study of the prophylactic and curative effect of melatonin on postoperative delirium after coronary artery bypass grafting surgery in elderly patients

Background: delirium is a common complication after cardiac surgical procedures and is associated with increased morbidity and mortality. Postoperative delirium is associated with an increased length of stay in the intensive care unit, long hospital stay and high hospital charges

Aim of the Work: to investigate the effectiveness of melatonin as a preoperative sedative as well as the preventive and the curative effect of melatonin supplementation in elderly patients undergoing coronary artery bypass surgery on postoperative delirium

Patients and Methods: this prospective, randomized, controlled, double blind study was conducted on a total of 50 patients allocated into 2 equal groups. It was conducted in Ain Shams University hospitals, in the cardiothoracic surgery unit

Results: melatonin has superior sedative effect at 30 min preoperatively compared with placebo [P=0.022]. Melatonin succeeded to treat about 56% of delirious patients. The incidence of delirium was 8% in the melatonin group vs. 28% in the control group [P= 0.046]. In univariate analysis, predictors of delirium in both groups were age [P= 0.049 in melatonin group, P=0.021 in control group], higher fentanyl dose [P= 0.021 in melatonin group, P=0.047 in control group], lower ejection fraction [P= 0.018 in melatonin group, P=0.008 in control group], longer cardiopulmonary bypass [CPB] times [P= 0.026 in melatonin group, P=0.04 in control group] and longer aortic cross clamping [ACC] times [P= 0.04 in melatonin group, P=0.019 in control group]

Conclusion: administration of melatonin significantly decreased the incidence of postoperative delirium [POD] after coronary artery bypass grafting in elderly patients and significantly increased preoperative sedation. Advanced age, higher total intraoperative fentanyl dose, lower ejection fraction and longer CPB and ACC times were independent predictors of POD with or without melatonin supplementation.

Effect of different lung ventilatory patterns during and after cardiopulmonary bypass on oxygenation parameters after cardiac surgery in adults: a comparative study

Background: pulmonary complications after cardiac surgery recorded incidence of 25% of all cardiac surgeries. Ventilation strategies before and after CPB also cause problems. Alveolar over-distention and reduced lung recruitment are involved in lung injury during general anesthesia in cardiac surgeries. Protective lung ventilation is a common practice during general anesthesia and includes positive end expiratory pressure [PEEP], recruitment maneuvers and the use of FiO2 levels not greater than 80%

Aim of the Work: the aim of the study was to compare the effect of application of continuous positive airway pressure [C-PAP] ventilation during cardiopulmonary bypass and application of positive end expiratory pressure [PEEP] after cardiopulmonary bypass [CPB] per se or followed by lung recruitment [RM] in the intensive care unit [ICU] on arterial oxygenation after cardiopulmonary bypass

Patients and Methods: after obtaining approval from the medical ethical committee, this study was conducted at Cardiothoracic Academy of Ain Shams University and Ain Shams University specialized hospitals. The study included 66 patients divided into three equal groups

Conclusion: the application of alveolar recruitment strategy showed short term improvement in the arterial oxygenation and ventilation perfusion mismatch in patients undergoing CABG using CPB. Further studies are needed to determine if this beneficial effect of recruitment maneuvers could be further prolonged and produce more lasting clinical effects

Exercise as a non pharmacological intervention and alternative to oral estrogen therapy in post menopausal women with endothelial dysfunction

Endothelial dysfunction is a key event in the progression of atherosclerosis and heart failure. When the vascular endothelium is healthy it become like Teflon and things don't stick but when it is unhealthy it become like a Velcro attracting blood born junk. Both exercise and postmenopausal estrogen therapy augments endothelial function through increasing bioavailability of nitric oxide [NO] which is a substance that keep your blood vessels opened. Determines the effects of acute bouts of exercise on brachial artery endothelium dependent flow mediated vasodilatation FMD in postmenopausal women. Whether these responses were augmented by the concurrent use of oral estrogen. Whether these two interventions independently or together achieve FMD values observed in pre menopausal women. This study was conducted on 30 apparently healthy post menopausal women their mean age was [54 +/- 4 years old]. FMD was quantified during supine rest and again 60 minutes after treadmill exercise for 45 minute at 60% v02 max - subjects were studied twice, before and after 4 weeks of oral estradiol. The normal reference values was obtained from concurrent determinant of FMD in 30 pre menopausal women their mean age was [28 +/- 2] years old under identical basal conditions. Flow mediated vasodilatation in post menopausal women markedly impaired when compared with pre menopausal women, the mean of absolute diameter change in brachial artery for flow mediated dilatation in post menopausal women was significantly less than premenopausal women [[2.01 +/- 0.2mm [6.1%] Vs 4.1 +/- 0.4mm [12%] P<0.05]. After exercise the absolute change in the brachial artery diameter for FMD in postmenopausal women significantly approximate normal values] [3.8 +/- 0.3mm [11.4%] P<0.05]. In contrast after estrogen therapy the mean of absolute brachial artery diameter change for FMD was augmented at rest [P < 0.01] but was not further enhanced after exercise. [3.7 +/- 0.6 mm [11.5%] VS 3.50 +/- 5mm [10.5%] P > 0.05]. Both interventions increased FMD to values in pre menopausal women. In post menopausal women both acute exercise and oral estrogen normalize FMD. However their effects weren't additive, so these results reinforce the concepts that exercise is an alternative non pharmacological intervention to estrogen in post menopausal women with endothelial dysfunction. For every post menopausal woman regular moderate intensity exercise training must continue to maintain improvement in your endothelial function

Clinical and surgical predictors of early post operative atrial fibrillation and sustained ventricular tachycardia after cardiac surgery

Post operative Atrial Fibrillation [AF]. Occurs up to 50% in cardiac surgery patients and represent the most common post operative complication. Although malignant ventricular tachycardia [V.T.] is uncommon arrhythmic complication early after cardiac surgery - it has a negative impact on mortality. The etiology of these arrhythmias [AF, V.T] after open heart surgery is incompletely understood and their prevention remains suboptimal. Identification of patients vulnerable for post operative [AF, V.T.] would allow targeting of these patients to benefit from aggressive prophylactic intervention. The aim of this work is to evaluate the incidence and identify risk factors of [AF, sustained V.T.] early postoperatively after cardiac surgery. 40 patients with a mean of age [55 +/- 10] years old [20 male, 20 female] under went isolated elective cardiac surgery [20 patients for valve replacement and 20 patients for CAPG]. Demographic and clinical data preoperative, operative and postoperative were collected. Patients continuously monitored and hemodynamically significant [AF, VT] were recorded. Detailed analysis was performed to define the risk factors. Post operatively AF occurred in [17/40] 42.5%. The mean age for patients with postoperative AF was 55 +/- 7.3 years old compared with 47.7 +/- 9.3 years old for patients without AF P<0.05. The mean heart rate variability [RMSSD] significantly differed between patients with post operative AF and patients without [15 +/- 2.1 msec VS 25 +/- 3 msec P<0.05]. The mean of P wave dispersion for patients with po AF was significantly prolonged compared to patients without AF [80 + 11 msec VS 42 +/- 12 msec, P<0.05]. Multivariate logesitic analysis [odds ratio +/- 95% CI, P value] was used to identify the following independent predictors of post operative AF: increasing age above VS below the mean age [OR = 2.8 CI [1.2-3.5] P<0.0] valve surgery VS CAPG [OR= 2.75 CI [1.2- 3.2] P<0.05], preoperative non use of beta blockers [OR= 1.5 CI [1.1-4.2] P<0.05] Considering several operative variables, use of internal mammary artery, pulmonary venting, cardiopulmonary bypass time, and aortic cross clamping time were significantly differed between the group with AF. And the group without AF. [26.6% VS 73.4% P=0.001] [71.4% versus 28.6% P=0.001], [113.8 +/- 33.5 m versus 92.4 +/- 36.3 m, P=0.002]. [97.8 +/- 21.5, versus 71.3 +/- 9.3, P = 0.001] respectively. Only one patient developed sustained VT post operatively [2.5%] of total study population, she was female had longer pump time than patient without sustained VT [120 min VS 80 +/- 9.5 min P<0.05]; longer Aortic cross clamping time [103 min VS 60 +/- 20 min P<0.05]; had increased QT[c]D than patient without sustained VT [120 msec VS 80 +/- 5 msec, P<0.05]. Patients with and without hemodynamically significant AF and sustained VT had similar body mass index preoperative heart rate and preoperative blood pressure. AF remains the most common complication after cardiac surgery. Increasing age and type of surgery identifies patients at risk for development of AF after cardiac surgery. Female sex, longer pump time, aortic cross clamping time, are independent predictors of developing sustanined VT post operatively. Increased QT[c] dispersion, decreased HRV, Root square of the mean of the sum of the Square of differences between adjacent R-R intervals [RMSSD] and increased PWD after cordic surgery may reflect disrupted electrophysiological stability of the myocardium and thus electrophysiological substrate for triggering malignant arrhythmias

Exercise as a non pharmacological intervention and alternative to oral estrogen therapy in post menopausal women with endothelial dysfunction

Both exercise and postmenopausal estrogen therapy augment endothelial function through increasing bioavailability of nitricoxide [NO]. The aim of this study was to: 1- determine the effects of acute bouts of exercise on brachial artery endothelium dependent flow mediated vasodilatation FMD in postmenopausal women. 2- Whether these responses were augmented by the concurrent use of oral estrogen. 3- Whether these two interventions independently or together achieve FMD values observed in pre menopausal women. This study was conducted on 30 apparently healthy post menopausal women their mean of age was [54 +/- 4 years old]. FMD was quantified during supine rest and again 60 minutes after treadmill exercise for 45 minute at 60% v[02] max - subjects were studied twice, before and after 4 weeks of oral estradiol. The normal reference values was obtained from concurrent determinant of FMD in 30 pre menopausal women their mean of age was [28 +/- 2] years old under identical basal conditions. flow mediated vasodilatation in post menopausal women markedly impaired when compared with pre menopausal women. The mean of absolute diameter change in brachial artery for flow mediated dilatation in post menopausal women was significantly less than premenopausal women [2.01 +/- 0.2mm [6.1%] Vs 4.1 +/- 0.4mm [12%] P<0.05]. After exercise the absolute change in the brachial artery diameter for FMD in postmenopausal women significantly approximate normal values [3.8 +/- 0.3mm [11.4%] P<0.05]. In contrast after estrogen therapy the mean of absolute brachial artery diameter change for FMD was augmented at rest [P < 0.01] but was not further enhanced after exercise. [3.7 +/- 1.32 mm [11.5%] VS 3.5 +/- 1.4mm [10.5%] P > 0.05]. Both interventions increased FMD to values in pre menopausal women. in post menopausal women both acute exercise and oral estrogen normalize FMD. However there effects weren't additive so these results reinforce that exercise is an alternative non pharmacological intervention to estrogen in post menopausal women with endothelial dysfunction

Stress tissue doppler echocardiography, is it has any prognostic implication after acute myocardial infarction?

The index could be a predictor of both systolic and diastolic myocardial performance after acute myocardial infarction [AMI]. Low-dose dobutamine stress echocardiography identifies viability in patients with myocardial dysfunction, and predicts the reversibility of myocardial function after AMI. Pulsed wave -Doppler tissue imaging [DTI] allows measuring regional myocardial velocities, and changes of both systolic and diastolic myocardial function

Aim of the work: This study aimed to assess the prognostic implication of resting and stress tissue Doppler echocardiographic variables in patients with first acute uncomplicated anterior myocardial infarction

Patients and Methods: This study included 159 patients They were divided into two groups; patients group included 129 patients with first acute anterior MI treated with thrombolytic therapy and control group included 30 age- and sex- matched healthy subjects. All patients were subjected to baseline demographic characteristics include age, sex, obesity and clinical data analysis, also coronary risk factors were assessed. Complete resting echocardiographic evaluation and resting Doppler tissue imaging [DTI] study for measuring Tei index and low dose dobutamine stress echocardiography to assess myocardial viability were done in all patients. Pulsed-wave Doppler tissue imaging study before and during low dose dobutamine stress echocardiography and follow-up of major adverse cardiac events by resting conventional echocardiography at one month, was done for every patient

Results: Patients were sub-divided into two groups according to the myocardial functional improvement at follow up; group I: included 68 patients with no improvement of myocardial function, and group II: included 52 patients with improvement on follow up. There was significant correlation between group I and the resting echocardiographic data, and there was significant positive correlation between group II and the viability demonstrated with low dose dobutamine echocardiography [LDDE], DTI, or both techniques together. During follow-up, two patients died from non cardiac cause, the remaining patients had cardiac events, forming the event group [group A], and the non-event group [group B]. Patients in group A were significantly older than patients in group B [P<0.000]. However, there was significant positive correlation between non event group and the myocardial viability. Tei index was the most significant constant independent predictor of early cardiac events

Conclusion: Resting and stress tissue Doppler echocardiographic variables found to have a significant prognostic implication in patients with acute anterior myocardial infarction

Methylene tetrahydrofolate reductase polymorphism as an atherosclerotic coronary risk factor among patients with coronary artery disease

Recently several studies revealed discrepancies about the association of methylenetetrahydrofolate reductase [MTHFR] gene polymorphism and the development atherosclerotic coronary artery disease [ACAD] in different races and population. The present study aimed to study MTHFR gene polymorphism among the controls and evaluate it as a risk factor for ACAD Egyptian patients. The study was conducted on 30 patients [58.7 +/- 6.02 years old]. Compared to age matehed 30 normal subjects. All patients underwent complete clinical ECG, enzymatic, assessment and coronary angiography fasting polymerase chain reaction-restricion fragment length polymorphism analysis was used to detect the C677T variants of the MTHFR gene in 30 patients with ACAD versus 30 healthy controls. Their serum homocysteine level was determined by ELISA technique. Fasling blood glucose, creatinine, cholesterol, high density lipoprotein cholesterol [HDL-C] and triglyceride were estimated by spectrophometric method, and low density lipoprotein cholesterol [LDL-C] was calculated. Frequencies of MTHFR CC, CT and TT genotypes were 50%, 30% and 20% in ACAD patient group versus 56.7%, 26.6% and 16.7% in control. Palients with ACAD showed significantly higher plasma homocyteine concentrations than control [12.03 +/- 3.4 imol/L VS 10.77 +/- 1.9 Rmol/L, P<0.05]. When palients and controls were classified according to their genotypes, no significant difference was found among the different genotypes in control group, as well as, between them and CC, CT type in patients group. In contrast, patients with MTHFR TT genotype had significantly higher homocysteine concentration compared to the same genotype in control group [17.01 +/- 3.4 Rmol/L VS 11.1 +/- 0.89 Rmol/L]. Furthermore, they had higher serum cholesterol and lower HDL-C, which have been correlated to their serum homocysteine concentrations. Relalive risk estimation revealed that palients with TT genotype were at greater risk than CT and CC genotypes. It could be concluded that MTHFR TT genotype could be considered as a risk factor that could interact with other environmental factors and contribute to ACAD

Color M-mode for the assessment of left ventricular diastolic function

During the last two decades, Doppler echocardiography has emerged as the principal clinical tool for the assessment of left ventricular [LV] diastolic function. Trans-mitral and pulmonary venous Doppler flow indices have been used to evaluate different parameters of diastolic function, but it is difficult to use these modalities in differentiation between a normal filling pattern and a pseudo-normal filling pattern. Recently, color M-mode [CMM] of LV inflow and tissue Doppler imaging [TDI] of mitral annulus have provided additional insights in the assessment of diastolic function. Aim of the work: was to correlate the new parameter CMM of LV inflow with trans-mitral flow [TMF] in different patterns of diastolic performance to evaluate its clinical utility. 70 patients [46 males, and 24 females] who are having diseases known to affect diastolic function and 10 normal individuals as a control group were included in the study. The 70 patients were divided into 3 groups according to their LV diastolic filling pattern based on the conventional TMF pattern and included, group I [impaired relaxation pattern, IR], group 2 [pseudo-normal pattern, PN] and group 3 [restrictive filling pattern. RFP]. All of them were subjected to trans-thoracic Doppler echocardiography [TTE] with TMF and CMM examinations. In group I [IR], flow propagation velocity [VP] was lower than that in PN and control groups but higher than that in RFP group. Time delay [TD] and E/VP ratio were lower than those in PN and RFP groups but higher than those in control group. In group 2 [PN], VP and TD were higher than those in IR and RFP groups but lower than those in control group. E/VP was higher than that in IR and control groups but lower than that in RFP. In group 3 [REP], VP was lower than that in all other groups. TD and E/VP were higher than those in all other groups. Tei index was significantly higher in group 2 and 3 as compared to the control group but did not show significant change between group 1 and the control group. Also there was statistically significant correlation between E/VP ratio with, E, TD and Tei index. While statistically significant negative correlation was recorded between E/VP ratio with EDT, IVRT and VP. The new modality CMM is helpful in differentiation of PN pattern from normal pattern and can be complementary to TMF to give an idea non-invasively about diastolic parameters

Protein losing enteropathy in measles

Serum and faecal alpha-1 antitrypsin concentration as well as alpha-1 antitrypsin clearance were measured in 10 malnourished children with measles, 10 well nourished children with measles, as well as 10 age matched normal Egyption children. Serum alpha 1-antitrypsin concentrations were significantly lower than normal in both groups of measles. The intestinal clearance of alpha-1 antitrypsin was significantly high in the malnourished group. The dual effect of measles [usually sever in PEM] and mal-nutrition on the intestinal mucosa makes it more permeable to plasma proteins