Successful treatment of enterocutaneous fistula in a hemodialysis patient with somatostatin.

Although cysticercosis is the most common parasitic disease affecting the central nervous system, spinal cysticercosis is rare. A rare form of spinal cysticercosis involving the whole spinal canal is presented. A 45-year-old Korean male had a history of intracranial cysticercosis and showed progressive paraparesis. Spinal magnetic resonance scan showed multiple cysts compressing the spinal cord from C1 to L1. Three different levels (C1-2, T1-3, and T11-L1) required operation. Histopathological examination confirmed cysticercosis. The patient improved markedly after surgery.

An unusual cause of mismanagement in an acute myocardial infarction case: pseudothrombocytopenia.

Thrombocytopenia determined by an automated counter may represent a benign, incidental finding in an asymptomatic patient or a potentially life-threatening disorder. Even if the low platelet count actually is a benign condition itself, in some conditions, any delay resulting from this condition consequently may be seriously hazardous. Low platelet count may alter the decision of heparin administration, which is an essential part of management during acute coronary syndromes. EDTA-dependent pseudothrombocytopenia (PTCP) is reported to have a prevalence of 0.1% in a general hospital; however, it is also reported that around 15% of the patients referred for a specialized center for isolated thrombocytopenia are actually cases of PTCP. In this report, we describe a patient with PTCP who could not receive reperfusion therapy during acute myocardial infarction because of the low platelet counts reported by an automated counter.

Mean platelet volume is elevated during paroxysmal atrial fibrillation: a marker of increased platelet activation?

Paroxysmal atrial fibrillation might be a risk factor for stroke such as chronic atrial fibrillation. We examined the relation between mean platelet volume and paroxysmal atrial fibrillation to determine the effect of paroxysmal atrial fibrillation on the thrombotic state via elevated mean platelet volume. Mean platelet volume is a marker of platelet size, function, and activation. Increased mean platelet volume reflects active and large platelets that release more thromboxane A2 than smaller ones. We hypothesized that mean platelet volume is elevated in patients with paroxysmal atrial fibrillation. The study population comprised 103 consecutive patients who were detected to have paroxysmal atrial fibrillation by 24-h Holter monitoring and 87 control individuals with normal Holter monitoring. Mean platelet volume and inflammatory parameters were measured. Comprehensive clinical and echocardiographic data were collected. Patients with aortic and mitral stenosis, hyperthyroidism, hypothyroidism, malignancy, infection, and pregnancy were excluded from the study. Mean age of the patients was 63 +/- 11 vs. 45 +/- 14 years (P < 0.001) in paroxysmal atrial fibrillation and control groups, respectively. Fifty-seven patients (55%) in paroxysmal atrial fibrillation and 19 (21%) (P < 0.001) patients in control group were men. Mean platelet volume was significantly higher in the paroxysmal atrial fibrillation group when compared with control group (10.0 +/- 2.0 vs. 8.3 +/- 1.5 fl, respectively; P < 0.001). C-reactive protein (18.5 +/- 28 vs. 3.8 +/- 2 mg/l, respectively; P = 0.004) and erythrocyte sedimentation rate (21 +/- 21 vs. 12 +/- 7 mm/h, respectively; P = 0.01) were also higher in the paroxysmal atrial fibrillation group. There was no difference in white blood cell and platelet counts between groups. In a multivariate analysis, elevated mean platelet volume was associated with the occurrence of paroxysmal atrial fibrillation before and after adjustment for age and sex. Our results indicate that inflammatory markers such as C-reactive protein and erythrocyte sedimentation rate and the marker of platelet size and activity mean platelet volume are elevated in patients with paroxysmal atrial fibrillation.

Altered autonomic neural control of the cardiovascular system in patients with polycystic ovary syndrome.

PURPOSE: Polycystic ovary syndrome (PCOS) is frequently accompanied by the presence of cardiovascular risk factors. It has also been recognized that there is a significant relationship between the autonomic nervous system and adverse cardiac events. Heart rate recovery (HRR) after exercise is a marker of parasympathetic activity and attenuation of this parameter has been shown to be associated with increased cardiac mortality. A delayed recovery of systolic blood pressure (SBP) after peak exercise has been found to have diagnostic value and might reflect sympathetic hyperactivity. The analysis of variations in heart rate has also been used to determine the balance between sympathetic and vagal nerve activities in the heart. Our objective was to determine HRR, the SBP response to exercise and heart rate variability (HRV) in patients with PCOS. METHODS: The study population consisted of 26 untreated patients with PCOS and 24 healthy controls who were matched with respect to age, body mass index and physical activity. All subjects underwent symptom-limited exercise tolerance test according to a modified Bruce protocol. Following peak exercise, subjects walked a 2-min cool-down period. Heart rate recovery was calculated as the difference between heart rate at peak exercise and heart rate at the relevant minute of recovery. Blood pressure recovery indexes were determined by dividing the systolic blood pressure at 1, 2 and 3 min in recovery to the systolic blood pressure at peak exercise. RESULTS: HRR at 1 min (HRR1) of the patients with PCOS were significantly lower than that of controls (20+/-4 vs 28+/-8 bpm, p<0.0001). Although, resting SBP of the two groups were similar (117+/-7 vs 117+/-10 mmHg, p=0.663), the SBP of the patients with PCOS at peak exercise were significantly higher when compared to controls (172+/-12 vs 156+/-14 mmHg, p<0.0001). In addition, the SBP of the patients with PCOS remained significantly elevated when compared to controls at the first, second and third minute of recovery (168+/-13 vs 148+/-15 mmHg, 162+/-13 vs 136+/-16 mmHg, 152+/-17 vs 127+/-15 mmHg, respectively, p<0.0001 for all three). The SBP recovery index at 2 and 3 min of the patients with PCOS were significantly higher than that of controls (0.93+/-0.04 vs 0.87+/-0.07, p<0.0001 and 0.87+/-0.07 vs 0.82+/-0.09, p=0.017, respectively). Both time domain and frequency domain parameters of patients with PCOS were significantly lower than that of controls. CONCLUSION: This study shows that the patients with PCOS have attenuated HRR1, exaggerated SBP response to exercise which is delayed to recover and a depressed HRV. These findings might also suggest alterations in autonomic neurol control of the cardiovascular system in this disorder.

Simvastatin improves the attenuated heart rate recovery of type 2 diabetics.

Heart rate recovery at 1min (HRR1) is a strong predictor of all-cause mortality. The effects of statins on the autonomic nervous system may account for their beneficial effects in survival. Our aim was to determine if statin therapy improves heart rate recovery in hypercholesterolemic patients with type 2 diabetes mellitus. Thirty type 2 diabetic patients without known coronary artery disease and low density lipoprotein cholesterol>100mg/dl and 30 age and sex matched non-diabetic controls were included in a prospective study. Patients with diabetes were treated with simvastatin 40mg/day for 1 year. No lipid-lowering therapy was administered to the control group. Exercise testing with 2min cool-down period was performed at baseline, 6, 12 weeks and at 1 year. The diabetics had significantly lower HRR1 compared with non-diabetics at baseline (19.2+/-5.4bpm versus 24.2+/-4bpm, p<0.0001). Simvastatin therapy significantly improved HRR1 after 12 weeks compared to baseline (19.2+/-5.4bpm versus 24+/-5bpm, p<0.0001) and this improvement remained significant at 1 year (26+/-4.4bpm, p<0.0001 compared to baseline). HRR1 did not change in the control group (p=0.39 by ANOVA). This study demonstrates that treatment with simvastatin might improve the attenuated heart rate recovery of diabetic subjects. In patients with diabetes, the mortality benefit provided by statins might involve their effects on the autonomic nervous system.

An experience on radial versus femoral approach for diagnostic coronary angiography in Turkey.

OBJECTIVE: The radial approach has been increasingly used as an alternative to femoral access. The purpose of the present study was to assess the feasibility, success, and safety of the transradial approach (TRA) for diagnostic coronary angiography, and to describe the difficulties associated with the technique as compared with transfemoral approach (TRF). METHODS: A series of 180 consecutive patients were divided to TRA or TFA groups by two operators. We compared the groups regarding procedural time, access time, fluoroscopy time, procedural failure, complications, contrast volume, length of hospital stay, and number of used coronary catheters. RESULTS: The number of used coronary catheters was not different between the two groups (p = 0.6). Total hospital length of stay was significantly shorter in the radial group (p <0.0001) than in femoral one. We found differences between the radial and femoral groups in the success rate (p<0.0001), contrast volume (p = 0.012), procedural time (p<0.0001), access time (p<0.0001), and fluoroscopy time (p<0.0001). We did not find any major complication in the radial group. There was a major bleeding in the femoral group. CONCLUSION: The TRA is a safe alternative to femoral catheterization although with lesser procedural success, longer procedural access, and radiation time, and more contrast volume.

Ruptured sinus valsalva aneurysm originating from the left coronary sinus: report of a rare case with computed tomography findings.

Sinus valsalva aneurysm is a rare condition. Most aneurysms usually originate from the right or non-coronary sinus. A few series were reported about the sinus valsalva aneurysm describing its origin, diagnostic tools and prognosis. We describe a case of a sinus valsalva aneurysm originating from the left coronary sinus that ruptured into the right atrium, diagnosed with echocardiography and cardiac computed tomography, confirmed by angiography and operational findings.

Comparison of carotid intima-media thickness in patients with stable angina pectoris versus patients with acute coronary syndrome.

In this study, we found that carotid intima-media thickness (IMT) was significantly increased and carotid artery atherosclerotic plaques were detected more frequently in patients who had early-onset coronary artery disease compared with control subjects (0.73 +/- 0.10 vs 0.60 +/- 0.10 mm, p <0.001, and 40% vs 11%, p <0.001, respectively). Further, patients who had coronary artery disease and presented with an acute coronary syndrome were found to have significantly increased carotid IMT compared with patients who had stable angina pectoris (0.76 +/- 0.10 vs 0.70 +/- 0.10 mm, p <0.05). The IMT was greater in the patients who had acute coronary syndrome than in those who had stable angina pectoris.

Procedural results and distal embolization after saphenous vein graft stenting and angioplasty for in-stent restenosis of grafts.

Saphenous vein graft (SVG) angioplasty is associated with frequent periprocedural complications due to distal embolization and a high risk of restenosis. The purpose of this single-center, retrospective study was to determine the distal embolization incidences and outcomes of stenting for SVG lesions and percutaneous angioplasty for in-stent restenosis of these SVGs. We studied 48 consecutive patients (mean age, 62 +/- 7 years, 92% men) who had prior CABG and underwent stent deployment to SVG lesions detected at our institution over a period of 4 years. Mean lesion length was 12.4 +/- 3.2 mm. The minimal lumen diameter increased from 0.7 +/- 0.3 mm to 3.2 +/- 0.4 mm after stenting. Distal embolization as no reflow/slow flow phenomenon occurred in 5 (10%) patients. Angiographic success was achieved in 98% of the patients. Procedural success was achieved in 96% of the patients. No reflow/slow flow phenomenon was observed, particularly in patients with acute coronary syndrome. During the follow-up, 11 patients (23%) had angiographic evidence of restenosis. Lesions were treated with balloon angioplasty and the minimal lumen diameter increased from 2.6 +/- 1.1 mm to 3.1 +/- 0.3 mm. The angiographic and procedural success rates were both 100%. There were no cases of "no" reflow/slow flow. Restenosis was particularly frequent in patients with diabetes mellitus, hypercholesterolemia, and acute coronary syndrome. Stent implantation in patients with de novo SVG lesions can be achieved with a high rate of angiographic and procedural success. The distal embolization risk is lower during angioplasty of in-stent restenosis lesions of SVGs compared to de novo SVG lesions.

Endothelin-1 and nitric oxide levels in patients with mitral annulus calcification.

Mitral annulus calcification (MAC) is a chronic degenerative noninflammatory process. The goal of this study was to determine endothelin-1 (ET-1) and nitric oxide (NOx) levels in patients with MAC and compare them with those in normal subjects. The study group included 39 patients [26 females (66%), age, 63 +/- 8 years] with MAC and 20 [11 females (55%), age, 61 +/- 7 years] healthy subjects. The patients were divided into two subgroups, group A with severe MAC and group B with mild MAC, according to the severity of the MAC. Plasma ET-1 levels were higher and NOx levels were lower in patients than controls [(6.5 +/- 5.6 pg/mL vs 3.7 +/- 2.9 pg/mL for ET-1 and 35.0 +/- 10.6 micromol/L vs 42.3 +/- 9.9 micromol/L for NOx; P < 0.05 for both)]. In the subgroups, ET-1 levels were higher in group A than group B (8.65 +/- 6.84 pg/mL vs 4.74 +/- 3.45 pg/mL, P < 0.05) and the control group (8.65 +/- 6.84 pg/mL vs 3.70 +/- 2.88 pg/mL, P < 0.05). There was no difference between group B and the control group. Plasma NOx levels were significantly decreased in group A compared to controls (32.22 +/- 11.88 micromol/L vs 42.25 +/- 9.99 micromol/L, P < 0.05). However, no significant difference was observed between group B (37.38 +/- 9.06 micromol/L) and the other groups. Diabetes mellitus, coronary artery disease, and dyslipidemia were significantly associated with ET-1 levels. However, this association was not observed for NOx. In conclusion, patients with MAC have increased ET-1 and decreased NOx levels. This seems to be more prominent in patients with severe MAC.

Effects of atrial pacing on coronary sinus endothelin-1 and nitric oxide levels in patients with myocardial bridging.

Myocardial bridging (MB) is associated with clinical and metabolic evidence of ischaemia. In the present study, we aimed to evaluate the extent of atherosclerosis and endothelial dysfunction in patients with MB. The study population consisted of 15 patients with MB [9 women (60%), aged 56 +/- 9 years] and 14 control subjects [8 women (57%), aged 54 +/- 10 years]. All patients underwent coronary angiography. The femoral artery and coronary sinus endothelin-1 (ET-1) and nitric oxide (NOx) plasma levels were measured before and after right atrial pacing in all subjects. Also, intravascular ultrasonography was performed in 13 patients with MB. With right atrial pacing, coronary sinus ET-1 levels increased significantly in patients with MB compared with baseline levels (5.77 +/- 6.76 versus 11.32 +/- 9.40 pg/ml, p < 0.05). The coronary sinus ET-1 levels remained unchanged in controls with pacing (3.99 +/- 4.00 versus 4.19 +/- 7.15 pg/ml, p > 0.05). There was no significant difference between the two groups according to the increase in NOx levels with atrial pacing. Ten (77%) of the 13 patients had plaque formation in the segments proximal to the bridge with an area stenosis of 37 +/- 21% (12% to 75%). In patients with MB, post-pacing levels of coronary sinus ET-1 correlated significantly with the cross-sectional area of the plaque (r = 0.65, p = 0,04). Increased ET-1 levels and the pathological data of intravascular ultrasonography may be associated with endothelial dysfunction and atherosclerosis development in patients with MB. The presence of atherosclerosis in the proximal segments to the bridge may contribute to the myocardial ischaemia detected in these patients.

Early and late angiographic and clinical outcome following helistent stent implantation.

There is still a lack of data on the influence of different stent designs on long-term restenosis rates and major adverse cardiac events (MACE) with the use of new antithrombotic regimens. We evaluated the midterm (6 months) clinical and angiographic and lateterm (2 years) clinical outcome of Helistent stent implantation. The study population consisted of 150 patients with high risk factor rates who had single or multivessel disease and had undergone coronary Helistent stent implantation with new antiplatelet regimens. The control coronary angiographies were done at 6 months and they were followed clinically to the end of 2 years. In 150 patients, 236 Helistent stents were implanted for 224 lesions. Helistent stent implantation was associated with a very high success rate (99%). The angiographic re-stenosis rate was 11.3% at 6 months. Only 16% of the patients experienced target lesion revascularization, 20% of the patients experienced MACE and of them, only 3.3% died at the end of two year follow-up period. The results demonstrate that the Helistent stent can be implanted with a high success rate with encouraging 6 month angiographic and late clinical outcomes.