Effect of carbon dioxide insufflation on free internal thoracic artery flows: is it a vasodilator?

BACKGROUND: This study was conceived to evaluate the effect of carbon dioxide insufflation on free internal thoracic artery flows. METHODS: We studied 56 consecutive patients who underwent coronary artery bypass grafting in which the left internal thoracic artery was anastomosed to the left anterior descending artery. The first 26 consecutive internal thoracic arteries were harvested as a pedicled graft (group 1), and the next 30 consecutive internal thoracic arteries were dissected by using the carbon dioxide insufflation technique (group 2). The internal thoracic artery harvesting was performed by 2 experienced surgeons by using the same instrumentation and technique. First, free flows of the internal thoracic arteries were registered after distal cutting of the vessel in both groups. After the first measurements, diluted papaverine was sprayed on the internal thoracic artery pedicle only in group 1, and then second measurements were registered after 15 minutes in both groups. Hemodynamic parameters were recorded with each measurement. RESULTS: The first free flow measurement was significantly higher in the carbon dioxide-insufflated internal thoracic arteries (group 2, 60 +/- 32 mL/min; group 1, 28 +/- 19 mL/min; P <.05). Although the second free flow measurement of the carbon dioxide-insufflated group was higher than in group 1, the difference was not statistically significant (68 +/- 46 mL/min vs 53 +/- 32 mL/min; P =.53). CONCLUSIONS: Carbon dioxide insufflation of the internal thoracic artery is an efficient technique to increase the flow and seems to be safe, simple, and reliable. When the internal thoracic artery is harvested in a carbon dioxide-insufflated fashion, arterial spasm and reduced early flow may be avoided, even without vasodilator agents such as papaverine.     

Brucellar spine infection--four case reports

Brucellosis can be difficult to diagnose because of the nonspecific and variable clinical picture. This systemic disease is still an important public health problem in the Mediterranean Basin. These four cases of brucellar spine infection originated from rural areas around Aydin, Turkey. The systemic complaints of fever, profuse sweating, malaise, polyarthromyalgia, and weight loss indicated the final diagnosis of brucellosis and presumptive diagnoses were made based on agglutination testing for brucellosis. Computed tomography and magnetic resonance imaging indicated signs of bone infection and soft tissue involvement. Good outcomes were obtained with prolonged treatment with antibrucellar drugs including streptomycin, rifampicin, and tetracycline. Early diagnosis is important and prompt antibrucellar chemotherapy is effective in most cases, but prolonged follow up is necessary in all patients with spinal brucellosis.     

Biochemical bone markers in nephrotic children

In this study we evaluated the effects of high-dose corticosteroid (CS) therapy and the character of the nephrotic syndrome (NS) itself on bones in patients with normal glomerular filtration rate. We measured serum osteocalcin (OC), alkaline phosphatase (ALP), intact parathyroid hormone (iPTH), 25-hydroxyvitamin D, calcium (Ca), phosphorus (P), and magnesium (Mg) levels, and urinary Ca and protein excretion in nephrotic children during the active phase before (group Ia) and after CS treatment (group Ib). The results were compared with age-matched control subjects. A significant increase in urinary Ca excretion was observed after CS treatment. Serum ALP, OC, and iPTH levels were within normal limits at the time of study entry. However, both serum OC and ALP levels showed a significant decrease after the completion of CS treatment (OC from 13.6±9.2 ng/ml to 6.7±5.2 ng/ml and ALP from 151.8±60.2 U/l to 116±43.8 U/l). 25-Hydroxyvitamin D levels increased to 17.2±8.9 g/l from 9.9±6.9 g/l after CS treatment. The effects of recurrent use of CSs were assessed by dividing nephrotic patients into two subgroups: infrequent relapsers (IFR) and frequent relapsers (FR). The cumulative dose of CS was 28,125 mg/m² for IFR and 105,000 mg/m² for FR. The changes in OC, ALP, and 25-hydroxyvitamin D levels after CS treatment were significantly different between IFR and FR. We conclude that high-dose CS treatment causes a decrease in bone formation, as shown by the changes in OC and ALP levels. 25-Hydroxyvitamin D levels remained lower than control subjects after CS therapy. The higher the cumulative dose of CS used the more marked the changes in biochemical bone markers. The contribution of FR to baseline 25-hydroxyvitamin D levels needs further study.     

Relationship between peripheral and central venous pressures in different patient positions, catheter sizes, and insertion sites

OBJECTIVE: To investigate the relationship between peripheral and central venous pressures in different patient positions (supine, prone, lithotomy, Trendelenburg, and Fowler), different catheter diameters (18 G and 20 G), and catheterization sites (dorsal hand and forearm) during surgical procedures. DESIGN: Prospective clinical study. SETTINGS: University hospital. PARTICIPANTS: Five hundred adult patients. INTERVENTIONS: Peripheral over-the-needle intravenous catheters were placed in the dorsal hand or forearm. Central venous catheters were inserted via the internal jugular or subclavian vein after induction of anesthesia. MEASUREMENTS and MAIN RESULTS: Simultaneous measurements of central and peripheral venous pressures were made during stable conditions at random time points in surgery; 1953 paired measurements were performed. Mean central venous pressure was 11 +/- 3.7 mmHg and peripheral venous pressure was 13 +/- 4 mmHg (p = 0.0001). The overall correlation between central venous and peripheral venous pressures was found to be statistically significant (r = 0.89, r(2) = 0.8, p = 0.0001). Mean difference between peripheral and central venous pressure was 2 +/- 1.8 mmHg. Ninety-five percent limits of agreement were 5.6 to -1.6 mmHg. CONCLUSION: It has been assumed that replacing central venous pressure by peripheral venous pressure would cause problems in clinical interpretation. If the validity of this data is confirmed by further studies, the authors suggest that central venous pressure could be estimated by using regression equations to compare the 2 methods.     

Analgesic effects of interpleural bupivacaine with fentanyl for post-thoracotomy pain

OBJECTIVE: The analgesic effect of bupivacaine/fentanyl with epinephrine given interpleurally after thoracotomy was investigated in a randomized placebo and intravenous controlled study. DESIGN: Prospective clinical study. SETTING: University teaching hospital. PARTICIPANTS: Sixty American Society of Anesthesiologists physical status II and III patients scheduled for posterolateral thoracotomy with general anesthesia. INTERVENTIONS: Patients were randomly divided into 4 groups to receive either 0.5% bupivacaine/1.5 microg/kg of fentanyl with 5 microg/mL of epinephrine (n = 15, group IPBF), 0.5 % bupivacaine with 5 microg/mL of epinephrine (n = 15, group IPB), or saline (n = 15, group IPS) in a total volume of 15 to 20 mL in 60 seconds by an interpleural catheter placed at the end of surgery by direct vision. The same volume of bupivacaine 0.25% and 1.5 microg/kg of fentanyl with 5 microg/mL of epinephrine to group IPBF, bupivacaine 0.25% with 5 microg/mL of epinephrine to group IPB or saline to group IPS was injected through the interpleural catheter every 6 hours for 48 hours postoperatively. Intravenous fentanyl (n = 15, group IVF) and interpleural saline groups received 1.5 microg/kg of fentanyl intravenously at the first complaint of pain. All patients also received patient-controlled analgesia (PCA) with fentanyl for 48 hours postoperatively. Metamizol sodium was used as a rescue analgesic. MEASUREMENTS and MAIN RESULTS: Adequacy of pain relief was evaluated with the "Prince Henry Pain Scale" and visual analog pain scale. Fentanyl consumption via PCA and complications were evaluated for 48 hours. Visual analog scale scores were significantly higher in the interpleural saline group at 4 and 12 hours (6.6 +/- 1.2 and 5.0 +/- 2.1, respectively) postoperatively. Significantly more patients in the IPBF group had lower pain scores during coughing and deep breathing. Fentanyl consumption via PCA device was significantly higher in the intravenous fentanyl group (1,069 +/- 96.9 microg) than the interpleural groups (577.3 +/- 72.2 microg, 651.1 +/- 61.9 microg, and 601.0 +/- 22.6 microg in IPBF, IPB, and IPS groups, respectively). CONCLUSION: It is concluded that total fentanyl consumption via PCA decreased in all interpleural groups, but pain during coughing and deep breathing was significantly reduced in only the interpleural bupivacaine/fentanyl with epinephrine group.     

Novel immunosuppressants

Advances in maintenance immunosuppression over the past decade has resulted in dramatic improvements in short- and long-term outcomes in organ transplantation as well as a decreased incidence of acute rejection. However, immunosuppressive drugs need to be given long term, lack specificity, and are accompanied by adverse metabolic derangements, toxicities, the risk of infection and cancer, and a myriad of other side effects. Further, they fail to prevent and control chronic rejection. This review will outline a number of immunosuppressive agents that are currently being explored in experimental and clinical transplantation. These include biologic agents that have more specificity and selectivity, and are aimed at T-cell depletion, blockade of costimulation, adhesion markers, or at novel targets. Most of the studies have been limited to adults but should be applied to the pediatric population as well.     

Iodine status remains critical in mother and infant in Central Anatolia (Kayseri) of Turkey

Summary. Background: Severe iodine deficiency disorders have been eradicated in many parts of the world, but milder forms still exist and may escape detection. Turkey has long been known to be a mild to moderate iodine deficiency area. Aim of the study: The aim of this study was to assess the iodine nutritional status and the thyroid function of pregnant women and their neonates in the region of Kayseri (central Anatolia of Turkey) that appeared to be iodine deficient in previous studies performed before the introduction of mandatory salt iodization. Methods: A cross-sectional voluntary screening study was performed in the Maternity Unit of a university hospital. A total of 70 mothers and their healthy full-term neonates were included in this study. Urinary iodine concentration was estimated in spot urine samples obtained from mothers and their neonates on day 5. All the neonates were breastfed. The iodine content was determined in the breast milk of all mothers on day 5. Serum concentrations of TSH, thyroglobulin (Tg), free triiodothyronine (FT3) and free thyroxine (FT4) were investigated in the cord serum of neonates and compared to those of mothers immediately after parturition Results: The median urinary iodine on day 5 in mothers and their babies were 30.20 and 23.80 µg/l, respectively. These figures are much lower than normal for these age groups (150–200 µg/l). The median iodine content of breast-milk was 73 µg/l. It is again much lower than in iodine sufficient areas, indicating that the status of iodine nutrition of pregnant and lactating women is clearly insufficient. The median concentrations (and ranges) of neonatal TSH, Tg, FT3 and FT4 were 7.44 mU/l, 71.62 ng/ml, 1.30 pg/ml and 1.34 ng/dl respectively. The corresponding levels for the mothers during labor were 2.19 mU/l, 25.65 ng/ml, 1.31 pg/ml and 1.23 ng/dl respectively. The median neonatal serum concentrations of TSH and Tg were significantly higher than the corresponding maternal levels (P < 0.0001, P < 0.0001, respectively) and 27.1% of the neonates had serum TSH concentrations above 10 mU/l and 57.1 % had cord blood serum Tg concentrations above 54 ng/ml. None of the mothers showed TSH concentrations above 5 mU/l and 41.4% had serum Tg concentrations above 30 ng/ml. Conclusion: Iodine deficiency with low urinary iodine excretion and high serum Tg and TSH concentrations were recognized among pregnant women and their babies in Kayseri in spite of the program of salt iodization. National measures are urgently required for improving the correction of iodine deficiency in Turkey. This includes regular supplementation with iodine, starting at preconception or in early pregnancy and continuing during the period of nursing in this region.     

Dementia in Parkinson's disease: cause and treatment

PURPOSE OF REVIEW: Dementia in Parkinson's disease is increasingly being recognized. A number of studies have recently appeared on the epidemiology, clinical features, pathological correlations and treatment of dementia in Parkinson's disease. The purpose of this article is to provide an overview of recent findings on dementia associated with Parkinson's disease, from February 2003 to the present. RECENT FINDINGS: The cumulative prevalence of dementia in Parkinson's disease can be as high as 78%; dementia is especially prevalent in older patients. The profile of dementia seems to be different from that of Alzheimer's disease and similar to that of dementia with Lewy bodies. Clinicopathological correlation studies have suggested that dementia correlates best with Lewy bodies in certain limbic and cortical areas, but not all patients with sufficient Lewy bodies for a pathological diagnosis of dementia with Lewy bodies are demented. Cholinergic deficits in the cerebral cortex can be shown with in-vivo imaging studies, and seem to be more severe than in Alzheimer's disease. Several small studies with three different cholinesterase inhibitors suggest that these drugs can be effective in the treatment of PD dementia. SUMMARY: Dementia is highly prevalent in Parkinson's disease. The prototype of dementia in Parkinson's disease is a dysexecutive syndrome with impaired attention, executive functions and secondarily impaired memory. Neurochemically the most significant deficit seems to be cholinergic; dementia seems to correlate best with cortical and limbic Lewy bodies. Preliminary evidence suggests that cholinesterase inhibitors may be effective in Parkinson's disease dementia, and the results of large-scale, randomized and controlled studies are awaited to confirm these findings.     

Ocular blood flow alteration in glaucoma is related to systemic vascular dysregulation

AIMS: To investigate the source of ocular blood flow alterations in glaucoma. METHODS: In 56 patients with open angle glaucoma, blood flow parameters were obtained from both eyes in the ophthalmic and central retinal artery by means of colour Doppler imaging, as well as in the choroidal circulation and the neuroretinal rim of the optic nerve by means of laser Doppler flowmetry. Based on these haemodynamic parameters, a cluster analysis (two groups) was performed and differences with regard to risk factors were assessed between clusters. RESULTS: Ocular blood flow data in the two clusters indicated that the two groups (cluster 1 = 26 patient with higher blood flow values; cluster 2 = 30 patients with lower blood flow values) differed mainly in choroidal and optic nerve blood flow. No differences in sex distribution, propensity to have normal tension glaucoma, age, endothelin-1 plasma levels, visual field damage, intraocular pressure, or systemic blood pressure parameters were observed between the two clusters. However, 12 patients (46%) from the cluster with high ocular blood flow values showed a vasospastic response in nailfold capillaroscopy, while such a response was observed in 24 patients (80%) of the cluster with low ocular blood flow values. This difference in vasospastic propensity was statistically significant (p = 0.0121). CONCLUSIONS: Ocular blood flow alterations in glaucoma patients seem, at least partly, to be related to a systemic vascular dysregulation.     

Prevalence of anti-HAV and anti-HEV antibodies in Konya, Turkey

OBJECTIVE: To determine the prevalence of antibodies to hepatitis A (HAV) and E (HEV) viruses in the different areas of Konya. METHODS: Anti-HAV and anti-HEV antibodies were investigated in 210 healthy children randomly selected (100 from rural areas and 110 from urban areas of Konya). None gave a history of previous icterus nor other signs of hepatitis, had received blood transfusion and HAV vaccine, or had been on hemodialysis. RESULTS: Evidence of HAV infection occurred in children under the age of 6 years. The seroprevalence rate was 67.8% in rural areas and 25.8% in urban areas. This increased rapidly with age and became universal after 11 years of age in both areas. In contrast, HEV infections were not detected until children were 6-11 year olds, and the 5.2% seroprevalence rate in urban areas and 8.5% seroprevalence rate in rural areas in this age group did not significantly increase in older age group. The prevalence of anti-HAV as well as anti-HEV was significantly higher in children with poor socio-economic conditions in both areas. CONCLUSIONS: These results suggest that HAV infection in rural areas of Konya is widespread and that environmental and socio-economic factors play a major role in its transmission. In contrast, hepatitis E is not a public health problem in Konya.