Endoscopic Management of Barrett’s Esophagus: Advances in Endoscopic Techniques

Barrett??s esophagus (BE) is a well-known premalignant condition that can be associated with the development of dysplasia and adenocarcinoma. In the past, esophagectomy was the standard treatment for patients with BE with high grade dysplasia (HGD) and early cancer (EC). However, esophagectomy is not necessarily the only treatment response to HGD and EC anymore. Over the past decade, a number of endoscopic therapies have been developed for management of BE. These include endoscopic mucosal resection, thermal ablation techniques that use laser irradiation, multipolar electrocoagulation, argon plasma coagulation, photodynamic therapy, and the recently developed cryotherapy and radiofrequency ablation.     

Use of knee height for the estimation of stature in elderly Turkish people and their relationship with cardiometabolic risk factors

The determination of the approximately truest value in height measurement is important in many fields, but it is difficult to perform true measurements, especially in the elderly individuals. We planned to investigate the following items in geriatric Turkish population: to calculate the decrease in height with advancing age by using the standing height measurement and estimated height derived from the knee height; to evaluate the significance of difference between the two measurement methods in the calculation of body mass index (BMI) and waist/height ratio (WHtR); to determine the cut-off value of WHtR according to estimated height in elderly individuals. We studied 551 cases aged between 19 and 97 years. Knee height was measured using a sliding caliper in a sitting position. Linear regression analysis was carried out to derive predictive equations for the estimation of stature with adults (≤50 years of age) according to the gender. This equation was then used to estimate height among elderly subjects. Of the cases, 60.3% were <60 years (mean: 48.75 ± 7.50); 39.7% of the cases were >60 years (mean: 69.51 ± 7.12). Estimated BMI (EBMI) measurements in the females and males >60 years were in average 1.23 kg/m² and 0.92 kg/m² higher than their real BMIs, respectively. EBMI measurements in the females <60 years were 0.32 kg/m² higher than their real BMIs (p < 0.01). There is a statistically significant difference between WHtR in the females of both age groups, and in the males >60 years, as compared to our estimated WHtR (EWHtR) measurements (p < 0.01). The cut-off point of WHtR was 0.61 and 0.58 in the female and male cases of >60 years in our study, respectively. WHtR seemed to be a better anthropometric index that could predict most cardiometabolic risk factors in our study. EWHtR emerged to be a better cardiometabolic risk index especially in the elderly group.     

Hospital acquired infections (HAI) in the elderly: comparison with the younger patients

The aim of this retrospective study is to determine the frequency, type, microbiological characteristics and outcome of HAIs in the elderly (age ≥ 65) and to compare the data with younger patients in a Turkish Training and Research Hospital. From January 2008 to December 2009, the infection control team analyzed HAIs among 60,585 hospitalized patients (20,109 aged ≥ 65 and 40,747 aged between 18 and 64 years) with a total number of 419,017 patient days. A total of 825 HAIs episodes were detected in 607 patients, of which 395 episodes were in 301 elderly patients. The incidence of HAIs per 1000 patient days was 2.49 in the elderly and 1.64 in the younger patients’ group (p < 0.001). The most common site of infection in the elderly patients was the urinary tract, whereas in non-elderly group this was the lower respiratory tract. The incidence density of urinary tract infections, respiratory tract infections, surgical site, skin and soft tissue infections, primary bacteremia, and prosthesis infections were significantly higher in the elderly group (p < 0.05). Gram-negative species were the most frequently isolated agents in both groups. There were no significant differences between the groups in the frequency of isolated pathogens or antibiotic susceptibility patterns. Overall, the fatality rate was found 16.8%. The elderly patients were more likely to have crude mortality rates (22% vs. 12%; p < 0.01). The death was most often related to pneumonia, primary bacteremia or intravascular catheter infections in both groups.     

Association between smoking and outcomes in older adults with atrial fibrillation

Tobacco smoking is a risk factor for atrial fibrillation (AF), but little is known about the impact of smoking in patients with AF. Of the 4060 patients with recurrent AF in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 496 (12%) reported having smoked during the past two years. Propensity scores for smoking were estimated for each of the 4060 patients using a multivariable logistic regression model and were used to assemble a matched cohort of 487 pairs of smokers and nonsmokers, who were balanced on 46 baseline characteristics. Cox and logistic regression models were used to estimate the associations of smoking with all-cause mortality and all-cause hospitalization, respectively, during over 5 years of follow-up. Matched participants had a mean age of 70 ± 9 years (± S.D.), 39% were women, and 11% were non-white. All-cause mortality occurred in 21% and 16% of matched smokers and nonsmokers, respectively (when smokers were compared with nonsmokers, hazard ratio=HR=1.35; 95% confidence interval=95%CI=1.01-1.81; p=0.046). Unadjusted, multivariable-adjusted and propensity-adjusted HR (95% CI) for all-cause mortality associated with smoking in the pre-match cohort were: 1.40 (1.13-1.72; p=0.002), 1.45 (1.16-1.81; p=0.001), and 1.39 (1.12-1.74; p=0.003), respectively. Smoking had no association with all-cause hospitalization (when smokers were compared with nonsmokers, odds ratio=OR=1.21; 95%CI=0.94-1.57, p=0.146). Among patients with AF, a recent history of smoking was associated with an increased risk of all-cause mortality, but had no association with all-cause hospitalization.     

The effect of ballroom dance on balance and functional autonomy among the isolated elderly

The aim of the present study was to analyze the influence of a ballroom dancing program on the functional autonomy and physical balance of institutionalized elderly individuals. The study enrolled 75 sedentary elderly subjects from long-term institutions who were randomly divided into a ballroom dance program group (EG; n=39) and a control group (CG; n=36). The protocol of the Latin American Group for Maturity (GDLAM) was used to evaluate functional autonomy. Physical balance was analyzed using a stabilometer and posture meter platforms. The level of significance in statistical tests was set at p<0.05. Regarding the physical balance evaluation, only the members of the EG achieved a significant reduction in weight (Δ=-0.98 kg) following the experiment, both in the intragroup (p=0.002) and in the intergroup analysis (p=0.012). In the evaluation of functional autonomy, only the EG showed a significant reduction in the execution time of all the tests and in the GDLAM index: GI (Δ=-6.99), both in the intragroup (p<0.001) and in the intergroup analysis (p=0.011). Thus, it can be inferred that sedentary elderly individuals who are residents of long-term institutions can improve their functional autonomy and balance with a ballroom dance program.     

Relation of Neutrophil/Lymphocyte Ratio to Coronary Flow to In-Hospital Major Adverse Cardiac Events in Patients With ST-Elevated Myocardial Infarction Undergoing Primary Coronary Intervention

With the growing understanding of the role of inflammation in patients with atherosclerotic disease, studies have focused on high-sensitivity C-reactive protein (hs-CRP) and other inflammatory markers in their association with outcomes in ST-segment elevation myocardial infarction. The goal of this study was to investigate the association of the neutrophil/lymphocyte (N/L) ratio and in-hospital major adverse cardiac events (MACEs) in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI). The association of hs-CRP and N/L ratio on admission with Thrombolysis In Myocardial Infarction (TIMI) flow grade after PCI was assessed in 418 consecutive primary patients with PCI. The N/L ratio was significantly higher in the no-reflow group (TIMI grade 0/1/2 flow, n = 158) compared to that of the normal-flow group (TIMI grade 3 flow, n = 260, 4.6 ± 1.7 vs 3.1 ± 1.9, p <0.001). In-hospital MACEs were significantly higher in patients with no reflow (23% vs 7%, p <0.001). There was a significant and positive correlation between hs-CRP and N/L ratio (r = 0.657, p <0.001). In receiver operating characteristic analysis, N/L ratio >3.3 predicted no reflow with 74% sensitivity and 83% specificity. In a multivariate regression model, N/L ratio remained an independent correlate of no reflow (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.34 to 1.76, p <0.001) and in-hospital MACEs (OR 1.14, 95% CI 0.98 to 1.32, p = 0.043). The N/L ratio, an inexpensive and easily measurable laboratory variable, is independently associated with the development of no reflow and in-hospital MACEs in patients with ST-segment elevation myocardial infarction undergoing primary PCI.     

Recessively inherited severe aortic aneurysm caused by mutated EFEMP2

Familial aortic aneurysm (AA) is mostly inherited as an autosomal dominant disorder. However, recessively inherited AA has also been observed but in association with skin manifestations of cutis laxa, which is caused by a mutated EFEMP2 gene. In the present study, we recruited 9 patients, from 4 unrelated consanguineous families, with recessively inherited AA. The index cases, their parents, and siblings underwent clinical evaluation and cardiac imaging. In the affected subjects, the clinical presentation ranged from sweating and cyanosis at 3 months of age to incidental findings in an asymptomatic adult. The echocardiogram revealed a wide spectrum of severity of the AA, with a Z-score varying from 5 to 33. Intrafamilial variability was also evident; 2 unrelated subjects were detected at 17 and 20 years of age through family screening. The skin manifestations of cutis laxa were not found in any patient. In 1 family, genome-wide single-nucleotide polymorphism analysis detected a homozygous block, shared by 2 affected siblings, on chromosome 11 at q13. Sequence analysis of EFEMP2, located on chromosome 11 at q13, identified a novel homozygous mutation (p.E161K) in all 9 affected subjects. In this largest cohort of reported patients with a mutated EFEMP2 gene, we illustrate the phenotypic spectrum of inherited AA due to a novel EFEMP2 mutation. In conclusion, our work suggests that in families with apparently recessively inherited AA, molecular analysis of EFEMP2 gene might be warranted.     

Contribution of closed mitral commissurotomy in the surgery of rheumatic mitral stenosis

The objective of this work was to study the indications, techniques and results of closed heart mitral commissurotomy in patients with rheumatic mitral stenosis in Morocco.MethodsAll patients who had undergone closed heart mitral commissurotomy for rheumatic mitral stenosis, operated between 1999 and 2008 were collected in this study. Mitral stenosis was diagnosed and evaluated using Doppler echocardiography. Patients with commissural calcification, severe mitral regurgitation, and surgical tricuspid or aortic valvular disease were excluded from this study.ResultsSix hundred and twenty-five patients have been collected. 62.2% were young with an age between 18 and 35 years and 491 (78.8%) were female. Seventy-nine percent of patients had stage III or IV NYHA and were in sinus regular rhythm. The closed heart mitral commissurotomy was performed for all patients through a left thoracotomy using either digital or dual dilatation. The mitral area was significantly increased postoperatively to 2.11 ± 0.32 with 100% opening of the anterior commissure, while the posterior commissure was opened only for 93.7% of patients. There were nine perioperative deaths (4.9%) and all patients who died had severe mitral stenosis (< 0.8 cm²) with an elevated systolic pulmonary artery pressure (> 60 mmHg).ConclusionThe closed heart mitral commissurotomy provides excellent results in young patients with rheumatic mitral stenosis.