Off-pump coronary artery bypass in multi-vessel disease: effect of ejection fraction on early and midterm mortality and morbidity

AIM: Left ventricular function is an independent predictor of operative mortality. The outcome of myocardial revascularization is greatly affected by the severity of impairment of cardiac function. The present study was undertaken to find the early and midterm mortality and morbidity among patients with different degrees of myocardial function undergoing off-pump bypass. METHODS: Hundred and forty two patients with isolated coronary revascularization were divided into three groups according to left ventricle ejection fraction (LVEF). Forty eight patients with LVEF<30% (group I), 48 patients with LVEF between 30-40% (group II), and 46 patients with LVEF >40% (group III). Clinical, operative and post operative outcome were compared. Patients were followed up to find midterm survival and control of symptoms. RESULTS: The mean age for the patients observed was 56.5+/-9.8 years. Preoperative predicted mortality according to euroSCORE was much higher in group I due to high incidence of preoperative heart failure and recent myocardial infarction. The extent of coronary vessel involvement was similar among the three groups, but those in group III had more single vessel disease. The number of grafts performed per patient was lowest in group I (1.7+/-0.6) and highest in group III (2.0+/-0.6) P=0.03. Overall hospital mortality was 4.2%.The mean euroSCORE of patients who died was 18.7+/-22.5. All in-hospital mortality was among patients who belonged to the high risk group I, 6 (12.5%). Morbidity was similar among all groups. The incidence of myocardial infarction, atrial fibrillation, and acute renal failure were slightly higher in group I; 95.6% of patients were followed up for 7-69 months (mean 27.6+/-17.6). The incidence of angina in group I, II, and III was 20%, 6.5%, and 2.2%. Symptomatic heart failure was seen in 17.5% in group I, 6.5% in group II, and 2.2% in group III. Cardiac interventions among group I, II, III was 12.5%, 4.3% and 2.3% respectively. Redo coronary artery bypass CABG was higher in group II (4.3%) compared to 2.5% in group I. Late mortality was similar among all groups. CONCLUSION: Off-pump bypass can be used safely among patients with different degrees of myocardial function. The results of surgery were better than the preoperative predicted euroSCORE. Early mortality and morbidity were directly related to ejection fraction .This is true only when LVEF is below 30%. Midterm mortality was similar among different risk groups.     

Effects of testosterone on erectile function: implications for the therapy of erectile dysfunction

Sexual potency declines with age, as does the efficiency of erection. Many studies show that different patterns of erectile dysfunction (ED), varying from occasional inability to obtain a full erection, impairment throughout intercourse and total absence of erectile response, might not be triggered by psychological factors only. Recent research indicates that ED relies on organic causes, and has challenged the development of new therapies. One therapeutic approach in patients who have testosterone deficiency is based on androgen therapy. Thus, we reviewed data on testosterone-induced effects relative to erectile function, summarizing the results from studies reported in 1991-2006 on testosterone therapy in patients with ED and hypogonadism, with a special focus on men not responding to phosphodiesterase-5 (PDE-5) inhibitors. We searched several computerized databases parallel with printed bibliographic references. Many studies have established animal models, which confirm that testosterone is important in modulating the central and peripheral regulation of ED. Testosterone deprivation has a strong negative impact on the structure of penile tissues and erectile nerves, which can be prevented by androgen administration. Combined therapy regimens with PDE-5 inhibitors and testosterone might improve ED in patients with hypogonadism of different causes. Thus, androgen treatment in hypogonadic patients, including those unresponsive to PDE-5 inhibitors, often results in an improvement of ED. Testosterone therapy is safe and convenient, while rapidly correcting low testosterone levels.     

A healthy infant with bloody tears: Case report and mini-review of the literature

A 4-month old healthy infant was brought by her parents to the emergency department with bloody tears of three days duration. There was also intermittent yellowish discharge since birth and a history of flu-like symptoms a week prior to presentation. Extensive investigations revealed no infection or other possible etiologies. The patient was treated with antibiotic eye drops and her condition resolved within a three-four days.In the literature, 15 cases with haemolacria of undermined source were reviewed; the median age of onset (12?years), bilateral involvement and female gender were more commonly encountered, and the most common associated illnesses were headache and epistaxis. The condition is self-limiting and spontaneous resolution is seen in majority of cases. Idiopathic haemolacria is a rare condition that can be presumed in patients presenting with bloody tears when all work-up turns to be negative. The condition is self-limiting with spontaneous resolution.     

Using Neuroleptics to Treat Delirium in Dying Cancer Patients at a Cancer Center in Saudi Arabia

Neuroleptics are commonly used for treating delirium as a common problem in terminally ill cancer patients. However, prescribing patterns are believed to substantially vary among health professionals. The aim of this study is to determine the pattern of prescribing neuroleptics for treating delirium in cancer patients dying in a palliative care unit in Saudi Arabia. We reviewed the medical records of adults with advanced cancer who died in the palliative care unit over 23 months. In addition to patients’ demographics, data collection included the pattern of prescribing neuroleptics for the treatment of delirium during the last week of life. For the 271 patients included (57.6% females), the median age was 54 years. Although 62% of patients were on around-the-clock (ATC) neuroleptics to treat delirium, about two thirds of these were requiring rescue doses (PRN [pro re nata]) as well. The ATC neuroleptics included haloperidol alone (89.3%), levomepromazine alone (2.4%), or both (8.3%). All neuroleptics were administered via the parenteral route. On average, the maximum daily doses of the ATC neuroleptics were 4 mg for haloperidol and 15.5 mg for levomepromazine. Patients with primary or metastatic brain cancers were less likely to be on neuroleptics (P < .0001). The authors conclude that in their palliative care unit, haloperidol is by far the most commonly used neuroleptic, followed by levomepromazine, to treat the common problem of delirium in patients dying with advanced cancer. The generally low doses of neuroleptics required may be attributed to several factors in this population, including cultural motives.     

General joint frailty model for recurrent event data with a dependent terminal event: Application to follicular lymphoma data

Many biomedical studies focus on delaying disease relapses and on prolonging survival. Usual methods only consider one event, often the first recurrence or death. However, ignoring the other recurrences may lead to biased results. The whole history of the disease should be considered for each patient. In addition, some diseases involve recurrences that can increase the risk of death. In this case, the death time may be dependent on the recurrent event history. We propose a joint frailty model to analyze recurrences and death simultaneously. Two gamma-distributed frailties take into account both the inter-recurrences dependence and the dependence between the recurrences and the survival times. We estimate separate parameters for disease recurrent event times and survival times in the joint frailty model to distinguish treatment effects and prognostic factors on these two types of events. We show how maximum penalized likelihood estimation can be applied to semiparametric estimation of the continuous hazard functions in the proposed joint frailty model with right censoring. We also propose parametrical approach. We evaluate the model by simulation studies and illustrate through a study of patients with follicular lymphoma.     

Protective role of CXC receptor 4/CXC ligand 12 unveils the importance of neutrophils in atherosclerosis

The CXC ligand (CXCL)12/CXC receptor (CXCR)4 chemokine-receptor axis controls hematopoiesis, organ development, and angiogenesis, but its role in the inflammatory pathogenesis of atherosclerosis is unknown. Here we show that interference with Cxcl12/Cxcr4 by a small-molecule antagonist, genetic Cxcr4 deficiency, or lentiviral transduction with Cxcr4 degrakine in bone marrow chimeras aggravated diet-induced atherosclerosis in apolipoprotein E-deficient (Apoe-/-) or LDL receptor-deficient (Ldlr-/-) mice. Chronic blockade of Cxcr4 caused leukocytosis and an expansion of neutrophils and increased neutrophil content in plaques, associated with apoptosis and a proinflammatory phenotype. Whereas circulating neutrophils were recruited to atherosclerotic lesions, depletion of neutrophils reduced plaque formation and prevented its exacerbation after blocking Cxcr4. Disrupting Cxcl12/Cxcr4 thus promotes lesion formation through deranged neutrophil homeostasis, indicating that Cxcl12/Cxcr4 controls the important contribution of neutrophils to atherogenesis in mice.     

Lack of suppression of insulin secretion by hyperinsulinemia in a patient with an insulinoma

The regulation of insulin secretion in patients with insulinoma is known to be abnormal. For example, physiological and pharmacological stimuli often fail to stimulate insulin in such patients. Recently, insulin has been found to inhibit its own secretion in normal subjects. To determine if insulin has this effect in patients with insulinoma, we infused insulin at rates of 1 and 10 mU/kg X min in such a patient and in eight normal subjects. Euglycemia was maintained by the euglycemic glucose clamp technique, and endogenous insulin secretion was estimated by measuring plasma C-peptide levels. In the normal subjects, plasma C-peptide declined from 1.60 +/- 0.22 (+/- SEM) to 1.16 +/- 0.17 and 0.82 +/- 0.11 ng/ml during the low and high dose insulin infusions, respectively, indicating 27% (P less than 0.01) and 48% (P less than 0.001) decreases in endogenous insulin secretion at moderately elevated and extremely elevated insulin levels, respectively. In the insulinoma patient, plasma C-peptide was 2.6 ng/ml basally, did not change during the low dose insulin infusion, and rose to 3.4 ng/ml during the high dose insulin infusion. We conclude that the feedback regulation of insulin secretion by insulin that occurs in normal subjects is absent in insulinoma patients. This finding could have pathophysiological and possibly diagnostic significance.