Advances in the Management of Coronary Chronic Total Occlusions

Chronic total occlusions (CTOs) have been called “the last frontier” of percutaneous coronary intervention (PCI) due to traditionally low success rates and high risk for restenosis and re-occlusion. Recent advances in equipment and crossing techniques have significantly increased CTO PCI success rates while maintaining low risk of complications. Specifically, the retrograde approach and controlled antegrade dissection and re-entry in conjunction with advanced guidewires and microcatheters have significantly improved procedural success rates. Moreover, the introduction of the “hybrid” approach has created a unified framework for operators to approach CTOs in a systematic and efficient fashion. Finally, drug-eluting stents, especially second generation, have improved long-term patency after CTO PCI.     

Update in the Percutaneous Management of Coronary Chronic Total Occlusions

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been rapidly evolving during recent years. With improvement in equipment and techniques, high success rates can be achieved at experienced centers, although overall success rates remain low. Prospective, randomized-controlled data regarding optimal use and indications for CTO PCI remain limited. CTO PCI should be performed when the anticipated benefit exceeds the potential risk. New high-quality studies of the clinical outcomes and techniques of CTO PCI are needed, as is the expansion of expert centers and operators that can achieve excellent clinical outcomes in this challenging patient and lesion subgroup. In the current review the authors summarize the latest publications in CTO PCI and provide an overview of the current state of the field.     

Lipid profile in Egyptian patients with coronary artery disease

BackgroundNo data are available about plasma lipid profile in Egyptians with coronary artery disease (CAD). Plasma lipid profile may differ according to ethnic origin and geographic area.ObjectivesIdentify plasma lipid abnormalities in Egyptians with CAD and define the role of age, type of CAD, and the presence of hypertension (HT) on lipid profile.MethodsRetrospective consecutive sampling of lipid profile of 1000 patients with CAD. Results were compared to a control group of 1920 non-coronary individuals.ResultsPatients’ age range was 19–90 years. HT was present in 56.7% of patients. The commonest isolated lipid abnormality was a reduced HDL-C in men and increased plasma triglycerides (TG) in women. Patients with myocardial infarction (MI) had a lower HDL-C than those with angina pectoris (AP). Abnormalities were more severe and more prevalent in the young age group. No significant difference in lipid profile was present between normotensive (NT) and hypertensive (HT) CAD patients.ConclusionDyslipidemia is common among Egyptians with CAD. Lipid profile was influenced by age, gender, type of CAD, but not by the presence of HT. The high prevalence rate of risk factors particularly among young Egyptians is remarkable and can explain the epidemic of CAD among Egyptians.     

Relationship between cortisol increment and basal cortisol: implications for the low-dose short adrenocorticotropic hormone stimulation test

BACKGROUND: We analyzed the low-dose (1 microg) rapid adrenocorticotropic hormone test (LDST) in 17 patients with a normal hypothalamic-pituitary-adrenal axis to determine reference intervals for the LDST on the basis of poststimulation cortisol increments. METHODS: We analyzed test results for 17 patients (14 females and 3 males; age range, 18-46 years) who had received a 2-mL aliquot of low-dose (1 microg) adrenocorticotropic hormone prepared from one 250-microg vial of Synacthen diluted in 500 mL of sterile normal saline solution. Sampling took place at 0, 20, 30, and 60 min post stimulation. The cortisol increment was plotted against basal cortisol. RESULTS: We observed a marked interdependence of the basal cortisol concentration with the increase in cortisol concentration. The relationship was inverse and linear with the best fit observed at 30 min post stimulation. The lower 95% prediction limit for basal cortisol at the zero increment was 400 nmol/L with a mean concentration of 600 nmol/L. CONCLUSIONS: We propose that a peak cortisol concentration <400 nmol/L is a sufficient single criterion for abnormal adrenal function as assessed by the LDST. Concentrations of 400-600 nmol/L are in the gray area, and those >600 nmol/L confirm normal adrenal function. Repeat analyses with larger sample sizes are warranted to confirm these observations.     

Stickiness prior to setting of some light cured resin-composites.

OBJECTIVES: To describe and evaluate a method for deriving a laboratory measure of stickiness, and to compare a set of dental resin-composites by this procedure. MATERIALS AND METHODS: Twelve commercial resin composites were selected. Each material was placed in a cylindrical mold (phi=6.1 x 2.2 mm(2) depth) held either at 23 or at 37 degrees C. A flat-ended stainless-steel instrument was placed onto the surface of the unset sample with a force 350 g. After 2s it was moved vertically at 2 cm/s. This caused a sticky composite to be elevated to a maximum height between 0.2 and 1.8 mm until detachment from the instrument occurred. The elevated material was immediately solidified by light curing at 600 mW/cm(2) for 40s. These elevated profiles were mapped for both height and projected area of elevation. An instrument was constructed for this purpose in our laboratories. Both the projected heights and areas were evaluated as potential measures of stickiness. One-way ANOVA and Duncan's multiple range test were used for statistical analysis. RESULTS: Projected heights ranged from 0.2 to 1.8 mm and projected areas of elevation ranged from 4.0 to 23.9 mm(2). The greatest values were found for microfine anterior composites (Silux plus, Filtek A110). There was a significant difference (p<0.05) between the material (SX) with the highest stickiness and all of the others. The set of profile height and area values were found to be strongly correlated (r(2)=0.9600). SIGNIFICANCE: Once inserted and the load removed, the ideal material stays in place. This is generally assisted by an increase in viscosity and a decrease in stickiness. The stickiness test described is original and may prove to be useful as a standard test method for characterizing the handling stickiness of resin composite materials.     

Neutrophilic myositis as a manifestation of celiac disease: a case report

A 42-year-old white man presented with recurrent attacks of muscle pain and swelling. Clinically, he looked like he had severe pyogenic infection. He failed to respond to multiple courses of wide-spectrum antibiotics. Repeated cultures from muscle lesions and from the blood were negative. Hospital course was very hectic and life threatening at times. Upon further questioning, the patient gave a history of frequent loose-bowel movements for many years. A duodenal biopsy with villous blunting and positive antiglidin antibodies confirmed the diagnosis of celiac disease. The patient had complete recovery and remained in remission on a gluten-free diet.     

Predictors of improvement in left ventricular ejection fraction with carvedilol for congestive heart failure

BACKGROUND: Beta-blocker therapy has been reported to improve survival and left ventricular ejection fraction (LVEF) in the setting of congestive heart failure (CHF). The magnitude and predictors of improved LVEF are unclear. METHODS: A total of 295 patients were enrolled in the study. Inclusion criteria were LVEF <35% at baseline and symptomatic (New York Heart Association class II to IV) CHF despite treatment with at minimum an angiotensin-converting enzyme inhibitor. Carvedilol was initiated at 3.125 mg twice daily and titrated to a target dose of 25 or 50 mg twice daily, depending on the patient's weight. Paired pretreatment baseline and 9 months with treatment follow-up quantitative LVEFs (assessed by resting radionuclide ventriculograms) were obtained in 161 (55 %) of the patients. RESULTS: LVEF improved from 25% +/- 6% at baseline to 36%+/-12% at follow-up (P<.001). Mean change in LVEF (deltaLVEF) was greater for nonischemic cardiomyopathy (NICM) (+14.5+/-2 LVEF points) than ischemic cardiomyopathy (deltaLVEF +/- 7.6+/-10 EF points, P = .001). The deltaLVEF was > or =21 LVEF points in 30% of the NICM group versus 10% of the ischemic cardiomyopathy group. Conversely, the deltaLVEF was unchanged to minimally improved (< or =5 LVEF points) in 21% of the NICM group versus 52% of the ischemic cardiomyopathy group. Multivariable analysis identified NICM and recent onset of congestive heart failure as correlates of improved LVEF. CONCLUSIONS: Carvedilol significantly improved LVEF, especially in patients with NICM and those with recent onset of CHF.