Cardiovascular autonomic function tests in healthy and diabetic subjects

Diabetic autonomic neuropathy [DAN] is common chronic complications of diabetes mellitus [DM] that occur in nearly half of diabetic patients. DAN in patients with diabetes is an irreversible complication, but early detection is important because the condition can't be reversed. The present study was undertaken primarily to investigate cardiovascular autonomic functions in normal healthy individuals and patients with diabetes mellitus [type 1 and type 2 diabetes mellitus; T1DM and T2DM], and to determine the relationship between diabetes and extent of autonomic function impairment. Autonomic functions using five standard tests were examined in 40 diabetic patients and 40 age and sex matched controls. The extent of autonomic dysfunction was determined in the patients. All the patients and the controls were subjected to measurement of heart rate [HR] and P-R interval were monitored from lead II of the ECG and BP was measured by electrosphygmomanometry. Significant [p <0.001] increase in resting heart rate in T2DM [112 +/- 10 bpm] than T1DM [65 +/- 12 bpm] associated with significant decrease in HR variation daring deep breathing T2DM [8 +/- 3 bpm] compared to T1DM [18 +/- 5 bpm], significant decrease in HR response to standing in T2DM [0.7 +/- 0.2 bpm] compared to T1DM [1.06 +/- 0.2 bpm], significant decrease in postural changes in SBP in T2DM [-15 +/- 3 mmHg] compared to T1DM [-3 +/- 8 bpm] and significant decrease in DBP response to hand grip inT2DM [6 +/- l mmHg] compared to T1DM [20 +/- 7 mmHg] within 2-5 years of both types of DM. Moreover, no significant difference between T1DM and T2DM in cardiovascular autonomic function tests after 5 years of DM. Autonomic dysfunction was significantly more frequent in type 2 diabetes mellitus [T1DM] compared with type 1 diabetes mellitus [T2DM]. This study showed that autonomic neuropathy is common in diabetic patients, and that it increases in severity with increase in extent of T2DM, and starts after 5 years in T1DM suggesting that diabetes mellitus contributes to these neurological derangements

Impact of an exercise program on postoperative complications and hospital stay following lung resection

To develop and implement an exercise program for patients undergoing lung resection and to assess the impact of this exercise program on postoperative pulmonary complications and hospital stay following lung resection. 59 patients underlying lung resection were included in the study. Patients were randamly assigned to two groups 35 as controls and 24 as intervention group. All patients had preoperative assessment [including history taking physical examination, general laboratory tests, arterial blood gases, pulmonary function tests, 12-lead surface ECG and color Doppler echocardiography as well as postoperative pulmonary function tests [3 months postoperative] and hospital stay. Postoperative pulmonary complications were noted according to a precise definition. The intervention group was subjected to pre- and postoperative exercise program. The risk of PPC's associated with selected factors was evaluated. The operations performed included 13 RUL, 9RML, 13RLL, 15LUL and 9 LLL. Fifty-nine patients were studied [35 patients as control and 24 patients as intervention]. There were no differences between the 2 groups regarding age, sex, BMI, pulmonary functions tests ABG, and general laboratory results also had preoperative cardiovascular evaluation criteria that did not differ between the 2 groups. PPCs occurred in 12 patients of controls [34.3%] compared to 2 patients in intervention group [8.3%]; a difference that was highly statistically significant [p<0.001]. The hospital slay was significantly shorter in the intervention group compared to controls [p<0.001] There was no significant difference between patients with and without postoperative complications regarding results of pulmonary function tests. Exercise program developed and evaluated in this study could decrease the frequency of PPCs and shorten hospital stay. Preoperative pulmonary function tests did not contribute to the identification of high-risk patients

measurement of serum lepoprotein [a] and apolipoprotein-B be of prognostic value in patients with type II diabetes mellitus with myocardial infarction and peripheral vascular disease?

Current clinical guidelines require that five indices [total cholesterol LDL cholesterol, HDL cholesterol triglycerides and the total/ HDL cholesterol ratio] be measured or calculated to assess the lipid related risk of vascular disease. Recently, quantification of plasma Lp [a] and Apo-B was proposed as recent clinical markers that will allow better prediction of coronary and peripheral arterial disease. This study prospectively examined whether high levels of Lp [a] and Apo-B have a significant risk and prognostic value in type II diabetic patients with myocardial infarction and peripheral vascular disease. The patients included in the study were selected properly from outpatient clinics of Vascular Surgery Unit as well as Internal Medicine Department [Cardiovascular Unit], Mansoura University. The patients were divided into 4 groups: Group I [n=15]: Type II DM with no CAD and no PVD. Group II [n=15]: Type II DM with history of myocardial infarction and No PVD. Group III [n=15]: Type II DM with no history of myocardial infarction but have symptomatic PVD. Group IV [n=15]: Type II DM with history of myocardial infarction and have PVD. Patients with acute illness or taking Niacin, Estrogen replacement or antibiotics were excluded. All patients were subjected to thorough history taking, cardiovascular and peripheral vascular system evaluation including BMI, ABJ, ECG, Doppler echocardiogram as well as peripheral vascular angiography. Laboratory evaluation of our patients include assessment of diabetic state, HbAlc, standard lipid profile parameters as well as evaluation of Lp [a] and Apo-B. Serum level of Lp [a] and Apo-B showed highly statistically significant results when comparing group I with any group of type II diabetic patients complicated with either MI or PVD [P<0.001]. However, serum apo-B level was highly significant in those complicated with PVD [P<0.001], while serum Lp[a] was statistically higher in those having myo-cardial infarction [P=0.03]. Our study revealed that elevation of serum level of both Lp [a] and Apo-B were significantly correlated with occurrence of myocardial infarction and different grades of peripheral vascular insufficiency in type II diabetic individuals. However, increased serum level of Lp[a] showed higher significant prediction for occurrence of MI while, elevation of serum level of Apo-B predict more the occurrence of PVD among our patients. Evaluation of serum Lp [a] and Apo-B levels should be considered a new risk factor and of prognostic value for occurrence of vascular complications in type II diabetic patients. More population-based prospective studies are needed to answer the question definitively of whether Lp [a] and Apo-B leuels are more predictive of CAD and PVD in type II diabetic individuals than the traditional lipid parameters

Right ventricular function in systemic sclerosis, relation to ICAM-1

Background: Cardiopulmonary involvement in patients with systemic sclerosis [SSc] carries a poor prognosis mainly due to pulmonary hypertension and right-heart failure. The early detection of right ventricle [RV] dysfunction may be important when assessing the prognosis and optimizing treatment. The study aimed to investigate earlier detection of right ventricular dysfunction in systemic sclerosis patients and investigate a possible role of intercellular adhesion molecule-1 [ICAM-1] to a such condition

Methods: The study included 23 SSc patients [mean age 45.4 +/- 10.9 years and disease duration 8.6 +/- 7.5 years] and 21 healthy age and sexmatched control subjects. Doppler echocardiography was used to evaluate cardiac function, high resolution CT to evaluate lung fibrosis. ICAM-1 levels was measured for patients as well as healthy control subjects

Results: An abnormal right ventricular function was established by SSc patients group by higher right ventricle myocardial performance index [RVMPI], lower fractional area shortening [FAS], decreased tricuspid valve E/A ratio, prolonged tricuspid valve deceleration time [TV DT], prolonged right ventricle isovolumic relaxation time [RV IVRT], reduced tricuspid valve filling time corrected to heart rate [0.303 +/- 0.031 vs 0.285 +/- 0.004, P=0.01 and 39.01 +/- 4.2vs 43.3 +/- 5.01, P=0.004 and 0.93 +/- 0.17, 1.03 +/- 0.19, P=0.02 and 191.1 +/- 24.9ms vs 172.4 +/- 28 ms, P=0.002, 60 +/- 23 ms vs 46 +/- 15ms, P=0.02 and 50 +/- 7ms vs 54 +/- 4.1 ms, P=0.02] respectively. These findings were associated with higher ICAM-1 levels in patients than control [468.8 +/- 77 vs 289 +/- 89, P<0.001] as well as higher pulmonary artery systolic pressure [PASP] in SSc patients than controls [38.56 +/- 9.7 mmHg vs 31.2 +/- 8.5 mmHg, P=0.02]. The subgroup of SSc patients [n=11] with stronger evidence of right ventricular systolic and diastolic dysfunction had significantly higher ICAM levels and higher PASP [0.324 +/- 0.03 ng/ml vs 0.286 +/- 0.0024 ng/ml, P<0.001 and 47 +/- 7.36 mmHg vs 30.8 +/- 2.24 mmHg, P<0.001] respectively. Moreover, ICAM-1 correlated significantly with RVMPI, RV FAS, TV E/A ratio, RV IVRT as well as PASP [P=0.004 and 0.032 and0.017 and 0.001 and 0.025] respectively. Also, higher ICAM-levels were associated with increased relative risk of valvular lesion, pulmonary hypertension, lung fibrosis, more advanced LV diastolic dysfunction, joint, muscle and gastrointestinal affection in the studied SSc patients

Conclusion: Altered right ventricular function is exhibited by a considerable percentage of SSc patients. Such alteration is detectable in patients without any clear cut evidence of cardiac disease. Such alteration could be adequately estimated by echo Doppler. Myocardial performance index could be a useful tool. sICAM-1 levels may reflect the extent of right ventricular involvement in SSc patients and point to a pathogenic role of adhesion molecules in systemic manifestation of the disease

Is their a role for oral L-carnitine therapy in anemia and cardiac dysfunction management in Egyptian patients on maintenance hemodialysis?

L-Carnitine is a short organic hydrosoluble molecule and is present in biological materials like free carnitine and acylcarnitines, which constitute the carnitine system. Long-term intermittent hemodialysis is associated with a reduction in plasma and tissue L-carnitine levels. Available studies on carnitine supplementation suggest the use of this molecule in dialysis, especially for those patients with cardiac complications, impaired exercise and functional capacities, and increased episodes of hypotension. Moreover, in some patients, the improved stability of erythrocyte membranes with L-carnitine supplementation may decrease erythropoietin requirements, thus, leading to a reduction of dialytic costs. To study if there a possible advantageous effects for L-Carnitine oral supplementation in anemia and cardiac dysfunction management in a cohort of Egyptian patients on maintenance hemodialysis. Fifty- five patients with chronic renal failure on maintenance hemodialysis were classified into 2 groups: L- Carnitine group: 20 patients [12 male and 8 female, Mean age 47.66 +/- 17.73 years, hemodialysis duration 51.36 +/- 18.14 months, subjected to three sessions /week reaching Kt/V of 1.48 +/- 0.37] they received oral L-Carnitine therapy 1.500 mg/day and Control group: 35 patients [24 male and 11 female, mean age 37.9 +/- 14.7 years, hemodialysis duration 53.83 +/- 15.17 months, subjected to three sessions /week reaching Kt/V of 1.33 +/- 0.28]. Both groups were on Erythropoietin therapy and IV iron whenever indicated. Echogardiographic studies were performed before and at the end of the study. Serum hemoglobin were comparable in the L- carnitine group and control group at the start and six months after therapy [8.63 +/- 1.77 and 9.39 +/- 2.02 gm/dl, P= 0.18, 10.49 +/- 1.60 and 10.29 +/- 2.48 gm/dl P= 0.76 respectively]. The weekly maintenance dose of Erythropoietin inspite of being lower in L-Carnitine group [Mean = 4750.12 +/- 2137.04 units] compared to control group [Mean= 5515.15 +/- 2292.94 units] it does not reach a statistical significance [P=0.24]. No significant improvement could be observed in echogardiographic findings in the L- Carnitine group after therapy. The role of L-Carnitine in hemodialysis patients is questionable. Our study revealed no observed significant improvement in echocardiographic findings 6 months after therapy. However, -a statistically non significant- reduction in Erythropoietin dose was achieved in the L- carnitine-treated compared to the control group while maintaining comparable target hemoglobin in both groups. Long-term studies including larger number of patients are required to clarify its role in hemodialysis patients