Long-term results after mitral valve surgery using minimally invasive versus sternotomy approach: a propensity matched comparison of a large single-center series

BACKGROUND

Mitral valve (MV) surgery has traditionally been performed by conventional sternotomy (CS), but more recently minimally invasive surgery (MIS) has become another treatment option. The aim of this study is to compare short- and long-term results of MV surgery after CS and MIS.

METHODS

This study was a retrospective propensity-matched analysis of MV operations between January 2005 and December 2015.

RESULTS

Among 1357 patients, 496 underwent CS and 861 MIS. Matching resulted in 422 patients per group. The procedure time was longer with MIS than CS (192 vs. 185 min; p = 0.002) as was cardiopulmonary bypass time (133 vs. 101 min; p < 0.001) and X-clamp time (80 vs. 71 min; p < 0.001). 'Short-term' successful valve repair was higher with MIS (96.0% vs. 76.0%, p < 0.001). Length of hospital stay was shorter in MIS than CS patients (10 vs. 11 days; p = 0.001). There was no difference in the overall 30-day mortality rate. Cardiovascular death was lower after MIS (1.2%) compared with CS (3.8%; OR 0.30; 95%CI 0.11-0.84). The difference did not remain significant after adjustment for procedural differences (aOR 0.40; 95%CI 0.13-1.25). Pacemaker was required less often after MIS (3.3%) than CS (11.2%; aOR 0.31; 95%CI 0.16-0.61), and acute renal failure was less common (2.1% vs. 11.9%; aOR 0.22; 95%CI 0.10-0.48). There were no significant differences with respect to rates of stroke, myocardial infarction or repeat MV surgery. The 7-year survival rate was significantly better after MIS (88.5%) than CS (74.8%; aHR 0.44, 95%CI 0.31-0.64).

CONCLUSION

This study demonstrates that good results for MV surgery can be obtained with MIS, achieving a high MV repair rate, low peri-procedural morbidity and mortality, and improved long-term survival.

Myocardial Accumulations of Reg3A, Reg3γ and Oncostatin M Are Associated with the Formation of Granulomata in Patients with Cardiac Sarcoidosis

Cardiac sarcoidosis (CS) is a poorly understood disease and is characterized by the focal accumulation of immune cells, thus leading to the formation of granulomata (GL). To identify the developmental principles of fatal GL, fluorescence microscopy and Western blot analysis of CS and control patients is presented here. CS is visualized macroscopically by positron emission tomography (PET)/ computed tomography (CT). A battery of antibodies is used to determine structural, cell cycle and inflammatory markers. GL consist of CD68⁺, CD163⁺ and CD206⁺ macrophages surrounded by T-cells within fibrotic areas. Cell cycle markers such as phospho-histone H3, phospho-Aurora and Ki67 were moderately present; however, the phosphorylated ERM (ezrin, radixin and moesin) and Erk1/2 proteins, strong expression of the myosin motor protein and the macrophage transcription factor PU.1 indicate highly active GL. Mild apoptosis is consistent with PI3 kinase and Akt activation. Massive amounts of the IL-1R antagonist reflect a mild activation of stress and inflammatory pathways in GL. High levels of oncostatin M and the Reg3A and Reg3γ chemokines are in accordance with macrophage accumulation in areas of remodeling cardiomyocytes. We conclude that the formation of GL occurs mainly through chemoattraction and less by proliferation of macrophages. Furthermore, activation of the oncostatin/Reg3 axis might help at first to wall-off substances but might initiate the chronic development of heart failure.

Comparison of flexible, open with semi-rigid, closed annuloplasty-rings for mitral valve repair

Background

Mitral regurgitation is a frequent valvular disease, with an increasing prevalence. We analysed the long-term outcomes of mitral valve repair procedures conducted over the last 10 years in our clinic using almost exclusively two different annuloplasty ring types.

Methods

A single-centre, retrospective analysis of mitral valve surgeries conducted between January 2005 and December 2015 for patients undergoing first-line mitral valve repair with either open (Cosgrove) or closed (CE Physio / Physio II) annuloplasty (OA or CA, respectively) rings.

Results

In total, 1120 patient documentations were available of which 528 underwent OA and 592 patients CA. The median age of patients was 64.0 years and 41.1% were female. The majority of these patients underwent the procedure because of degenerative valve disease. Rates of successful repair were about 90%, 72 h procedural mortality was 0.6% and the rate of re-intervention was 0.6% within the first 30 days. Functional (mitral regurgitation, left ventricular ejection fraction, left ventricular end-diastolic and systolic diameter and New York Heart Association class) as well as hard outcomes were comparable. 77.7 and 74.4% of patients were alive at the 10-year follow-up in the OA and CA groups, respectively. Upon multivariable adjustment, the hazard ratio was 0.926 (95% CI: 0.642–1.3135; p = 0.681).

Conclusions

The functional outcome and survival rates up to 10 years after mitral valve repair were comparable using open and closed annuloplasty rings. Whether this means these rings are interchangeable or a carefully selection of the best-for-the-patient devices will be subject of future investigations.

Minimally invasive left atrial appendage (LAA) clip insertion after challenging LAA occluder implantation to minimize the risk of stroke

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, requiring lifelong anticoagulation or interventional, transseptal left atrial appendage (LAA) occluder implantation to minimize stroke risk. Incomplete LAA closure post implantation is a frequent observation. Incomplete LAA occlusion after transseptal occluder implantation necessitates anticoagulation in cases of persistent AF to minimze risk of embolism and/or apoplexy. Patients with contraindications to lifelong anticoagulation therapy are challenging to treat and alternative options are needed. We present a case of a patient with persistent AF who underwent frustraneous LAA occluder implantation. The patient's anatomy necessitated surgical closure of the LAA, which was accomplished with an LAA clip 4 weeks after implantation. The patient was discharged in excellent clinical status 5 days after the surgery. No further complications were observed within the following year.

Pulmonary herniation after minimally invasive cardiac surgery: review and implications from a series of 20 cases

Minimally invasive cardiac surgery (MICS) via right lateral mini thoracotomy is the gold standard treatment approach for mitral and tricuspid valve disorders. Other selected procedures (e.g. transapical aortic valve implantation, MIDCAB) require a left lateral mini thoracotomy for surgical access. Advantages of MICS over complete sternotomy are well known, but access-related complications post MICS, such as pulmonary herniation, are often underestimated/overlooked. In males, a pulmonary herniation in the proximity of the former thoracotomy is often clinically visible, especially when the intrathoracic pressure rises (e.g. during coughing). In females, clinical symptoms may be hidden by the breast and patients often have unspecific complaints or occasional pain when coughing, making identification of a lung herniation more difficult. Chest computed tomography is the diagnostic tool of choice for pulmonary herniations. Using a series of 20 patients with pulmonary herniation post MICS, we report our findings in diagnosis and treatment of this condition.

Long-term results of endoclamping in patients undergoing minimally invasive mitral valve surgery where external aortic clamping cannot be used - a propensity matched analysis

Background

Minimally invasive mitral valve surgery is standard of care in many centres and it is commonly associated with the need for cardiopulmonary bypass. Conventional external aortic clamping (exoclamping) is not always feasible, so endoaortic clamping (endoclamping) has evolved as a viable alternative. The aim of this study is to compare endoclamping (Intraclude™, Edwards Lifesciences) with exoclamping (Chitwood) during minimally invasive mitral valve procedures.

Methods

This single-centre study included 822 consecutive patients undergoing minimally invasive mitral valve procedures. The endoclamp was used in 64 patients and the exoclamp in 758. Propensity-score (PS) matching was performed resulting in 63 patients per group. Outcome measures included procedural variables, length of intensive care unit (ICU) and hospital stay, major adverse cardiac and cerebrovascular events (MACCE) and repeat surgery.

Results

The mean age was similar in the two group (62.2 [endoclamp] vs. 63.5 [exoclamp] years; p = 0.554), as were the cardiopulmonary bypass (145 vs. 156 min; p = 0.707) and the procedure time (203 vs. 211 min; p = 0.648). The X-clamp time was significantly shorter in the endoclamp group (88 vs. 99 min; p = 0.042). Length of ICU stay (25.0 vs. 23.0 h) and length of hospital stay (10.0 vs. 9.0 days) were slightly longer in the endoclamp group, but without statistical significance. There were nominal but no statistically significant differences between the groups in the rates of stroke, vascular complications, myocardial infarction or repeat mitral valve surgery. The conversion rate to open sternotomy approach was 2.4% without difference between groups. The estimated 7-year survival rate was similar for both groups (89.9% [endoclamp]; 84.0% [exoclamp]) with a hazard ratio of 1.291 (95% CI 0.453–3.680).

Conclusions

Endoaortic clamping is an appropriate and reasonably safe alternative to the conventional Chitwood exoclamp for patients in which the exoclamp cannot be used because the ascending aorta cannot be safely mobilised.

Long-term outcomes of concomitant tricuspid valve repair in patients undergoing mitral valve surgery

Background

We aimed to find out how the concomitant performance of tricuspid valve repair (TVR) affects outcomes of patients undergoing mitral valve surgery (MVS).

Methods

Single-centre, retrospective analysis of 1357 patients who underwent MVS between January 2005 and December 2015, including 1165 patients with isolated MVS and 192 patients with MVS plus TVR. We used propensity scores to match patients for baseline characteristics other than valve related parameters and arrived at a matched sample of 182 patients per group.

Results

The overall procedure duration was longer in the MVS + TVR (224 min) versus the MVS group (176 min; p < 0.001), as were the duration of mechanical ventilation (13 vs. 11 h; p < 0.001), X-clamp (90.5 vs. 66 min; p < 0.001) and cardiopulmonary bypass time (136 vs. 95.5 min; p < 0.001). Rates of procedural complications were not different between groups with the exception of pacemaker rates which were 16.0% in the MVS + TVR group and 8.8% in the isolated MVS group (p = 0.037).

There was no difference in death rates within 30 days, stroke, myocardial infarction or repeat MVS. The long-term survival rate was 60.8% in the MVS + TVR vs. 57.5% in the isolated MVS group (HR 1.048; 95%CI 0.737–1.492; p = 0.794). The rate of grade III/IV tricuspid regurgitation (TR) remained low after MVS + TVR during long-term follow-up while the rate of grade ≥ II TR increased slightly in the isolated MVS group.

Conclusion

The data show that the concomitant performance of TVR in patients undergoing MVS is a safe and effective procedure with good long-term outcomes. Patients can undergo MVS + TVR with confidence as it improves their prognosis up to the level of patients undergoing isolated MVS.

Macrophages represent the major pool of IL-7Rα expressing cells in patients with myocarditis

Myocarditis is characterized by infiltration and activation of cytokine as well as chemokine receptors frequently producing heart failure. Causes are often infections triggering inflammatory and immune responses but these initial lines of defense might be finally disastrous. To identify mediators we screened various receptors by confocal microscopy and identified cardiac interleukin-7 (IL-7) receptor-α (IL-7Rα) expressing cells in patients with myocarditis. IL-7Rα+ cells were analyzed by markers for leukocytes (CD45), B cells (CD19), T cells (CD3, CD4, CD8) and macrophages (CD68, CD163, CD206). Immune cells were hardly detected in controls. In patients with myocarditis main inflammatory populations consisted of macrophages and T cells. B cells were hardly present. 90% of CD68+ macrophages but less than 20% of CD3+ T cells were IL-7Rα+. This was surprising since T and B lymphocytes are generally regarded as the major IL-7Rα+ cells. Since IL-7 acts as a chemokine, the expression of its receptor might orchestrate cardiac macrophage infiltration. In contrast, consumption of IL-7 by IL-7Rα+ cardiac macrophages might potentially prevent a certain overshooting immune reaction and sepsis by reducing proliferation and survival of lymphocytes. Our data suggest a participation of IL-7Rα+ macrophages in the development of myocarditis and heart failure.

Mitral valve repair for posterior leaflet prolapse: Long-term comparison of loop implantation vs resection

BACKGROUND

Resection (triangular or quadrangular) is considered the gold standard for the treatment of posterior leaflet prolapse and loop implantation a more recent alternative. We aimed to compare the long-term outcomes of triangular or quadrangular resection vs loop implantation.

METHODS

Single-centre, retrospective analysis of mitral valve (MV) surgeries conducted from January 2005 to December 2015. Propensity score matching was based on seven key baseline variables.

RESULTS

Data from 721 patients were analyzed; 358 patients received loop implantation and 363 patients underwent resection. Patients had a mean age of 62 years, 33.0% were female and 50.6% had hypertension. Propensity score matching resulted in a matched group of 263 patients who received loop implantation or underwent resection, respectively. Postoperatively, the patients' mitral insufficiency was reduced from grade III/IV to either zero or trace (45.8%) or I (49.8%) and New York Heart Association class reduced from 66.9% in class III/IV preoperatively to 8.3% with no significant differences between groups. Fewer patients receiving loops had procedure-related complications. Fewer patients in the loop implantation group required permanent pacemaker implantation at 30 days (8.4% vs 2.3%; P = .002). The 10-year survival for patients in the resection (88.0%) and loop implantation (89.3%) groups had a hazard ratio of 1.224 (95% confidence interval, 0.633-2.367).

CONCLUSION

Our study showed that both loop implantation and resection were associated with comparable long-term survival in patients with posterior leaflet prolapse. Loop implantation is associated with a significantly higher rate of a successful repair, a significantly lower rate of MV replacement after repair failure, fewer procedure-related complications and better 30-day at comparable long-term outcomes.

Atresia of the inferior vena cava in a patient undergoing mitral and tricuspid valve surgery

We report on a 61-year-old man with a previously unknown interruption of the inferior vena cava who was scheduled to undergo minimally invasive mitral and tricuspid valve surgery. We aimed to establish a cardiopulmonary bypass using femorofemoral cannulation under transoesophageal echocardiography. In spite of multiple attempts, the positioning of the venous wire in the right atrium was not accomplished. The intervention was subsequently performed by an open sternotomy. Further to the intervention, the patient underwent thoraco-abdominal multislice computed tomography that excluded the presence of an abdominal tumour or vena cava thrombosis but revealed atresia of the inferior vena cava.

Long-term outcome after mitral valve replacement using biological versus mechanical valves

BACKGROUND

This study compared long-term outcomes of biological and mechanical mitral valve replacement (MVR) in patients requiring replacement of the mitral valve where repair was not feasible.

METHODS

A single-centre registry of patients receiving MVR between 2005 and 2015 was established. Thirty-day mortality and long-term outcomes were analysed and compared.

RESULTS

Three hundred twenty four patients underwent MVR (265 biological; 59 mechanical valves). Patients receiving biological valves were older (p < 0.001), had a higher log EuroSCORE (p < 0.001) and received less minimally invasive surgery (p < 0.001). Immediate procedural mortality was 1.9%, which only occurred in the biological valve group. At 30 days, 9.0% of patients had died, 4.0% experienced stroke, 8.0% received a pacemaker and 10.5% suffered an acute renal failure. The rate of re-thoracotomy (14.2%) was lower in the biological (12.5%) than in the mechanical valve group (22.0%; adjOR 0.45 [0.20-1.00]; p = 0.050). Frequent long-term complications were stroke (9.2%) and bleeding (4.8%), with bleeding complications being higher in the mechanical valve group (p = 0.009). During the follow-up period biological valves showed a numerically higher survival rate during the first years, which shifted after 3 years in favour of mechanical valves. At 10 years, survival rates were 62.4% vs. 77.1% in the biological and mechanical valve groups (p = 0.769). Hazard ratio after adjustment was 0.833 (95% CI 0.430-1.615).

CONCLUSION

These data confirm that mechanical valve implantation is associated with an increased risk of bleeding. While there was a potential survival benefit during the first years after surgery for patients receiving a biological valves the difference became insignificant after a follow-up of 10 years.

Explantation and reimplantation of a breast implant to facilitate minimally invasive mitral valve surgery and cryoablation of atrial fibrillation

Clinicians can feel confident about performing mitral repair/replacement in patients who have previously undergone mammoplasty. It may also have applications in performing atrial septal defect closure, Maze procedures for atrial fibrillation, and tricuspid valve surgery in patients with breast implants.

Combined mitral valve repair and heart transplantation

In times of donor organ shortage, organs with extended allocation criteria, for example, valve pathologies, have to be taken into consideration for transplantation. The donor pool can be extended to hearts with mitral valve insufficiency. Mitral valve repair can rapidly be performed in the donor heart on the back table with excellent results.

Clinical and Laboratory Features of Metformin Intoxication in Suicidal Patients Attending an Intensive Care Unit

Introduction

This study has been performed for the purpose of researching the complications occurred at patients who took metformin overdose in an attempt to suicide. None of the patients has the diagnosis of diabetes mellitus and never used metformin.

Materials and Methods

This retrospective cross-sectional study was carried out with 21 patients who has neither diagnosed diabetes mellitus nor taken metformin for suicide before.

Results

It was observed that there is a moderate, negative (r = -0.63) statistically significant correlation (P < 0.001) between the time of applying to the hospital and arterial blood pH at the arrival and a statistically significant positive mild correlation (P < 0.041) between applying and blood lactate level (r = 0.45), and a moderate positive (r = 0.63) and statistically significant correlation (P < 0.001) between the total metformin dose and blood lactate level at the arrival and a positive, moderate (r = 0.68) significant correlation (P < 0.001) between the creatinine and metformin dose at the arrival. Lactic acidosis has been detected at 8 of 21 patients, 6 patients were hemodialized, 2 patients needed mechanical ventilation, and 2 patients died. It is observed that there is no mortality for early hemodialized patients.

Conclusion

The most important reason of the mortality in patients who has metformin intoxication is metformin-associated lactic acidosis (MALA). It was considered that hemodialysis therapy could be effective in MALA.

Protective effect of oxymatrine against renal ischemia/reperfusion injury in rats

BACKGROUND

Renal ischemia/reperfusion (I/R) injury is a common cause of acute kidney injury. The pathologic mechanisms underlying renal I/R injury are complicated, involving reactive oxygen species, necrosis, cell apoptosis, and inflammation, but the exact mechanisms remain unclear.

OBJECTIVES

This study aimed to investigate the effect of oxymatrine (OMT) on renal I/R injury and its underlying mechanism.

METHODS

Thirty male Sprague-Dawley rats were randomly allocated to three groups (n = 10): the sham-control group, the renal I/R-untreated (I/R-untreated) group, and the I/R-OMT group. Renal I/R injury were induced by clamping the left renal artery for 45 min followed by 24 h of reperfusion. At 10 min before reperfusion, the rats in the I/R-OMT-treated group rats received an intravenous injection of 40 mg/kg OMT. Renal function and histological changes were compared and the relevant parameters of oxidative stress and inflammation were detected.

RESULTS

Oxymatrine pretreatment significantly decreased the level of renal dysfunction, attenuated the renal histological changes, the levels of reactive oxygen species production in renal tissue upon I/R. Additionally, OMT pretreatment could further activate the serum antioxidant enzyme activities.

CONCLUSION

The beneficial effects of OMT were likely mediated by the inhibition of lipid peroxidation and the increase in endogenous antioxidant activity. The results of this study indicate that oxymatrine may represent a potent anti-oxidant drug to protect the kidney against I/R injury (Fig. 5, Ref. 29).

Effects of Nigella sativa seeds and certain species of fungi extracts on number and activation of dural mast cells in rats

In this study, we aimed to investigate the effects of Nigella sativa seeds and certain species of fungi extracts on the number and degranulation states of dural mast cells in rats. Rats were fed ad libitum with normal tap water or tap water with extract of N. sativa seed, Ramaria condensata, Lactarius salmonicolor, Lactarius piperatus, and Tricholoma terreum for 3 days. Mast cells in dura mater were counted and evaluated in terms of granulation and degranulation states. Compound 48/80, a mast cell degranulating agent, and T. terreum significantly increased the percent of degranulated mast cells in dura mater, respectively (p < 0.01 and p < 0.05). Moreover, T. terreum causes a significant increase in the total number of mast cells (p < 0.05). N. sativa significantly inhibited mast cell degranulation induced by both the compound 48/80 and T. terreum (p < 0.05), and significantly decreased the mast cell numbers increased by T. terreum (p < 0.05). Our results suggested that T. terreum following ingestion can contribute to headaches like migraine via dural mast cell degranulation and N. sativa may be able to exert analgesic and anti-inflammatory effects by stabilizing dural mast cells. However, investigation is needed to determine the ingredients of N. sativa that may be responsible for these beneficial effects.

The MEK1 inhibitors UO126 and PD98059 block PDGF-AB induced phosphorylation of threonine 292 in porcine smooth muscle cells

PDGF-AB and FGF-2 (GFs) induce smooth muscle cell (SMC) proliferation which is indispensible for arteriogenesis. While there is common agreement that GFs stimulate SMC proliferation through phosphorylation (P-) of MEK1/2 at Ser218/222, we previously demonstrated that the MEK inhibitors PD98059 and UO126 did not inhibit P-Ser218/222 as originally proposed but caused strong hyperphosphorylation. Here, we demonstrate that GFs increased phosphorylation of MEK1 at Thr292 while UO126 and PD98059 blocked this phosphorylation. This was again surprising since phosphorylation of Thr292 is regarded as a negative feedback loop. Our findings suggest that inhibition of Thr292 phosphorylation in combination with hyperphosphorylation of Ser218/222 serves as an "off" switch of SMC proliferation and potentially of arteriogenesis.

The effects of L-carnitine and N-acetylcysteine on carbontetrachloride induced acute liver damage in rats

AIM

To investigate the effects of L-carnitine (LCAR) and N-acetylcysteine (NAC) on carbon tetrachloride (CCl4)-induced acute liver damage in rats.

MATERIAL AND METHODS

Totally, 40 rats in 5 groups were included in the study. The first group was the control group. Group 2 received CCl4 (2 ml/kg). Group 3 was given CCl4 + NAC (150 mg/kg). The rats in the Group 4 were administered CCl4 + LCAR (100 mg/kg), and the rats in the Group 5 were given CCl4 + NAC + LCAR. Both CCl4 and the treatment protocols were administered via intraperitoneal route for 10 days. Tissue oxidative stress and antioxidant markers were investigated in liver tissue and serum liver enzymes were measured.

RESULTS

The levels of blood liver enzymes (ALT and AST) increased significantly in the Group 2. However, they decreased markedly in all treatment groups. While malondialdehyde and myeloperoxidase levels in the liver tissue samples increased significantly in the 2nd group, those levels were determined to be decreased significantly in all treatment groups. When the liver tissue antioxidant levels were evaluated; reduced glutathione and catalase decreased markedly in the 2nd group, but increased following the administration of NAC and LCAR. The activities of liver tissue superoxide dismutase did not differ significantly among the groups. In the histopathologic evaluation of liver tissues, on the other hand, diffuse hepatosteatosis was observed in all groups except the control group and there was no significant difference among the groups from the point of steatosis.

CONCLUSION

LCAR and NAC were concluded to have beneficial effects on the acute liver damage induced by CCl4 administration (Tab. 1, Fig. 5, Ref. 52). Text in PDF www.elis.sk.

The protective effects of ketamine and propofol in obstructive jaundice: an experimental study

OBJECTIVE

In this study, we investigated the protective effects of frequently used intravenous anesthetics (ketamine, propofol, thiopental, and fentanyl) in oxidative stress in a rat liver model of obstructive jaundice.

MATERIALS AND METHODS

Thirty-two Wistar albino rats were divided into four groups in a randomized fashion. All rats were subjected to laparotomy, common bile duct ligation and severance on day 0. Following 7 days, laparotomy was again performed using ketamine, propofol, pentobarbital, or fentanyl anesthesia. After 2 hours, the animals were sacrificed and tissue specimens were acquired for histopathological scoring and determination of malondialdehyde (MDA), superoxide dismutase (SOD) and catalase (CAT) activities.

RESULTS

All rats demonstrated enlargement in the bile duct, obstructive jaundice, and histopathologic ductal proliferation. MDA and SOD levels were significantly lower in the ketamine group compared with the thiopental and fentanyl groups. CAT was significantly increased in the ketamine group compared with the other groups. The best portal polymorphonuclear leukocyte and necrosis scores were in the ketamine group, but this difference was not statistically significant ( p=0.07).

CONCLUSION

Ketamine and propofol were observed to cause the least amount of oxidative stress in this rat model of induced oxidative stress generated by ligation of the common bile duct. This experiment is the first study on this subject in the literature (Tab. 3, Ref. 65).

RNA interference-mediated URG4 gene silencing diminishes cyclin D1 mRNA expression in HepG2 cells

Up-regulated gene 4 (URG4), stimulated by HBxAg, is a novel gene located on chromosome 7 (7p13). The full-length URG4 clone is 3.607 kb and encodes a polypeptide of 922 amino acids, with a molecular weight of 104 kDa (GeneID: 55665). It promotes cell growth, growth factor-independent survival, and anchorage-independent growth in HepG2 cells, and it accelerates tumor formation in nude mice. Hence, URG4 may be a natural effector of HBxAg and a putative oncogene that contributes to multi-step hepatocarcinogenesis. Cyclin D1 is frequently over-expressed in hepatocellular carcinoma, exhibiting a number of malignant phenotypes. We found that down-regulation of URG4 through RNA interference-mediated silencing suppressed cell proliferation in HepG2 cells. Over-expression of URG4 up-regulated cyclin D1 mRNA expression, whereas RNA interference-mediated URG4 silencing diminished cyclin D1 mRNA expression in HepG2 cells. The data suggest that URG4 may play an important role in the development of hepatocellular carcinoma by partially regulating the expression of cyclin D1 and has potential for use as a therapeutic target for hepatocellular carcinoma.

Metabolic conditions of fatty liver in non-diabetic obese women

INTRODUCTION

Steatosis of the liver has a close association with metabolic conditions such as obesity, dyslipidemia and diabetes mellitus. We aimed to determine metabolic features of subjects with different degrees of ultrasonographic steatosis.

MATERIALS AND METHODS

One hundred and thirty non-diabetic obese women were investigated (average age 43.47+/-12.55 yr, range 18-77 yr). They were negative for hepatitis virus and had no history of alcohol usage and diabetes mellitus. All subjects had a complete work-up including clinical examination, anthropometric measurements, laboratory tests, and a routine liver ultrasonographic scanning. Steatosis was graded as absent, mild, moderate, and severe.

RESULTS

A progressive increase was observed in the body mass index (p<0.05), waist circumference (p<0.01), body fat percentage (p<0.05), fasting plasma glucose (p<0.01), triglyceride (p<0.05), alanine aminotransferase (p<0.01), and aspartate aminotransferase (p<0.05) levels as the severity of ultrasonographic fatty liver increased. Also, insulin resistance, which was calculated via homeostasis model assessment, metabolic syndrome, and the prevalence of high alanine aminotransferase levels increased significantly with the degree of the steatosis. On the other hand, hypertriglyceridemia was found to be the independent risk factor for the severity of the steatosis.

CONCLUSION

The present study suggests that liver steatosis may be considered with some metabolic risk factors and particularly in the presence of insulin resistance and metabolic syndrome.

Relationship between optokinetic nystagmus response and recognition visual acuity

PURPOSE

The aim of this study was to investigate the relation between recognition visual acuity (RVA) and optokinetic nystagmus (OKN) response exhibited to different bar sizes with varying contrast.

METHODS

OKN testing was performed in 52 children aged between 3 and 11 years. The children were evaluated in two groups according to their RVA. Group I consisted of 22 eyes with RVA equal to or better than 0.1 logMAR units. Group II consisted of 30 eyes with RVA 0.2-1 logMAR units. Each subject was seated 60 cm from the screen of Ophthimus device, and was exposed to consecutive black and white stripes of seven different spatial frequencies (0.08-1.6 cycle/degree). The narrowest bar that elicited OKN was identified, and then the OKN contrast threshold at this bar size was established.

RESULTS

Twenty-one of the 22 eyes in Group I, and 26 of the 30 eyes in Group II exhibited 1.6 cycle/degree spatial frequency (P=0.287). In Group II, 88.9% of the 18 eyes with RVA 0.2-0.5 logMAR responded at this maximum spatial frequency, whereas the corresponding figure for the 12 eyes with RVA 0.6-1 logMAR was 83.3% (P=0.531). Contrast sensitivity (CS) significantly changed with age in Group I (P=0.006). When the eyes that responded at maximum spatial frequency in the two groups were compared, the mean CS in Group II was significantly lower than that in Group I (P=0.005).

CONCLUSIONS

The results indicate no relation between spatial frequency threshold for OKN response and RVA in children. However, the children with RVA deficits had significantly lower CS.

Decision-making in second-eye cataract surgery: can presence of Pulfrich phenomenon help?

PURPOSE

To determine whether testing for the Pulfrich phenomenon (PP) can be used as a tool to assess the need for and optimal timing of second-eye cataract surgery.

METHODS

A total of 61 patients with logMAR 0 visual acuity (VA) after cataract surgery in one eye and logMAR 0.2-0.7 VA in the other eye were tested for PP using a computer-generated oscillating target at Baskent University Hospital. Only patients who had no ophthalmologic or systemic problem that could cause PP were included. In all, 15 normal patients with logMAR 0 VA in both eyes served as controls. The main outcome measures were presence and magnitude (measured by neutral density filters) of PP and presence of complaints related to binocular vision.

RESULTS

Of the 61 patients, 36 (59%) and none of the controls were PP (+) (P<0.001). A total of 27 (75%) of the PP (+) patients had logMAR 0.7-0.4 VA, and nine (25%) had logMAR 0.3-0.2 VA (P=0.01). In all, 16 patients (all PP (+)) had developed binocular vision-related complaints since cataract surgery. The mean PP magnitude in these cases was significantly greater than the mean for the 20 patients without complaints (1.2+/-0.5 vs0.6+/-0.4 log units, respectively; P<0.001). There was no significant difference between the mean VA in the complaint (+) and complaint (-) subgroups (P=0.213).

CONCLUSION

PP testing may detect binocular visual dysfunction after first-eye cataract surgery; thus, it could help assess the need for second-eye cataract surgery on this basis.

Association of adenosine deaminase, superoxide dismutase, and catalase activities with Helicobacter pylori

Our purpose was to investigate associations between adenosine deaminase (ADA), superoxide dismutase (SOD), and catalase (CAT) activities and H. pylori.Ninety-nine patients were studied. Eight antral mucosal biopsies were taken for biochemical assessment of ADA, CAT, AND SOD activity and histological assessment. H. pylori density wAS evaluated according to the updated Sydney system. Patients were divided into three groups according to Sydney classification. ADA activity was found to be higher in patients having H. pylori in the present study. Also, ADA activity was higher in patients with a severe density of H. pylori. SOD level was found to be significantly higher with increased H. pylori density in our study (P < 0.05). In addition, SOD activity was higher in it H. Pylori-positive than H. pylori-negative patients. We did not find CAT activity in some antral tissue specimens. The significantly high levels of ADA activity in patients with H. pylori infection may reflect the regulator role of ADA in acid secretion. The higher ADA level with increased H. pylori density and H. pylori positivity indicate the probable malign lymphoid process of the stomach. But these findings must be confirmed with larger studies that include different gastric lesions.

Comparison of additional intraocular pressure-lowering effects of latanoprost vs brimonidine in primary open-angle glaucoma patients with intraocular pressure uncontrolled by timolol–dorzolamide combination

PURPOSE

To compare the additive intraocular pressure (IOP)-lowering effects of latanoprost 0.005% and brimonidine 0.2% in primary open-angle glaucoma (POAG) patients uncontrolled on fixed combination of timolol 0.5% and dorzolamide 2% (TDC) alone.

METHODS

In all, 80 eyes of 80 POAG patients with IOP inadequately controlled by TDC were randomly assigned to receive either latanoprost 0.005% or brimonidine 0.2%. IOP measurements were recorded at 1000 (peak effect) and 1600 (trough effect) on day 0 (baseline) and at 1 and 3 months. At each stage and time point, the mean IOP reductions from baseline were evaluated for both groups, and success rates (minimum 15% reduction) were determined.

RESULTS

At baseline, the mean peak/trough IOPs with TDC were 20.2/21.6 and 19.9/21.4 mmHg in latanoprost and brimonidine groups, respectively. Latanoprost+TDC reduced the mean peak/trough IOP by 4.4/3.4 and 5.2/3.5 mmHg at 1 and 3 months. The corresponding values for brimonidine+TDC were 3.9/2.9 and 4.6/2.9 mmHg. Each of these results represented a significant reduction from baseline (P<0.001 for all); however, the groups' peak/trough reductions from baseline did not differ at any time point (P>0.05 for all). With the latanoprost+TDC combination, the peak/trough success rates at 1 and 3 months were 76.3%/42.1% and 77.1%/40%. The corresponding values with the brimonidine+TDC combination were 71.8%/41% and 77.7%/41.7%. There were no significant differences in the groups' success rates at any time point (P>0.05 for all).

CONCLUSION

Addition of latanoprost 0.005% or brimonidine 0.2% to TDC reduces peak/trough IOPs significantly and the effects of these combinations are comparable.

Effects of the sibutramine therapy on pulmonary artery pressure in obese patients

AIM

Obesity is a major global public health problem. Previous drugs (dexfenfluramine and fenfluramine) used for the treatment of obesity have been withdrawn due to various cardiac side effects. Sibutramine is an anti-obesity agent. The purpose of this study was to assess cardiac valve disease and pulmonary artery pressure (PAP) of the patients who used once daily doses of sibutramine.

METHODS

One hundred and six obese patients (51 men and 55 women) determined to have minimal tricuspid regurgitation (TR) on echocardiographic examination were included in the study. All patients had a complete physical examination, complete blood count and measurement of lipid parameters, and echocardiography was performed by which cardiac valves and PAP were evaluated. After the mean duration of 24-week of follow up, all examinations were repeated for each patient.

RESULTS

The drug was well tolerated by all patients for the follow-up period. A significant weight loss was recorded in all patients compared to the baseline values (93.1 +/- 9.6 kg vs. 85.8 +/- 7.7 kg, p<0.001). Blood pressures and heart rate of the patients increased compared to the baseline measurements (systolic 122.3 +/- 8.5 vs. 124 +/- 10.2 mmHg, p=0.128, diastolic 79.3 +/- 4.7 vs. 80 +/- 5.7 mmHg, p=0.42 and heart rate 79.5 +/- 6.5 vs. 85 +/- 5.7 beats/min, p<0.001). Echocardiographically determined aortic or mitral valve dysfunction appeared in none of the patients. PAP lightly increased after the treatment but the difference between pre and post-treatment values was not found statistically significant (14.7 +/- 1.8 vs. 16.3 +/- 1.6 mmHg, p=0.06).

CONCLUSIONS

A 24-week treatment with sibutramine does not affect heart valves and pulmonary artery pressure.

Results of cataract surgery in renal transplantation patients

PURPOSE

To evaluate the results of conventional extracapsular cataract extraction and phacoemulsification cataract surgery, in renal transplant patients.

METHODS

A total of 11 eyes of eight renal transplant recipients who underwent cataract surgery in Ankara between 1995 and January 2001 were evaluated. Each individual underwent routine ophthalmologic examination including visual acuity with Snellen chart testing, slit-lamp examination, intraocular pressure measurement, and fundus examination. Of these, seven patients had posterior subcapsular cataracts and four had nuclear cataracts. Conventional extracapsular cataract extraction (cECCE) was performed in four eyes with single-piece all-polymethylmethacrylate posterior chamber intraocular lens implantation. The other seven eyes were treated with small-incision phacoemulsification and implantation of a foldable hydrophilic acrylic lens.

RESULTS

We observed intraoperative posterior capsule rupture and vitreous loss in one patient, postoperative intraocular tension elevation in one patient, and sterile suture infiltration in one patient in our series. Average of the visual acuities 6 months after the operation was 20/30 (range, 20/60-20/20).

CONCLUSIONS

In this, the first published report to describe outcomes of cataract surgery in renal transplant patients, most complications were associated with high of steroids use and immunosuppressives, and were independent of the type of cataract surgery used, either ECCE or phacoemulsification surgery. The study suggests the need for additional care before, during, and after operation.

Risk factors for ocular surface disorders in patients with diabetes mellitus

OBJECTIVE

To evaluate risk factors for ocular surface disorders and tear dysfunction in patients with type 2 diabetes.

STUDY DESIGN AND METHODS

This prospective case controlled study included 41 patients with type 2 diabetes and 20 healthy subjects as the control group. All subjects underwent routine ophthalmic examination, tear film break-up time (BUT) test, Schirmer test, fluorescein dye test, rose bengal staining test, and a questionnaire for subjective complaints. The relationship of metabolic control of diabetes mellitus, duration of diabetes, severity of diabetic retinopathy, and argon laser photocoagulation (ALP) to tear dysfunction was evaluated.

RESULTS

Tear film BUT and Schirmer test values were significantly lower in diabetic patients compared with control subjects (P < 0.001). In the diabetic group, significantly more subjects had abnormal fluorescein and rose bengal staining than in the control group (P < 0.001). Abnormal tear function tests were associated with poorer metabolic glucose control, panretinal ALP, and proliferative diabetic retinopathy (P < 0.05), but not with duration of diabetes (P > 0.05).

CONCLUSIONS

The results of the study indicate that poor metabolic control, panretinal ALP, and proliferative diabetic retinopathy are high risk factors for ocular surface disorders in type 2 diabetes. These patients should be followed more carefully, and should be referred to an ophthalmologist when required.

Changes in malondialdehyde levels in bronchoalveolar fluid and serum by the treatment of asthma with inhaled steroid and beta2-agonist

OBJECTIVE

Oxidative stress plays an important role in the pathogenesis of asthma. Recent data suggest that clinical indices of the patients with asthma may not correlate with the underlying inflammatory process. We aimed to measure the level of malondialdehyde (MDA), which is a marker of lipid peroxidation, a free radical-mediated process, before and after a well-accepted treatment of asthma.

METHODOLOGY

Nine non-smoking females and five non-smoking males with mild-moderate asthma were included. Twenty-four age- and sex-matched, non-smoking healthy people (17 females and seven males, mean age 32.1 years, range 20-59) were included for control. After initial evaluation, spirometry, bronchoscopy with bronchoalveolar lavage (BAL), and blood sample were maintained. The patients were treated with twice-daily salmeterol inhaler (100 microg/d) and fluticasone propionate inhaler (500 microg/d). One month later the investigations were repeated. Serum MDA levels before treatment were compared with both the levels after treatment and levels of controls. Malondialdehyde levels of BAL were compared before and after treatment.

RESULTS

Serum MDA level of the patient before treatment was 6.7+/-0.8 nmol/mL, significantly higher than that of healthy controls; 3.8+/-0.4, P < 0.001. One month after the treatment, serum MDA level decreased to 5.3+/-0.7 nmol/mL (P < 0.001). However, this level is still significantly higher than healthy controls (P < 0.0001). Forced expiratory volume in 1 s level of the patients increased from 2.43+/-0.79 L to 3.50+/-1.21 L after the treatment (P < 0.001).

CONCLUSION

Although treatment with beta2-agonist and corticosteroid inhalers for the duration of 1 month reduced lipid peroxidation significantly, it was still at a level significantly higher than healthy controls. The treatment may need a longer duration to improve lipid peroxidation or an alternative regimen which is more effective in controlling inflammation may be warranted.