Management of Saphenous Vein Graft Disease in Patients with Prior Coronary Artery Bypass Surgery.

PURPOSE OF REVIEW: In this review, we summarize the pathogenesis of saphenous venous graft (SVG) failure in patients following coronary artery bypass graft (CABG) surgery. We also provide an update on various aspects of prevention and management of SVG failure. RECENT FINDINGS: Application of perioperative measures and medical therapies to promote SVG patency is crucial to optimize clinical outcomes in patients following CABG. Percutaneous coronary intervention (PCI) of SVG disease is fraught with complications, with the highest risk being no-reflow and periprocedural myocardial infarction due to distal embolization of microemboli. Minimizing this risk with use of distal embolic protection when feasible and understanding the role of adjunctive pharmacotherapies is critical in reducing the risk of adverse cardiac events. The long-term patency of SVGs remains a contemporary challenge and is adversely affected by thrombotic occlusion, intimal fibrosis, and accelerated atherosclerosis. Prevention of SVG failure is multifactorial. Use of perioperative measures, medical therapies, and PCI techniques to promote SVG patency is vital to optimize outcomes in patients following CABG. Further prospective trials are needed to define the optimal medical and surgical therapy to maintain short- and long term SVG patency.

Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials.

BACKGROUND: Telemedicine, the use of telecommunications to deliver health services, expertise and information, is a promising but unproven tool for improving the quality of diabetes care. We summarized the effectiveness of different methods of telemedicine for the management of diabetes compared with usual care. METHODS: We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials databases (to November 2015) and reference lists of existing systematic reviews for randomized controlled trials (RCTs) comparing telemedicine with usual care for adults with diabetes. Two independent reviewers selected the studies and assessed risk of bias in the studies. The primary outcome was glycated hemoglobin (HbA1C) reported at 3 time points (≤ 3 mo, 4-12 mo and > 12 mo). Other outcomes were quality of life, mortality and episodes of hypoglycemia. Trials were pooled using randomeffects meta-analysis, and heterogeneity was quantified using the I2 statistic. RESULTS: From 3688 citations, we identified 111 eligible RCTs (n = 23 648). Telemedicine achieved significant but modest reductions in HbA1C in all 3 follow-up periods (difference in mean at ≤ 3 mo: -0.57%, 95% confidence interval [CI] -0.74% to -0.40% [39 trials]; at 4-12 mo: -0.28%, 95% CI -0.37% to -0.20% [87 trials]; and at > 12 mo: -0.26%, 95% CI -0.46% to -0.06% [5 trials]). Quantified heterogeneity (I2 statistic) was 75%, 69% and 58%, respectively. In meta-regression analyses, the effect of telemedicine on HbA1C appeared greatest in trials with higher HbA1C concentrations at baseline, in trials where providers used Web portals or text messaging to communicate with patients and in trials where telemedicine facilitated medication adjustment. Telemedicine had no convincing effect on quality of life, mortality or hypoglycemia. INTERPRETATION: Compared with usual care, the addition of telemedicine, especially systems that allowed medication adjustments with or without text messaging or a Web portal, improved HbA1C but not other clinically relevant outcomes among patients with diabetes.

Use of electrocardiogram indices of myocardial ischemia for risk stratification and decision making of reperfusion strategies.

After about a century since its clinical introduction, the 12-lead electrocardiogram (ECG) remains a cornerstone in diagnosis and management of acute ST-elevation myocardial infarction (STEMI). It provides clinicians and researchers with invaluable information regarding the presence, location, and extent of myocardial infarction. Moreover the ECG contains a wealth of prognostic information useful in risk stratification of STEMI patients and identification of particular subgroups that may benefit from more aggressive therapeutic interventions. New data suggest the ECG may be useful in guiding the choice of reperfusion treatment when primary percutaneous coronary intervention (PCI) cannot be delivered in the timeframe recommended by current STEMI guidelines. This paper summarizes the role of the ECG in assessing the baseline risk of patients with STEMI and evaluates the use of ECG indices in decision making of reperfusion strategies.

A systematic review and meta-analysis on the safety and efficacy of febuxostat versus allopurinol in chronic gout.

OBJECTIVE: To evaluate the safety and efficacy of febuxostat compared to allopurinol for the treatment of chronic gout. METHODS: We did a systematic review and meta-analysis of randomized and non-randomized controlled trials that compared oral febuxostat to oral allopurinol for treatment of chronic gout. Two reviewers independently selected studies, assessed study quality, and extracted data. Risk ratios (RR) were calculated with random effects and were reported with corresponding 95% confidence intervals (CI). RESULTS: From 1076 potentially relevant citations, 7 studies and 25 associated publications met inclusion criteria; 5 studies were ultimately included in the analysis. Febuxostat did not reduce the risk of gout flares compared with allopurinol (RR = 1.16, 95% CI = 1.03-1.30, I(2) = 44%). Overall, the risk of any adverse event was lower in febuxostat recipients compared to allopurinol (RR = 0.94, 95% CI = 0.90-0.99, I(2) = 13%). Patients receiving febuxostat were more likely to achieve a serum uric acid of <6 mg/dl than allopurinol recipients (RR = 1.56, 95% CI = 1.22-2.00, I(2) = 92%). Subgroup analysis did not indicate any significant difference between high- and low-dose febuxostat on the risk of gout flares. CONCLUSION: Although febuxostat was associated with higher likelihood of achieving a target serum uric acid level of <6 mg/dl, there was significant heterogeneity in the pooled results. There was no evidence that febuxostat is superior to allopurinol for clinically relevant outcomes. Given its higher cost, febuxostat should not be routinely used for chronic gout.

Histopathologic and clinical findings of congenital nephrotic syndrome in Iranian children: a study of two centers.

INTRODUCTION: Congenital nephrotic syndrome (CNS), an uncommon form of kidney disease, presents during the first year of life and is a diagnostic and therapeutic challenge for the pediatricians as well as pediatric nephrologists. Our study is the first study of Iranian children with CNS in two pediatric nephrology centers in Tehran, Iran. MATERIALS AND METHODS: We reviewed medical charts of 30 infants diagnosed with CNS from 1990 to 2005. RESULTS: There were 15 boys and 15 girls with CNS (mean age, 1.7 months). The presentation of the disease was nephrotic syndrome in 96.6% of the patients. Eighty percent of the patients presented within 3 months of life and 16 in the neonatal period. The Finnish type of CNS was seen in 43.3% and diffuse mesangial sclerosis in 50%. Preterm labor and low birth weight was seen in 20%. A family history of nephrotic syndrome in infancy was noted for 8 children (26.7%). Numerous complications of nephrotic syndrome occurred in 73.3%. Seventy percent of the patients had 27 episodes of infections. Sepsis was seen in 43.3% of the children, of which 61.5% were caused by gram-negative bacteria and 38.6% were caused by Staphylococcus aureus. Thrombotic complications and hypertension developed in 6.6% and 23.3% of the patients, respectively. The mortality rate of patients was 86.6%. CONCLUSIONS: Diffuse mesangial sclerosis is an important cause of CNS. The outcome of our patients was poor and most of our patients died before reaching the age of 5 years old.

The value of serum uric Acid as a mortality prediction in critically ill children.

OBJECTIVE: The role of initial serum uric acid on admission in critically ill patients is controversial; we presumed that uric acid level can predict the mortality of the admitted patients to intensive care unit as a simple test. METHODS: Totally, 220 consecutively admitted children (96 girls, 124 boys) with mean age 3.5 years, who were at least 24 hours in pediatric intensive care unit (PICU), were enrolled in a prospective cohort study during January 2006 to December 2007. The subsequent PICU admission in the same hospitalization, those who were discharged from the hospital and then re-admitted to the PICU during the observation period, and the patients with chronic renal failure were excluded. Serum uric acid level was measured during the first day of PICU admission. Death or transfer from PICU was considered as final outcome. The statistical analysis was done by using linear regression analysis, ROC curve, Student t-test, and Chi- square. P value less than 0.05 was considered significant. FINDINGS: From 44 patients who had serum uric acid level more than 8 mg/dl, 17 cases died showing with a higher relative risk of 1.88, higher mortality (P<0.05). The relative risk of death in patients who had serum uric acid >8 mg/dl and needed vasopressor was 1.04, and in those under mechanical ventilation 1.33. In patients who scored pediatric risk of mortality of >38 it was 1.4, and in septic cases 4 (P<0.05). Stepwise linear regression analysis showed that mainly the need for mechanical ventilation (P=0.001) and vasopressor had statistically significant correlation with the poor outcome (P=0.001). CONCLUSION: Uric acid level during the first day of intensive critical care admission is not an independent risk of mortality in PICU. Need for mechanical ventilation or inotropic agents was associated with poor outcome and only higher uric acid level in sepsis played an additive risk factor role.