Brief Depression Screening with the PHQ-2 Associated with Prognosis Following Percutaneous Coronary Intervention with Paclitaxel-Eluting Stenting

BACKGROUND  Depression is associated with adverse prognosis in cardiac patients, warranting the availability of brief and valid instruments to identify depressed patients in clinical practice. OBJECTIVES  We examined whether the two-item Patient Health Questionnaire (PHQ-2) was associated with adverse events in percutaneous coronary intervention (PCI) patients treated with paclitaxel-eluting stenting (using the continuous score and various cutoffs), overall and by gender. DESIGN  Prospective follow-up study. PARTICIPANTS  Consecutive PCI patients (n = 796) seen at a university medical centre. MEASUREMENTS  PHQ-2 at baseline. The study endpoint was an adverse event, defined as a combination of death or non-fatal myocardial infarction (MI) at follow-up (mean of 1.4 years). RESULTS  At follow-up, 47 patients had experienced an adverse event. Using the continuous score of the PHQ-2 and the recommended cutoff ≥3, depressive symptoms were not associated with adverse events (ps > 0.05). Using a cutoff ≥2, depressive symptoms were significantly associated with adverse events (HR: 1.89; 95% CI: 1.06–3.35) and remained significant in adjusted analysis (HR: 1.90; 95% CI: 1.05–3.44). Depressive symptoms were associated with an increased risk of adverse events in men (HR: 2.69; 95% CI: 1.36–5.32) but not in women (HR: 0.76; 95% CI: 0.24–2.43); these results remained in adjusted analysis. CONCLUSIONS  Depression screening with a two-item scale and a cutoff score of ≥2 was independently associated with adverse events at follow-up. The PHQ-2 is a brief and valid measure that can easily be used post PCI to identify patients at risk for adverse health outcomes. An erratum to this article can be found at     

Atrial natriuretic peptide predicts impaired atrial remodeling and occurrence of late postoperative atrial fibrillation after surgery for symptomatic aortic stenosis

BACKGROUND: Aortic stenosis (AS) and atrial fibrillation (AF) are commonly encountered in clinical practice. Natriuretic peptides (NP) are endogenous cardiac hormones, which have been shown to increase in patients with heart failure, and valvular or congenital heart disease. We aimed to determine the association between atrial NP (ANP) and late postoperative AF after surgery for AS along with temporal changes in plasma ANP levels and left atrial (LA) volumes. METHODS: 22 patients (16 males/6 females, mean age: 61 years) with symptomatic AS and 8 healthy volunteers (5 males/3 females) were enrolled into our study. All the patients studied underwent transthoracic echocardiography, which was repeated during the follow-up. N-terminal ANP (N-ANP) was studied initially and at the 2-month follow-up. Postoperatively, the patients were followed up for 12 months for AF attacks. RESULTS: Patients with AS had significantly higher levels of N-ANP, left ventricular (LV) end-diastolic pressure, E/A ratio, LV mass and LA volumes compared to the controls. Patients with postoperative AF attacks were significantly older, had higher N-ANP levels and LV end-diastolic pressure in addition to higher LA volumes and longer symptom duration compared to patients without AF. Age at the time of operation (p = 0.011) and N-ANP at the 2nd month (p = 0.047) were found to be independent predictors for late AF attacks during follow-up in regression analysis. Besides, N-ANP (p < 0.001) at the 2-month follow-up independently predicted impaired LA remodeling. CONCLUSION: ANP might be an important factor to identify AS patients at risk for late postoperative AF attacks.     

Superiority of Asymmetric Modified Limberg Flap for Surgical Treatment of Pilonidal Disease

Purpose Cases treated surgically using wide excision plus classic Limberg flap or wide excision plus asymmetric modified Limberg flap were compared with respect to complications and patient comfort in the postoperative period. Methods In this prospective, randomized study, 68 of 70 patients were followed for a mean of 29.22 (range, 6–44) months after wide excision plus classic Limberg flap (Group 1, n = 35) and after asymmetric modified Limberg flap closure (Group 2, n = 33). Results There were significantly more macerations in Group 1 (P < 0.001). All macerations were detected on the lower part of the incision left on the intergluteal sulcus, and infections occurred subsequent to maceration. The infection rate was statistically higher in Group 1 than in Group 2 (P = 0.028). We noted that as a result of these complications, time to suture removal (P = 0.001), discharge from hospital (P = 0.001), and time off from work (P = 0.001) were significantly longer for Group 1 than for Group 2. There were two recurrences in the inferior part of the suture line in Group 1 and none in Group 2, which showed no statistical difference (P = 0.493). Conclusions The deep intergluteal sulcus and midline gap were slightly flattened over the anococcygeal region. The vacuum effect was decreased, and there were less macerations and fewer infections. Time off from work and discharge time from hospital were shortened by eliminating the moisture effect and reducing complications by lateralizing the lower part of the suture line.     

The role of systemic hypermobility and condylar hypermobility in temporomandibular joint dysfunction syndrome

Objective: To evaluate the risk of temporomandibular joint dysfunction (TMD), when both systemic joint hypermobility (SJH) and localized condylar hypermobility (LCH) exist. Materials and methods: Sixty-four consecutive outpatients with temporomandibular joint clicking or pain, and 77 sex- and age-matched control subjects, were recruited in the study. LCH was diagnosed when condylar subluxation was present, and SJL was diagnosed by using Beightons method. The frequency of symptoms, mean mouth opening, and the frequency of subjects with SJL and LCH were the main outcome measures. Results: Out of the 64 patients, 16 patients were suffering from pain, 20 patients from joint-clicking and 28 patients from both. Both SJH and LCH were more frequently observed in those patients with TMD than in control subjects. The risk of TMD was higher if LCH and SJH existed jointly. Conclusion: Both systemic and localized hypermobility may have a role in the etiology of TMD.     

Anatomic considerations and the relationship between the piriformis muscle and the sciatic nerve

Stating background  The piriformis syndrome is one of the non-discogenics causes of sciatica. It results from the compression of the sciatic nerve (SN) by the piriformis muscle (PM) in the neutral and piriformis stretch test position. The evidence of the increase in pain in the test position requires a detailed anatomical study addressing the changes that occurred in the SN and PM anatomy during the test position. The aim of this study is to examine this relationship morphometrically. Materials and methods  A total of 20 right and left lower limbs of ten adult cadavers were examined. The SN and the PM were made visible. The location of the SN was evaluated with respect to the consistent bony landmarks, including the greater and the lesser trochanter of the femur, the ischial tuberosity, the ischial spine of the hip bone, the posterior inferior iliac spine of the hip bone and the posterior superior iliac spine of the hip bone. The study was done in both neutral and test positions (i.e., 30° adduction 60° flexion and approximately 10° medial rotation position of the hip joint). Results  The width of the greater sciatic notch was 63.09 ± 13.59 mm. The length of the lower edge of the PM was 95.49 ± 6.21 mm, and whereas the diameter of the SN where it emerged from the infrapiriforme was 17.00 ± 3.70 mm, the diameter decreased to 11.03 ± 2.52 mm at the level of the lesser trochanter of the femur. The SN intersected the PM most commonly in its medial second quarter anatomically. The vertical distance between the medial edge of the SN–PM intersection point and the ischial tuberosity was 85.62 ± 17.23 and 72.28 ± 7.56 mm (P < 0.05); the angle between the SN and the transverse plane was 66.36° ± 6.68° and 71.90 ± 8.48° (P < 0.05); and the vertical distance between the medial edge of the SN and the apex of the ischial spine of the hip bone was 17.33 ± 4.89 and 15.84 ± 4.63 mm (P > 0.05), before and after the test position, respectively. Conclusion  This study provides helpful information regarding the course and the location of the SN. The presented morphometric data also revealed that after stretch test position, the infrapiriforme foramen becomes narrower; the SN becomes closer to the ischial spine of the hip bone, and the angle between the SN and the transverse plane increases. This study confirmed that the SN is prone to be trapped in the test position, and diagnosis of this situation requires dynamic MR and MR neurography study.     

The acute effects of acetate-balanced colloid and crystalloid resuscitation on renal oxygenation in a rat model of hemorrhagic shock

IntroductionFluid resuscitation therapy is the initial step of treatment for hemorrhagic shock. In the present study we aimed to investigate the acute effects of acetate-balanced colloid and crystalloid resuscitation on renal oxygenation in a rat model of hemorrhagic shock. We hypothesized that acetate-balanced solutions would be superior in correcting impaired renal perfusion and oxygenation after severe hemorrhage compared to unbalanced solutions.MethodsIn anesthetized, mechanically ventilated rats, hemorrhagic shock was induced by withdrawing blood from the femoral artery until mean arterial pressure (MAP) was reduced to 30 mmHg. One hour later, animals were resuscitated with either hydroxyethyl starch (HES, 130/0.42 kDa) dissolved in saline (HES-NaCl; n = 6) or a acetate-balanced Ringer's solution (HES-RA; n = 6), as well as with acetated Ringer's solution (RA; n = 6) or 0.9% NaCl alone (NaCl; n = 6) until a target MAP of 80 mmHg was reached. Oxygen tension in the renal cortex (CμPO₂), outer medulla (MμPO₂), and renal vein were measured using phosphorimetry.ResultsHemorrhagic shock (MAP = 30 mmHg) significantly decreased renal oxygenation and oxygen consumption. Restoring the MAP to 80 mmHg required 24.8 ± 1.7 ml of NaCl, 21.7 ± 1.4 ml of RA, 5.9 ± 0.5 ml of HES-NaCl (p < 0.05 vs. NaCl and RA), and 6.0 ± 0.4 ml of HES-RA (p < 0.05 vs. NaCl and RA). NaCl, RA, and HES-NaCl resuscitation led to hyperchloremic acidosis, while HES-RA resuscitation did not. Only HES-RA resuscitation could restore renal blood flow back to ～85% of baseline level (from 1.9 ± 0.1 ml/min during shock to 5.1 ml ± 0.2 ml/min 60 min after HES-RA resuscitation) which was associated with an improved renal oxygenation (CμPO₂ increased from 24 ± 2 mmHg during shock to 50 ± 2 mmHg 60 min after HES-RA resuscitation) albeit not to baseline level. At the end of the protocol, creatinine clearance was decreased in all groups with no differences between the different resuscitation groups.ConclusionWhile resuscitation with the NaCl and RA (crystalloid solutions) and the HES-NaCl (unbalanced colloid solution) led to hyperchloremic acidosis, resuscitation with the HES-RA (acetate-balanced colloid solution) did not. The HES-RA was furthermore the only fluid restoring renal blood flow back to ～85% of baseline level and most prominently improved renal microvascular oxygenation.