Single-Actuator-Based Lower-Limb Soft Exoskeleton for Preswing Gait Assistance.

In this research, we proposed a lower-limb soft exoskeleton for providing assistive forces to patients with muscle weakness during the preswing phase of a gait cycle. Whereas conventional soft exoskeletons employ two motors to assist each leg individually, we designed a single motor for actuation. Our design assists hip flexion for light weights and prevents some slip problems that can arise from rotary motors. The actuation mechanism was based on a pulley system that converted the power supplied by the single motor into linear reciprocating motions of a slider. When the single motor rotated, the slider moved linearly, first in one direction and then in the opposite direction. The slider pulled knee braces through cables with an assistive force of 100 N. The actuation was triggered when the system detected that the backward swing of the wearer's thigh had ended. A prototype was designed, fabricated, and examined with 7 subjects (average age, 24). Subjects were measured while they wore our exoskeleton in power-off and power-on modes. Comparisons proved that wearing the exoskeleton caused a negligible deviation of gait, and that the soft exoskeleton could reduce metabolic cost during walking. The research results are expected to be beneficial for lightweight soft exoskeletons and integration with exosuits that provide assistive forces through the wearer's entire gait.

2019 Consensus of the Taiwan Hypertension Society and Taiwan Society of Cardiology on the Clinical Application of Central Blood Pressure in the Management of Hypertension.

The Taiwan Society of Cardiology (TSOC) and the Taiwan Hypertension Society (THS) have appointed a joint consensus group for the 2019 Consensus of the TSOC and THS on the Clinical Application of Central blood pressure (BP) in the Management of Hypertension with the aim of formulating a management consensus on the clinical application of central BP in the management of hypertension. This consensus document focuses on the clinical application of central BP in the care of patients with hypertension. The major determinants of central BP are increased arterial stiffness and wave reflection, which are also the dominant hemodynamic manifestations of vascular aging. Central BP can be measured noninvasively using various techniques, including with convenient cuff-based oscillometric central BP monitors. Noninvasive central BP is better than conventional brachial BP to assess target organ damage and long-term cardiovascular outcomes. Based on the analysis of long-term events, a central BP threshold of 130/90 mmHg for defining hypertension has been proposed. Recent studies have suggested that a central BP strategy to confirm a diagnosis of hypertension may be more cost-effective than conventional strategies, and that guiding hypertension management with central BP may result in the use of fewer medications to achieve BP control. Although noninvasive measurements of brachial BP are inaccurate and central BP has been shown to carry superior prognostic value beyond brachial BP, the use of central BP should be justified in studies comparing central BP-guided therapeutic strategies with conventional care for cardiovascular events.

Risks of acute coronary syndrome in patients with osteoarthritis: a nationwide population-based cohort study.

Recent studies have reported that osteoarthritis (OA) is related to inflammation and atherosclerosis. Studies on the relationship between OA and acute coronary syndrome (ACS) are scant. We evaluated the risk of ACS in OA patients of an Asian population. This longitudinal, population-based cohort study investigated the incidence and risk of ACS in 46,042 patients with newly diagnosed OA and 46,042 controls selected randomly from the general population and frequency matched according to age, sex, and entry year (2002-2003). The follow-up period ranged from the entry date until the date of an ACS event, loss to follow-up, or the end of 2010. We employed Cox proportional hazard models to estimate the effects of OA on the risk of ACS. The OA patients showed a 15 % higher risk of ACS than did the controls after adjustment for covariates (adjusted hazard ratio [aHR] = 1.15, 95 % confidence interval [CI] = 1.08-1.23). The risk of ACS in the OA patients was the greatest in young adults (aHR = 2.0, 95 % CI = 1.44-2.78), followed by middle-aged (aHR = 1.15, 95 % CI = 1.01-1.31) and older adults (aHR = 1.11, 95 % CI = 1.03-1.20). The risk of ACS was 1.96-fold in young adults with mild to moderate OA and 3.51-fold in young adults with severe OA compared with their counterparts without OA. OA carries an increased risk of ACS, particularly in young adults with severe OA. Clinicians should employ proactive strategies for preventing ACS occurrence in these patients.

The Protective Role of Autophagy in Matrix Metalloproteinase-Mediated Cell Transmigration and Cell Death in High-Glucose-Treated Endothelial Cells.

Diabetes mellitus may cause vascular endothelial damage via endothelial matrix metalloproteinase-2 (MMP-2). The role of endothelial autophagy in MMP-2-mediated cell injury in response to high-glucose (HG) stimulation was rarely described. In this study, we used HG-treated human umbilical vein endothelial cells (HUVECs) to investigate the effect of autophagy on MMP-2-induced cell transmigration and apoptosis. THP-1 transmigration was detected by the transmigration assay. Light chain 3 (LC3, representing autophagy), MMP-2, and poly (ADP-ribose) polymerase (PARP, representing apoptosis) of HG (33 mM)-treated HUVECs were evaluated by western blot analysis. The MMP-2 activity was also examined by gelatin zymography. We used GM6001 (10 µM, an MMP-2 inhibitor) to investigate the relationship of MMP-2 and THP-1 transmigration. Using 3-methyladenine (3MA, 5 mM, an LC3 inhibitor), we explored the effects of autophagy on MMP-2 expression, THP-1 transmigration, and apoptosis. Our results showed that HG increased LC3-II expression, MMP-2 activity, THP-1 transmigration, and cleaved PARP expression in a time-dependent manner (0-48 h); among them, LC3-II appeared earlier (0-24 h) than the others (24-48 h). GM6001 suppressed MMP-2 activity and ameliorated THP-1 transmigration. 3MA suppressed LC3-II expression and increased MMP-2 expression, THP-1 transmigration, and cleaved PARP expression. From these sequential findings, we demonstrated that autophagy plays a protective role in MMP-2-mediated cell transmigration and cell death in HG-stimulated HUVECs.

Association of Plasma Thrombospondin-1 Level with Cardiovascular Disease and Mortality in Hemodialysis Patients.

BACKGROUND: Thrombospondin-1 (TSP-1) is known to be involved in the regulation of angiogenesis, inflammation, and vascular function. Clinical studies have demonstrated its correlation with peripheral artery disease, coronary artery disease, and pulmonary hypertension. In this study, we explored its potential roles in the background of end-stage renal disease (ESRD). METHODS: A total of 140 ESRD outpatients (ages 61.0 ± 12.4 years) were prospectively followed for 34 ± 7 months. Their TSP-1 levels were analyzed from pre-hemodialysis blood sample. Cardiovascular survey included ankle- brachial index (ABI), echocardiography and Tl-201 dipyridamole single-photon emission computed tomography (SPECT). RESULTS: Plasma TSP-1 levels were higher in those patients with preexisting clinical evidence of cardiovascular disease (CVD) than those without (p = 0.002). TSP-1 concentrations were also correlated with ABI, left ventricular ejection fraction, and scar burden in SPECT. Stepwise logistic regression analysis revealed that TSP-1 level was independently associated with the presence of CVD, with an odds ratio of 1.38 [95% confidence interval (CI), 1.09-1.75, p = 0.008]. In survival analyses, 31 patients (22%) died during the follow-up, 16 (52%) arising from cardiovascular causes. Cox hazards analysis revealed that the patients with TSP-1 levels in the highest tertile had a 5.32- and 6.75-fold higher risk for all-cause and cardiovascular mortality than those in the lowest tertile. This predictive value for all-cause mortality still persisted after multivariate adjustment (hazard ratio, 8.71; 95% CI, 1.36-55.68; p = 0.02). CONCLUSIONS: This study hallmarks the association of elevated TSP-1 level with CVD and adverse outcome among hemodialysis patients. KEY WORDS: Thrombospondin-1; End-stage renal disease; Cardiovascular disease; Mortality.

Feasibility and Safety of Coronary Procedures via an Arteriovenous Graft Approach in Patients on Maintenance Hemodialysis.

BACKGROUND: Traditionally, a radial or brachial arterial approach is unadvisable in hemodialysis patients. Consequently, coronary angiography or angioplasty is usually performed via a femoral artery approach in these patients, who carry a higher risk of vascular access complications. In hemodialysis patients, arteriovenous grafts (AVG) are created for repeated punctures; however, the feasibility and safety of a trans-AVG approach for coronary angiography or angioplasty remains unclear. METHODS: In our institution, cardiac catheterizations were attempted via AV grafts in hemodialysis patients with a U-shaped forearm AVG. We retrospectively identified coronary angiography or angioplasty procedures in hemodialysis patients from a computer-based database in our hospital. The procedure details and outcomes were obtained from review of the clinical, angiographic and hemodialysis records. RESULTS: From 2008 to 2013, 167 procedures in hemodialysis patients were identified from 2866 diagnostic or interventional coronary procedures in our institution. Out of these, 24 procedures in 17 patients were performed via a trans-AVG approach. In all AVG procedures, a 6F 16-cm or 7F 10-cm sheath was placed from the AVG into the brachial artery. All diagnostic procedures were successfully performed. In 14 procedures, the patients also underwent angioplasty and all of the angioplasty procedures were successful. There was no arterial spasm, arterial dissection, puncture site hematoma, or acute thrombosis of the AVG during or after the procedures. CONCLUSIONS: A trans-AVG approach appears to be a feasible and safe route for coronary angiography or angioplasty in hemodialysis patients with a U-shaped forearm AVG. However, further studies with a larger patient number are necessary. KEY WORDS: Arteriovenous graft; Hemodialysis; Percutaneous coronary intervention.

2015 guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the management of hypertension.

It has been almost 5 years since the publication of the 2010 hypertension guidelines of the Taiwan Society of Cardiology (TSOC). There is new evidence regarding the management of hypertension, including randomized controlled trials, non-randomized trials, post-hoc analyses, subgroup analyses, retrospective studies, cohort studies, and registries. More recently, the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) published joint hypertension guidelines in 2013. The panel members who were appointed to the Eighth Joint National Committee (JNC) also published the 2014 JNC report. Blood pressure (BP) targets have been changed; in particular, such targets have been loosened in high risk patients. The Executive Board members of TSOC and the Taiwan Hypertension Society (THS) aimed to review updated information about the management of hypertension to publish an updated hypertension guideline in Taiwan. We recognized that hypertension is the most important risk factor for global disease burden. Management of hypertension is especially important in Asia where the prevalence rate grows faster than other parts of the world. In most countries in East Asia, stroke surpassed coronary heart disease (CHD) in causing premature death. A diagnostic algorithm was proposed, emphasizing the importance of home BP monitoring and ambulatory BP monitoring for better detection of night time hypertension, early morning hypertension, white-coat hypertension, and masked hypertension. We disagreed with the ESH/ESH joint hypertension guidelines suggestion to loosen BP targets to <140/90 mmHg for all patients. We strongly disagree with the suggestion by the 2014 JNC report to raise the BP target to <150/90 mmHg for patients between 60-80 years of age. For patients with diabetes, CHD, chronic kidney disease who have proteinuria, and those who are receiving antithrombotic therapy for stroke prevention, we propose BP targets of <130/80 mmHg in our guidelines. BP targets are <140/90 mmHg for all other patient groups, except for patients ≥80 years of age in whom a BP target of <150/90 mmHg would be optimal. For the management of hypertension, we proposed a treatment algorithm, starting with life style modification (LSM) including S-ABCDE (Sodium restriction, Alcohol limitation, Body weight reduction, Cigarette smoke cessation, Diet adaptation, and Exercise adoption). We emphasized a low-salt strategy instead of a no-salt strategy, and that excessively aggressive sodium restriction to <2.0 gram/day may be harmful. When drug therapy is considered, a strategy called "PROCEED" was suggested (Previous experience, Risk factors, Organ damage, Contraindications or unfavorable conditions, Expert's or doctor's judgment, Expenses or cost, and Delivery and compliance issue). To predict drug effects in lowering BP, we proposed the "Rule of 10" and "Rule of 5". With a standard dose of any one of the 5 major classes of anti-hypertensive agents, one can anticipate approximately a 10-mmHg decrease in systolic BP (SBP) (Rule of 10) and a 5-mmHg decrease in diastolic BP (DBP) (Rule of 5). When doses of the same drug are doubled, there is only a 2-mmHg incremental decrease in SBP and a 1-mmHg incremental decrease in DBP. Preferably, when 2 drugs with different mechanisms are to be taken together, the decrease in BP is the sum of the decrease of the individual agents (approximately 20 mmHg in SBP and 10 mmHg in DBP). Early combination therapy, especially single-pill combination (SPC), is recommended. When patient's initial treatment cannot get BP to targeted goals, we have proposed an adjustment algorithm, "AT GOALs" (Adherence, Timing of administration, Greater doses, Other classes of drugs, Alternative combination or SPC, and LSM + Laboratory tests). Treatment of hypertension in special conditions, including treatment of resistant hypertension, hypertension in women, and perioperative management of hypertension, were also mentioned. The TSOC/THS hypertension guidelines provide the most updated information available in the management of hypertension. The guidelines are not mandatory, and members of the task force fully realize that treatment of hypertension should be individualized to address each patient's circumstances. Ultimately, the decision of the physician decision remains of the utmost importance in hypertension management.

Carotid stenting improves cognitive function in asymptomatic cerebral ischemia.

OBJECTIVES: Asymptomatic critical internal carotid artery (ICA) stenosis may lead to cognitive impairment. Carotid stenting (CS) may improve cerebral perfusion, but its impact on neuro-cognitive function has been controversial. METHODS: We prospectively enrolled 34 asymptomatic patients with unilateral ICA stenosis or occlusion, in whom CS was attempted. Computed tomography cerebral perfusion (CTP), and functional assessments including National Institutes of Health Stoke Scale (NIHSS), Bathel Index (BI), and a battery of neuropsychological tests including Mini-Mental State Examination (MMSE), Alzheimer Disease Assessment Scale-Cognitive Subtest (ADAS-Cog), verbal fluency, and Color Trail Making A and B, were done prior to and 3 months after the procedure. RESULTS: Successful CS was achieved in 28 of 34 patients (82%). Based on the baseline CTP finding and intervention result, patients were divided into three groups: group I (n=6) as ipsilateral cerebral ischemia with failed CS procedure, group II (n=17) as ipsilateral cerebral ischemia with successful CS procedure, and group III (n=11) as normal baseline CTP with successful CS procedure. The demographics and baseline cognitive performances were similar among the three groups. In group II, there were significant improvement in Alzheimer Disease Assessment Scale (pre 6.8 ± 4.3 vs post 4.9 ± 2.8, p=0.033), Mini-Mental State Examination Score (pre 25.8 ± 3.8 vs post 27.4 ± 3.5, p=0.007), and Color Trail test A (pre 120.4 ± 73.9s vs post 95.8 ± 57.6s, p=0.004) after CS. In groups I and III, however, no significant difference was observed in any of the cognitive tests. CONCLUSIONS: Successful CS improves neurocognitive function in asymptomatic ICA stenosis or occlusion with objective ipsilateral ischemia.

Neurocognitive improvement after carotid artery stenting in patients with chronic internal carotid artery occlusion and cerebral ischemia.

BACKGROUND AND PURPOSE: Chronic cerebral hypoperfusion may lead to impairment in neurocognitive performance in patients with chronic internal carotid artery occlusion, and the effects of carotid artery stenting on neurocognitive function have been unclear. METHODS: We prospectively enrolled 20 chronic internal carotid artery occlusion patients with objective ipsilateral hemisphere ischemia, in whom carotid artery stenting was attempted. Functional assessments, including the National Institutes of Health Stroke Scale, Barthel Index, and a battery of neuropsychological tests, including the Mini-Mental State Examination, Alzheimer Disease Assessment Scale-Cognitive Subtest, verbal fluency, and Color Trail Making A and B, were administered before and 3 months after intervention. RESULTS: Successful recanalization was achieved in 12 of 20 patients (60%). There was no procedural or new cerebral ischemic event, except for 1 intracranial hemorrhage, which occurred during the procedure and had neurologic sequelae; this case was excluded from analysis. The demographics and baseline cognitive performance were similar between the group with a successful outcome (group 1, n=12) and patients who did not (group 2, n=7). Ten of 12 patients in group 1 had improvement in ipsilateral brain perfusion after the procedure, but none in group 2 had improvement. Significant improvement in the scores on the Alzheimer Disease Assessment Scale-Cognitive Subtest (before, 7.7±8.9 versus after, 5.7±7.1; P=0.024), Mini-Mental State Examination (before, 25.8±3.8 versus after, 27.7±2.7; P=0.015), and Color Trail Making A (before, 123.2±68.6 versus after, 99.3±51.5; P=0.017) were found in group 1 but not in group 2. CONCLUSIONS: Successful carotid artery stenting improves global cognitive function as well as attention and psychomotor processing speed in patients with chronic internal carotid artery occlusion.

The application of infrared thermography in evaluation of patients at high risk for lower extremity peripheral arterial disease.

OBJECTIVE: We investigated the usefulness of infrared thermography in evaluating patients at high risk for lower extremity peripheral arterial disease (PAD), including severity, functional capacity, and quality of life. METHODS: A total of 51 patients (23 males; age 70 ± 9.8 years) were recruited. They completed three PAD-associated questionnaires, including walking impairment, vascular quality of life, and 7-day physical activity recall questionnaires before a 6-minute walking test (6MWT). Ankle-brachial index (ABI) and segmental pressure were analyzed for PAD diagnosis and stenotic level assessment. The cutaneous temperature at shin and sole were recorded by infrared thermography before and after the walk test. Detailed demographic information and medication list were obtained. RESULTS: Twenty-eight subjects had abnormal ABI (ABI <1), while PAD was diagnosed in 20. No subjects had non-compressible artery (ABI >1.3). Demographic profiles and clinical parameters in PAD and non-PAD patients were similar, except for age, smoking history, and hyperlipidemia. PAD patients walked shorter distances (356 ± 102 m vs 218 ± 92 m; P < .001). Claudication occurred in 14 patients, while seven failed in completing the 6MWT. The rest temperatures were similar in PAD and non-PAD patients. However, the post-exercise temperature dropped in the lower extremities with arterial stenosis, but was maintained or elevated slightly in the extremities with patent arteries (temperature changes at sole in PAD vs non-PAD patients: -1.25 vs -0.15°C; P < .001). The exercise-induced temperature changes at the sole were not only positively correlated with the 6MWD (Spearman correlation coefficient = 0.31, P = .03), but was also correlated with ABI (Spearman correlation coefficient = 0.48, P < .001) and 7-day physical activity recall scores (Spearman correlation coefficient = 0.30, P = .033). CONCLUSION: By detecting cutaneous temperature changes in the lower extremities, infrared thermography offers another non-invasive, contrast-free option in PAD evaluation and functional assessment.

Cost-effectiveness of drug-eluting stents in patients with stable coronary artery disease.

BACKGROUND/PURPOSE: Drug-eluting stents (DESs) have been shown to reduce in-stent restenosis and target vessel revascularization (TVR) in large clinical trials. We conducted this study to elucidate the differences in the cost and clinical outcome of DESs and bare metal stents (BMSs). METHODS: We retrospectively analyzed the clinical data and costs of patients with stable angina treated with coronary stents from September 2003 to January 2005 at the National Taiwan University Hospital, Taipei, Taiwan. RESULTS: We enrolled 186 patients treated with DESs and 194 patients treated with BMSs. The use of DESs is associated with a lower rate of TVR compared with that with BMSs (12%vs. 22%, p = 0.011). Compared with the BMS group, the overall costs were significantly higher in the DES group (NT$352,495 ± 140,408 vs. NT$298,947 ± 131,289, p<0.001). The incremental cost to avoid one TVR at 2 years was NT$546,444 (95% confidence interval: NT$151,071-2,565,793). CONCLUSION: The use of DESs reduces the rate of TVR at 2 years after intervention, but is probably not cost-effective compared with BMSs in patients with stable coronary artery disease.

Plasma fatty acids and the risk of metabolic syndrome in ethnic Chinese adults in Taiwan.

BACKGROUND: Evidence of predictive power of various fatty acids on the risk of metabolic syndrome was scanty. We evaluated the role of various fatty acids, including saturated fat, monounsaturated fat, transfat, n-6 fatty acid, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), for the risk of the metabolic syndrome in Taiwan. RESULTS: A nested case-control study based on 1000 cases of metabolic syndrome and 1:1 matched control subjects. For saturated fat, monounsaturated fat and transfat, the higher the concentration the higher the risk for metabolic syndrome: participants in the highest quintile had a 2.22-fold (95% confidence interval [CI], 1.66 to 2.97) higher risk of metabolic syndrome. In addition, the participants in higher EPA quintiles were less likely to have the risk of metabolic syndrome (adjusted risk, 0.46 [0.34 to 0.61] for the fifth quintile). Participants in the highest risk group (low EPA and high transfat) had a 2.36-fold higher risk of metabolic syndrome (95% CI, 1.38 to 4.03), compared with those in the lowest risk group (high EPA and low transfat). For prediction power, the area under ROC curves increased from 0.926 in the baseline model to 0.928 after adding fatty acids. The net reclassification improvement for metabolic syndrome risk was substantial for saturated fat (2.1%, P = 0.05). CONCLUSIONS: Plasma fatty acid components improved the prediction of the metabolic syndrome risk in Taiwan.

Grape seed extract ameliorates tumor necrosis factor-α-induced inflammatory status of human umbilical vein endothelial cells.

BACKGROUND: Inflammation has played a key role in the causation of atherosclerosis. However, the effects of grape seed extract (GSE) on the pro-inflammatory intracellular signaling, enzyme activity, and inflammatory mediators of endothelial cells have not been sufficiently studied, and less information exists on the comparison between GSE and vitamin C, a well-known antioxidant compound, on their anti-inflammatory properties. PURPOSE: We investigated the effects of GSE and vitamin C on the cell viability, oxidative stress, monocyte adhesion, the expression of nuclear factor-κB inhibitor (IκB), intercellular adhesion molecule-1 (ICAM-1) and cyclooxygenase-2 (COX-2), and the production of prostaglandin E(2) (PG E(2)) in TNF-α-treated human umbilical vein endothelial cells (HUVECs). METHODS: Cell viability was measured by MTT assay. The adhesion of THP-1 to HUVECs was evaluated by cell adhesion assay. The oxidized nucleoside 8-hydroxydeoxyguanosine (8-OHdG) (an indicator of oxidative damage to DNA), ICAM-1, and PG E(2) were measured by ELISA. IκB and COX-2 expression were evaluated by western blot analysis. RESULTS: TNF-α (10, 20, and 50 ng/mL), GSE (50 and 200 µg/mL), or vitamin C (100 µM) did not affect cell viability. GSE (50-100 µg/mL) attenuated TNF-α (20 ng/mL)-induced 8-OHdG production, THP-1 adhesion, the expression of IκB degradation, ICAM-1 and COX-2, and the production of PGE(2) in a dose-dependent manner. Vitamin C (100 µM) also showed significant antioxidative and anti-inflammatory effects. CONCLUSIONS: GSE effectively ameliorates TNF-α-induced inflammatory status of HUVECs. The findings of the present study suggest that consumption of GSE may be beneficial to inflammatory atherosclerosis.

Naringenin more effectively inhibits inducible nitric oxide synthase and cyclooxygenase-2 expression in macrophages than in microglia.

Macrophages and microglia are thought to account for initial disease progression in acute myocardial infarction and acute ischemic stroke. Before our study, the inhibitory effects of naringenin, a flavonoid, on lipopolysaccharide (LPS)-induced inflammation in macrophages and microglia have not been fully reported and compared. We hypothesized that naringenin can effectively inhibit LPS-induced inflammation of macrophages and microglia at different concentrations, the range of which is broader, with the lowest concentration more easily achieved in macrophages. In this study, we compared the anti-inflammatory effects of naringenin on LPS-stimulated RAW 274.6 macrophages and BV2 microglia and the suppression effects of naringenin and vitamin C (a well-known anti-inflammatory agent) on LPS-induced nitrite production. The results show that macrophages could maintain cell viability at higher naringenin concentrations and were more easily activated by LPS in comparison to microglia (200 vs 100 µmol/L; 0.1 vs 1 µg/mL). Under LPS (1 µg/mL) stimulation in both cell types, naringenin (up to 200 µmol/L in macrophages and 100 µmol/L in microglia) inhibited nitrite production and inducible nitric oxide synthase and cyclooxygenase-2 expression in a dose-dependent manner. The range of naringenin concentrations for inhibition was broader, and the lowest concentration was more easily achieved in macrophages; the lowest effective concentrations of naringenin to achieve constant suppression effect were 50 µmol/L in macrophages and 100 µmol/L in microglia, respectively. Vitamin C (100 µmol/L), compared with naringenin (100 µmol/L), had less and no suppression effect on LPS (1 µg/mL)-induced nitrite production in macrophages and microglia, respectively. In conclusion, naringenin more effectively inhibits the LPS-induced inflammatory status, including nitrite production and inducible nitric oxide synthase and cyclooxygenase-2 expression, in macrophages than in microglia. The findings of the present study suggest that consumption of naringenin-containing flavonoids might be beneficial to the cardiovascular and cerebrovascular inflammatory process.

The relationship between aminoterminal propeptide of type III procollagen and heart rate variability parameters in heart failure patients: a potential serum marker to evaluate cardiac autonomic control and sudden cardiac death.

BACKGROUND: Cardiac extra-cellular matrix (ECM) fibrosis plays an important role in the pathophysiology of heart failure (HF). It may provide electrical heterogeneity and a substrate for arrhythmogenicity, which may cause sudden cardiac death (SCD). METHODS: Twenty-one patients with manifestations of HF and a left ventricular ejection fraction (LVEF) ≤50% were enrolled. The median age was 62 years and median LVEF was 33%. Time- and frequency-domain analysis of heart rate variability (HRV) on 24 h ambulatory electrocardiography recording was assessed. Serum markers of ECM turnover including type I and III aminoterminal propeptide of procollagen (PINP and PIIINP), matrix metalloproteinase-2 and -9 (MMP-2 and MMP-9), and tissue inhibitor of metalloproteinase-1 (TIMP-1) were analyzed. RESULTS: The serum PIIINP concentration was correlated significantly with standard deviation of all normal to normal R-R intervals (SDNN) (r=-0.722, p=<0.001), percentage of adjacent NN interval differences >50 ms (pNN50) (r=-0.528, p=0.014), percentage of adjacent NN interval differences >20 ms (pNN20) (r=-0.545, p=0.002), very low frequency (VLF) (r=-0.490, p=0.024), low frequency (LF) (r=-0.491, p=0.024), and high frequency (HF) (r=-0.513, p=0.018). PINP, MMP-2, -9, TIMP-1 were not correlated with time- and frequency-domain analysis of HRV. CONCLUSIONS: PIIINP was significantly correlated with time- and frequency-domain analysis of HRV in HF patients. PIIINP is a potential serological marker to evaluate cardiac autonomic control and risk of SCD in HF patients.

Catheter-based neurosalvage for acute embolic complication during carotid intervention.

OBJECTIVES: Iatrogenic emboli may be released during carotid intervention, causing permanent neurologic complications and catastrophic outcomes. This article reports the procedural details and clinical results of our series of neurosalvage techniques to manage thromboembolic events during carotid procedures. METHODS: Between March 2003 and December 2007, 342 patients (283 men, 72.1 +/- 8.9 years old, 121 symptomatic) underwent percutaneous stent deployment in 407 cervical internal carotid arteries in our institution. Visible distal embolization with flow occlusion caused neurologic complications in 10 patients (2.5%), and a structured and stepwise neurosalvage approach was attempted. RESULTS: Guidewire fragmentation and microcatheter injection of heparin and nitroglycerin were performed in all 10 patients as step 1. Intra-arterial thrombolysis was given in four patients and balloon angioplasty in five, as step 2. Intracranial stenting was done in one patient as the last step. Successful angiographic recanalization (Thrombolysis in Myocardial Infarction [TIMI] grade 2-3) occurred in 9 of 10 (90%). Residual neurologic sequel was observed in five, including three patients with hemorrhage complications (1 received emergent craniotomy). There was no neurologic mortality in this series. CONCLUSIONS: Acute embolic complication during carotid artery stenting can be managed by catheter-based neurosalvage with effective angiographic recanalization and marginal clinical success.

Type A aortic dissection manifesting as acute myocardial infarction: still a lesson to learn.

OBJECTIVE: Type A aortic dissection manifesting as acute myocardial infarction (AMI) is relatively rare but could be catastrophic if the management is not appropriate. This study investigated the incidence, outcome and potential diagnostic pitfalls of patients with such manifestations, and proposes a useful diagnostic paradigm. METHODS AND RESULTS: From 1 January 1995 to 31 July 2006, 531 patients admitted to our hospital with the initial or later diagnosis of acute aortic dissection were reviewed. Two hundred and thirty-nine patients were diagnosed as Stanford type A aortic dissection with a mortality rate of 17% (41/239). Eleven (5%) of the 239 patients had initial presentation of AMI (chest pain and elevation of cardiac enzymes, with or without ST-segment elevation) and a high mortality rate of 36% (4/11). All six patients with ST-segment elevation underwent coronary angiography without awareness of type A aortic dissection; three patients were detected to have eccentric aortic regurgitation by transthoracic echocardiography (TTE) before angiography but type A aortic dissection was neglected at that time. Three of the five patients without ST-segment elevation also had eccentric aortic regurgitation by TTE before the confirmative diagnosis was made; prompt suspicion of type A aortic dissection was assisted with an elevation of D-dimer value in one of these three patients. The presence of eccentric aortic regurgitation by TTE, and the increased D-dimer value provided hints of the coexistence of AMI and type A aortic dissection. CONCLUSIONS: Type A aortic dissection manifesting as AMI is a catastrophe in disguise. Prompt checks of TTE and the D-dimer value would bring the hidden diagnosis of acute aortic dissection more to the forefront.

The relationship between serum galectin-3 and serum markers of cardiac extracellular matrix turnover in heart failure patients.

BACKGROUND: A growing body of evidence links macrophage activation and fibrosis to the pathogenesis of heart failure (HF). Galectin-3 is one of the most likely mediators between macrophage activation and myocardial fibrosis. However, the exact relationship is unknown in humans. We assessed the impact of galectin-3 on serum markers of cardiac extracellular matrix (ECM) turnover in HF patients. METHODS: Patients with HF manifestations and a left ventricular ejection fraction (LVEF)