A comparative analysis of major clinical outcomes using drug‐eluting stents versus bare metal stents in diabetic versus nondiabetic patients

Objectives: We aim to explore the clinical outcome of drug‐eluting stents (DES) versus bare‐metal stents (BMS) implantation in diabetics versus nondiabetic patients. Background: Diabetic patients sustain worse long‐term clinical outcomes after percutaneous coronary interventions (PCI) when compared with nondiabetics. The use of DES decreases the rate of repeat revascularization in this population but data concerning long‐term clinical benefits, such as myocardial infarction (MI) or mortality is scant. Methods: We analyzed data from a comprehensive registry of 6,583 consecutive patients undergoing PCI at our center. A propensity score was used for analysis of outcomes and for matching (DES vs. BMS). Outcome parameters were total mortality, MI, repeat target vessel revascularization (TVR) rates, and risk‐adjusted event‐free survival. Within this cohort, we identified 2,571 nondiabetic patients and these were compared with 1,826 diabetic coronary patients. Results: Mean and median follow up time was 3 and 3.25 years, respectively. Overall, diabetics had higher rates of major‐adverse cardiovascular events (MACE) at 4 years compared with nondiabetics (23.03 vs. 31.96 P > 0.001). DES use was associated with lower rates of TVR in both groups [diabetics hazard ratio (HR) = 0.56, 95% confidence interval (CI): 0.42–0.76, P < 0.001, nondiabetics HR = 0.73, 95% CI: 0.55–0.97, P = 0.03] while sustained decreased rates of both mortality and MI were evident solely among diabetics (HR = 0.71, 95% CI: 0.56–0.89, P = 0.004 in diabetic vs. HR = 0.88, 95% CI: 0.69–1.13, P = 0.3). Conclusions: In a “real‐world,” unselected population and extended clinical use, DES in diabetics was associated with sustained decreased rates of MI, death, TVR, and MACE while this benefit was attenuated in the nondiabetic population. © 2011 Wiley‐Liss, Inc.     

Validation study to determine the accuracy of central blood pressure measurement using the SphygmoCor XCEL cuff device in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

Central aortic blood pressure could be helpful in the evaluation of patients with aortic stenosis (AS). The SphygmoCor XCEL device estimates central blood pressure (BP) measurement with its easy‐to‐use, operator‐independent procedure. However, this device has not been properly validated against invasive measurement in patients with severe AS. We evaluated the relationship between cuff‐brachial BP, transfer function‐estimated and invasively measured central aortic pressure in patients with severe AS before and after transcatheter aortic valve replacement (TAVR). Agreement between techniques was analyzed and, according to the ARTERY Society recommendations, the minimum acceptable error was a mean difference ± SD ≤5 ± ≤8 mm Hg. A total of 94 patients with AS undergoing TAVR had simultaneous non‐invasive and invasive measurements of central BP before and after the procedure. Before TAVR central systolic BP was in average slightly underestimated, though with wide variability, when using the default calibration of brachial‐cuff SBP (mean difference ± SD, −3 ± 15 mm Hg), and after TAVR the degree of underestimation increased (mean difference ± SD, −9 ± 13 mm Hg). The agreement tended to improve for those patients with low aortic gradient stenosis compared to those with high gradient at baseline (mean difference ± SD, −2 ± 11 mm Hg vs. −4 ± 17, respectively, p = .3). The cuff‐brachial systolic BP yielded numerically lower degree of agreement and weaker correlation with invasive measurements than SphygmoCor XCEL. In patients with severe AS the SphygmoCor XCEL cuff device, despite showing strong correlation, does not meet the ARTERY Society accuracy criteria for non‐invasive measurement of central SBP.     

Endothelial-dependent vasodilation is impaired in children with sickle cell disease

Impairment of endothelial-dependent vasodilation has been demonstrated in adults with sickle cell anemia (SCA). We enrolled 21 SCA children, mean age 10.4+/-3.3 yrs, and 23 Afro-Caribbean controls. We examined flow-mediated (FMD) and nitroglycerine-mediated (GTNMD) dilation of the brachial artery, using echotracking techniques, and measured intima-media thickness (IMT) and mechanical properties of the common carotid artery. FMD was significantly decreased in SCA children vs controls (5.6+/-0.2 vs 8.0+/-0.2%, p=0.008), while IMT, stiffness of the common carotid artery, and GTNMD were comparable. In conclusion, endothelial dysfunction is present as early as childhood in SCA patients.     

Use of Adenosine Test for the Exclusion of Preexcitation Syndrome in Asymptomatic Individuals

Background: Resting electrocardiogram is a routine procedure for the identification of potentially fatal conditions, including preexcitation syndrome (PES). Intravenous adenosine is a sensitive and specific means of exposing inapparent pathways in such patients. Yet, it may not be sensitive when complete atrioventricular (AV) block is not achieved because a low dose of adenosine is used. We evaluated the yield of a high‐dose adenosine test that achieved complete AV nodal block for unmasking inapparent pathway in a healthy population. Methods: We retrospectively reviewed all Israeli air force (IAF) academy candidates who were referred to adenosine test based on a cardiologist's suspicion of PES. The results of the adenosine test were recorded, including the adenosine dose required to achieve complete AV block. The medical records of the subjects were reviewed to identify any adverse cardiovascular outcome. Results: Fifty‐nine subjects who underwent adenosine test were followed for 35.42 ± 24 months. Complete AV block was achieved in all subjects with an average adenosine dose of 22.51 ± 12.67 mg. None of the subjects had evidence of an inapparent pathway. All subjects completed military service without adverse outcomes. Conclusions: The vast majority of young patients with a short PR interval do not have evidence of an accessory pathway and have a favorable prognosis. Thus, the yield of adenosine test in young combat recruits is questionable. Yet, if there is no evidence of an accessory pathway while achieving complete AV block on adenosine test, the chance of an accessory pathway being present is probably extremely low. Ann Noninvasive Electrocardiol 2011;16(2):180–183     

Gastrointestinal eosinophil-mediated disorders and their treatment

Eosinophilic esophagitis has become a diagnosis familiar to allergists and immunologists who treat pediatric patients presenting with complaints of recurrent vomiting, feeding difficulty, abdominal pain, dysphagia, and food impaction. Over the past 3 years, published research has addressed several clinically important issues, including incidence among special patient populations, adult patients and familial cases, diagnostic features, natural history and complications, therapies with topical steroids, and pathogenesis with distinct genetic markers of the disorder.     

A second‐time percutaneous aortic‐valve implantation for bioprosthetic failure

We report a case of an 84‐year‐old man with a history of surgical aortic‐valve replacement for chronic aortic regurgitation (AR) who later developed severe prosthetic valve AR. Subsequent treatment with a Corevalve^® was unsuccessful with severe AR seen at 3 years after the valve‐in‐valve procedure. The patient was then successfully treated with a second catheter‐based Corevalve^® implantation.     

Sacrococcygeal Pilonidal Sinus Treated by a New Fascio-Cutaneous Flap

Purpose This study reported the technical details and preliminary clinical outcomes of a new fascio-cutaneous transposition flap for the surgical treatment of pilonidal sinus. Methods Fifty-two patients with pilonidal sinus were surgically treated. During the surgical procedure, an inferiorly pedicled, fascio-cutaneous flap with specific geometric characteristics was prepared and transposed. Postoperative pain, complications, duration of hospital stay, and time off worked were assessed. Patients were followed for eighteen months after surgery. Results The mean hospital stay was 2 days. Drains and sutures were removed after 3 and 12 days, respectively. No flap ischemia, wound dehiscence or major complications were observed. Tension on suture lines and pain after surgery were negligible. Wound infections occurred in 4 patients (7.7 percent) and were managed by removing a few sutures. Seroma was detected in 6 patients (11.5 percent). The mean time patients missed work was 7 days. No recurrence was observed during the follow-up period of 18 months. Conclusions With no disease recurrence, minimal complication rate, time off work, and acceptable aesthetic outcome, this fascio-cutaneous transposition flap technique is a safe and effective method for surgically treating pilonidal sinus.     

Rectal administration of d-alpha tocopherol for active ulcerative colitis： A preliminary report

AIM： To investigate the anti-oxidant and antineutrophil recruitment effects of rectal d-alpha （d-α） tocopherol administration on mild and moderately active ulcerative colitis （UC）.
METHODS： Fifteen patients with mild and moderately active ulcerative colitis were enrolled in an openlabel study of d-α tocopherol enema （8000 U/d） for 12 wk. All patients were receiving concomitant therapy with 5-aminosalicylic acid derivatives （5-ASA） and/or immunomodulator medications. Endoscopic evaluation was performed at baseline and after 4th and 12th weeks. Disease activity was measured with the Mayo disease activity index （DAI） and remission was defined as DAI of ≤ 2 with no blood in stool. Clinical response was defined as a DAI reduction of ≥ 2.
RESULTS： At the end of 12th week, the average DAI score significantly decreased compared to the beginning of the study （2.3 ± 0.37 vs 8 ± 0.48, P 〈 0.0001）. One patient was withdrawn after 3 wk for being unavailable to follow-up. On the 4th week of therapy, 12 patients showed clinical response, 3 of whom （21.4%） achieving remission. After 12 wk, all 14 patients responded clinically to the therapy and remission was induced in 9 of them （64%）. No patient reported adverse events or was hospitalized due to worsened disease activity.
CONCLUSION： This preliminary report suggests that rectal d-α tocopherol may represent a novel therapy for mild and moderately active UC. The observed results might be due to the anti-inflammatory and anti-oxidative properties of vitamin E.