Total Occlusion of the Left Descending and circumflex Coronary Artery without ST Elevation: the De Winter electrocardiographic pattern

de Winter syndrome, or anterior ST segment elevation myocardial infarction (STEMI), constitutes 2% of acute myocardial infarctions. In contrast to classic ST segment elevation as seen with STEMI, it involves ST depression with precordial derivations and sharp waves. de Winter syndrome indicates critical narrowing of the left ascending coronary artery (LAD). Recognizing this presentation is important in terms of both mortality and morbidity. We present the case of a 71-year old patient presenting at the Emergency Department with chest pain, who had findings of de Winter syndrome on their ECG. Coronary angiography confirmed occlusions in the LAD and circumflex (CX) coronary arteries.

P908 The novel predictor for mortality in patients with functional mitral regurgitation: the modified MIDA-Score

EuroSCORE and STS-Score are used to assess surgical risk in patients with valvular heart diseases. The MIDA- Score has been recently published as a representative predictor for short- and long-term prognosis in patients with degenerative mitral regurgitation (DMR). The adequate assessment of long-term prognosis in patients with functional MR is scarce. We aim to adapt this classical score system for patients with FMR.

We retrospectively included 105 patients with FMR who underwent transcatheter mitral regurgitation therapy (TMVR) between January 2014 and August 2016 in our center. Due to the different underlying pathomechanisms of FMR, annular dilatation and impaired left ventricle function, and more elderly patient population we adapted some cut-off values to FMR patients (Age > 65 to Age > 75; LV-EF ≤ 60% to LV-EF ≤ 45%; sPAP≥50mmHg to sPAP≥45mmHg). Moreover, according to Cox proportional hazard analysis of our patient collective we re-calculated the weights of the risk factors: Age 2 points, Symptoms 1 point, atrial fibrillation 2 points, left atrial diameter 1 point, right ventricle systolic pressure 2 points, left ventricle end-systolic diameter 2 points, left ventricle ejection fraction 2 points. We defined three risk groups according to total points from the risk factors; Grade 1 (0-4 points): low risk, Grade 2 (5-9 points): moderate risk, Grade 3 (10-12 points): high risk.

We retrospectively included 105 patients (76.7 ± 8.8 years, 50,6% female) with symptomatic (functional NYHA class > II ) moderate-to-severe FMR (PISA: 0.7 ± 0.4cm, VC width: 0.8 ± 0.3cm, EROA: 0.22cm2, RegVol: 38.1 ± 19.2ml) at surgical high risk (EuroSCORE II: 5.4 ± 3.8%, STS-Score: 4.7 ± 2.8%). We found all-cause mortality 7% at one-year follow-up. 34.1% of our collective were hospitalized.

The classical MIDA Score was not significantly correlated with mortality and rehospitalization in patients with FMR at follow-up (p = 0.5); however, the modified MIDA score was found to be a strong predictor for mortality and rehospitalization in patients with FMR (AUC: 0.89). According to multivariate analysis, the modified MIDA score was found to be superior compared to the other conventional score systems (The modified MIDA-Score HR: 4.1, p = 0.021; EuroSCORE II; HR: 1.2, p = 0.004, STS-Score; HR: 1.7, p = 0.005).

We performed Cox proportional hazard analysis to assess the weighting factor of the predictors. As a result of this, we found age (HR: 2,95, p = 0.03) as the most reliable parameter to predict the combined outcome.

The 12,5% of grade 1, 27% grade 2, 57% grade 3 patients showed combined endpoint. According to regression analysis, the modified score >9 points found to be a strong predictor for high mortality and rehospitalization (OR: 3.35, p = 0.011).

We found the modified MIDA Score sufficient and extensive to assess outcomes in patients with FMR. The modified MIDA Score offers a sufficient promising tool to predict individual prognosis in patients with FMR.

The diagnostic value of the serum irisin level in patients with acute pericarditis and acute myopericarditis

OBJECTIVE

This preliminary study aims to examine a change in the blood levels of irisin in patients with acute pericarditis (AP) and acute myopericarditis (AMP) and examine the diagnostic value of the serum irisin level in AP and AMP.

METHODS

10 patients, who applied to the emergency service and cardiology clinic with chest pain and who were diagnosed with AP and 5 patients, who were diagnosed with AMP as a result of routine examinations, were included in the study. The basal laboratory parameters, echocardiography findings and serum irisin levels of the patients and during check one month later were examined.

RESULTS

While the basal irisin levels were found to be significantly low in the AMP group and high during the check (6.6 ± 1.58, 8.19 ± 1.43, respectively), no statistically significant difference was determined (p = 0.23). It was observed that the basal and control irisin levels did not vary significantly in the AP group (8.03 ± 1.6, 8.19 ± 1.43, respectively) (p = 0.84).

CONCLUSION

In this preliminary study, the basal irisin levels were found to be significantly low in the AMP group, while there was no statistically significant difference between the basal irisin levels and control irisin levels in the AP and AMP groups (Tab. 5, Ref. 17).

Successful intravenous lipid emulsion therapy: Olanzapine intoxication

Olanzapine is an antipsychotic drug used in psychiatric diseases. At high doses it exhibits cardiovascular and neurological sideeffects in particular. Lipid emulsion therapy for the removal of medication from plasma in high-dose lipophilic drug use has recently become very widespread. In the light of current literature, this report discusses the successful treatment of a patient within 4 hrs of olanzapine overdose as an attempted suicide, who presented with agitation and clouded consciousness.

Individual variations in treatment decisions by Swedish rheumatologists regarding biological drugs for rheumatoid arthritis

OBJECTIVES

In Sweden, reports indicate surprisingly large regional variation in prescription of biological drugs despite a growing number of clinical studies describing their beneficial effects and guidelines by professional organizations and agencies. Our objectives were to ascertain whether there is also variation between individual rheumatologists in prescribing biologics to patients with rheumatoid arthritis (RA) and to evaluate reasons for treatment choices.

METHOD

Ten hypothetical patient cases were constructed and presented to 26 rheumatologists in five regions in Sweden. The cases were based on actual cases and were thoroughly elaborated by a senior rheumatologist and pre-tested in a pilot study. The respondents were asked whether they would treat the patients with a biological agent (Yes/No) and to explain their decisions.

RESULTS

The response rate was 26/105 (25%). Treatment choices varied considerably between the rheumatologists, some prescribing biologics to 9/10 patients and others to 2/10. In five of the 10 hypothetical cases, approximately half of the respondents would prescribe biologics. No regions with particularly high or low prescription were identified. Both the decisions to prescribe biologics and also not to prescribe biologics were mainly motivated by medical reasons. Some rheumatologists also referred to lifestyle-related factors or the social function of the patient.

CONCLUSIONS

The choice of initiation of biologics varied substantially among rheumatologists presented with hypothetical patient cases, and there were also disparities between rheumatologists practicing at the same clinic. Treatment choices were motivated primarily by medical reasons. This situation raises concerns about a lack of consensus in RA treatment strategies.

Changes in sociodemographic characteristics at baseline in two Swedish cohorts of patients with early rheumatoid arthritis diagnosed 1996-98 and 2006-09

OBJECTIVES

To compare baseline sociodemographic characteristics in two rheumatoid arthritis (RA) cohorts enrolled 10 years apart, and to examine differences with respect to the general population.

METHOD

Clinical and sociodemographic data were collected in 320 early RA patients during 1996-98 (TIRA-1) and 467 patients in 2006-09 (TIRA-2). Multivariate logistic regression tests were performed and intercohort comparisons were related to general population data, obtained from official databases.

RESULTS

TIRA-2 patients were older than TIRA-1 (58 vs. 56 years). Women (both cohorts, 67%) were younger than men in TIRA-1 (55 vs. 59 years) and in TIRA-2 (57 vs. 61 years). Disease activity was similar but TIRA-2 women scored worse pain and worse on the HAQ. Approximately 73% were cohabiting, in both cohorts and in the general population. Education was higher in TIRA-2 than in TIRA-2 but still lower than in the general population. Women had consistently higher education than men. Education was associated with age, younger patients having higher education. In both cohorts, lower education was associated with increased disability pension and increased sick leave. Sick leave was lower in TIRA-2 than in TIRA-1 (37% vs. 50%) but disability pension was higher (16% vs. 10%). In TIRA-1, 9% of women had disability pension compared with 17% in TIRA-2. A similar decrease in sick leave and an increase in disability pension were also seen in the general population. Older age and a higher HAQ score were associated with increased sick leave and being in the TIRA-2 cohort was associated with decreased sick leave.

CONCLUSIONS

TIRA-2 patients were slightly older, better educated, had lower sick leave and higher disability pension than those in TIRA-1. Similar changes were seen simultaneously in the general population. Belonging to the TIRA-2 cohort was associated with decreased sick leave, indicating that societal changes are of importance.

The relationship between the neutrophil-lymphocyte ratio and the coronary collateral circulation in patients with chronic total occlusion

OBJECTIVES

Previous studies showed the association between the major adverse cardiovascular outcomes and both higher neutrophil and lower lymphocyte counts. We aimed to investigate whether there is an association between the neutrophil-lymphocyte ratio (NLR) value and the development of coronary collateral circulation (CCC) in patients with coronary chronic total occlusion (CTO).

METHODS

A total of 274 patients with CTO were included in this study. Patients were then classified according to their Rentrop collateral grades as either poor (Rentrop grades 0-1) or good (Rentrop grades 2-3). Clinical information and analyses of blood samples were obtained from a review of the patients' charts.

RESULTS

Although there was no difference between the two groups with regard to cardiovascular risk profiles, the NLR values were significantly higher in the patients who had poorly developed CCC (2.6 ± 0.5 vs 2.2 ± 0.4, p<0.001). NLR, high-sensitivity C-reactive protein (hs-CRP), white blood cell count (WBC), age, diabetes, fasting glucose levels and body mass index were found to have univariate association with poorly developed CCC (p<0.1). In a multivariate logistic regression model, NLR (odds ratio 1.88, 95% confidence interval (CI) 1.37-2.74; p<0.001), high-sensitivity C-reactive protein and WBC were found to be the independent predictors of poor CCC. In receiver operator characteristic curve analysis, the optimal cut-off value of NLR to predict poor CCC was found as 2.17, with 77% sensitivity and 65% specificity.

CONCLUSION

NLR, as a novel cardiovascular risk marker, is an important, simple and inexpensive method which can be used by the cardiologist as a screening inflammation tool to estimate the development of CCC in patients with CTO.

Naturally Occurring Cutaneous Anthrax: Antibiotic Treatment and Outcome

<i>Objectives:</i> Cutaneous anthrax (CA) is the most common clinical presentation in human anthrax, but the duration of antibiotic therapy in naturally occurring CA is controversial. The aim of this study was to compare the clinical outcomes of patients receiving antibiotic treatment for either 3-5 days (group 1) or 7-10 days (group 2) in uncomplicated CA. <i>Methods:</i> A total of 66 patients were enrolled; 29 (44%) in group 1 and 37 (56%) in group 2. Infections were classified as mild (n = 22, 33%) or severe (n = 44, 67%) CA. <i>Results:</i> There were no significant differences between the groups in symptom resolution time, fever clearance time, healing of lesions, development and healing of eschars, requirement for surgical intervention or the development of complications. Both edema resolution time and duration of hospital stay were longer in group 2. There were no therapeutic failures, relapses or deaths in either group. Steroid therapy was used in 32% of patients with severe CA, but a beneficial effect on resolution of edema was not demonstrated. <i>Conclusions:</i> These results suggest that short-course antibiotic therapy is as effective as standard-duration therapy in uncomplicated CA and that steroid therapy may not be effective.

Lipid peroxidation levels in patients with acute brucellosis

The purpose of this study was to investigate levels of lipid peroxidation, indicated by plasma malondialdehyde (MDA), with consideration of clinical status and treatment outcomes in patients with acute brucellosis. Plasma MDA levels were measured in patients with acute brucellosis and healthy subjects. Significantly higher MDA levels were detected in plasma of patients with acute brucellosis compared to controls (P<0.01). Plasma levels of MDA were significantly decreased after the brucellosis treatment (P<0.01). The results of the present study indicate for the first time that a considerable level of lipid peroxidation is involved in acute brucellosis cases and this may be of importance with respect to the understanding of disease pathogenesis and may serve as a target for treatment regime.

Hepatocyte growth factor (HGF) in patients with hepatitis B and meningitis

OBJECTIVES

The present study investigates serum hepatocyte growth factor (HGF) levels in patients with acute and chronic hepatitis B and the relation between these levels and intrahepatic inflammatory markers of the liver and fibrosis, as well as the cerebrospinal fluid (CSF) HGF levels in patients with meningitis and the relation between these levels and CSF findings. To our knowledge this is the first study regarding CSF HGF levels in tuberculous meningitis.

PATIENTS AND METHODS

The study consisted of 35 patients with chronic hepatitis B (HbeAg and HBV-DNA positive), 20 with acute hepatitis B, 20 with acute bacterial meningitis and 15 having tuberculous meningitis. HGF levels in the serum and CSF samples were measured by using the ELISA method.

RESULTS

The mean serum HGF levels in acute hepatitis B group were found statistically significantly higher than those in the control group and chronic hepatitis B group (p<0.0001). It was established that serum HGF levels in patients with chronic hepatitis B were significantly correlated with serum alanine aminotransferase (ALT) and HBV-DNA levels (r: 0.816, 0.951; p<0.05, respectively). Similarly, serum HGF levels of patients with chronic hepatitis B were correlated with fibrosis score and hepatic activity index of the liver histopathology (r: 0.750, 0.459; p<0.05, respectively). The mean CSF HGF levels of patients with acute bacterial meningitis and tuberculous meningitis were higher than those in the control group (p<0.05). In addition, it was observed that mean CSF HGF levels in patients suffered from tuberculous meningitis were statistically significantly higher than those in acute bacterial meningitis (p<0.05).

CONCLUSIONS

We suggest that serum HGF level in patients with chronic hepatitis B might reflect viral load, necro-inflammatory activity in the liver and the degree of structural progression. Our findings have demonstrated that tuberculous meningitis cause increased HGF concentrations in CSF. It is, therefore, suggested that examination of HGF levels in CSF may provide additional information in the differential diagnosis.

Incidence of bacteraemia after urodynamic study

The aim of the present study was to determine the incidence of bacteraemia after urodynamic study (UDS) in patients with lower urinary tract symptoms, and to evaluate the role of bacteraemia as a morbidity factor related to UDS. A total of 57 patients (mean age: 52.8 years, range: 8-76 years) were evaluated by UDS. Prophylactic antibiotics were not administered to any of the patients before the procedure. Before UDS, urine cultures were examined for the presence of infection of the urinary tract (UTI). Venous blood was taken before and just after performing UDS. There was no bacterial growth in blood cultures of any patients before the UDS. Of the 57 patients, two had bacteriuria before study. After UDS, bacteraemia was determined in four (7%) out of 55 patients. The two patients with a bacteriuria before the procedure also had positive blood cultures. Infectious complications are the most important morbidity factors related to the UDS. Despite the use of strict aseptic techniques, bacteraemia may occur in patients undergoing UDS. The results of the present study may help when counselling patients who are to undergo UDS.

Cutaneous Anthrax in Adults: A Review of 25 Cases in the Eastern Anatolian Region of Turkey

BACKGROUND

The clinical features, therapy and outcome of anthrax cases from the Elazig province (the eastern Anatolian region) of Turkey seen in our clinic over an 8-year period were reviewed.

PATIENTS AND METHODS

The records of 25 anthrax cases observed in our clinic during the period January 1994 to April 2002 were examined.

RESULTS

All cases were cutaneous; 18 (72%) patients exhibited malignant pustules and seven (28%) malignant edema. Three of the patients with a malignant pustule developed anthrax sepsis when admitted to our clinic. All cases were treated with penicillin. One patient who had penicillin allergy was treated with ciprofloxacin. In addition, patients with malignant edema were also treated with systemic corticosteroids (methylprednisolone or dexamethasone). Two patients died due to anthrax sepsis; one case with anthrax sepsis recovered. The mortality rate was 8%.

DISCUSSION

Anthrax is still a reality in Turkey. Cutaneous anthrax should be considered in any patient with a painless ulcer with vesicles, edema and a history of exposure to animals or animal products. In our series, penicillin and ciprofloxacin were effective in treatment of anthrax. Our anthrax sepsis case demonstrates that anthrax sepsis is not always fatal if antibiotic treatment is given early after diagnosis.

Levels of plasma malondialdehyde and erythrocyte antioxidant enzyme activities in patients with chronic hepatitis B

BACKGROUND/AIMS

Hepatitis B virus infection, extensively seen throughout the world, can become highly chronic. Pathogenesis of chronic hepatitis is not yet known fully. It is shown that oxidative stress may play a role in pathogenesis and may regulate collagen synthesis and thus may contribute to the process of liver damage. This study is aimed at investigating the existence of oxidative stress in chronic hepatitis B cases and its relation with alanine aminotransferase and aspartate aminotransferase which are the serum indicators of liver damage; along with interaction of erythrocyte antioxidation enzyme activities in the same cases.

METHODOLOGY

Eighty patients with chronic hepatitis B under follow-up, and 40 healthy volunteers were included in this study. In the control and patients groups, together with serological markers for viral etiology, alanine aminotransferase and aspartate aminotransferase levels; plasma malondialdehyde level; erythrocyte superoxide dismutase, glutathione peroxidase and catalase activities were analyzed.

RESULTS

Malondialdehyde levels of chronic hepatitis B cases were statistically high compared to control group (p < 0.05). There was correlation between serum malondialdehyde levels and serum alanine aminotransferase, aspartate aminotransferase levels in the patient group (r = 0.324, p < 0.01, r = 0.273, p < 0.05). Average superoxide dismutase and catalase activities were found to be significantly low compared to control group (p < 0.001); average glutathione peroxidase activity were significantly high when considered statistically (p < 0.001). No correlation between serum alanine aminotransferase and aspartate aminotransferase levels and glutathione peroxidase, catalase and superoxide dismutase activities was found in the patients group (p > 0.05).

CONCLUSIONS

In the study we showed that there is correlation between serum malondialdehyde level and alanine aminotransferase and aspartate aminotransferase levels of chronic hepatitis B patients. According to the results of our study, it might be thought that serum malondialdehyde level might be a marker of hepatocellular damage in chronic hepatitis B cases. We suggest that antioxidant treatment for chronic hepatitis B patients should be examined in future studies.

The effects of acute phase proteins on serum albumin, transferrin and haemoglobin in haemodialysis patients

In the present study, the effects of C-reactive protein (CRP) and ferritin on serum albumin, transferrin and haemoglobin (Hb) were assessed to investigate the relationship between inflammation, hypoalbuminaemia and anaemia in haemodialysis patients. A total of 117 patients who were followed at three haemodialysis units in Kocaeli were enrolled. The mean age was 47.83 +/- 16.85 years. The median time on dialysis was 26 (minimum 1, maximum 209) months. Serum CRP albumin and ferritin concentrations were measured in our laboratory and transferrin, urea reduction ratio (URR) and Kt/V were calculated. There was significant inverse correlation between serum CRP level and albumin (p<0.001), serum CRP and Hb (p<0.001), and serum transferrin and ferritin (p<0.05). There was significant positive correlation between serum albumin and Hb (p<0.001), serum CRP and ferritin (p<0.05), and transferrin and URR (p<0.05). Our findings suggest that inflammation is a contributor in the development of hypoalbuminaemia and anaemia in haemodialysis patients as well as malnutrition and inadequate dialysis.

Traumatic spinal cord injuries in Turkey: a nation-wide epidemiological study

STUDY DESIGN

An epidemiological study conducted all over the country.

OBJECTIVE

The present retrospective study was conducted to survey the new traumatic spinal cord injury (SCI) cases during 1992 in Turkey.

SETTING

Intensive care units, emergency services and departments of orthopaedic surgery, neurosurgery and rehabilitation of state hospitals, rehabilitation centers, military and university hospitals.

METHODS

Postal questionnaires were used for data collection and the records from medical institutes nation-wide were reviewed for the analysis of the epidemiological factors.

RESULTS

Five hundred and eighty-one new traumatic SCI cases were reported in 1992. The annual incidence was found to be 12.7 per million population. Male to female ratio was 2.5:1 and the average age at injury was 35.5+/-15.1 (35.4+/-14.8 for males and 35.9+/-16.0 for females). The most common cause of injury was motor vehicle accidents (48.8%) followed by falls (36.5%), stab wounds (3.3%), gunshot injuries (1.9%) and injuries from diving (1.2%). One hundred and eighty-seven patients (32.18%) were tetraplegic and 394 patients (67.8%) were paraplegic. The most common level of injury was C5 among tetraplegics and T12 among paraplegics. The most prevalent associated injury was head trauma followed by extremity fractures. Severe head trauma resulting in death may obscure the real incidence of SCI and may cause underreporting of cases in epidemiological studies.

CONCLUSION

Considering that motor vehicle accidents and falls were found to be the leading causes of traumatic SCI, it was concluded that the prevention measures should be focused mainly on these in order to reduce the frequency of SCI in Turkey.

Effect of antibiotics and anti-inflammatory agents on the purified protein derivative response in the rat

We investigated the effects of several antibiotics and anti-inflammatory agents on the purified protein derivative (PPD) response in the rat. Animals were immunized with Mycobacterium bovis vaccine BCG. Antibiotics and anti-inflammatory drugs were administered at therapeutic doses for 10 d. Chloramphenicol, erythromycin, aspirin and ibuprofen suppressed the PPD response, but penicillin and acetaminophen had no significant effects.

Adenosine deaminase and guanosine deaminase activities in sera of patients with viral hepatitis

In order to investigate purin and primidin metabolism pathways in hepatitis, adenosine deaminase (ADA) and guanosine deaminase (GDA) activities in sera of patients with different types and manifestations of viral hepatitis disease (A, B, C, D, E, chronic, acute) were investigated and compared with the control group of healthy individuals. Hepatitis cases were classified with respect to their serological findings and clinics. When compared all the hepatitis cases with the controls, levels of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase enzymes, as well as ADA and GDA, were significantly higher than the control group (p<0.01). Levels of ADA and GDA in hepatitis cases were determined as 26.07 11.98 IU/l and 2.37 1.91 IU/l, respectively. When compared their ADA and GDA levels amongst the classified hepatitis groups, there was no difference in ADA levels amongst cases (p>0.05). However, GDA levels in hepatitis A group were closed to the controls. Increase in serum ADA activities in hepatitis forms may be dependent on and reflect the increase in phagocytic activity of macrophages and maturation of T-lymphocytes, and may be valuable in monitoring in viral hepatitis cases.