Diagnostic performance of 64-slice computed tomography coronary angiography to detect significant coronary artery stenosis

OBJECTIVE: We aimed to determine the diagnostic accuracy of 64-slice multi-slice computed tomography (MSCT) to detect significant coronary artery stenosis with comparison to conventional coronary angiography (CCA). METHODS: In 100 patients (70 men, average age 58 +/- 10 years and age range 31-75 years) scheduled to have conventional coronary angiography, MSCT was performed before catheterization (within 2 months). All patients were in sinus rhythm, able to hold breath for 15 seconds, and had serum creatinine levels < 1.5 mg/dl. MSCT scans were analysed by a radiologist and a cardiologist. Sensitivity, specificity, positive and negative predictive values for the detection of significant stenoses by MSCT in comparison with CCA were calculated on patient, vessel, and segmental bases. RESULTS: 64-slice computed tomography is able to detect significant coronary artery stenosis on a segmental basis with a sensitivity of 88% and specificity of 99% when compared with CCA. All patients with significantly stenotic coronary artery disease are correctly diagnosed. The presence of significant stenosis was correctly diagnosed by MSCT in 126 of 144 segments. Twelve non-significant lesions on CCA were overestimated by MSCT. On vessel-based analysis, the sensitivity and specificity of MSCT for detecting significant stenosis were 91% and 97%, respectively. CONCLUSION: Our results indicate that 64-slice computed coronary angiography is a reliable diagnostic modality for the detection of significant coronary artery stenosis in patients with sinus rhythm and scheduled to have CCA, but still has limitations of diagnostic performance on a per-segment and per-vessel basis.     

A case of acute esophageal necrosis (black esophagus) in a young man with Down syndrome

Acute esophageal necrosis, commonly referred to as ‘black esophagus?, is a rare clinical entity arising from a combination of ischemic insult, corrosive injury and decreased function of mucosal barrier systems and reparative mechanisms present in debilitating diseases. We describe the case of an 18-year-old man affected by Down syndrome, presenting with a streptococcus β-hemolytic group A infection of the upper airways. Although the patient was intensively treated with antibiotics, he developed a streptococcal toxic shock-like syndrome and died 5 days after admission. At autopsy, circumferential black discoloration of the esophageal mucosa that extended along the entire esophagus and ended abruptly at the esophageal-gastric junction was found. Neither ulceration nor esophageal perforation were present. Black esophagus is well known to the gastroenterology community, whereas it has been described only twice in the pathology literature. To the best of our knowledge, this is the first case ever reported complicating a streptococcal infection.     

Plasma levels of tumor necrosis factor-α and its receptors in patients with mitral stenosis and sinus rhythm undergoing percutaneous balloon valvuloplasty

This study aimed to determine whether plasma levels of tumor necrosis factor-α (TNF-α) and soluble TNF receptor (sTNF-R) increases in rheumatic mitral stenosis (MS) patients with sinus rhythm and to examine the effect of percutaneous mitral balloon valvuloplasty (PMBV) on these parameters. Twenty-six patients with MS and sinus rhythm (study group, 20 female, mean age 33 ± 8 years), who were scheduled for PMBV, and a well-matched control group consisting of 21 healthy volunteers (15 female, mean age 35 ± 6 years) were enrolled in the study. Tumor necrosis factor-α and sTNF-R levels were compared between study patients and controls, and between peripheral and left atrium (LA) blood. Changes in TNF α and sTNF-R levels 24 h and 4 weeks after PMBV were analyzed. Significantly higher baseline TNF-α and sTNF-R levels were noted in the study group. In the study group, TNF-α and its receptors were also found to be higher in LA blood than in baseline peripheral blood. After PMBV, mitral valve area (MVA) increased and transmitral pressure gradient decreased significantly. At the 24th hour after PMBV, the TNF-α level decreased from 29.61 ± 12.22 pg/ml to 22.42 ± 8.81 pg/ml (P < 0.0001) and at the 4th week, from 22.42 ± 8.81 pg/ml to 18.92 ± 7.37 pg/ml (P < 0.0001). Similar reductions were observed in the sTNF-R level. Regression analysis between the difference in sTNF-R level measured 24 h after and before PMBV and the difference in MVA measured 24 h after and before PMBV showed a significant direct relationship between these variables. This study suggests that isolated rheumatic MS without atrial fibrillation is accompanied by increased TNF-α and sTNF-R level. The successful PMBV establishes a significant reduction in TNF-α and its receptors, probably due to improved postprocedural hemodynamic parameters.     

Activation of nuclear receptor CAR ameliorates diabetes and fatty liver disease

Constitutive androstane receptor CAR (NR1I3) has been identified as a central mediator of coordinate responses to xenobiotic and endobiotic stress. Here we use leptin-deficient mice (ob/ob) and ob/ob, CAR^−/− double mutant mice to identify a metabolic role of CAR in type 2 diabetes. Activation of CAR significantly reduces serum glucose levels and improves glucose tolerance and insulin sensitivity. Gene expression analyses and hyperinsulinemic euglycemic clamp results suggest that CAR activation ameliorates hyperglycemia by suppressing glucose production and stimulating glucose uptake and usage in the liver. In addition, CAR activation dramatically improves fatty liver by both inhibition of hepatic lipogenesis and induction of β-oxidation. We conclude that CAR activation improves type 2 diabetes, and that these actions of CAR suggest therapeutic approaches to the disease.     

Impact of obstructive sleep apnea-related symptoms on surgical wound complications in breast cancer patients: pilot study in a tertiary health center in Turkey

Purpose

Wound healing is an important factor influencing morbidity following surgical procedures. The association of obstructive sleep apnea (OSA) with numerous postoperative complications has been previously reported. In this study, we report the impact of OSA-related symptoms on wound complications in breast cancer patients in the postoperative period.

Methods

Breast cancer patients were enrolled for a prospective observational study. Outcome measures included sociodemographic data, self-reported sleep-wake questionnaires (Berlin questionnaire, STOP-BANG, and Epworth sleepiness scale [ESS]) as well as type of surgery, smoking status, duration of anesthesia, the need for postoperative opioid drugs, and complications for surgical wounds. Patients’ general preoperative health status was quantified by using American Society of Anesthesiologists (ASA) scores.

Results

A total of 132 women were included in the study, of whom 61% (n?=?81) underwent mastectomy, and 39% (n?=?51) had breast conserving surgery. Mean ESS score of the study group was 7.7?±?0.5. Multivariant analysis identified, either being at medium high risk by STOP-BANG questionnaire (OR:1.77, p: 0.04) or being at high risk by Berlin questionnaire (OR:1.96, p: 0.04) as well as high BMI (OR:2.76 95% CI:1.73–4.65, p: 0.02), smoking history (OR:3.04 95% CI: 2.25–3.86, p: 0.01) and type of surgery (OR:2.64 95% CI: 1.63–2.89, p: 0.03) were independent factors for wound healing.

Conclusions

The study results suggest that patients with high risk for OSA have a tendency to develop postoperative wound complications after breast cancer surgery. This study lays groundwork for further scrutiny using more robust methodology.

     

A Mysterious Crescent in the Heart: Ruptured Sinus of Valsalva Dissecting Interatrial Septum,Multimodality Imaging,and Full Recovery

A 59‐year‐old man who was admitted to the emergency department with new and spontaneous onset of fatigue, dyspnea, and palpitations. There was neither a history of trauma, chest pain, nor infection. Transthoracic two‐ and three‐dimensional echocardiography and computer tomography demonstrated sinus of Valsalva aneurysm rupture dissecting interatrial septum and leading to a huge thrombus formation in it. The diagnosis with multimodality imaging performed within hours, and urgent surgery saved the patient's life.     

Effect of serum uric acid on the positive predictive value of dobutamine stress echocardiography

There is controversial data regarding the relationship between uric acid (UA) and coronary artery disease and cardiovascular events. Despite the deleterious effects of hyperuricemia on endothelial function, the effect of UA on myocardial ischemia has not been previously studied. We aimed to investigate the relationship between UA and myocardial ischemia that was identified using dobutamine stress echocardiography (DSE). In this retrospective study, the laboratory and DSE reports of 548 patients were reviewed. The patients were divided into two groups based on the presence of ischemia and further subdivided into three groups according to the extent of ischemia (none, ischemia in 1–3 segments, ischemia in >3 segments). Serum UA levels were compared. Determinants of ischemia were assessed using a regression model. UA was increased in patients with ischemia and was correlated with the number of ischemic segments (p < 0.001). A cutoff value of UA > 5 mg/dl had 63.9 % sensitivity, 62.0 % specificity, 42.5 % positive predictive value (PPV), and 79.6 % negative predictive value for ischemia. When the positive DSE exams were further sorted according to the UA cutoff, the PPV of DSE increased from 80.2 to 94.0 %. Uric acid (odds ratio 1.51; 95 % CI 1.14–1.99), diabetes mellitus, HDL and glomerular filtration rate were found to be independent determinants of myocardial ischemia in DSE. Increased UA is associated with both the presence and extent of DSE-identified myocardial ischemia. A UA cutoff may be a good method to improve the PPV of DSE.