Late saphenous vein graft occlusion in patients with coronary bypass: possible role of aspirin resistance

BACKGROUND: Late venous graft thrombosis, leading to recurrent ischemia, is frequently encountered in old, degenerated vein grafts with advanced atherosclerotic plaque formation. Aspirin has been indicated to maintain venous graft patency in the post-operative period. However, there is considerable evidence that aspirin resistance is of concern in patients with venous grafts. MATERIAL AND METHOD: Prospectively enrolled 14 patients (11 male, 3 female, Group 1), who were shown to have at least one occluded saphenous vein graft on their late control coronary angiogram after bypass operation, were compared for the presence of aspirin resistance by PFA-100 with age- and sex-matched 14 patients (10 male, 4 female, Group 2), who were found patent and well-functioning vein grafts without wall irregularities on late post-operative coronary angiograms (mean 6.5+/-2.5 years), enrolled as a control group. RESULTS: Mean CT of collagen/epinephrine cartridge in Group 1 was 197+/-85 s and significantly less than in Group 2 (279+/-44 s; p=0.011). It was found that 50% of patients in Group 1 were so-called aspirin resistant, whereas in Group 2, this ratio was 7.1% (p=0.033). BMI (p=0.038, Beta=-0.322), uric acid level (p=0.023, Beta=-0.355), and CT by collagen/epinephrine cartridge (p=0.008, Beta=0.431) were independently predicting late occlusion of saphenous vein graft. CONCLUSION: Aspirin resistance is highly prevalent in patients with occluded venous grafts at a relatively late period.     

Sjogren’s syndrome associated with bilateral peripheral facial paralysis

Sjogren’s Syndrome (SS) is a chronic autoimmune disorder that may be complicated by neurological dysfunctions. The involvement of cranial nerves in SS was described as a very rare complication. Moreover, bilateral peripheral facial paralysis associated with SS has been described only in 3 patients in the literature and the first case was described by Henrik Sjogren himself in 1935. We report a 59-year-old female with bilateral peripheral facial paralysis associated with Sjogren’s syndrome. She was treated with 5-day IVIG consecutively and continued oral methylprednisolone 16mg/day and almost fully recovered at 2 months of follow-up examination. Acute bilateral peripheral facial palsy in SS is a very rare condition and Lyme disease, Guillain-Barré syndrome, HIV infection, and central nervous system lymphoma should be considered in the differential diagnosis. As a result, SS should be considered as an underlying cause of bilateral facial paralysis.

Sjögren’s Syndrome (SS) is a systemic chronic autoimmune and vasculitic disorder characterized by lymphocytic infiltration of lacrimal and salivary glands.¹ In 39% of the affected cases, the disease can start with neurological findings. The most common peripheral involvement of SS is sensory neuropathies.²Peripheral facial paralysis associated with primary SS has been described in very few cases, and most of them were unilaterally affected.³ Only three had bilateral facial nerve involvement.⁴ Here, we described a patient with SS, who presented with bilateral facial nerve involvement.     

Chronic hepatitis B associated with hepatic steatosis,insulin resistance,necroinflammation and fibrosis

BackgroundThe effect of hepatitis B virus (HBV) infection on fatty liver disease is unclear.ObjectivesThe aim of this study was to investigate the viral and host causes of fatty liver in chronic hepatitis B (CHB) patients. This study included 88 CHB patients of which 17 were not treated. Liver biopsy was performed in each patient. Group 1 included those with hepatic steatosis (n=28) and group 2 those without hepatic steatosis. The groups were compared in terms of age, body mass index (BMI), Homeostasis Model Assessment- Insulin Resistance (HOMA-IR), viral load, biochemical parameters and histological findings. Patients in group 1 were subdivided according to the degree of steatosis as follows: grade 1 (15 patients, 53.6%), grade 2 (6 patients, 21.4%), and grade 3 (7 patients, 25%).ResultsIn group 1 (n=28), mean age, BMI, cholesterol, and HOMA-IR were found to be significantly higher than in group 2 (n=60). There were no significant differences in the positivity of viral load, HbeAg, treatment, fibrosis and other laboratory parameters between the two groups. HOMA-IR was the only independent predictive factor of liver steatosis in patients with CHB in logistic regression analysis.ConclusionHepatic steatosis in CHB patients was associated with host metabolic factors.     

Effects of dietary acids on surface microhardness of various tooth-colored restoratives

The aim of this in vitro study was to investigate if surface microhardness of Fuji IX GP, Vitremer, Dyract AP, and Prodigy is influenced by conditioning in aqueous solutions of lactic, orthophosphoric, citric, and acetic acids against bidistilled water (which was used as control). The pH values of acids used in this study were representative of dietary acids. All specimens were stored in bidistilled water for one week and then conditioned in the respective test solutions for another week. Citric (p<0.05) and acetic acids reduced, while lactic and orthophosphoric acids (p<0.05) increased the microhardness of both Fuji IX GP and Vitremer. On the other hand, microhardness of both Dyract AP and Prodigy was significantly reduced by all acidic media (p<0.05). The observed differences in the surface microhardness of various tooth-colored restorative materials conditioned in several media varied not only with the pH but also the nature of the acidic solution, and with the composition of the evaluated material.     

Vena cava superior syndrome due to sternal plasmacytoma in the course of systemic myeloma

Here we present a patient with multiple myeloma course. The first clinical manifestation was superior vena cava syndrome due to a huge sternal plasmocytoma. The patient was treated with a combination of high dose radiotherapy and autologous peripheral blood stem cell transplantation. We suggest careful evaluation of these patients with respect to aggressive therapy.     

Metabolic syndrome is associated with extension of coronary artery disease in patients with non-ST segment elevation acute coronary syndromes

BACKGROUND: Metabolic syndrome (MS) comprises a group of factors that are associated with increased risk for cardiovascular events. Acute coronary syndromes account for the most important part of cardiovascular events with considerable morbidity and mortality. We aimed to investigate the association of MS with extension of coronary artery disease in patients presenting with non-ST segment elevation (NSTE) acute coronary syndromes (ACS). METHODS: Three hundred and six consecutive patients (220 men, 86 women patients) with the diagnosis of NSTE ACS, who were hospitalized within the first 24 h of their chest pain in the coronary care unit, were prospectively enrolled into our study. Patients with elevation of troponins (T or I) were classified as NSTE myocardial infarction (MI) and otherwise as unstable angina pectoris (USAP). Components of MS were noted as previously identified. Coronary angiograms were evaluated by two authors, who were blinded to the study plan and each other, via Sullivan's method. RESULTS: MS was noted in 49% of all patients, and was significantly more common in women than in men (62.8 versus 43.6%, P=0.003). The mean total stenosis score of patients with MS was significantly higher than for those without MS (16+/-6 versus 12+/-5, P<0.001), and the mean extension score of patients with MS was significantly higher than for those without MS (63+/-29 versus 44+/-26, P<0.001). The presence of MS together with some clinical factors and poor total cholesterol/high-density lipoprotein cholesterol ratio, hypertension and diabetes mellitus, was found to be independently predictive of extension of coronary artery disease (CAD) in a group of patients presenting with NSTE ACS. CONCLUSIONS: MS is independently associated with CAD extension, and hence, might account for poor cardiovascular outcomes through CAD extension in patients with NSTE ACS.     

Metabolic syndrome increases the risk of significant coronary artery involvement in patients with peripheral artery disease

BACKGROUND: Peripheral artery disease is a common condition, mainly associated with clinical cardiovascular risk factors. Patients with peripheral artery disease suffer from coronary artery disease-related complications. On the other hand, metabolic syndrome, as a constellation of specific risk factors, represents a risk factor for cardiovascular mortality. Metabolic syndrome might increase the risk of significant coronary artery disease in patients with peripheral artery disease. We aimed to examine the association of metabolic syndrome with the angiographically shown coronary artery involvement in patients with peripheral artery disease. METHODS: Two hundred and forty-seven patients with peripheral artery disease (mean age 60+/-9.5 years, 223 men/24 women), who were referred to coronary angiography, were evaluated. The resting ankle-brachial pressure index was measured with the patient in supine position. Patients with >70% diameter stenosis were considered to have significant coronary artery disease. RESULTS: In all, there were 223 male/24 female patients with mean ankle-brachial pressure index of 0.7+/-0.2, and mean age of 60+/-9.5 years. Metabolic syndrome was present in 53% (n=131) of all patients. Significant coronary artery disease was more frequently encountered in patients with peripheral artery disease and metabolic syndrome than in those without metabolic syndrome (73.3 vs. 40.5%, P<0.001). The presence of metabolic syndrome increased the risk of having significant coronary artery disease in patients with peripheral artery disease by 4.027 fold. Lower ankle-brachial pressure index (P=0.038, B=2.567), older age (P<0.001, B=1.075), presence of metabolic syndrome (P=0.015, B=2.247), and presence of diabetes mellitus (P<0.001, B=1.293) were found to be independent predictors of significant coronary artery disease in patients with peripheral artery disease in multivariable regression. CONCLUSION: Metabolic syndrome seems to increase the risk of significant coronary artery disease in patients with peripheral artery disease.     

Fistulous connection between internal mammary graft and pulmonary vasculature after coronary artery bypass grafting: a rare cause of continuous murmur

A 58-year-old male who had undergone coronary artery bypass grafting (CABG) using left internal mammary artery and a sequential saphenous vein graft 2 years ago presented with new onset angina. His initial physical examination revealed an unexpected continuous murmur over the left sternal border, and two-dimensional echocardiography has failed to identy the cause. Cardiac catheterization then performed and revealed patent left internal mammary artery and saphenous vein grafts. Besides, selective injection of the left internal mammary artery graft also showed a fistula formation between left internal mammary artery graft and pulmonary vasculature of the left upper lobe. He was managed conservatively because of the severely diseased left anterior descending artery distal to internal mammary artery anastomosis and low pulmonary artery pressure. The development of fistulous connection between internal mammary artery and pulmonary vasculature is an extremely rare complication following CABG. Patients with such fistulae usually present with chest pain due to coronary steal syndrome. A new heart sound, especially a continuous murmur, may be detected during physical examination. Surgical correction is indicated in the event of refractory angina, growing fistula causing heart failure or endarteritis. Otherwise, a conservative approach with instruction of the patient for prophylactic precautions of subacute bacterial endocarditis may be recommended for asymptomatic patients.