Evaluation of P wave duration and P wave dispersion in adult patients with secundum atrial septal defect during normal sinus rhythm

BACKGROUND: Paroxysmal atrial arrhythmias especially atrial fibrillation (AF) are frequently encountered in adult patients with atrial septal defect (ASD). Previously it was shown that maximum P wave duration and P wave dispersion in 12-lead surface electrocardiograms are significantly increased in individuals with a history of paroxysmal AF. The aim of this study was to determine whether P maximum and P dispersion in adult patients with ASD and without AF are increased as compared to healthy controls. In addition, the relationship of pulmonary to systemic flow ratio (Qp/Qs) and these P wave indices were investigated. METHODS AND RESULTS: Sixty-two consecutive patients [39 women, 23 men; mean age 33+/-13 years (range 16 to 61 years)] with ostium secundum type ASD and 47 healthy subjects [25 women, 22 men; mean age 36.6+/-9.5 years (range 18 to 50 years)] were investigated. P maximum, P minimum and P dispersion (maximum minus minimum P wave duration) were measured from the 12-lead surface ECG. There were no significant differences with respect to age (P=0.08), gender (P=0.3), heart rate (P=0.3), left atrial diameter (P=0.5) and left ventricular ejection fraction (P=0.3) between patients and controls. Pulmonary artery peak systolic pressure was significantly higher in patients with ASD as compared to controls (P<0.0001). P maximum was significantly longer in patients with ASD as compared to controls (P<0.0001). In addition, P dispersion of the patients was significantly higher than controls (P=0.001). P minimum was not different between groups (P=0.12). Mean Qp/Qs of the patients with ASD was 2.5+/-0.7 (minimum 1.5; maximum 4.1) and found to be significantly correlated with P maximum (r=0.34; P=0.006) and P dispersion (r=0.61; P<0.0001). CONCLUSIONS: Prolongation of P maximum and increased P dispersion could represent mechanical and electrical changes of atrial myocardium in patients with ASD. These changes of atrial myocardium may be more prominent with higher left to right shunt volumes.     

Mean Platelet Volume and Exercise Stress Test

BACKGROUND: Long-term moderate or strenuous physical activity is associated with a considerable reduction in cardiovascular morbidity and mortality. However acute exercise leads to a transient activation of the thrombotic system. Healthy individuals can react this by increasing their fibrinolytic capacity acutely. However, patients with ischemic heart disease, lacking fibrinolytic potential, may be at considerable risk for acute ischemic events if exposed to heavy physical exertion. Platelet size has been shown to reflect platelet activity. The mean platelet volume (MPV) can reflect changes in either the level of platelet stimulation or rate of platelet production. DESIGN AND METHODS: We evaluated Treadmill exercise test (TMET) and compared MPV values (fl) before and after TMET in 63 consecutive patients who, then, underwent coronary angiography and found to have significant coronary artery disease in more than one coronary artery (>70% diameter stenosis in left anterior descending, right coronary or circumflex artery and >50% diameter stenosis in left main coronary artery). Sixty-three male patients were enrolled as a patient group with a mean age of 52.43 +/- 4.08 years and with strongly positive exercise test (> or =2 mm ST segment depression, horizontal or down-sloping). Thirty-five patients without significant coronary artery disease were selected as a control group with a mean age of 52.66 +/- 4.39 years having undergone TMET. RESULTS AND DISCUSSION: In the patient and control groups, mean MPV values before TMET were the same, 8.52 +/- 0.63 and 8.45 +/- 0.58 respectively. Following TMET within 30 minutes, mean MPV were 10.03 +/- 0.96 and 8.50 +/- 0.45 respectively ( p < 0.001). When pre and post-TMET MPV values were evaluated together, the patient group had a significant increase in the MPV ( p < 0.001), whereas, the control group had no significant increase in the MPV ( p = 0.379). It was concluded that exercise possibly makes patients with significant coronary artery disease, more susceptible to a thrombotic event through various routes, one of that is platelet activation that could be measured indirectly via MPV. Healthy subjects react this thrombotic process by increasing their fibrinolytic capacity acutely. Patients with ischemic heart disease, particularly those with significantly narrowed coronary arteries, known to lack fibrinolytic capacity and have high shear stress, on the other hand, might face ischemic events, including sudden death following acute exercise.     

Role of mean platelet volume in triagging acute coronary syndromes

Background: Acute coronary syndromes, characterized by the rupture of unstable plaque and the subsequent thrombotic process involving platelets, have been increasing in relative frequency. The central role of platelet activation has long been noticed in this pathophysiology; hence, many therapies have been directed against it. In this study, we have aimed to search prospectively the value of mean platelet volume (MPV), which is a simple and accurate measure of the functional status of platelets, in patients hospitalized with diagnosis of acute coronary syndromes (ACS). Materials and methods: A total of 216 consecutive patients (156 male, 60 female) hospitalized with the diagnosis of non-ST segment elevation (NSTE) ACS within the first 24 h of their chest pain were enrolled. One hundred and twenty patients, matched according to sex and age, with stable coronary heart disease (CHD) (85 male, 35 female) were enrolled as a control group. Patients were classified into two group: those with unstable angina (USAP, n = 105) and those with non-ST segment elevation myocardial infarction (NSTEMI, n = 111). Results: MPVs were 10.4 +/- 0.6 fL, 10 +/- 0.7 fL, 8.9 +/- 0.7 fL consecutively for NSTEMI, USAP and stable CHD with significant differences. Patients with ischemic attacks in the first day of hospitalization accompanied by >0.05 mV ST segment shift had significantly higher MPV compared to those without such attacks (P = 0.001). Multivariable logistic regression analysis yielded that MPV (P = 0.016), platelet count (P < 0.001), and the presence of >0.05 mV ST segment depression at admission (P = 0.002) were independent predictors of development of NSTEMI in patients presenting with NSTE ACS. Conclusion: In patients presenting with NSTE ACS, higher MPV, though there are overlaps among subgroups, indicates not only more risk of having NSTEMI but also ischemic complications.     

Tryptophan degradation and neopterin levels in treated rheumatoid arthritis patients

Increased kynurenine/tryptophan—reflects trytophan degradation—and neopterin levels have been regarded as a biochemical marker of cell-mediated immune response and inflammation. This study was designed to evaluate the usefulness of tryptophan degradation and neopterin levels in active rheumatoid arthritis patients under therapy. In this case–control study, kynurenine and tryptophan levels were determined by HPLC; neopterin and tumor necrosis factor-α levels were measured with ELISA in 32 active rheumatoid arthritis patients and 20 healthy controls. Although mean values of tryptophan, kynurenine, ratio of kynurenine to tryptophan, neopterin, and tumor necrosis factor-α levels did not show statistically significant differences between patient and control groups, neopterin levels correlated positively with kynurenine (r = 0.582, p < 0.02), kynurenine/tryptophan (r = 0.486, p < 0.05), erythrocyte sedimentation rate (r = 0.472, p < 0.05) and RF (r = 0.478, p < 0.05) in the rheumatoid arthritis group. CRP levels of the patient group correlated with kynurenine levels (r = 0.524, p < 0.03). Determination of tryptophan degradation and neopterin levels in chronic inflammatory disease may provide a better understanding of progression of the disease.     

Management of the axilla with sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer: A single-center study

The neoadjuvant chemotherapy (NAC) is the gold standard initial treatment of the locally advanced breast cancer (LABC). However, the reliability of methods that used to assess response the NAC is still controversial. In this study, patients with LABC who underwent NAC were evaluated retrospectively. The assessment of response to NAC and the effect of axillary approach were investigated on LABC course.The study comprised 94 patients who received NAC with an LABC diagnosis between 2008 and 2020. In our center, magnetic resonance imaging, ultrasonography, and ¹⁸ F-flouro deoxyglucose positron emission tomography/computed tomography, and, for some patients, fine-needle aspiration biopsy of suspicious axillary lymph nodes have been performed to assess the effects of NAC. Patients with positive hormone receptor status received adjuvant hormonotherapy, and those with human epidermal growth factor receptor 2 gene expression were treated with trastuzumab. Adjuvant radiotherapy was applied to all patients undergoing breast conserving surgery. Radiotherapy was applied to the peripheral lymphatic areas in the clinical N1 to N3 cases regardless of the response to NAC.The clinical response to the NAC was found that partial in 59% and complete in 19% of the patients. However, 21.2% of the patients were unresponsive. The mean of lymph nodes that excised with the procedure of sentinel lymph node biopsy (SLNB) was 2.4 (range 1–7). In 22 of the 56 patients who underwent SLNB, axillary dissection (AD) was added to the procedure upon detection of metastasis in frozen section examinations. There was no difference between the SLNB and AD groups regarding overall survival (OS; P = .472) or disease-free survival (DFS) rates (P = .439). However, there were differences in the OS (P < .05) and DFS (P = .05) rates on the basis of the LABC histopathological subtypes.The study found that a relationship between molecular subtypes and LABC survival. However, the post-NAC axillary approach had no effect on OS or DFS. Therefore, multiple imaging and interventional methods are needed for the evaluation of NAC response. In addition, morbidity can be avoided after AD by the use of SLNB in cN0 patients.     

Potential neuroprotective effect of Anakinra in spinal cord injury in an in vivo experimental animal model

Objective:

To evaluate the therapeutic effects of inhibiting interleukin-1 beta (IL-1β) in vivo using Anakinra in an experimental model of spinal cord injury (SCI).

Methods:

All experimental procedures were performed in the animal laboratory of Ankara Education and Research Hospital, Ankara, Turkey between August 2012 and May 2014. The SCI was induced by applying vascular clips to the dura via a 4-level T5-T8 laminectomy. Fifty-four rats were randomized into the following groups: controls (n = 18), SCI + saline (n = 18), and SCI + Anakinra (n = 18). Spinal cord samples were obtained from animals in both SCI groups at one, 6, and 24 hours after surgery (n = 6 for each time point). Spinal cord tissue and serum were extracted, and the levels of IL-1β, malondialdehyde, glutathione peroxidase, superoxide dismutase, and catalase were analyzed. Furthermore, histopathological evaluation of the tissues was performed.

Results:

The SCI in rats caused severe injury characterized by edema, neutrophil infiltration, and cytokine production followed by recruitment of other inflammatory cells, lipid peroxidation, and increased oxidative stress. After SCI, tissue and serum IL-1β levels were significantly increased, but were significantly decreased by Anakinra administration. Following trauma, glutathione peroxidase, superoxide dismutase, and catalase levels were decreased; however, Anakinra increased the activity of these antioxidant enzymes. Malondialdehyde levels were increased after trauma, but were unaffected by Anakinra. Histopathological analysis showed that Anakinra effectively protected the spinal cord tissue from injury.

Conclusion:

Treatment with Anakinra reduces inflammation and other tissue injury events associated with SCI.Post-traumatic inflammatory reactions may play an important role in the secondary injury processes that occur after spinal cord injury (SCI).1,2 New treatment strategies like Anakinra aim to block or attenuate the critical mediators of inflammation in ischemia and reperfusion damage after spinal cord injuries. Primary traumatic mechanical injury to the spinal cord may cause neuronal death with irreversible recovery or regeneration. Neurons continue to die for several hours after SCI; however, this neuronal death could potentially be prevented. A large number of biochemical, and molecular cellular interactions result in secondary neuronal death. One of these interactions is the local inflammatory response in the injured spinal cord. It is thought that microglial cells might be the source of cytotoxic cytokines such as tumor necrosis factor alpha (TNF-α) and interleukin-1 beta (IL-1β), which kill oligodendrocytes. Within one hour after SCI, increased synthesis, and/or secretion of IL-1β, is detectable at the injury site. Interleukin-1β is a member of the IL-1 cytokine family. The gene encoding this cytokine, and 8 other IL-1 family genes, form a cytokine gene cluster on chromosome 2.3 The mentioned cytokine is produced due to the activation of macrophages as a proprotein; the active form is produced secondary to the proteolytic action of caspase 1. The IL-1β is an important mediator of the inflammatory response, and is involved in a variety of cellular activities including cell proliferation, differentiation, and apoptosis.3 Anakinra is shown as an IL-1 receptor antagonist blocking the inflammation and cartilage degradation effects of naturally occurring IL-1 in rheumatoid arthritis, by competitively inhibiting the binding of IL-1 to the IL-1 type receptor.4 The IL-1 is produced in response to inflammatory stimuli and mediates various physiological responses including inflammatory and immunological reactions. In patients with rheumatoid arthritis, the natural IL-1 receptor antagonist is not found in sufficient concentrations in the synovium and synovial fluid to counteract the elevated IL-1 concentrations. Anakinra is considered a “biological response modifier” rather than a “disease-modifying antirheumatic drug” because it is able to selectively target the pathological elements of the disease.5 For this study, we determined the following endpoints of the inflammatory response: 1) histological damage, 2) cytokine expression (IL-1β), and 3) measurement of lipid peroxidation and oxidative stress (glutathione peroxidase [GPx], malondialdehyde [MDA], and superoxide dismutase [SOD]).6 The aim of the present study was to evaluate whether Anakinra administration could protect the spinal cord from lipid peroxidation and oxidative stress after SCI in rats.     

Monitoramento dos efeitos da raquianestesia sobre a saturação de oxigênio cerebral em pacientes idosos com o uso de espectroscopia de luz próxima ao infravermelho

Objective

Central blockage provided by spinal anaesthesia enables realization of many surgical procedures, whereas hemodynamic and respiratory changes influence systemic oxygen delivery leading to the potential development of series of problems such as cerebral ischemia, myocardial infarction and acute renal failure. This study was intended to detect potentially adverse effects of hemodynamic and respiratory changes on systemic oxygen delivery using cerebral oxymetric methods in patients who underwent spinal anaesthesia.

Methods

Twenty‐five ASA I–II Group patients aged 65–80 years scheduled for unilateral inguinal hernia repair under spinal anaesthesia were included in the study. Following standard monitorization baseline cerebral oxygen levels were measured using cerebral oximetric methods. Standardized Mini Mental Test (SMMT) was applied before and after the operation so as to determine the level of cognitive functioning of the cases. Using a standard technique and equal amounts of a local anaesthetic drug (15 mg bupivacaine 5%) intratechal blockade was performed. Mean blood pressure (MBP), maximum heart rate (MHR), peripheral oxygen saturation (SpO₂) and cerebral oxygen levels (rSO2) were preoperatively monitored for 60 min. Pre‐ and postoperative haemoglobin levels were measured. The variations in data obtained and their correlations with the cerebral oxygen levels were investigated.

Results

Significant changes in pre‐ and postoperative measurements of haemoglobin levels and SMMT scores and intraoperative SpO₂ levels were not observed. However, significant variations were observed in intraoperative MBP, MHR and rSO2 levels. Besides, a correlation between variations in rSO2, MBP and MHR was determined.

Conclusion

Evaluation of the data obtained in the study demonstrated that post‐spinal decline in blood pressure and also heart rate decreases systemic oxygen delivery and adversely effects cerebral oxygen levels. However, this downward change did not result in deterioration of cognitive functioning.     

A practical approach to imaging characteristics and standardized reporting of COVID-19:A radiologic review

Novel coronavirus (2019-nCoV),also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2),is a pathogen that has caused a rapidly spreading pandemic all over the world.The primary mean of transmission is inhalation with a predilection for respiratory system involvement,especially in the distal airways.The disease that arises from this novel coronavirus is named coronavirus disease 2019 (COVID-19).COVID-19 may have a rapid and devastating course in some cases leading to severe complications and death.Radiological imaging methods have an invaluable role in diagnosis,follow-up,and treatment.In this review,radiological imaging findings of COVID-19 have been systematically reviewed based on the published literature so far.Radiologic reporting templates are also emphasized from a different point of view,considering specific distinctive patterns of involvement.