impact of intraoperative transoesophageal echocardiography on decision-making during cardiac surgery

Real time intraoperative transoesophageal echocardiograpgy [TOE] has an expanding role in peri-operative management and surgical decision making. Studies of the effect of transoesophageal echocardiography [TOE] on intraoperative decision making commonly emphasise major changes in operative plans. We examined more subtle effects using a novel scale, recording influences on management as follows: Level 1: TOE had no effect on management, confirmed and quantified known pathology. Level 2: TOE altered hemodynamic and/or anesthetic management. Level 3: TOE evaluated the adequacy of surgical intervention/or repair. Level 4: TOE led to an alteration in the surgical plan. We compared the impact of TOE as an aid to intra-operative management in coronary artery bypass cases with other types of cardiac surgery. Retrospective, observational study in a single centre, university-affiliated hospital included 319 patients undergoing cardiac surgery and suitable for TOE. TOE was performed in each patient before and after the institution of cardiopulmonary by-pass. Normal and abnormal echocardiographic findings as well as immediate outcomes of the surgical procedure were recorded using a standard database form. Instances where TOE lead to alteration in operative management were documented. The findings were also compared with those documented on preoperative echocardiography. In 141 CABG patients TOE had a level 1 impact in 73%, level 2 impact in 11.6%, levels 3 and 4 in 7% and 7.8% respectively. In 178 non CABG patients these values were 2%, 1.6%, [p < 0.05], 72.4% [p < 0.05] and 23.6% [p < 0.05] respectively. The impact of TOE in CABG procedures, while significantly less than that in non-CABG surgical procedures, remains substantial

pilot study of pioglitazone for the treatment of non-alcholic fatty liver disease

Insulin resistance appears to be a major factor involved in the pathogenesis of non-alcoholic fatty liver disease [NAFLD] and nonalcoholic steatohepatitis [NASH]. In this pilot study, we examined the effect of pioglitazone, an insulin-sensitizing agent, on patients with NAFLD and NASH. The medical records of patients referred to our clinic over a 48-month period were reviewed, and individuals with a clinical diagnosis of NAFLD or NASH, who were overweight [BMI >/= 25] with chronic elevated liver enzymes were included in this study. The patients were either treated with pioglitazone or advised to start a weight-reduction diet and exercise, in a non-blinded random method based on the treating physicians' discretion. Thirty-four patients' charts were retrospectively analyzed. Nineteen patients were treated with pioglitazone and 15 patients were advised to start a weight reduction diet and exercise. There were significant improvements in mean ALT and AST in the pioglitazone group at the end of treatment when compared to pretreatment values and to the diet/exercise group. There were no significant changes in the lipid profiles, body mass index or fasting glucose levels between baseline and at the end of the therapy in either group. There were no adverse side effects, including hypoglycemia, in patients treated with pioglitazone. Preliminary results using pioglitazone in patients with NAFLD or NASH are promising. However, larger prospective studies are further needed to validate the results of our study and to examine histological response