Abnormal left ventricular relaxation and symptoms of heart failure

Objectives

The purpose of our study was to assess the echocardiographic and angiographic parameters in patients with symptomatic heart failure (HF) and mild diastolic dysfunction (grade I).

Background

It remains uncertain why some patients with mild diastolic dysfunction exhibit HF symptoms and others are asymptomatic.

Methods

The study enrolled 80 hospitalized patients with impaired left ventricular (LV) relaxation. Patients were divided into two groups; one group had chronic functional class II to III dyspnea and the other group had no symptoms of HF. After admission, echocardiography and coronary angiography were performed for all patients and LV systolic and diastolic parameters were compared between the two groups.

Results

More patients in the asymptomatic group were hypertensive (p-value: 0.012). However, coronary artery disease was more prevalent in symptomatic patients (p-value: 0.022). The LV ejection fraction (EF) was significantly lower in symptomatic patients [median 54.33 %, 95 % confidence interval (53.76–54.87 %) in asymptomatic patients and median 49.43, 95 % confidence interval (47.23–50.91 %) in symptomatic patients, p-value <0.001]. Furthermore, the systolic LV internal dimension was significantly larger in this group (p-value: 0.037). The results of logistic regression identified that only the absolute level of the LVEF was the negative determinant of the occurrence of HF in patients with impaired LV relaxation.

Conclusion

Our study showed that LV systolic performance has an important role in occurrence of HF symptoms in patients with grade I diastolic dysfunction.

     

Premedication during micturating cystourethrogram to achieve sedation and anxiolysis

Micturating cystourethrogram (MCUG) is an imaging technique indicated in the diagnosis and follow-up of many diseases. We investigated the reliability and the efficacy of midazolam and chloral hydrate in sedation and anxiolysis during micturating cystourethrogram. Fifty-three children of similar ages (39 girls, 14 boys, mean age of 5.8±3.5 years) were randomized to midazolam (n=17), chloral hydrate (n=18) and control groups (n=18). Oral midazolam 0.6 mg/kg or chloral hydrate 25 mg/kg or saline were administered to the study groups 15–30 min prior to the urinary catheterization. Brietkopf and Buttner, Frankl and Houpt scales and Spielbergers State Anxiety Inventory and parents impressions were used to assess the level of sedation and anxiety. The Brietkopf and Buttner classification of emotional status and Houpt behavior rating scale demonstrated a significantly better emotional status and sedation in the midazolam group when compared to controls (P=0.01 and P=0.018, respectively). The catheterization was described as a more unpleasant and distressing event by the parents of the control and the chloral hydrate groups when compared to the parents of the midazolam group (P<0.05). Bladder capacity and frequency of detection of residual urine were not statistically different between the three study groups (P>0.05). Vital signs did not change significantly in any child. Sedation with midazolam does not have adverse effects on the results of micturating cystourethrogram, while it reduces the discomfort in children undergoing this radiological technique.This paper was presented as an oral poster at the Thirteenth Congress of the International Pediatric Nephrology Association.     

Traumatic avulsion of knee joint

The report describes complete avulsion of knee joint en bloc, from the confines of the soft tissues of the leg but the patient was able to show full range of motion at his ankle and foot with palpable dorsalis paedis and posterior tibial vessels. Arthrodaesis was the best available management option.     

Risk factors for stroke following coronary artery bypass operations

BACKGROUND: Although the overall complication rates have been decreased significantly in recent years, stroke rates still remain high in patients undergoing coronary bypass operations. This study is designed to evaluate the risk factors for stroke in patients who had undergone coronary artery bypass surgery in an 8-year period in our clinic. METHODS: Between 1995 and 2003, 8547 coronary artery operations under cardiopulmonary bypass were performed. Retrospective analysis of the patient files revealed that 75 (0.9%) patients had stroke in the early postoperative period. RESULTS: Mean age of these patients was 62.3 +/- 9.5 years, and 54 (72%) were males. Stroke rate was 1.2% between 1995 and 1998 and this was significantly higher from the stroke rate (0.7%) of the period 1998 to 2003 (p = 0.03). Major technical differences between these two periods were the routine application of preoperative carotid arteries Doppler evaluation and intraoperative epiaortic echocardiography after 1998. Higher age (p = 0.000), female sex (p = 0.005), smoking (p = 0.03), presence of diabetes mellitus (p = 0.01), hypertension (p = 0.008), and left main coronary artery disease (p = 0.001), carotid surgery (p = 0.000), and peripheral vascular disease (p = 0.049) were identified as important risk factors in univariate analysis for stroke development. Higher age (p = 0.000; OR = 21.38), left main coronary artery disease (p = 0.007; OR = 7.26), peripheral vascular disease (p = 0.050; OR = 3.08), and operation date before 1998 (p = 0.012; OR = 6.33) were identified as important risk factors in logistic regression analysis. According to intraoperative epiaortic ultrasonography, operative strategy was changed in 9% of patients. Thirty-seven (49.3%) of the stroke patients died. Female sex (p = 0.023; OR = 5.18) and preoperative hypertension (p = 0.045; OR = 4.03) were observed as significant risk factors for mortality after stroke. CONCLUSION: Development of stroke is one of the major reasons of mortality after coronary artery bypass operations. It is essential to take all the measures to prevent this complication, especially in patients with known risk factors. Evaluation of carotid arteries prior to operation and application of routine intraoperative epiaortic echocardiography may in part eliminate stroke.     

Individualization of the biopsy protocol according to the prostate gland volume for prostate cancer detection

PURPOSE: In this study we assessed the relative yield of 10 core biopsy, and the whole range of alternative 8 and 6 core biopsy protocols over that of the classic sextant biopsy protocol. We determined the optimum number of cores per biopsy according to prostate volume in patients who experienced prostate biopsy for the first time. MATERIALS AND METHODS: A total of 503 men with the indications of abnormal digital rectal examination and/or serum prostate specific antigen greater than 2.5 ng/ml were included in the study. All patients underwent a 10 core biopsy protocol with an additional 1 core from each suspicious area detected by transrectal ultrasound. Prostate volume was divided into quartiles, namely 14.9 to 35, 35.1 to 50, 50.1 to 65 and 65.1 to 150 cc. The optimum number of biopsy cores was determined in patients with different prostate volumes. RESULTS: Median age was 63 years and prostate specific antigen was 7.4 ng/ml in the whole group. Of 503 patients 159 (31.6%) were positive for prostate cancer. Cancer detection rates decreased significantly from 49.6% to 20.8% as prostate volume increased in preset quartiles. Lesion biopsies revealed the lowest unique cancer detection rates for all prostate volume quartiles (0% to 3%). There was an obvious positive trend in cancer detection rates in favor of the 10 core biopsy protocol over sextant biopsies in all patient groups. Classic sextant biopsy protocol proved to be inadequate for all prostate volumes. Among sextant biopsy protocols laterally placed cores including the apex, lateral mid gland and lateral base had the best cancer detection rates (81% to 95%). The 8 core biopsy scheme consisting of the apex, mid gland, lateral mid gland and lateral base resulted in an only 1% lower detection rate (97%) than the 10 core biopsy protocol in the lowest quartile. The yield of the 10 core biopsy protocol in patients with a prostate volume of between 35.1 and 150 cc outscored that of the optimal 8 core biopsy scheme including the apex, base, lateral mid gland and lateral base with 3% to 8% differences in the cancer detection rate. CONCLUSIONS: The 10 core biopsy protocol must be used in all group of patients except patients with a prostate volume of 14.9 to 35 cc. In patients with a prostate volume of 14.9 to 35 cc the 8 core biopsy protocol consisting of the apex, mid gland, lateral mid gland and lateral base can be used since it revealed results similar to those of the 10 core biopsy protocol. The classic sextant biopsy protocol seemed inadequate for all prostate volumes. Patients with a larger prostate had lower cancer detection rates. Transrectal ultrasound directed lesion biopsies may be omitted when using 10 core biopsy protocols since the yield of these biopsies was less than 2%.     

Approach to fragmented central venous catheters

Prolonged venous access devices are needed in cancer patients for central venous access. Catheter fragmentation leading to catheter malfunction represents a rare problem. Herein we present our experience in the management of fragmented catheters. Between 2001 and 2003, 183 catheters were placed via the subclavian vein, and five cases of fragmented catheters were observed. Fragments were removed by an Amplatz gooseneck snare (Microvena, St. Paul, MN) with angiographic intervention. The diagnosis of the breakage was made by chest radiography. The incidence of catheter breakage was 2.7%. All fragments were removed by the snare, without any complications. Catheter narrowing and breakage owing to its medial positioning in the subclavian vein were the main causes of catheter malfunction. In any case of catheter malfunction, radiologic evaluation of the catheter must be done to rule out its rupture. Removal of the fragments using the Amplatz snare is a safe and easily applied procedure.     

Intestinal lymphangiectasia in children: A favorable response to dietary modifications

Intestinal lymphangiectasia (IL) is a rare disease characterized by dilatation of intestinal lymphatics. It can be classified as primary or secondary according to the underlying etiology. The clinical presentations of IL are pitting edema, chylous ascites, pleural effusion, acute appendicitis, diarrhea, lymphocytopenia, malabsorption, and intestinal obstruction. The diagnosis is made by intestinal endoscopy and biopsies. Dietary modification is the mainstay in the management of IL with a variable response. Here we report 2 patients with IL in Bahrain who showed positive response to dietary modification.Intestinal lymphangiectasia (IL) is a rare1-4 benign disease characterized by focal or diffuse dilation of the mucosal, submucosal, and subserosal lymphatics.2,5 In addition to being an important cause of protein losing enteropathy (PLE),6 IL is frequently associated with extraintestinal lymphatic abnormalities.5 Depending on the underlying pathology IL can be classified as primary or secondary disease.1,2,4,5 Primary IL (PIL) probably represents a congenital disorder of mesenteric lymphatics.1,3 The IL can be secondary to diseases like constrictive pericarditis, lymphoma, sarcoidosis, and scleroderma.1 A secondary disorder should always be ruled out before labeling IL as primary, this is by testing for proteinuria, rheumatic, neoplastic, and parasitic infection.1,3 Recently, a functional form of PIL with typical endoscopic and pathological findings but without clinical symptoms has been reported.3 The clinical presentations of IL are pitting edema, chylous ascites, pleural effusion, acute appendicitis, diarrhea, lymphocytopenia, malabsorption, and intestinal obstruction.1,2,4 Palliative treatment with lifelong dietary modification is the most effective and widely prescribed therapy.6 Limiting the dietary fat intake reduces chyle flow and therefore, protein loss.1 Once protein level is within the normal range, recurrence of enteric protein loss can be prevented by total parenteral nutrition (TPN) and medium chain triglycerides (MCT).1 In cases of secondary IL, treating the underlying primary disorder may be curative.2 Although the therapeutic approach for this disorder have gained a lot of attention lately, few studies have considered the therapeutic effects, nutritional condition, and long-term results in PIL patients.4 Here, we report 2 patients with PIL who were diagnosed by endoscopy and biopsy, and showed positive response to dietary modifications. We present these particular cases to highlight the effect of dietary modifications on the clinical status of patients with IL.