A single coronary artery from the right sinus of valsalva associated with atherosclerosis

Anomalous origin of the main coronary arteries from the aorta is rare. We report a case with a single coronary artery from the right sinus of Valsalva associated with atherosclerosis.The patient was treated with a coronary artery bypass procedure: left internal mammary artery (LIMA) to the left anterior descending artery (LAD), right internal mammary artery (RIMA) to the right coronary artery (RCA).The postoperative course was uneventful.     

Risk factors associated with changes in oxygenation and pulse rate during colonoscopy.

BACKGROUND/AIMS: Although hypoxemia is a relatively common complication of colonoscoy, the possible predictive factors of oxygen desaturation and tachycardia in patients undergoing this procedure are not well known. In this study, the possible predictive factors of severe oxygen desaturation (SaO2<90%) and tachycardia in patients with undergoing colonoscopy were investigated. METHODS: A total of 79 consecutive patients were evaluated in the study (46 men and 33 women). Significant oxygen desaturation was considered to be a reduction of arterial oxygen saturation (SaO2) to less than 90%. Tachycardia was defined as a heart rate above 100/min. Patients with inadequate colonoscopy were excluded from the study. The incidence of arterial hemoglobin oxygen desaturation and changes of heart rate during colonoscopy were evaluated and clinical factors in relation to these findings were assessed. RESULTS: The SaO2 during colonoscopy fell below 90% in 19 of the 79 patients (24.1%). The risk factors for desaturation were advanced (>60yr) age (OR: 6.03; 95% CI, 1.35-26.99), receiving sedation (OR: 11.42; 95% CI, 2.05-63.49), chronic lung disease (OR: 4.54; 95% CI and 1.40-11.68), and obesity (OR: 8.95; 95% CI, 1.17-68.55). The presence of hypertension and anemia, a history of cigarette smoking and duration of the colonoscopy had no significant effect on arterial oxygen desaturation (p>0.05). The pulse rate was raised above 100/min during colonoscopy in 26 of 79 patients (32.9%). lncrease in heart rate was found to be related to arterial oxygen desaturation (OR: 13.72; 95% CI, 2.67-70.32), anemia (OR:6.17; 95% CI, 1.15-32.91) and advanced (>60 yr) age (OR: 6.08; 95% CI, 1.62-22.81). Gender, sedation, obesity, hypertension, chronic lung disease and smoking did not affect the heart rate (p>0.05). Two patients had transitional bradyarrythmia, which had no relationship with the parameters studied. There was no incidence of significant hypoxia or change in heart rate which might have caused termination of the procedure. CONCLUSIONS: Benign and transient arterial oxygen desaturation and tachycardia may occur during colonoscopy procedure. Sedation, obesity, advanced age and chronic lung disease might contribute to these adverse events.     

Debulking prior to stenting--a worthwhile effort?

The rationale of debulking prior to stenting is to improve acute and long-term results of complex lesion angioplasty by reduction of plaque burden and/or reduction of calcified material prior to stenting, thus, allowing subsequent optimized stent-implantation and expansion. There are several registries analyzing the effect of various debulking-strategies prior to stenting in groups of selected patients and in high-risk subgroups. The majority of these studies performed DCA prior to stenting. In summary, these studies showed a reduction in restenosis rates and need for reintervention at long-term follow-up. The total TLR-rate (PCI, CABG) during a mean follow-up of 6 to 14 months is reported to be 4 to 14%; the rate of restenosis is given as 7 to 14%. However, until now, no large scale randomised "debulking prior to stenting" versus "conventional stenting without debulking" study has been published in detail. Several studies suggest benefit for debulking prior to stenting in complex lesion subsets, e.g., total chronic occlusions, ostial lesions, bifurcation lesions and saphenous vein grafts, but as of now, no convincing strategy has evolved.     

Absolute levels and ratios of proinflammatory and anti-inflammatory cytokine production in vitro predict clinical immunity to Plasmodium falciparum malaria

The relationship between malaria-related outcomes and cytokine production in whole blood cultures associated with cellular immune responses and immunity to Plasmodium falciparum malaria was examined in a study in southern Ghana. Production of malaria-specific interferon (IFN)-gamma was associated with reduced risk of fever and clinical malaria. Protective IFN-gamma responses were induced by live schizonts but not by dead parasites. Production of malaria-specific tumor necrosis factor (TNF)-alpha was associated with reduced risk of fever during follow-up. Baseline levels of TNF-alpha and phytohemagglutinin (PHA)-induced interleukin (IL)-10 were positively associated with hemoglobin concentration. IL-12 production was associated with reduced risk of parasitemia. PHA-induced transforming growth factor-beta production was associated with reduced risk of fever during follow-up. High ratios of proinflammatory to anti-inflammatory cytokines were associated with increased risk of fever and higher hemoglobin concentrations. Thus, absolute levels and ratios of proinflammatory and anti-inflammatory cytokines influence susceptibility to infection, clinical disease, and anemia. These data contradict data from cross-sectional clinical studies and indicate a need for detailed analysis of the relationship between cellular immunity to malaria and resistance to disease.     

Association Between Diastolic Dysfunction and Health Status Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement

ObjectivesThe aim of this study was to assess the association of baseline left ventricular diastolic dysfunction (LVDD) with health status outcomes of patients undergoing transcatheter aortic valve replacement (TAVR).BackgroundAlthough LVDD in patients with aortic stenosis is associated with higher mortality after TAVR, it is unknown if it is also associated with health status recovery.MethodsIn a cohort of 304 patients with interpretable echocardiograms, undergoing TAVR, LVDD was categorized at baseline as absent (grade 0), mild (grade 1), moderate (grade 2), or severe (grade 3). Disease-specific health status was assessed using the 12-item Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OS) at baseline and at 1-month and 12-month follow-up. Association of baseline LVDD with health status at baseline and follow-up after TAVR was assessed using a linear trend test, and association with health status recovery (change in KCCQ-OS) was examined using a linear mixed model adjusting for baseline KCCQ-OS.ResultsTwenty-four (7.9%), 54 (17.8%), 186 (61.2%), and 40 (13.2%) patients had LVDD grades of 0, 1, 2, and 3, respectively. Baseline KCCQ-OS was 61.3 ± 22.7, 51.0 ± 26.1, 44.7 ± 25.7, and 44.4 ± 21.9 (p = 0.004) in patients with LVDD grades of 0, 1,2 and 3. At 1 and 12 months after TAVR, LVDD was not associated with KCCQ-OS. Recovery in KCCQ-OS after TAVR was substantial and similar in patients across all severities of LVDD.ConclusionsAlthough LVDD is associated with health status prior to TAVR, patients across all severities of LVDD have similar recovery in health status after TAVR.     

Novel TSHR mutations in consanguineous families with congenital nongoitrous hypothyroidism

Objective Nonsyndromic autosomal recessively inherited nongoitrous congenital hypothyroidism (CHNG) can be caused by mutations in TSHR, PAX8, TSHB and NKX2‐5. We aimed to investigate mutational frequencies of these genes and genotype/phenotype correlations in consanguineous families with CHNG. Design Because consanguinity in individuals with a presumptive genetic condition is often an indicator of an autosomal recessive inheritance and allows firmer correlations to be established between genotype and phenotype, we planned to execute our study in consanguineous families. Patients Hundred and thirty‐nine children with CHNG phenotype born to consanguineous families. Measurements First, we investigated cases for evidence of linkage to the four known CHNG genes by microsatellite marker analysis. Mutation analysis by direct sequencing was then performed in those cases in whom linkage to the relevant candidate gene could not be excluded. In addition, in silico analysis of the predicted structural effects of TSHR mutations was performed and related to the mutation‐specific disease phenotype. Results Homozygous germline TSHR mutations were detected in six families (5%), but no mutations were detected in PAX8, TSHB and NKX2‐5. Four of TSHR mutations had not previously been described. Genotype–phenotype correlations were established and found to be related to the predicted structural effects of the mutations. Conclusions Known causative genes account for the development of CHNG only in a minority of cases, and our cohort should provide a powerful resource to identify novel causative genes and to delineate the extent of locus heterogeneity in autosomal recessively inherited CHNG.     

Laparoscopic pancreatic surgery: a review of present results and future prospects

Pancreatic surgery is still associated with a relatively high morbidity and mortality compared with other specialties. This is a result of the complex nature of the organ, the difficult access as a result of the retroperitoneal position and the number of technically challenging anastomoses required. Nevertheless, the past two decades have witnessed a steady improvement in morbidity and a decrease in mortality achieved through alterations of technique (particularly relating to the pancreatic anastomoses) together with hormonal manipulation to decrease pancreatic secretions.Recently minimally invasive pancreatic surgery has been attempted by several centres around the world which has stimulated considerable interest in this approach. The majority of the cases attempted have been distal pancreatectomies, because of the more straightforward nature of the resection and the lack of a pancreatic ductal anastomosis, but more recently reports of laparoscopic pancreaticoduodenectomy have started to appear.The reports of the series to date have been difficult to interpret and although the results are claimed to be equivalent or better than those associated with a traditional approach a careful examination of the literature and comparison with the best results previously reported does not presently support this. In the present review we examined all the reports of pancreatic procedures performed laparoscopically and compared the results with those previously achieved at open surgery.     

Use of the Brucella IgM and IgG flow assays in the serodiagnosis of human brucellosis in an area endemic for brucellosis

The clinical utility of two complementary tests for brucellosis, the Brucella IgM and IgG flow assays, was evaluated in a hospital in eastern Turkey. The results show that the flow assays are convenient diagnostic tests for use in endemic areas. A positive result in the flow assays was obtained in 91% and 97% of the admission sera from adult and pediatric patients with brucellosis, respectively, and the sensitivity at admission was 100% for culture-confirmed brucellosis. The assay system performed equally well in diagnosing patients at different stages of illness including patients with acute, subacute, or chronic disease and with relapse. The results of the flow assays correlated well with those of a serum agglutination test at a cut-off > or =1:160. The agreement was 92%. Application of the flow assays on serum samples collected during a village survey for brucellosis after an outbreak demonstrated their diagnostic potential as field tests.     

Color and duplex Doppler sonography to detect sacroiliitis and spinal inflammation in ankylosing spondylitis. Can this method reveal response to anti-tumor necrosis factor therapy?

OBJECTIVE: To investigate the role of color and duplex Doppler ultrasound (CDDUS) in the detection of sacroiliac (SI) and spinal inflammation, as well as response to anti-tumor necrosis factor (TNF) therapy in patients with ankylosing spondylitis (AS). METHODS: We included 39 consecutive patients with AS followed at our center and 14 healthy controls. In the AS and control groups, blood vessels in SI joints and lumbar vertebral (LV) and thoracal vertebral (TV) paraspinal areas were investigated by CDDUS. When the artery was found, the resistive index (RI) was measured by CDDUS. Disease activity characteristics (ESR, CRP, BASDAI, and BASMI) were evaluated in patients with AS. In 11 patients for whom anti-TNF therapy was indicated, CDDUS measurements were performed before and on Week 12 of therapy. RESULTS: In patients with AS, RI values of SI joints and of LV and TV areas were lower than in controls (all p < or = 0.01). In AS patients with active disease according to BASDAI, RI values of TV (p = 0.0013) and LV (p = 0.027) were significantly lower than in the inactive group. In the group with active AS, SI RI was nonsignificantly lower (p = 0.16). After anti-TNF therapy, there were significant increases in mean SI RI (p = 0.028) and LV RI (p = 0.039), and a nonsignificant increase in TV RI (p > 0.05). CONCLUSION: CDDUS may be an alternative, less expensive, and easier method for detecting inflammation secondary to increased SI and spinal vascularization and in evaluating response to anti-TNF therapy in AS.