Femoral tripod arteries: Surgical anatomic variants

AIM

To describe the surgical anatomy of the femoral tripod arteries and their anatomical variants.

MATERIALS AND METHODS

Patients who underwent vascular surgery by external arciform approach of the Scarpa between May 2022 and July 2022 were selected. The surgical anatomy was assessed by direct observation. The origin and the course of major branches of the femoral artery (FA) were studied. Diameters and the distance of the origin of the femoral profunda artery (FPA) from the midpoint of the inguinal ligament was measured in millimeters and recorded. The observed anatomical variations were photographed and compared to those in the literature.

RESULTS

A total of 40 patients (34 men, 85%) were included. The median diameter of the common femoral artery (CFA) was 9mm (IQR: 7-12mm). The Modal bifurcation was noted in 95% of cases. The collateral branches of the CFA were found to be distributed as follows: the superficial circumflex iliac artery (SCIA) in 34 cases (85%), the superficial epigastric artery (SEA) in 22 cases (55%), the deep external pudic artery in 16 cases (40%), and the superficial external pudic artery in 18 cases (45%). The median diameter of the FPA was 5mm (IQR: 4-6mm). The FPA originated from the posterolateral side of the CFA in 90% of cases, from the posterior side in 5% of cases and from the medial side in 5% of cases. The median diameter of the SFA was 6mm (IQR: 4-9mm).

CONCLUSION

The anatomic variants of the femoral tripod arteries are extremely frequent. Therefore, it is important to recognize the anatomy in order to avoid possible diagnostic errors and to minimize the risk of per and post procedural complications.

Supervision by direct observation with video recording in the operating room: educational tool for learning and formative evaluation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Directly observed supervision with video recording (DOSVR) is used as a learning method in several countries. This technique has proven itself, but remains little used in Tunisia. On the other hand, the use of DOSVR in surgery is rarely described. The objectives of our work were to describe the development and experimental implementation of DOSVR in surgery and to evaluate the feedback from residents and teachers.

Methods

This is a prospective, observational and descriptive study concerning the experimentation of DOSVR in five surgical procedures performed by residents of cardiovascular surgery department. These video recordings were followed by a backscatter with self and heteroevaluation.

We based ourselves on the methodology of teaching by simulation for the design of the protocol: the Briefing, the scenario and then the debriefing.

Results

A total of ten took part in this experiment. The average age was 28.5 years [26 -33 years] with a sex ratio F/M of 4. All residents declared that the protocol provided was easy to understand and apply. After obtaining the consent of the patients, five interventions were filmed in whom three were in emergency. Seven residents said that using a smartphone to vdeo recording was not easy and 8 easily got rid of the presence of the camera. All the learners denied having to change their operating techniques because they were being filmed. All the residents agreed that a minimum number of six DOSVR sessions in each residency year is appropriate and praised the technique as a powerful tool for the development of their practical training.

Conclusions

Our study showed that the application of Directly observed supervision with video recording in vascular surgery is feasible. It is a promising educational tool for the practical learning of residents as well as a tool for the continuous formative evaluation of their progress.

Aortic Coarctation of the newborn and infant: predictors of morbidity and mortality

Funding Acknowledgements

Type of funding sources: None.

Introduction

Aortic coarctation represents 8% of all congenital heart disease. Whether isolated or associated with an intra or extra cardiac anomaly, newborns or infants coarctation could lead to early heart failure. this specific form can be associated with peri-operative difficulties and subsequent complications especially recoarctation and late hypertension.

Objective : our objective is to determine the predictive factors of morbi-motality in this disease.

Methods

It’s a monocentric and restrospcetive study of 34 newborns and infants operated on for aortic coarctation between January 2010 and december 2019. Clinical, paraclinical and therapeutic data have been collected.

Results

Our study include 23 newborns and 11 infants, with sex ratio of 2,4. The diagnosis was retained at an average age of 2 months and  2/3 of which before the age of 1 month. The main clinical signs were an abnormality of the femoral pulses in 92% of cases (abolished in 15 babies), tachycardia with polypnea in 68% of cases and hypertension in 48% of patients. Other signs are less common, such as hepatomegaly (44%), left side-sternal murmur (38%) and hypotrophy (20.6%). The mean gradient in blood pressure between the upper and lower limbs was 22 mm Hg [17-38mmHg]. Eight patients required mechanical ventilation. Biological examinations showed metabolic acidosis in 8 patients hepatic failure and renal failure in five patients each one. On the chest x-ray, 60% had cardiomegaly and 42% had pulmonary edema. The trans-thoracic echocardiography detect coarctation in all cases which was preductal in 70.6% of cases. The averge of trans-isthmic gradient was 37mmHg. The main associated cardiac abnormalities were: IVC in 7 patients and aortic bicuspid in 6. However, persistent ductus arteriosus was in 27 cases (79.4%). Cardiac catheterization was used in 5 babies aged between 4 and 9 months with a mean trans-isthmic hemodynamic gradient of 65 mmHg [45-100] and MRI and Ct scann was done in 3 patients each one.

The average weight at the time of the operation was 4.780 kg [2.4-9.8]. 3 newborns were operated between the 9th and 20th days of life. The first approach was a posterolateral thoracotomy in the left 4th intercostal space in 33 patients and a vertical midline sternotomy in a single infant with a total abnormal pulmonary venous return. The modified Crafoord technique (extended-anastomosis) was performed in the majority of cases (97.05%) and 4 patients with unrestricted IVC required also pulmonary artery banding. The overall mortality rate was 29.4%. Prematurity, a birth weight <2.5 kg, an operative age <120 days and  complex heart disease were significantly associated with mortality (P< 0.05).

Conclusion

Coarctation of the aorta in newborns and infants is a surgical emergency in some cases, with still high mortality despite the surgical and anesthetic progress.

Post cardiac surgery Mediastinitis : Risk factors and therapeutic management

Funding Acknowledgements

Type of funding sources: None.

Background : Despite the progress in therapy and patient management in cardiac surgery, postoperative mediastinitis remains an serious complication. Our study aims to study the incidence of mediastinitis after cardiac surgery and to identify the risk factors.

Methods

We conducted a retrospective, descriptive study including patients who had undergone cardiac surgery by sternotomy during a period of 5 years ( 2015 – 2019)and who meet the definition of mediastinitis proposed by the "Centers of disease control and disease". We collected the demographic characteristics of the patients and operative operative data of the first intervention as well as those relating to mediastinitis.

Results

 25 patients ( 2.93%)  among 1042 patients operated for cardiac surgery during the cited period presented mediastinitis. The main clinical signs were : surgical wound infection (80%), fever (40%) and sternal instability (30%). Biological tests showed : hyperleukocytosis and high C-Reactive Protein  in 22.7 % and 58.1 % of cases respectively. Gram-positive cocci are largely predominant and one case of Candida mediastinitis was found. type 1 diabetes and coronary artery bypass grafting were significantly associated with the occurrence of mediastinitis with P <0.01. The mean duration of intra venous antibiotic therapy was 21 days.

92 % of patients operated on for mediastinitis are cured, 4 % had a recurrence of infection and 4 % died.

CONCLUSION

Mediastinitis after heart surgery is rare but serious. The main risk factors are  insulin-dependent diabetes and coronary bypass surgery. The curative treatment is heavy and it is based on a rigorous and long medico-surgical care.

Post cardiac surgery Mediastinitis : Risk factors and therapeutic management

Funding Acknowledgements

Type of funding sources: None.

Background : Despite the progress in therapy and patient management in cardiac surgery, postoperative mediastinitis remains serious complication. Our study aims to study the incidence of mediastinitis after cardiac surgery and to identify the risk factors.

Methods

We conducted a retrospective, descriptive study including patients who had undergone cardiac surgery by sternotomy during a period of 5 years ( 2015 – 2019)and who meet the definition of mediastinitis proposed by the "Centers of disease control and disease". We collected the demographic characteristics of the patients and operative operative data of the first intervention as well as those relating to mediastinitis.

Results

 25 patients ( 2.93%)  among 1042 patients operated for cardiac surgery during the cited period presented mediastinitis. The main clinical signs were : surgical wound infection (80%), fever (40%) and sternal instability (30%). Biological tests showed : hyperleukocytosis and high C-Reactive Protein  in 22.7 % and 58.1 % of cases respectively. Gram-positive cocci are largely predominant and one case of Candida mediastinitis was found. type 1 diabetes and coronary artery bypass grafting were significantly associated with the occurrence of mediastinitis with P <0.01. The mean duration of intra venous antibiotic therapy was 21 days.

92 % of patients operated on for mediastinitis are cured, 4 % had a recurrence of infection and 4 % died.

CONCLUSION

Mediastinitis after heart surgery is rare but serious. The main risk factors are  insulin-dependent diabetes and coronary bypass surgery. The curative treatment is heavy and it is based on a rigorous and long medico-surgical care.

Changes in the hearing threshold of workers in a steel industry: 5-year follow-up

Introduction: noise is one of the most important harmful factors in the workplace. The physiological effects of noise on humans are gradual in the long run. Despite industrial advances, exposure to excessive noise is one of the health problems of workers in the world's steel industry. This study aimed to investigate the effect of noise on hearing loss in steel industry workers. Materials and Methods: This descriptive cross-sectional study was designed and conducted. The study population was 121 workers in a steel rolling industry whose 5-year audiometry was studied from 1391 to 1395. An audiometer performed the audiometric test of these workers in 5 years. Their audiometric results were extracted from their medical records and examined under ethical principles. Data were analyzed using SPSS software version 21, and T-Test and Wilcoxon Signed Ranks Test was used for statistical analysis. Results: The mean age of participants was 38.88 ± 4.92 years and the mean work experience was 10.94 ± 3.57 years. In this study, a gradual increase in the average hearing threshold at different frequencies in both ears was seen from 2012 to 2016. Conclusion: noise as a detrimental factor in the steel industry causes a gradual increase in exposed workers' hearing threshold.

Tuberculosis lymphadenopathy: A rare etiology of the superior vena cava syndrome

Superior vena cava syndrome is the clinical expression of the obstruction of the superior vena cava reducing the blood flow. Malignant etiologies are the most common. Its management is multidisciplinary and despite the progress of endovascular procedures, conventional surgery retains its place in certain indications. Mediastinal fibrosis secondary to tuberculosis lymphadenopathy may be associated with superior vena cava syndrome. In the presence of symptomatic SVCS associated with extensive mediastinal fibrosis compressing the superior vena cava with sub occlusive thrombosis, conventional surgery remains a treatment option, with cavo-venous derivation by prosthetic bypass.

[Arterial trauma of the upper limbs: Particularities of the population in Tunisia and risk factors for amputation]

AIM OF THE STUDY

The purpose of our study was to review the population at risk of upper limb arterial injury, to determinate the rate of upper limb salvage and the predictive factors of limb loss.

METHODS

This was a retrospective study, involving 128 patients with upper extremity arterial trauma operated between January first, 2006 and June 30, 2017. Exclusion criteria were arterial ligation, primary limb amputation and arterial iatrogenic injuries. End points were immediate technical success, primary patency and limb salvage rate.

RESULTS

The average age was 27.7 years with a sex ratio M/F=41, causes of trauma were self-inflicted wounds (51%), assaults (23%), road traffic accidents (10%), work accidents (9%) and domestic accidents (7%). Injured arteries were brachial (66.5%) usually because of self-inflicted injuries; arteries of the forearm (31%) and axillery arteries (2.5%). The techniques of arterial repair were vein graft interposition in 52% of cases, end-to-end anastomosis in 23%, primary arterial repair in 21% and venous patch in 4%. Eight reconstructions occluded during the first week (6.25%). Four patients required secondary amputation and limb salvage rate was 96.8%. After a median follow-up time of 62 days, only 21% were followed at 3 months. Mechanism of injury, soft tissue loss and arterial reconstruction thromboses were selected as factors influencing the rate of limb salvage. One death occurred at day 14 secondary to multi-component poly-trauma.

CONCLUSION

Prompt diagnosis, appropriate multidisciplinary management of the upper extremity arterial trauma and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage. Associated soft tissue injury is a poor limb salvage factor.

[Conservative aneurysmorrhaphy for hemodialysis arteriovenous fistula]

The aim of this study was to evaluate the results of conservative surgical treatment of the aneurysmal complications of arteriovenous hemodialysis fistulae and to determine the factors predictive of long- and mid-term patency of treated fistulae. The surgical treatment was mainly based on caliber reduction and reconstruction.

METHODS

This was a descriptive retrospective study with a five-year duration, going from January 2013 to December 2018. This study included 40 patients presenting aneurysmal complications of their hemodialysis vascular access who were treated with aneurysmorrhaphy.

RESULTS

The mean age of the aneurysmal-complicated hemodialysis vascular access was 42 months. The indications for treatment were puncture-related difficulties in 42.5% of cases, rapid increase of the aneurysmal diameter in 27.5%, skin thinning in 25% and aneurysmal rupture in 5%. The mean aneurysmal course was 6.6 months with an average diameter of 3.25cm at the moment of management. The initial technical success rate was 100%. Twenty patients had complications in the postoperative period. Patency rates at 3, 6, 12 and 24 months were 89.5%, 81.6%, 71% and 63.1%, respectively. Factors predictive of thrombosis were diabetes (P=0.001), peripheral arterial disease (P=0.003), number of punctures per week (P=0.003) and context of emergency presentation (P=0.001).

CONCLUSION

Aneurysmorrhaphy seems to be the best conservative surgical treatment for aneurysmal complications of hemodialysis vascular access fistulae. This surgical approach allows us to conserve the native autologous vascular access and spare the patient's venous network.

[Endovascular treatment of chronic mesenteric ischemia]

INTRODUCTION

Atherosclerosis occurring in the digestive arteries is rare and often asymptomatic. When it becomes symptomatic, surgical care is indicated. Conventional procedures are giving way to improved endovascular techniques applied to the mesenteric arteries. The aim of this single-center study was to evaluate short- and mid-term outcome after endovascular revascularization of the mesenteric arteries.

METHODS

We report a retrospective study about patients who underwent endovascular treatment of chronic mesenteric ischemia between 2013 and 2018.

RESULTS

Our population consisted of 10 patients. The average age was 60 years [range 45-78]. Clinical symptomatology associated abdominal pain and weight loss. All patients underwent computed tomographic angiography (CTA). Severe stenosis (>70%) involved the superior mesenteric artery (SMA) in ten cases, the celiac trunk in four cases and the inferior mesenteric artery in three. The procedure was performed under local anesthesia in all cases. The superior mesenteric artery was revascularized in all cases and the celiac trunk in two. Transluminal angioplasty was followed by deployment of a stent in all cases. The postoperative course was satisfactory. Outcome was good with all patients being symptom-free at one month. Our average follow-up was three years [range 1-5]. All patients underwent a Duplex ultrasound every six months. Recurrence of symptomatology was reported in two patients at 18 months and 24 months. The first patient underwent CTA that showed superior mesenteric artery and celiac trunk stent stenosis. The patient underwent a second transluminal angioplasty with a drug eluting balloon. The second patient was admitted to the emergency room for acute mesenteric ischemia related to acute thrombosis of the superior mesenteric artery stent. Laparotomy enabled extensive resection of the small bowel and aorto-mesenteric venous antegrade bypass, but the patient died the same day.

CONCLUSION

Endovascular treatment has an important role to play in the management of chronic mesenteric ischemia. It is associated with a high rate of technical success. Patients should be carefully followed-up because of the mid-term risk of recurrent symptoms associated with intra-stent restenosis or thrombosis.

Design, synthesis and biological activity of novel tacrine-isatin Schiff base hybrid derivatives

A series of novel tacrine-isatin Schiff base hybrid derivatives (7a-p) were designed, synthesized and evaluated as multi-target candidates against Alzheimer's disease (AD). The biological assays indicated that most of these compounds displayed potent inhibitory activity toward acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE) and specific selectivity for AChE over BuChE. It was also found that they act as excellent metal chelators. The compounds 7k and 7m were found to be good inhibitors of AChE-induced amyloid-beta (Aβ) aggregation. Most of the compounds inhibited AChE with the IC₅₀ values, ranging from 0.42 nM to 79.66 nM. Amongst them, 7k, 7m and 7p, all with a 6 carbon linker between tacrine and isatin Schiff base exhibited the strongest inhibitory activity against AChE with IC₅₀ values of 0.42 nM, 0.62 nM and 0.95 nM, respectively. They were 92-, 62- and 41-fold more active than tacrine (IC₅₀ = 38.72 nM) toward AChE. Most of the compounds also showed a potent BuChE inhibition among which 7d with an IC₅₀ value of 0.11 nM for BuChE is the most potent one (56-fold more potent than that of tacrine (IC₅₀ = 6.21 nM)). In addition, most compounds exhibited the highest metal chelating property. Kinetic and molecular modeling studies revealed that 7k is a mixed-type inhibitor, capable of binding to catalytic and peripheral site of AChE. Our findings make this hybrid scaffold an excellent candidate to modify current drugs in treating Alzheimer's disease (AD).

Tetrahydroquinolinone derivatives as potent P-glycoprotein inhibitors: design, synthesis, biological evaluation and molecular docking analysis

P-glycoprotein (P-gp) is a transmembrane efflux pump that has been associated with ineffective cancer chemotherapy and multidrug resistance (MDR). Chemical inhibitors of P-gp could have potential cancer therapeutic applications by preventing or reversing MDR. To exploit this, we designed twenty-five tetrahydroquinolinone analogs bearing pyridyl methyl carboxylate at C₃ and different substituents at C₄ as MDR reversal agents. The inhibitory effects of the synthesized compounds against P-gp were assessed by flow cytometric determination of rhodamine 123 accumulation in P-gp over-expressing MES-SA/DX5 cells. Fluorescence imaging of intracellular rhodamine 123 accumulation in MES-SA/DX5 cells was also performed. Furthermore, the effect of active derivatives on the reduction of doxorubicin's IC₅₀ in MES-SA/DX5 cells was evaluated using MTT assay. Molecular docking was used to confirm the binding mode of some of the synthesized compounds. Five compounds in group A, bearing a 2-pyridyl methyl ester substituent at the C₃ position, significantly increased rhodamine accumulation at 25 μM comparable to verapamil, a well-established P-gp inhibitor, while only 2 compounds in group B bearing 3-pyridyl methyl ester at the same position had this effect. This study shows that tetrahydroquinolinones containing methyl pyridine esters could represent an attractive scaffold for the discovery of P-gp inhibitors as MDR reversal agents in cancer cells.

[Femoropopliteal angioplasty: Short- and mid-term results]

BACKGROUND

Percutaneous endovascular therapy is becoming a primary option for managing femoropopliteal occlusive disease. The purpose of this study was to evaluate the mid-term results of endovascular treatment of femoropopliteal arterial disease.

METHODS

Femoropopliteal percutaneous transluminal angioplasty was performed on 162 consecutive limbs (160 patients) from January 2006 to January 2016.

RESULTS

In our study, 87.6% of patients had critical limb ischemia. Lesions were classified as Trans-Atlantic Inter-Society Consensus (TASC) A (43%), B (43%), C (7%), and D (7%). Femoropopliteal interventions included angioplasty only in 70 cases (43.2%), and the remaining 92 (56.8%) received at least one stent. Technical success was achieved in 98.7% of patients, with three deaths and a major morbidity rate of 15%. The actuarial primary patency at 12 and 36 month was 65.4% and 40.2%, respectively, 33 peripheral reinterventions were performed after femoropopliteal axis occlusion, resulting in an actuarial primary limb preservation rate of 94.4 at 12 months. Comparison between angioplasty only and the use of stent show no difference in primary patency (P=0.832) and limb salvage (P=0.67). Negative predictors of primary patency determined by univariate analysis included popliteal location (P<0.001) and TASC D (P<0.001). However, diabetes mellitus (P=0.001) and poor run off (P<0.001) were the principal predictive factors of limb loss.

CONCLUSION

Femoropopliteal angioplasty can be performed with a low morbidity and mortality. Intermediate primary patency is directly related to TASC classification and popliteal localization.

Stereoselective reduction of prochiral ketones by plant and microbial biocatalysts

Chiral alcohols are the key chiral building blocks to many enantiomerically pure pharmaceuticals. The biocatalytic approach in asymmetric reduction of corresponding prochiral ketones to the preparation of these optically pure substances is one of the most promising routes. The stereoselective reduction of different kinds of prochiral ketones catalyzed by various plants and microorganisms was studied in this work. Benzyl acetoacetate, methyl 3-oxopentanoate, ethyl 3-oxopentanoate, and ethyl butyryl acetate were chosen as the model substrates for β-ketoesters. Benzoyl acetonitrile, 3-chloro propiophenone, and 1-acetyl naphthalene were chosen as aromatic aliphatic ketones. Finally, 2-methyl benzophenone and 4-chloro benzophenone were selected as diaryl ketones. Plant catalysis was conducted by Daucus carota, Brassica rapa, Brassica oleracea, Pastinaca sativa, and Raphnus sativus. For microbial catalysis, Aspergillus foetidus, Penicillum citrinum, Saccharomyces carlbergensis, Pichia fermentans, and Rhodotrula glutinis were chosen. Chiral alcohols were obtained in high yields and with optical purity. A superiority in the microorganisms' performance in the bioreduction of prochiral ketones was detected. Among microorganisms, Rhodotrula glutinis showed remarkable results with nearly all substrates and is proposed for future studies.

Hydroxycinnamic acid as a novel scaffold for the development of cyclooxygenase-2 inhibitors

The most active hydroxycinnamic acid derivative, caffeic acid diethyl ester (CA-DE), demonstrated 88.5/30.5% inhibition at 100/20 μM against COX-2 and negligible COX-1 inhibitory effect. CA-DE showed preferred interactions with COX-2 active site.

Preparation and assessment of chitosan-coated superparamagnetic Fe3O4 nanoparticles for controlled delivery of methotrexate

In this study, Fe3O4 superparamagnetic nanoparticles were synthesized and stabilized by chitosan. Then the nanoparticles were characterized by Fourier transform infrared spectroscopy and transmission electron microscopy (TEM). Particle size distribution and Zeta potential of the particles also was assessed using Malvern Zetasizer. The paramagnetic behaviors of the uncoated and chitosan coated nanoparticles were measured using vibrating scanning magnetometry Particles morphology and size ranges of uncoated iron oxide nanoparticles were evaluated by TEM, showing uniform and narrow size distribution about 10 nm. After coating nanoparticles with chitosan and loading of methotrexate (MTX), the change in size was assessed using Zetasizer. Considerable increase in size was observed following the coating of the particles with chitosan and loading with MTX (the average size was 152 nm). Paramagnetic properties of the uncoated and chitosan-coated particles were assessed showing significant decrease in paramagnetic behavior after coating with chitosan, but it was enough to respond to the magnetic field. Finally loading efficiency, release rate and cytotoxicity of MTX were assessed indicating slow release behavior with the same levels of cell toxicity in SK-BR-3 cell lines, suggesting this formulation as a good candidate for the controlled delivery of MTX.

Antioxidant therapy: current status and future prospects

Reactive oxygen species (ROS) are widely believed to cause or aggravate several human pathologies such as neurodegenerative diseases, cancer, stroke and many other ailments. Antioxidants are assumed to counteract the harmful effects of ROS and therefore prevent or treat oxidative stress-related diseases. In this report, recent human studies exploring the efficiency of antioxidants in prevention and treatment of various diseases are reviewed. Few antioxidants including edaravone (for ischemic stroke in Japan), Nacetylcysteine (for acetaminophen toxicity), alfa-lipoic acid (for diabetic neuropathy) and some flavonoids (polyphenolic compounds present in dietary plants), such as micronized purified flavonoid fraction (diosmin and hesperidin) and oxerutins (for chronic venous insufficiency) as well as baicalein and catechins (for osteoarthritis) have found accepted clinical use. However, despite much enthusiasm in the 1980s and 1990s, many well-known agents such as antioxidant vitamins and also more recently developed compounds such as nitrones have not successfully passed the scrutiny of clinical trials for prevention and treatment of various diseases. This has given rise to a pessimistic view of antioxidant therapy, however, the evidence from human epidemiological studies about the beneficial effects of dietary antioxidants and preclinical in vitro and animal data are compelling. We have probably wasted too much time on agents like antioxidant vitamins instead of focusing on more disease specific, target-directed, highly bioavailable antioxidants. We here discuss possible reasons for the lack of success in some clinical trials and seek to provide some suggestions to be considered if antioxidant therapy is to succeed as an effective therapeutic strategy.

Cutaneous application of menthol 10% solution as an abortive treatment of migraine without aura: a randomised, double-blind, placebo-controlled, crossed-over study

OBJECTIVE

To investigate the efficacy and safety of the cutaneous application of menthol 10% solution for the abortive treatment of migraine.

BACKGROUND

Peppermint and its active ingredient menthol have long been used for the treatment of various pain conditions including headache.

METHODS

This is a randomised, triple-blind, placebo-controlled, crossed-over study conducted in the neurology Clinic of Nemazee Hospital, affiliated with Shiraz University of Medical Sciences, Shiraz, southern Iran, from March 2007 to March 2008. The patients were recruited via local newspaper advertisements. Eligible patients were categorised into two groups and a 10% ethanol solution of menthol (as drug) and 0.5% ethanol solution of menthol (as placebo) were applied to the forehead and temporal area in a crossover design. Pain free, pain relief, sustained pain free and sustained pain relief end-points were measured by questionnaires using a visual analogue scale.

RESULTS

The intent-to-treat population consisted of 35 patients (80% women, 20% men, mean age: 29.6 +/- 6.2) with 118 migraine attacks. In the intent-to-treat population, the menthol solution was statistically superior to the placebo on 2-h pain free (p = 0.001), 2-h pain relief (p = 0.000), sustained pain free and sustained pain relief end-points (p = 0.008). The menthol solution was also more efficacious in the alleviation of nausea and/or vomiting and phonophobia and/or photophobia (p = 0.02). In the per-protocol population, there was significantly higher number of patients who experienced at least one pain free/pain relief after the application of menthol rather than the placebo (p = 0.002). No significant difference was seen between the adverse effects of the drug and the placebo groups (p = 0.13).

CONCLUSION

Menthol solution can be an efficacious, safe and tolerable therapeutic option for the abortive treatment of migraine.

Computerized optimization of biventricular pacing using body surface potential map

An improvement of biventricular pacing (BVP) could be possible by detecting the patient specific optimal pacemaker parameters. Body surface potential map (BSPM) is used to obtain the electrophysiology and pathology of an individual patient non-invasively. The clinical measurements of BSPM are used to parameterize the computer model of the heart to represent the individual pathology. The computer model of the heart is used to simulate the dyssynchrony of the ventricles and myocardial infarction (MI). Cardiac electrophysiology is simulated with ten Tusscher cell model, while excitation propagation is intended with adaptive cellular automaton at physiological and pathological conduction stages. The optimal electrode configurations are identified by minimizing the QRS duration error of healthy and pathology case with/without pacing between pre and post-implantation. Afterwards, the simulated ECGs for optimal pacing are compared to the post implantation clinically measured ECGs. The optimal electrode positions found by simulation are comparable to the ones meausured in hospital. The QRS duration reduction error between measured and simulated 12 ECG signals are similar with a constant offset of 15 ms. The personalized model present in this research is an effective tool for therapy planning of BVP in patients with congestive heart failure.

Comparison of the electrophysiologically based optimization methods with different pacing parameters in patient undergoing resynchronization treatment

Many studies conducted on patients suffering from congestive heart failure have shown the efficacy of cardiac resynchronization therapy (CRT). The presented research investigates an off-line optimization algorithm based on different electrode positioning and timing delays. A computer model of the heart was used to simulate left bundle branch block (LBBB), myocardial infarction (MI) and reduction of intraventricular conduction velocity in order to customize the patient symptom. The optimization method evaluates the error between the healthy heart and pathology with/without pacing in terms of activation time and QRS length. Additionally, a torso model of the patient is extracted to compute the body surface potential map (BSPM) and to simulate the ECG with Wilson leads to validate the results obtained by the electrophysiological heart model optimization.

Computer based optimization of biventricular pacing according to the left ventricular 17 myocardial segments

Cardiac resynchronization therapy (CRT) has shown to improve hemodynamics and clinical symptoms of congestive heart failure. The present article investigates an automated non-invasive strategy based on a computer model of the heart to optimize biventricular pacing as a CRT with respect to electrode positioning and timing delays. Accurate simulations of the electrical activities of the heart require suitable anatomical and electrophysiological models. The anatomical model used in this work, is based on segmented MR data of a patient in which a variety of tissue classes for left ventricle are considered based on AHA standard in accordance with fiber orientation. The excitation propagation is simulated with the ten Tusscher et al. electrophysiological cell model using an adaptive cellular automaton. The simulated activation times of different myocytes in the healthy and diseased heart model are compared in terms of root mean square error (ERMS). The results of our investigation demonstrate that the efficacy of biventricular pacing can greatly be improved by proper electrode positioning and optimized A-V and V-V delay.