Volume 4, Issue 3

To determine if delaying the primary precutaneous coronary intervention (PCI) for >6 hours for acute coronary syndrome with preserved ST elevation (STE-ACS) affects the PCI angiography effectiveness and clinical prognosis. The PCI was performed: for 71% of patients <6h (group 1), for 29% of patients >6h from the beginning of pain (group 2). For 1% of patients from group 1 and 3.4% of patients from group 2, no passage has been opened in the artery after STE-ACS. In spite of opening the passage mechanically, the phenomenon of lack of tissue reflow occurred in 2.7% of patients from group 1 and 12% of patients from group 2. Dangerous ventricular arrhythmias occurred more frequently in patients from group 2, including VF, asystole, haemodynamic complications classed 4° according to the Killip-Kimball scale and death. In an univariate logistic regression analysis, the following risk factors for death during the hospital phase were identified: delayed PCI >6 hours, 4° haemodynamic complications according to the Killip-Kimball scale, LVEF <40%, FV, p-k III block, TIMI <3, and no-reflow. In a multivariate logistic regression analysis, 4° according to the Killip-Kimball scale turned out to be the only risk factor for death during the hospital phase. Delaying PCI during STE-ACS for >6 hours significantly lowers the statistical chance to recover both full permeability and effective tissue reflow in the artery responsible for STE-ACS, which is connected with a significantly higher risk of serious complications, as well as with 8.5% risk of death during the hospital phase. The most significant, independent factor determining the survival of patients with STE-ACS after PCI is lack of cardiogenic shock.

The association of elevated serum uric acid (hyperuricemia, gout) with the presence of classical coronary risk factors and coronary artery disease (CAD) or myocardial infarction (MI) has been analysed in many epidemiological studies. Numerous studies have revealed that hypertension, high body mass index (BMI), lipid disorders (especially raised triglyceride (TG) levels and low high dense lipoprotein cholesterol (HDL-C) level), and increased creatinine or insulin levels have caused hyperuricemia. Gout has often occurred with typical disorders for the metabolic syndrome X. Significant correlation of the serum uric level and the CAD presence and severity of coronary atherosclerosis confirmed by coronary angiography has been observed in women. Hyperuricemia has also indirect influence on progress of CAD by physical activity restriction, what causes sedentary mode of life and lead to obesity. Therefore, we conducted our study in order to estimate uric acid levels in patients with metabolic syndrome and coexisting cardiovascular system diseases.

Bone marrow-derived stem cells (BMSC) may be an alternative for the treatment of patients with severe coronary artery disease ineligible for either percutaneous or surgical revascularization. This case report presents a 65-year-old male patient with untreatable angina pectoris (Canadian Cardiovascular Society Class III) and severe coronary artery disease. A mixture of BMSC containing approximately 3×106 CD34+ cells was directly injected into preoperatively determined ischemic regions of the myocardium by median sternotomy. At baseline, at 3 months, and at 1 year of follow-up, echocardiography (demonstrating wall motions of 16 segments), single-photon emission computed tomography, and coronary angiography (at baseline and at 1 year) were performed to assess myocardial perfusion, left ventricular (LV) function and coronary anatomy. The patient reached Canadian Cardiovascular Society Class I after 6 months of cell implantation. The ejection fraction increased from 34% to 37% at the third month and 40% at 1 year of follow-up. At 1 year of follow-up, preoperatively akinetic mid-base septum and anteroseptal regions progressed to mild hipokinesia and severe hypokinetic mid-base-apical anterior regions and apical lateral-inferior regions became normokinesia. Single-photon emission computed tomography revealed a visible improvement in anterior and lateral segments at 1 year of follow-up. Coronary angiography showed newly developed collateral arteries at 1 year of follow-up. BMSC transplantation in a patient with severe coronary artery disease resulted in increase of LV ejection fraction, an increase of the perfusion of ischemic myocardial regions, and improvement in wall motion defects without any adverse events.

Transfusion after cardiac surgery is very common. This rate varies between institutions and has remained high despite established transfusion guidelines. We analyzed our database of patients who underwent isolated CABG (Coronary Artery Bypass Graft) to determine the predictive factors of homologous transfusion and associated postoperative morbidity, mortality and resource utilization. All 14,152 patients who underwent first-time isolated CABG, with or without cardiopulmonary bypass (CPB) who had postoperative homologous transfusion between February 2002 and March 2008 in Tehran Heart Center, were evaluated retrospectively. Overall, 16.5% of patients received transfusion. Transfused patients demonstrated a significantly higher incidence of postoperative complications (cardiac, infectious, ischemic, reoperation) and mortality (p<0.001). Homologous blood transfusion effect on mortality, morbidity and resource utilization. By Multivariable logistic regression analysis adjusted for confounders: Homologous blood transfusion effect on Mortality (30-days) (OR=3.976, p<0.0001), Prolonged ventilation hours (OR=4.755, p<0.0001), Total ICU hours (β =14.599, p<0.0001), Hospital length of stay (β =1.141, p<0.0001), Post surgery length of stay (β =0.955, p<0.0001). We conclude that the isolated CABG patients receiving blood transfusion have significantly higher mortality, morbidity and resource utilization. Homologous blood transfusion is an independent factor of increased resource utilization, morbidity and mortality.

The report by Gumaste et al. [Gastroenterology 1991;101:1361–1366] that the lipase/amylase ratio (Lip/Amy) could be a new index distinguishing acute episodes of alcoholic (Lip/Amy >2) from nonalcoholic pancreatitis (Lip/Amy <2), with the critical value being Lip/Amy =2, has been followed by some debate between supporters and opponents. By comparing the Lip/Amy in a group of 16 carefully selected patients with mild acute gallstone-related (biliary) pancreatitis with that in a reference group of 44 controls, this study examines whether or not this ratio could be a useful index for diagnosing biliary pancreatitis. Considering that both pancreatic and hepatobiliary systems are blocked by stones, hepatic biochemical parameters such as serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and total bilirubin (TB) were also included in fitting the regression equation. The average value of Lip/Amy in the biliary pancreatitis group was 2.29 ± 0.93, while that in the control group was 1.30 ± 0.99. Thus, Lip/Amy was found to be a significant index for distinguishing mild acute biliary pancreatitis from nonpancreatitis. However, the critical value of Lip/Amy seemed to depend on the diet pattern and cultural background.

In the course of cirrhosis, a variety of disturbances of endocrine glands occur. Degenerative changes in the testes with atrophia and fibrosis of the glandular tissue are often found in men. Twenty-one males with compensated alcoholic liver cirrhosis were studied. The age ranged from 29 to 61 years (mean 47,1). Efficiency of the liver was evaluated according to Child classification. HBC (this needs to be spelled out in parenthesis) or HBV (Hepatitis B Virus) infections were excluded. Levels of serum testosterone were determined and the volume size of the testes was measured using 7,5 MHz sector probe, B&K Medical ultrasonograph, 3535 model. Volume size of the testes was measured in 22 healthy control volunteers, as well; age ranged from 25 to 66 years (mean-46,6). All patients were interviewed about sexual function, particularly possible erectile dysfunction using IIEF-5 questionnaire. The mean testosterone level was 8,89 umol/l (ranged: 7,4–10,9 umol/l) in the study patients [the normal range interval: 8,2–34,6 umol/l]. The level was below the normal range in 4 patients, and low but within the normal range in the remaining patients. Statistically significant lower values of both testes volumes were estimated in patients with compensated alcoholic liver cirrhosis in comparison to healthy controls (p<0,001), however only 5 (23,81 %) study group subjects admitted impaired libido and erectile dysfunction. Decreased levels of testosterone in the peripheral blood and diminished volume size of testes are found in patients suffering from alcoholic liver cirrhosis. Erectile dysfunction in patients with liver cirrhosis needs further evaluation.

Parkinson’s disease (PD) belongs to group of neurodegenerative diseases. PD diagnosis is clinical, based on these signs: tremor, rigidity, bradykinesia, akinesia or hypokinesia. The aim of the work was to determine the frequency of separate clinical forms of Parkinson’s disease and difficulties at this disease diagnosis. After examining 267 patients, foreseen clinical criterion of Parkinson’s disease correspond 202 (44.0% persons) − 115 women and 87 men and for 65 patients diagnosis of PD was not confirmed, because they did not correspond with accepted criteria of Parkinson’s disease. While analyzing clinical peculiarities of disease we ascertained that rigidity-tremor form of disease prevailed for 152 (75.2%, 86 women and 66 men) patients. The rigidity form was more rare − 28 (13.9%, 13 women and 15 men). Not very frequent was a tremor form of disease -− 22 (10.9%, 16 women and 6 men) patients. According to data of our research, for almost one fourth of patients (65, 24.3%) the diagnosis of Parkinson’s disease was not confirmed after clinical examination. These patients did not correspond with clinical criteria of PD. The data of our research maintain that for almost one fourth (one fourth of what?) (24.3%) the diagnosis was incorrect. Although these patients did not correspond with accepted criteria of PD, they had been treated with antiparkinsonic medications. The PD diagnosis for them was determined only according to separate symptoms: tremor, gait alterations or memory deterioration and behaviour alternations. It must be noted, that symptoms of Wilson’s disease, MSA or brain infarction were estimated as PD. Examining patients at home, we ascertained that not all patients use prescribed L-dopa preparations. A part of patients or their relatives stopped using of this drug independently. We also made note of the fact that urinary incontinence manifested using dopamine agonist ropinirole. This side effect became significant problem for patient himself and for his relatives.

The aim of this study was to evaluate vitamin B12 and folate levels, thyroid functions, sex hormones and bone mineral density in idiopathic epileptic patients taking oxcarbazepine as monotherapy. Newly diagnosed pediatric patients with idiopathic partial epilepsy taking oxcarbazepine (OXC) as monotherapy were enrolled in this study. The pre-treatment and 6 months post-treatment values of vitamin B12, folate, thyroid functions, sex hormones, and bone mineral density (BMD) were obtained from all patients. A total of 32 patients (22 (68.8%) males and 10 (31.2%) females) were included in this study. The mean age was 7.4 ± 3.2 years (range: 2–14 years). There were no significant differences between the pre-treatment and 6 months post-treatment values of vitamin B12, folate, thyroid functions, sex hormones, and BMD. However, the 6 month post-treatment sex hormone binding globulin (SHBG) values (159.92 ± 48.14 nmol/L) were significantly higher than the pre-treatment values (137.88 ± 43.12 nmol/L) (p=0.009). We found that OCX treatment in children did not have an effect on serum folate and vitamin B12 levels, thyroid functions, sex hormones and BMD but caused increased SHBG. Over time, the increase in serum SHBG levels may lead to diminished bioactivity of sex steroids, and thus to reduced fertility. The further studies are needed to demonstrate the clinical importance of increased SHBG levels.

Colorectal cancer ranks third as the most common malignancy in the United States and represents the second leading cause of cancer-related mortality. The appendix is thought to have a productive effect against colorectal carcinoma by the immune function based on its association with substantial lymphatic tissue. But, an appendectomy is still the most commonly performed emergency surgical procedure. It is aimed to assess the association between colorectal cancer and appendicectomy. The medical records of 455 patients who received medical and/or surgical treatment with the diagnosis of colorectal carcinoma in two medical centers in a-five-year period were reviewed. The patients were divided into subgroups according to the colonic localization of the tumor, appendectomy status and their body mass indexes (BMI). In order to define independent predictors of colon adeno-cancer, multiple logistic regression analysis was used. Statistically significant variables according to the univariate statistics were selected as candidate variables for multiple logistic regression analysis. A p-value<0.05 was considered statistically significant. Out of 455 colorectal adenocarcinoma patients, 122 (26.81%) were in right colon adenocarcinoma (CA) group, 267 (56.68%) were in left CA group and 66 (14.5%) were in the rectum adenocarcinoma group. Appendectomy was found as the second highest risk factor in rectum and right colon adenocarcinoma. Being appendectomized increases the risk of rectum adenocarcinoma 3.232 times (95%CI: 1.670–6.254), left CA 2.537 times (95%CI: 1.544–4.168) and right CA 3.607 times (95%CI: 2.056–6.330). In the light of our findings, we suggest that being appendectomized might increase the risk of colorectal adenocarcinoma in sporadic cases.

Experimental studies in animals and epidemiological evidence supporting the health benefits from apples encouraged the authors to assess the potential protective impact of apples on the risk of colorectal cancer in the course of the hospital based case-control study. A total of 186 incident cases of colorectal cancer — for which the information on histology, anatomic location, and stage of cancer were available — have been enrolled to the study. The comparison group included 211 controls chosen from the patients of the same hospital with no history of cancer and admitted for treatment of non-neoplastic conditions. Interviews of both cases and controls were conducted in hospital settings by trained interviewers. The results showed that the risk of colorectal cancer inversely correlated with daily number of apple servings, but the significant reduction of OR estimates were observed for an intake of one or more apple servings daily (OR = 0.37, 95%CI: 0.15 − 0.91). The risk of colorectal cancer was estimated from the multivariate logistic model including a set of potential confounding variables, such as, demographic characteristics of subjects (age, gender, place of residency, marital status and occupational activity), total energy intake (in tertiles) and intake of vegetables (number of servings per day). No fruits except for apples were significantly associated with the reduced risk of colorectal cancer. The reduction of colorectal risk associated with apple consumption may result from their rich content of flavonoid and other polyphenols, which can inhibit cancer onset and cell proliferation.

The aim of the study was to investigate the role of cTnT for the prediction of long term cardiac dysfunction after epirubicin-containing adjuvant chemotherapy for breast cancer. The study group comprised of 45 patients (all female; mean age 48 ±8 years), treated with epirubicin-containing adjuvant chemotherapy for stage 2 and stage 3 breast cancer. Patients received either 4 cycles of cyclophosphamide plus epirubicin (90 mg/m2) (n=23; stage 2 breast cancer) or 6 cycles of cyclophosphamide plus epirubicin (75 mg/m2) plus fluorouracil (n=18; stage 3 breast cancer). Venous blood samples were drawn, before and 72 hours after, every cycle of chemotherapy for the measurement of cTnT. Cardiac assessment was carried out at baseline and 1 year after chemotherapy by clinical evaluation, electrocardiography, radio-nuclide ventriculography (RNV) and transthoracic echocardiography. All patients remained free of clinical heart failure during the study period. In 26 patients (63%), cTnT was elevated after chemotherapy. Mean left ventricular ejection fraction, assessed by RNV at baseline and one year after chemotherapy, were 61±8% and 56±7% (p<0.0001). The sensitivity and specifity of cTnT for the detection of left ventricular systolic dysfunction at one year were 69% and 39% respectively. Echocardiographic examinations at baseline and one year after chemotherapy revealed a significant decrease in E/A ratio from 1.15±0.3 to 0.9±0.2 in cTnT positive patients, suggesting diastolic dysfunction. In conclusion, elevated serum cTnT levels after epirubicin-containing adjuvant chemotherapy for stage 2 and stage 3 breast cancer, predict future cardiac dysfunction with moderate sensitivity and poor specificity.

Incisional hernias and abdominal-wall defects consume large amounts of healthcare resources. Use of mesh is effective in treatment of these disorders and can decrease the rate of recurrence. This experimental study focused on the safety of mesh use in the setting of malnutrition, a condition that impairs wound healing. Rats were divided into two groups: normally fed and food-restricted. An abdominal-wall defect, 2 by 2 cm, was covered with polypropylene mesh, 2.5 by 2.5 cm. After sacrifice of the rats at the 21st and 60th days, tissue samples were sent for tensiometric and histopathological studies. No significant difference in infectious complications was observed between the two groups. Tensiometry revealed no significant differences between the groups. On histopathological examination, the only difference noted was in the vascularization scores of normally fed rats. For malnourished subjects that survived after surgery, the use of polypropylene mesh appeared safe in the closure of abdominal-wall defects, with no increase in infection rate and satisfactory wound healing.

Henoch The aim of the study was to evaluate the efficacy of preoperative embolization in the management of carotid body tumours. Of the 15 patients admitted to the Department of Vascular Surgery (General Surgery Unit II), Christian Medical College, Vellore, from January 1st 2002 to December 31st 2006 for management of carotid body tumours, 4 patients underwent preoperative embolization and were grouped together. Of the remaining 9 patients who underwent surgical excision, there were 5 with comparable tumour size and these were grouped together into the control group. Surgical outcome of both the groups were compared in terms of operating time, intraoperative blood loss, nerve injury, postoperative morbidity and mortality. There was statistically significant reduction in blood loss and duration of surgery in patients who underwent preoperative embolization. In conclusion, the preoperative embolization is effective in the management of Shamblin type III carotid body tumours.

The present study was designed to evaluate the effect of Plasmodium and Salmonella co-infection in LACA mice. The parasitaemic level, bacterial load, histological alterations and levels of oxidants/antioxidant activity were measured. Co-infected mice had a high parasitaemic level, increased bacterial load, and died earlier than Plasmodium-infected mice. Histologically, co-infected mice had more architectural damage in the liver, spleen, kidney, and brain than the control groups. The level of lipid peroxidation was significantly increased and the activities of antioxidative enzymes (superoxide dismutase and catalase) were decreased in all organs of co-infected mice compared to the control groups, indicating depression of the antioxidant defense system. The present study demonstrates more severe histological and biochemical alterations in co-infected mice, highlighting the importance of early diagnosis for selection of appropriate treatments and reducing the likelihood of further complications.

Palliative care aims at improving the patient’s quality of life. The assessment of this quality of life (QoL) is crucial for the evaluation of palliative care outcome. Many patients require hospital admissions for symptom control during their cancer journey and most of them die in hospitals, although they would like to stay at home until the end of their lives. In 1986, the European Organization for Research and Treatment (EORTC) initiated a research programme to develop an integrated, modular approach for evaluating the quality of life of patients participating in international clinical trials. This questionnaire measures cancer patients’ physical, psychological and social functions and was used in a wide range of clinical cancer trials with large numbers of research groups and also in various other non-trial studies. The aim of this study was to evaluate the psychometric properties, especially the reliability, validity and applicability of the EORTC QLQ-C30 in a German sample of terminally ill cancer patients receiving palliative care in different settings. The questionnaire was well accepted in the present patient population. Scale reliability was good (pre-treatment 0.80) especially for the functional scale. The results support the reliability and validity of the QLQ-C30 (version 3.0) as a measure of the health-related quality of life in German cancer patients receiving palliative care treatment.

The most common injuries reported in the literature regarding the sport of boxing are to the brain, eyes, kidneys and hands. Shoulder injuries have not been fully reported in the literature until recently, as a result we aimed to present our arthroscopic findings in amateur boxers. Ten amateur boxers with complaints of pain in the shoulder region and decreased performance during sportsplay were enrolled. They were evaluated by physical examination, radiology and arthroscopy. There were no clinical findings of instability. One patient was found to have subacromial impingement; six had crepitation at various degrees during shoulder movements. At arthroscopy, all patients had a variety of pathological findings. Five patients had Grade 1, three had Grade 2, and two had Grade 3 chondropathy. Various degrees of fraying of the anterosuperior and posterosuperior regions of the glenoid labrum were noted in all cases. Three patients had superior labrum anterior and posterior lesions, one patient had a posterior labroligamentous lesion, and one had chondral erosion in the anterosuperior portion of the humeral head. In conclusions, although the injury mechanism of the shoulder during boxing is unknown, this study shows that shoulder complaints in boxers should be considered as possible indicators of serious intra-articular lesions.

Childhood aplastic anaemia (AA) is an uncommon but potentially fatal haematological disorder. Patients with AA receive supportive care based on transfusions and timely treatment of opportunistic infections, along with specific therapies, which may be bone marrow transplantation and immunosuppressive therapy. Early diagnosis and supportive therapy are required to prevent fatal complications like overwhelming sepsis or life threatening haemorrhages. We report two cases of aplastic anaemia having a different aetiology. The diagnostic work-up and the therapeutic management for each case are described below.

Hereditary hemorrhagic telangiectasia (HHT) is a genetic vascular disorder characterised by epistaxis, telangiectases, and visceral arteriovenous malformations. Hyperdynamic blood flow associated with arteriovenous malformations may lead to pulmonary hypertension, global heart failure, and valvular insufficiencies. We report a patient who had HHT with severe heart failure (New York Heart Association [NYHA] class III-IV) and pulmonary hypertension caused by an hepatic arteriovenous fistula. After successful transarterial embolisation of the right branch of the hepatic artery with polyvinyl alcohol (PVA) particles and coils, 4 to 7 mm in size, the patient was discharged with functional class II (NYHA) heart failure.

Adenocarcinomas of Ileal Duplication Cysts are an extremely rare occurrence, this is a case report and review of current literature as to the best management of this condition.

We report a case of a 36-year-old obese man who presented with newly onset diabetes mellitus type 2 and hypertension. The estimated value of glomerular filtration rate — 203.7 ml/min was associated with the patient being at high risk of developing progressive renal disease. In this case, in order to prevent nephropathy, the preferred therapy was a gradual bodyweight reduction. A low-calorie diet providing an 800 kcal/day deficit was recommended to the patient, as well as an increase in physical activity. After a total weight reduction of 50 kg (33% of initial bodyweight), the patient’s glomerular filtration, body mass index, and blood pressure normalized without any drug therapy. Glucose, blood pressure and lipid target levels can only be simultaneously achieved through body-weight reduction. In the presented case, we show the beneficial effects of bodyweight reduction, and dietary and physical activity changes on high glomerular filtration rate. Bodyweight reduction stops the cascade of events that are caused by glomerular hyperfiltration and the progression toward irreversible renal damage.

Lateral unicompartmental knee arthroplasty (UKA) outcomes have been inferior to those described after medial UKA. Inaccurate implant positioning and mechanical axis malalignment appear to be the most common technical errors. Rare studies or failure identification on lateral UKA are currently presented in the literature. We describe the utilization of computer-assisted lateral UKA placement for lateral knee osteoarthritis with a valgus malalignment of 10°. Navigation allows for a dynamic intraoperative visualisation of the mechanical axis, as well as for accurate component positioning and overall postoperative limb alignment. The systems allow the knee position to be captured with appropriate tension in extension and flexion prior to making definite cuts. Postoperatively, no instabilities occurred with a precise component placement. Navigation can be used in rare cases for lateral UKA.

Sarcoidosis is a systemic granulomatous disease of unknown cause that commonly involves the lungs, lymph nodes, bones, liver, spleen, or skin. Cutaneous findings of sarcoidosis occur in 20% to 35% of patients with systemic disease. The recognition of cutaneous lesions is important, because it gives important clues to diagnosis and also allows for easy biopsy. We report a 71-year-old Turkish woman with erythematous lesions, which included widespread, erythematous macules of various sizes on the chest, abdomen, and back on both sides of her body. Fine white scales covered some of the lesions. Hepatomegaly and bilateral hilar lymphadenopathy were also observed. Biopsy specimens of the skin showed dermal, noncaseating, epitheloid granulomas. The diagnosis, based on correlation of the clinical presentation and histopathological findings, was ichthyosiform sarcoidosis with systemic involvement. The difference between our case and other cases of ichthyosiform sarcoidosis described in the literature is that ours involved only the trunk and not the extremities. We are presenting this case because it is an interesting and rare variant of ichthyosiform sarcoidosis.

Calciphylaxis is a relatively rare disorder associated with calcification of small- and medium-sized blood vessels, progressive ischemic skin necrosis, and ulcerations. This situation is a potentially life-threatening condition seen in patients with endstage renal disease (ESRD). A 64-year-old man with ESRD on dialysis for 6 years was admitted to our clinic with severe pain and partial necrosis of some fingers on his right hand. In addition, the patient had suffered from diabetes for 22 years and had been on insulin therapy for 17 years. His necrotic fingers were amputated. After two months, necrosis on his glans penis developed despite medical management. Penile amputation was performed. In this case report, the patient serves to illustrate the spectrum of complications with which calciphylaxis can be associated.