Percutaneous coronary intervention after fibrinolysis: a multiple meta-analyses approach according to the type of strategy.

OBJECTIVES: We performed a meta-analysis of randomized trials that enrolled ST-segment elevation myocardial infarction patients treated with fibrinolysis to assess the potential benefits of: 1) rescue percutaneous coronary intervention (PCI) versus no PCI; 2) systematic and early (< or =24 h) PCI versus delayed or ischemia-guided PCI; 3) fibrinolysis-facilitated PCI versus primary PCI alone. BACKGROUND: The impact of PCI strategies after fibrinolysis on mortality or reinfarction remains to be established. METHODS: The meta-analysis was performed using the odds ratio (OR) as the parameter of efficacy with a random effect model. Fifteen randomized trials (5,253 patients) were selected. The primary end point was mortality or the combined end point of death or reinfarction. RESULTS: Rescue PCI for failed fibrinolysis reduced mortality (6.9% vs. 10.7%) (OR, 0.63; 95% confidence interval [CI], 0.39 to 0.99; p = 0.055) and the rate of death or reinfarction (10.8% vs. 16.8%) (OR, 0.60; 95% CI, 0.41 to 0.89; p = 0.012) compared with a conservative approach. Systematic and early PCI performed during the "stent era" led to a nonsignificant reduction in mortality compared with delayed or ischemia-guided PCI (3.8% vs. 6.7%) (OR, 0.56; 95% CI, 0.29 to 1.05; p = 0.07) and to a 2-fold reduction in the rate of death or reinfarction (7.5% vs. 13.2%) (OR, 0.53; 95% CI, 0.33 to 0.83; p = 0.0067). This benefit contrasted with a nonsignificant increase in the rate of both mortality (5.5% vs. 3.9%, p = 0.33) or death or reinfarction (9.6% vs. 5.7%, p = 0.06) observed in the "balloon era." Fibrinolysis-facilitated PCI was associated with more reinfarction as compared with primary PCI alone (5.0% vs. 3.0%) (OR, 1.68; 95% CI, 1.12 to 2.51; p = 0.013) without significant impact on mortality (OR, 1.30; 95% CI, 0.92 to 1.83; p = 0.13). CONCLUSIONS: Our findings support rescue PCI and systematic and early PCI after fibrinolysis. However, the current data do not support fibrinolysis-facilitated PCI in lieu of primary PCI alone.     

Relationships between weight loss and circulating cytokines in patients with Alzheimer's disease

106 consecutive patients with Alzheimer's disease living in the community were examined in a memory clinic from a neurological department. They were screened for weight loss over the last 2 years. Age, duration of the disease, behavioral disorders, mini mental status examination, body mass index were recorded. Tumor necrosis factor alpha (TNFalpha), interleukin-1beta (IL-1beta), interleukin 6 (IL-6) and interleukin 2 (IL-2) blood levels were measured. Weight loss was reported in 42.5% of the patients. TNFalpha levels were significantly higher in these patients (18.8 versus 15.8 pg/mL; p=0.04) than in patients without weight loss. Weight loss was also associated with a lower MMSE score (16.9 versus 19.3; p=0.03), current pacing (20% versus 1.6%; p=0.002), and hallucinations (20.0% versus 3.3%; p=0.008). The levels of the other cytokines did not differ between the patients with and without weight loss. Our findings suggest an association between high levels of circulating TNFalpha and unexplained weight loss in Alzheimer's disease.     

Diffuse large and small bowel necrosis in catastrophic antiphospholipid syndrome

The catastrophic variant is an accelerated form of the antiphospholipid syndrome resulting in multiorgan failure because of multiple small vessel occlusions. We report a case of catastrophic antiphospholipid syndrome in a patient with subacute cutaneous lupus erythematosus and ischemic bowel, who presented with acute abdominal pain due to diffuse right colon and small bowel necrosis requiring large resection, associated with acute respiratory distress syndrome, thrombocytopenia and disseminated intravascular coagulation. Histopathological examination of resected tissues showed diffuse arteriolar and venous thrombosis but no vasculitis, and mesenteric artery lumen severely narrowed by intimal fibrosis. The patient died 15 days after admission despite treatment with anticoagulation, steroids, continuous hemofiltration and plasma exchange. Ischemic bowel and diffuse intestinal necrosis may be secondary to the antiphospholipid syndrome, and a high level of suspicion and an early diagnosis are required.     

Posterior leaflet preservation in mitral valve prolapse: a new approach to mitral repair

The most common repair technique for P2 prolapse is quadrangular resection of the posterior leaflet associated with a plication of the mitral annulus or with a sliding plasty. Although effective, these techniques do not respect the anatomy of the mitral valve, especially the physiological role of the posterior leaflet. Herein is described another technique which does not include P2 removal, thus preserving the posterior leaflet mobility. This technique represents a new approach to mitral valve repair that respects the motion of the two leaflets, allowing a more physiological opening of the mitral valve.     

Relationship of circulating biomarkers of inflammation and hemostasis with preclinical atherosclerotic burden in nonsmoking hypercholesterolemic men

BACKGROUND: Relations of mediators of inflammation and hemostasis with preclinical atherosclerosis have been poorly analyzed. The aim of this study was to test potential associations of these blood markers with indicators of cardiovascular risk and atherosclerotic burden in asymptomatic, nonsmoking, hypercholesterolemic men. METHODS: A total of 87 men underwent cardiovascular risk assessment by means of 10-year Framingham risk calculation (median 9%) and atherosclerotic burden evaluation by means of ultrasonographic measurement of common carotid intima-media thickness and assessment of atherosclerotic plaques at three arterial sites (three-site plaques). RESULTS: Of the markers C-reactive protein, tumor necrosis factor-alpha, interleukin-10, factor VIIc, fibrinogen, plasminogen activator inhibitor-activator, soluble intercellular adhesion molecule-1, soluble P-selectin (sP-selectin), and von Willebrand factor, only sP-selectin was positively and independently associated with high Framingham risk score (>9%) (71.7 +/- 3.6 ng/mL, n = 33 v 59.6 +/- 2.8, n = 54; mean +/- SEM; P < .05) and with three-site plaques (75.4 +/- 5.7 ng/mL, n = 14 v 62.0 +/- 2.5, n = 73; P < .05). After adjustment for all of the above markers and for cardiovascular risk factors, odd ratios of having high Framingham risk and three-site plaques were 3.38 (1.43 to 10.21) and 5.23 (1.74 to 23.52) respectively, per 1-standard deviation increase in sP-selectin. CONCLUSIONS: These results confirm that among several hemostasis and inflammation mediators, only sP-selectin blood level was associated with preclinical atherosclerosis. It might confer to sP-selectin measurement a clinical usefulness for detecting and managing high cardiovascular risk in primary prevention.     

Is High Job Strain Associated With Hypertension Genesis?

BACKGROUND: The aim of this analysis was to test, in a large sample of normotensive subjects, the short-term influence of job strain on the onset of hypertension. METHODS: According to the questionnaire of Karasek et al, job strain was divided into four modalities: (high strain, low strain, passive, and active) based on job demand (eg, the need to work hard and quickly) and job latitude (eg, control over skill use, time allocation, and organizational decisions) scores. High strain (HS) was defined by a high demand and a low job decision latitude. Individual data obtained in 926 (age 41 +/- 6 years) healthy normotensive or newly diagnosed hypertensive subjects were analyzed. Subjects participated in two prospective work site surveys designed to assess the influence of job strain on hypertension development. Relationships between job strain modalities and work site blood pressure (BP) levels were assessed using a general linear model. A complementary analysis using the the Pearson Phi coefficient (Z analysis) was implemented to explore nonlinear or scattered relationships between job strain and onset of hypertension. RESULTS: Systolic BP (SBP) was linearly related significantly to BMI and alcohol consumption, whereas diastolic BP (DBP) was related to age. The linear model did not find any relationship between SBP or DBP and job strain modalities. Using the Z analysis, development of systolic hypertension (SBP >140 mm Hg) was significantly associated with high job strain (P < .001). CONCLUSIONS: Our results suggest that there is no global relationship between job strain and BP levels. However our methodology revealed a significant association between job strain and work site BP in a predominantly male subgroup of newly diagnosed hypertensive subjects exposed to high job strain.     

Endoscopic management of post-laparoscopic cholecystectomy biliary strictures. Long-term outcome in a multicenter study

OBJECTIVES: The aim of this retrospective study was to assess the long term results of long-lasting endoscopic stenting for benign biliary strictures related to laparoscopic cholecystectomy. Additional biological and morphological data were collected from these patients during follow-up. METHODS: Patients undergoing ERCP for post-laparoscopic cholecystectomy biliary stricture in one of the three participating centers between 1990 and December 2001 were identified. Only patients with successful endoscopic stenting were subsequently included and analyzed. Follow-up data were obtained from referring centers, general practitioners and patients or relatives. Hepatic blood tests and abdominal ultrasound were proposed to all the patients who had not undergone further treatments after stent removal. RESULTS: Eight-eight patients had undergone ERCP for benign biliary stricture related to laparoscopic cholecystectomy. Stenting failed in 19 patients. Balloon dilatation alone was used in four patients. Strictures were successfully stented in 65 patients. The mean number of stents inserted at the same time was 1.6. The mean duration of stenting was 14 months (range 1-120 months). Eighteen patients (28%) developed biliary or pancreatic symptoms during stenting. ERCP was considered satisfactory at the end of stenting (i.e. no remaining stricture or minor remaining change on ERCP) in 45 patients (69%). Twenty-two patients were lost to follow-up. Twenty-nine out of forty-three patients (67%) remained symptom-free with normal updated blood tests and abdominal ultrasound during a mean follow-up of 28 months (range 12-117 months) after stent removal. None of the patients with a normal ERCP at the end of stenting developed stricture recurrence during follow-up. Eleven patients were operated (8 with persistence of stricture, 2 for stricture recurrence up to 63 months after stent removal, 1 for pancreatitis). CONCLUSION: Based on clinical, morphological and biological criteria, a long-term success was obtained in 70% of patients with post-laparoscopic cholecystectomy benign biliary strictures, after several months of endoscopic stenting.     

Predictive factors for masked hypertension within a population of controlled hypertensives

CONTEXT: Prevalence of masked hypertension (MH) is far from negligible reaching 40% in some studies. The SHEAF study (Self measurement of blood pressure at Home in the Elderly: Assessment and Follow-Up) and others clearly showed that masked hypertension (MH) as detected by home blood pressure measurement (HBPM) is associated with poor cardiovascular prognosis. OBJECTIVE: Systematic HBPM to detect MH is not yet routine. The aim of this work is to better define the clinical profile of masked hypertensives within a population with controlled office blood pressure (BP) and the factors associated with a higher prevalence of MH. MATERIALS AND METHODS: BP was measured at the clinic by the doctor and at home by the patient himself. Risk factors for MH were analysed in a cohort of 1150 treated hypertensive patients over the age of 60 (mean age 70 +/- 6.5, 48.9% men) with controlled office BP. (SBP < 140 mmHg and DBP < 90 mmHg). RESULTS: 463 patients (40%) were masked hypertensives (SBP > or = 135 mmHg or DBP > or = 85 mmHg at home). Three parameters were associated with MH (odds ratio OR): office SBP (OR = 1.110), male gender (OR = 2.214) and age (OR = 1.031). Decision trees showed a 130 mmHg SBP was an efficient threshold to propose HBPM with a higher probability to detect MH. Subsequent variables were male gender and age over 70 in males. CONCLUSION: To detect masked hypertension, it would be logical to first of all select patients whose office SBP is between 130 and 140 mmHg.