-efficacy, and post course satisfaction.

KEY RESULTS

Following the course, adjusted overall CGCAHPS scores for physician communication were higher for intervention physicians than for controls (92.09 vs. 91.09, p?<?0.03). No significant interactions were noted between physician specialty or baseline CGCAHPS and improvement following the course. Significant improvement in the post-course HCAHPS Respect domain adjusted mean was seen in intervention versus control groups (91.08 vs. 88.79, p?=?0.02) and smaller, non-statistically significant improvements were also seen for adjusted HCAHPS communication scores (83.95 vs. 82.73, p?=?0.22). Physicians reported high course satisfaction and showed significant improvement in empathy (116.4?±?12.7 vs. 124?±?11.9, p?<?0.001) and burnout, including all measures of emotional exhaustion, depersonalization, and personal accomplishment. Less depersonalization and greater personal accomplishment were sustained for at least 3 months.

CONCLUSIONS

System-wide relationship-centered communication skills training improved patient satisfaction scores, improved physician empathy, self-efficacy, and reduced physician burnout. Further research is necessary to examine longer-term sustainability of such interventions.

     

Endoscopic ultrasound-guided transesophageal thoracentesis for minimal pleural effusion

Background

Pleural effusion is a common finding both in patients with benign and malignant diseases of pleura and lung with diagnostic thoracentesis establishing the diagnosis in the majority of cases. The diagnostic thoracentesis can be done either blindly or under the guidance of ultrasound or computed tomography. However, minimal pleural effusion is difficult to sample even under image guidance. Endoscopic ultrasound (EUS) is known to detect smaller volume of pleural effusion and, thus, can help in guiding thoracentesis.

Aim

To analyze the safety and efficacy of EUS-guided diagnostic thoracentesis in patients with undiagnosed minimal pleural effusion retrospectively.

Methods

Retrospective analysis of the data of patients with minimal pleural effusion, who underwent EUS-guided transesophageal diagnostic thoracentesis over last 2 years, was performed.

Results

Thirteen patients (11 male; mean age 46.7?±?16.2 years) with undiagnosed minimal pleural effusion underwent successful EUS-guided transesophageal diagnostic thoracentesis using a 22-G needle. Seven (53%) patients had fever on presentation whereas two presented with cough and loss of appetite. Eight to 54 mL fluid was aspirated with an attempt to completely empty the pleural cavity. There were no complications of the procedure.

Conclusions

EUS-guided diagnostic thoracentesis is a safe and effective alternative for evaluating patients with minimal pleural effusion.

     

Right ventricular geometry and mechanics in patients with obstructive sleep apnea living at high altitude

Purpose

Repetitive obstruction of larynx during sleep can lead to daytime pulmonary hypertension and alterations in right ventricular morphology and function in a small fraction of obstructive sleep apnea syndrome (OSAS) patients. Environmental effects, particularly high altitude, can modify the effects of OSAS on pulmonary circulation, since altitude-related hypoxia is related with pulmonary vasoconstriction. This potential interaction, however, was not investigated in previous studies.

Methods

A total of 41 newly diagnosed OSAS patients were included in this study after pre-enrolment screening. Two-dimensional, three-dimensional, and Doppler echocardiographic data were collected after polysomnographic verification of OSAS. Three-dimensional echocardiograms were analyzed to calculate right ventricular volumes, volume indices, and ejection fraction.

Results

Systolic pulmonary artery pressure (38.35?±?8.60 vs. 30.94?±?6.47 mmHg; p?=?0.002), pulmonary acceleration time (118.36?±?16.36 vs. 103.13?±?18.42 ms; p?=?0.001), right ventricle (RV) end-diastolic volume index (48.15?±?11.48 vs. 41.48?±?6.45 ml; p?=?0.009), and RV end-systolic volume index (26.50?±?8.11 vs. 22.15?±?3.85; p?=?0.01) were significantly higher in OSAS patients, with similar RV ejection fraction (EF) between groups. No significant differences were noted in other two-dimensional, Doppler or speckle-tracking strain, measurements. Both RVEF and pulmonary acceleration time were predictors of disease severity.

Conclusions

A greater degree of RV structural remodeling and higher systolic pulmonary pressure were observed in OSAS patients living at high altitude compared to healthy highlanders. The reversibility of these alterations with treatment remains to be studied.

     

Impact of a computer assisted navigation system on radiation exposure during pediatric ablation procedures

Background

During catheter ablation procedures, non-radiologic navigation systems may reduce fluoroscopic exposure and energy applications, as well as improve procedural success rates.

Objective

To examine the impact of a non-radiologic navigation system on ablation procedures in pediatric patients, the procedural characteristics and success rates prior to and following incorporation of the LocaLisa® (LL) navigation system into a pediatric electrophysiology laboratory were compared.

Methods

Between January 2000 and April 2005, 246 consecutive patients underwent catheter ablation for either Atrioventricular Reentry Tachycardia AVRT (168) or Atrioventricular Nodal Reentry Tachycardia AVNRT (78). Ablation procedures performed prior to LL (108) were compared to ablation procedures performed using LL (113). The first 25 patients using LL were censored to remove the bias of a learning curve.

Results

There was no difference in demographic features between the two groups. Statistically significant decreases were found in the diagnostic (11.4?±?6.1 min v 18.8?±?9.8 min w/o LL), ablation (5.7?±?10.3 vs 18.5?±?20.1 min w/o LL) and total (17.2?±?12.6 vs 37.3?±?21.3 min w/o LL) fluoroscopy times for the LL group, as well as in the total number of energy applications (9.0?±?8.5 vs 12.3?±?12.2 w/o LL). Success rates were 99.1% w/ LL v 97.2% w/o LL (p?=?NS). No major complications were observed in either group.

Conclusions

The use of a computer assisted navigation system significantly decreased the diagnostic, ablation, and total fluoroscopy times, as well as the number of energy applications, without affecting procedural success or complication rates. Non-radiologic navigation systems reduce radiation exposure during transcatheter electrophysiologic procedures and thus lower the lifetime radiation cumulative risk, a goal particularly important in children.

     

Left ventricular end diastolic pressure for detection of intracoronary ergonovine-induced myocardial ischemia

Background

Recent consensus on variant angina defines significant spasm as total or subtotal occlusion of a coronary artery. However, the clinical significance of “less-than-subtotal” spasm needs to be reappraised, especially if the coronary spasm is combined with chest pain. Therefore, we evaluated the feasibility of left ventricular end diastolic pressure (LVEDP) as a tool to detect myocardial ischemia during ergonovine provocation testing.

Methods

After achieving two access sites, 29 patients underwent successful LVEDP monitoring using 5-Fr pigtail catheters during ergonovine provocation tests. Patients were divided into two groups based on the occurrence of anginal symptoms.

Results

Of the 29 patients, 16 (55?%) patients had anginal symptoms. LVEDP was significantly increased in the symptomatic group compared with the nonsymptomatic group (?LVEDP 5.6?±?4.2 vs. 1.2?±?2.0 mmHg, p?=?0.002). However, of the 16 patients with anginal symptoms, positive provocation test results were confirmed in only six patients (38?%) as per the traditional standard (>?90?% inducible spasm of the epicardial coronary artery).

Conclusion

Compared with the traditional standard, LVEDP may have advantages in terms of elucidating anginal symptoms in patients suspected of having coronary vasospasm when performing ergonovine provocation tests.

     

Assessment of Sleep in Patients Receiving Invasive Mechanical Ventilation in a Specialized Weaning Unit

Introduction

A restful sleep is essential for regenerative processes and remains crucial for patients recovering from stressful periods in the intensive care unit. The current study aimed to assess sleep quality in critically ill patients receiving invasive mechanical ventilation within a specialized weaning unit in hospital.

Methods

Tracheotomized subjects undergoing prolonged weaning from mechanical ventilation were included in the study. Polysomnography and gas exchange monitoring was performed during nocturnal ventilation. Subjective evaluation of sleep quality and health-related quality of life were also assessed.

Results

Nineteen subjects completed the study protocol. Sleep architecture was highly heterogeneous across individual subjects. Mean total sleep time (TST) was 273?±?114 min, sleep efficacy 70?±?23%, slow-wave sleep 25.7?±?18.4%/TST, rapid eye movement sleep 9.6?±?7.5%/TST, and arousal index 18.7?±?12.4/h. No significant difference in sleep quality was found between subjects with successful (N?=?7) or unsuccessful (N?=?12) weaning. Bicarbonate levels were negatively correlated both with sleep efficacy and sleep quality, that latter of which was subjectively assessed by the subjects using a visual analogue scale.

Conclusion

Subjects who were undergoing prolonged weaning from mechanical ventilation and admitted to a specialized weaning unit, showed reduced sleep quality with preservation of high amounts of slow-wave sleep.

     

Cardiovascular autonomic dysfunction in patients with idiopathic diabetes insipidus

Introduction

Central diabetes insipidus (DI) is a rare disease characterized by the excretion of excessive volumes of dilute urine due to reduced levels of the antidiuretic hormone arginine vasopressin (AVP), caused by an acquired or genetic defect in the neurohypophysis. The aim of this study was to identify any autonomic dysfunction (AD) in patients with DI as a possible cofactor responsible for their reportedly higher mortality.

Methods

The study involved 12 patients (6 females) with central idiopathic DI and a well-controlled electrolyte balance, and 12 controls matched for age, sex and cardiovascular risk factors, who were assessed using the tilt, lying-to-standing, hand grip, deep breath, Valsalva maneuver and Stroop tests.

Results

The tilt test showed a significantly more pronounced decrease in both systolic (??20.67?±?18 vs. ??1.92?±?6.99 mmHg, p?=?0.0009) and diastolic blood pressure (??10.5?±?14.29 vs. ??1.5?±?5 mmHg, p?=?0.012) in patients than in controls. Three patients with DI had to suspend the test due to the onset of syncope. The lying-to-standing test also revealed a marked reduction in blood pressure in patients with DI (1.05?±?0.13 vs. 1.53?±?0.14, p?=?0.0001). Similar results emerged for the Valsalva maneuver (Valsalva ratio, 1.24?±?0.19 vs. 1.79?±?0.11, p?<?0.0001) and deep breath test (1.08?±?0.11 vs. 1.33?±?0.08, p?<?0.0001).

Conclusions

All the principal autonomic tests performed in the study were concordant in indicating that patients with central DI have an impaired autonomic nervous system function despite a normal hydroelectrolytic balance under desmopressin therapy. This impairment may reflect damage to the autonomic system per se and/or the absence of any vasoactive effect of AVP on vascular smooth muscle. In our opinion, patients with central DI should be educated on how to prevent orthostatic hypotension, and pharmacological treatment should be considered for patients with a more marked impairment.

     

Different polysomnographic patterns in military veterans with obstructive sleep apnea in those with and without post-traumatic stress disorder

Introduction and objectives

Obstructive sleep apnea (OSA) is a prevalent disorder among military veterans. The goal of this study is to compare the polysomnographic patterns of OSA in military veterans who have a history of post-traumatic stress disorder (PTSD) with those of veterans who have not PTSD.

Materials and methods

Seventy-two Iranian military male veterans were classified into two groups: those with PTSD (40 cases) and those without PTSD (32 cases). Each participant was diagnosed with OSA using an overnight polysomnography, during which sleep-related parameters such as sleep efficiency (SE) and apnea-related events were detected. The body mass index (BMI) and Epworth Sleepiness Scale (ESS) were also assessed.

Results

For the PTSD group, mean age was 53.83?±?7.3 years, elapsed time since they participated in war was 28.3?±?3.4 years, apnea-hypopnea index (AHI) was 41.2?±?27, SE was 77.7?±?17.55%, ESS was 7.93?±?2.04, BMI was 26.5?±?5.7, and PLM index was 12.725?±?8.64. The above respective parameters for the non-PTSD group were 51.33?±?5.9 years, 28.3?±?3.4 years, 30.33?±?14.7, 82.4?±?15.65%, 10.08?±?3.02, 31.5?±?6.7, and 8.8?±?3.54. The relationships of AHI with ESS and BMI were not significant in PTSD group.

Conclusion

OSA in military veterans suffering from PTSD presents more often with insomnia than obesity or increased daytime sleepiness. These findings are different from those typically seen in non-PTSD veterans with OSA.

     

Suppression of glucagon secretion is lower after oral glucose administration than during intravenous glucose administration in human subjects

Aims/hypothesis

The incretin effect describes the augmentation of postprandial insulin secretion by gut hormones. It is not known whether glucagon secretion is also influenced by an incretin effect. A glucagon suppression deficiency has been reported in some patients with type 2 diabetes, but it is unclear whether this abnormality is present prior to diabetes onset. We therefore addressed the questions: (1) Is glucagon secretion different after oral and during intravenous glucose administration? (2) If so, is this related to the secretion of incretin hormones? (3) Is glucagon secretion abnormal in first-degree relatives of patients with type 2 diabetes?

Materials and methods

We examined 16 first-degree relatives of patients with type 2 diabetes and ten matched control subjects with an oral glucose load (75 g) and with an ‘isoglycaemic’ intravenous glucose infusion.

Results

Glucagon levels were significantly suppressed by both oral and intravenous glucose (p?p?r?=?0.60, p?=?0.001) and glucagon-like peptide (GLP)-1 (r?=?0.46, p?

Conclusions/interpretation

Despite the glucagonostatic actions of GLP-1, the suppression of glucagon secretion by glucose is diminished after oral glucose ingestion, possibly due to the glucagonotropic actions of GIP and GLP-2. Furthermore, in this group of first-degree relatives, abnormalities in glucagon secretion did not precede the development of other defects, such as impaired insulin secretion.

     

Effects of Tolvaptan on Volume Overload in Japanese Patients with Heart Failure: Results of a Phase II,Multicenter, Randomized,Double-blind,Placebo-controlled,Parallel-group Study

Purpose

Tolvaptan may reduce the signs of volume overload in heart failure (HF) patients who experience volume overload despite using conventional diuretics. In this study, we evaluated the dose-response effects of tolvaptan on weight loss, urine volume and electrolyte excretion in furosemide-treated Japanese HF patients exhibiting volume overload.

Methods

In the study, 117 HF patients with volume overload on stable doses of furosemide (≥40 mg/day) were treated with tolvaptan (15, 30 or 45 mg) or placebo once-daily for 7 days.

Results

The decrease in body weight from baseline to the day after the final dose with 15, 30 or 45 mg tolvaptan (–1.62?±?1.55, –1.35?±?1.54 and –1.85?±?1.10 kg, respectively), was significantly greater compared with that in the placebo group (–0.53?±?0.96 kg) (p?<?0.05). However, the decrease in body weight with tolvaptan was not significantly dose-dependent. Signs of volume overload improved at all doses of tolvaptan. Tolvaptan elicited a dose-dependent increase in urine volume and a decrease in urine osmolality, but did not affect urinary sodium or potassium excretion. Adverse reactions associated with diuresis were most frequently observed at the higher doses of tolvaptan.

Conclusions

Once-daily tolvaptan (15, 30 or 45 mg) was effective and tolerable as an add-on treatment to furosemide therapy in Japanese HF patients with volume overload.

     

Pressure monitoring predicts pulmonary vein occlusion in cryoballoon ablation

Purpose

Pulmonary venography is routinely used to confirm pulmonary vein (PV) occlusion during cryoballoon ablation. However, this technique is significantly limited by the risks associated with contrast media, such as renal injury and contrast allergy. We hypothesized that PV occlusion can be predicted by elevation of the balloon catheter tip pressure, avoiding the need for contrast media.

Methods

Forty-eight consecutive patients with paroxysmal atrial fibrillation who underwent PV isolation with the cryoballoon technique were enrolled. The balloon catheter tip pressure was measured in each PV before and after balloon inflation.

Results

We analyzed 200 applications of cryoballoon ablation in 185 PVs (excluding 3 common PVs and 1 extremely small right inferior PV) of 48 patients (age, 70?±?11 years; male, n?=?28; mean left atrial diameter, 38?±?6 mm). Compared with patients with unsuccessful occlusion, patients with successful occlusion demonstrated a larger change in pressure after balloon inflation (6?±?8 vs. 2?±?4 mmHg, P?<?0.001), a lower minimum temperature (??49?±?6 vs. ??40?±?8 °C, P?<?0.001), and a higher PV isolation rate (97 vs. 64%, P?<?0.001). The best cutoff value of a change in pressure for predicting PV occlusion was 4.5 mmHg, with a sensitivity of 67%, specificity of 83%, and predictive accuracy of 72%.

Conclusion

Pressure monitoring is helpful to confirm PV occlusion during cryoballoon ablation.