Transcatheter Aortic Valve Implantation through a Left Aortoiliac Graft

The indications for transcatheter aortic valve implantation have been increasing with the development of new-generation valves and delivery systems. Our patient, an 81-year-old man with aortic stenosis, had an existing coronary artery bypass graft and bilateral aortoiliac bypass grafts. We used the transfemoral approach through the left femoral artery and the left aortoiliac graft to successfully deploy a new-generation Edwards SAPIEN valve.Key words: Aortic stenosis, arterial disease, peripheral, heart valve prosthesis implantation/methods, transcatheter aortic valve implantationTranscatheter aortic valve implantation (TAVI) has emerged as a promising alternative to conventional aortic valve replacement for patients whose severe, symptomatic aortic stenosis is otherwise left untreated due to comorbidities and to the high operative mortality rates associated with open-heart surgery under those circumstances.¹ The first application of this method in human beings was performed in 2002 by Cribier and colleagues.² Today, there are 2 widely used valve types. These are the balloon-expandable Edwards SAPIEN transcatheter valves (Edwards Lifesciences LLC; Irvine, Calif) and the self-expanding CoreValve® valves (Medtronic CV Luxembourg S.a.r.l.; Luxembourg). The first-generation Edwards SAPIEN valve is approved for use in the United States, but the latest generations of both valves are awaiting approval.     

Primary Malignant Melanoma of the Oesophagus

Primary malignant melanoma arising in the oesophagus is a rare condition with a dismal prognosis. The diagnosis is often made following surgical resection even though the endoscopic features may be pathognomonic. The classical treatment is oesophagectomy even though the advanced disease stage at the time of presentation and aggressive biological behaviour of the tumour usually results in a fatal outcome. We report the case of a male patient initially diagnosed with squamous oesophageal carcinoma and treated with conventional neo-adjuvant chemo-radiotherapy. Poor clinical and radiological response resulted in a review of the original histology confirming a diagnosis of primary malignant melanoma of the oesophagus. The subsequent alteration in management conferred the patient an improved quality of life. A short review of the literature on primary malignant melanoma of the oesophagus supplements this case report.     

Validation of the Korean Version of the Oxford Knee Score in Patients Undergoing Total Knee Arthroplasty

Background

Although translated versions of the Oxford Knee Score (OKS) in several languages are available, the absence of a Korean version precludes comparing data from Korea with that from other countries using the OKS.

Questions/purposes

We therefore evaluated the reliability and validity of the adapted Korean version of the OKS.

Methods

We first translated the English version of the OKS into Korean, then back into English, then held expert committee discussions to finalize the Korean version. We then mailed the Korean version of the VAS for pain, OKS, and the previously validated SF-36 to 142 patients who underwent TKAs for knee osteoarthritis. Factor analysis and reliability assessment using the kappa statistic of agreement for each item, the intraclass correlation coefficient, and Cronbach’s alpha were conducted. To determine the subscales of the OKS, we used the factor analysis. We also evaluated concurrent and construct validity by comparing the responses to the OKS with the results of the VAS and SF-36 using Pearson’s correlation coefficient.

Results

All items had a kappa statistic of agreement greater than 0.6. The OKS showed test and retest reliability as follows: OKS, 0.848; Factor 1, 0.867; and Factor 2, 0.819. Internal consistency of Cronbach’s alpha was as follows: OKS, 0.932; Factor 1, 0.907; Factor 2, 0.867. The OKS correlated (r = 0.692) with the VAS. The Korean version of the OKS correlated with the SF-36 total and individual domain (physical functioning, role physical, bodily pain) scores.

Conclusions

The adapted Korean version of the OKS was translated and showed acceptable measurement properties. The data suggest it is suitable for assessing outcomes in Korean-speaking patients having TKAs.     

Effect of bed head elevation during sleep in symptomatic patients of nocturnal gastroesophageal reflux

Background and Aim: Nocturnal gastro‐esophageal reflux causes heartburn and sleep disturbances impairing quality of life. Lifestyle modifications, like bed head elevation during sleep, are thought to alleviate the symptoms of gastroesophageal reflux. We tested the hypothesis that bed head elevation might decrease recumbent acid exposure compared to sleeping in a flat bed. Methods: Patients of symptomatic nocturnal reflux and documented recumbent (supine) reflux verified by esophageal pH test entered the trial. On day 1, baseline pH was measured while the patient slept on a flat bed. Then patients slept on a bed with the head end elevated by a 20‐cm block for the next 6 consecutive days from day 2 to day 7. The pH test was repeated on day 2 and day 7. Each patient acted as his own control. Results: Twenty of 24 (83.3%) patients with mean age of 36 ± 5.5 years completed the trial. The mean (± SD) supine reflux time %, acid clearance time, number of refluxes 5 min longer and symptom score on day 1 and day 7 were 15.0 ± 8.4 and 13.7 ± 7.2; P = 0.001, 3.8 ± 2.0 and 3.0 ± 1.6; P = 0.001, 3.3 ± 2.2 and 1.0 ± 1.2; P = 0.001, and 2.3 ± 0.6 and 1.5 ± 0.6; P = 0.04, respectively. The sleep disturbances improved in 13 (65%) patients. Conclusions: Bed head elevation reduced esophageal acid exposure and acid clearance time in nocturnal (supine) refluxers and led to some relief from heartburn and sleep disturbance.     

Surgical repair of atrial septal defect with severe pulmonary hypertension during pregnancy: a case report with literature review

We are reporting a case of a 37-year-old pregnant woman with a large secundum atrial septal defect with left-to-right shunt and severe pulmonary hypertension. Her atrial septal defect was undiagnosed before this pregnancy. After carefully considering all the options, we repaired her atrial septal defect with an open heart surgical closure at 20 weeks of gestation. A substantial and consistent reduction in pulmonary arterial pressure after the surgery and subsequent uneventful delivery indicate that surgical repair of atrial septal defects is a viable option that should be considered for such patients.     

"The end of good luck'--long-term survival without anticoagulation: a case report and review of the literature

Long-term anticoagulation in patients with metallic prosthetic valve disease is required according to current guidelines. We describe a patient with a functioning mitral mechanical valve without anticoagulation for 27 years. A 46-year-old man admitted to the emergency department with complains of palpitation. The patient had a mitral valve replacement because of severe mitral stenosis. He discontinued warfarin treatment 1 month after surgery because of the unavailability of this drug in Turkey. Transthoracic echocardiography revealed functioning metalic mitral valve with a mean gradient of 9 mm Hg. Fluoroscopy showed normal excursions of the mechanical mitral valve. Transesophageal echocardiography was performed and revealed fresh thrombus formation in the left atrial appendix. Admission international normalized ration (INR) level was 1.79. Due to the higher INR level and long-term survival, genetic analysis of warfarin polymorphism was performed. There was a homozygous mutation in the vitamin K epoxide reductase complex 1 (VKORC1) 1173C>T and 1639G>A genotypes. The possible explanations of long-term survival and baseline higher INR level were linked to the mutation in warfarin metabolism. We also briefly review the literature.     

The effects of aging on the central nervous system steroid profiles and myelin basic protein in rats

The aim of this study was to investigate the effects of aging on the central nervous system steroid and myelin basic protein (MBP) profiles. Forty-seven male Sprague-Dawley rats (newborn, 1, 6, 12 and 24-monthsold) were studied. Tissues were obtained from the cerebellum and parietal, frontal, temporal cortex of the central nervous system of the rats for steroid extraction. The estradiol, progesteron, testosterone and dehydroepiandrosterone (DHEA) levels were measured by Enzyme Linked Immunosorbent Assay (ELISA). The average levels of estradiol (pg/g), progesteron (ng/g), DHEA (ng/g) and testosterone (ng/g) in the brain tissues were respectively 24.29, 4.59, 0.27, 0.92 in the newborn-rats; 4.18 ± 1.10, 1.54 ± 0.30, 0.28 ± 0.01, 0.57 ± 0.10 in the 1 month-old-rats; 11.02 ± 1.10, 2.96 ± 0.30, 0.27 ± 0.01, 0.61 ± 0.10 in the 6 month-old-rats; 15.80 ± 1.10, 4.80 ± 0.30, 0.28 ± 0.10, 0.67 ± 0.10 in the 12 monthold- rats; 20.07 ± 1.10, 4.12 ± 0.30, 0.28 ± 0.01, 0.55±0.10 in the 24 month-old-rats. The myelin basic protein levels were determined by immunohistochemical staining and an elevation was observed in conjunction with the aging process. The results of the study indicate that the alterations in MBP, DHEA, progesterone, testosterone and estrodiol concentrations in the central nervous system of the rats during aging can be considered fundamental for future animal and human studies.     

The detection of sensitivity of proprioception by a new clinical test: The dual joint position test

Objectives

To date, very few studies have paid attention to the joint sense (proprioception) of toes other than the big toe. We evaluated the sensitivity of joint position sense at the joint of the great toe in comparison to other digits, and with that determined by the dual digit stimulation test, in a sample of healthy normal controls and patients with clinical diagnosis of the lemniscal system dysfunction.

Material and methods

Seventy-two patients with lemniscal system dysfunction (55 clinically definitive multiple sclerosis, 17 vasculitis) and 110 healthy volunteers participated in the study. All subjects underwent the joint position sense test of all digits of upper and lower extremities. The position sense resulting from the combined operation of the joints of the second and the fourth digits (simultaneous two digits position sense) was also measured and subsequently compared with the results of the great toe position sense.

Results

Upper extremities: no difference was found in recognition of the position sense in the single digits of the upper extremities between patients and healthy volunteers. There was a significant difference in the dual joint position test of the right upper extremity between patients and the case group (p < 0.05) but not in the left upper extremity. Lower extremities: there was no significant difference in proprioception of the great toe neither in the right and nor in the left side between patients and normal subjects. However, the joint position sense of other single digits was deteriorated in the patients, a difference that was significant compared to normal controls (p < 0.05). Additionally, patients and normal controls displayed a difference in dual digit position sense of the right and left lower extremities (p < 0.05).

Conclusions

We show in this paper that the proprioception of simultaneous dual digits is diminished in patients when compared to a single digit position sense. Moreover, the great toe proprioception is less sensitive than other digits. Taken together, these observations lend evidence for a new clinical method which we named as dual joint position test. We suggest this novel method offers clinical utility to demonstrate lemniscal system dysfunction.     

Variation in surface properties,metabolic capping,and antibacterial activity of biosynthesized silver nanoparticles: comparison of bio-fabrication potential in phytohormone-regulated cell cultures and naturally grown plants

We compared surface properties, metabolic capping and antibacterial activity of silver nanoparticles, synthesized through extracts of cell cultures of Fagonia indica and its naturally grown form. Extracts from cell cultures (produced with thidiazuron (TDZ) or melatonin (MLN)) were compared to the naturally grown whole plant extracts (WPEs) for their reducing potential, and their effects on physical and biochemical properties of the biosynthesized silver nanoparticles. UV-Vis spectroscopy revealed that the surface plasmon resonance peaked at λ = 415 nm for MLN-AgNPs, λ = 430 nm for TDZ-AgNPs and λ = 460–465 nm for WPE-AgNPs. Transmission electron microscopy and energy dispersive X-rays of AgNPs showed that compared to WPE-AgNPs (mean diameter = 22 nm), extracts from MLN- and TDZ-induced cell cultures produced particles with spherical shapes and smaller diameters (i.e. mean diameter = 15 nm and 19 nm, respectively). Size distribution analysis also showed that TDZ-AgNPs were nearer to a symmetric distribution in terms of diameter (skewness = 0.80) as compared to WPE-AgNPs (skewness = 0.9) and MLN-AgNPs (skewness = 1.4). Furthermore, MLN-induced cell culture extracts produced AgNPs in higher concentration (210 μg mL⁻¹) compared to AgNPs from TDZ-induced cell culture extracts (160 μg mL⁻¹) and WPE (138 μg mL⁻¹). Two-way comparisons of LC-MS/MS profiles of TDZ-AgNPs, MLN-AgNPs, and WPE-AgNPs revealed differences in their secondary metabolite profiles, which might account for differences in their differential response in bio-fabrication, and size distribution. Activity against different pathogenic bacterial strains, Escherichia coli, Bacillus cereus, Xanthomonas citri, Agrobacterium tumefaciens, Streptomyces griseus, and Erwinia carotovora suggested that MLN-AgNPs were more effective compared to TDZ- and WPE-AgNPs. These results indicated that phytohormones induced cell cultures can enhance the production, physical and biochemical properties of AgNPs.

We compared surface properties, metabolic capping and antibacterial activity of biosynthesized silver nanoparticles, synthesized through extracts of cell cultures of Fagonia indica and its naturally grown form.