A146 BENIGN GASTRIC ULCER COMPLICATED BY GASTROJEJUNAL FISTULA FORMATION HEALED WITH PROTON-PUMP INHIBITOR

Background

We report a case of a benign gastric ulcer (GU) complicated by gastrojenunal (GJ) fistulization which healed with proton-pump inhibitor (PPI) therapy. It presented in an elderly malnourished patient.

Purpose

To highlight this rare complication of benign peptic ulcer disease, as only 13 similar cases are reported. Additionally, our case is one of the few demonstrating medical treatment can effectively heal both the ulcer and GJ fistula, thus obviating the need for surgery.

Method

A detailed chart review was conducted to summarize all salient clinical data. Using PubMed database, a comprehensive literature review identified similar cases using MeSH terms such as “gastrojejunal”, “fistula”, and “ulcer” under the case report filter.

Result(s)

An 83-year-old previously healthy woman presented with four weeks of weakness, abdominal pain, and nausea. She denied any overt GI bleeding or NSAID use. Physical exam demonstrated cachexia (36.6kg) with benign abdominal and rectal examinations. Initial workup revealed anemia (hemoglobin of 38g/L), iron deficiency, hypoalbuminemia (20g/L) and depleted B12 (108pmol/L). She was started on IV pantoprazole and transfused 3 units of red cells.

A gastroscopy revealed a giant, penetrating gastric ulcer at the lesser curvature. The ulcer base showed protruding tissue consistent with a segment of intestine (Figure 1 - left image). Examination to the distal duodenum was normal. Biopsies of the ulcer edge were negative for neoplasia. Urease testing of antrum and body samples were negative. CT scan demonstrated a 3.1 cm gastric ulcer with a linear tract communicating with the proximal jejunum, confirming the endoscopic impression.

Surgical consultation was obtained; conservative treatment was advised given her age and cachexia. Calorie intake was optimized and the patient commenced twice daily PPI. She rapidly gained 7 kg in the community, accompanied by normalization of albumin (33g/L) and B12 (293 pmol/L) levels. Hemoglobin remained stable near 100g/L after initial transfusion. At month three, repeat gastroscopy was performed. The ulcer and fistula had completely healed. (Figure 1 - right image).

Image

Conclusion(s)

Gastro-enteric fistulas complicating benign ulcers are rare. When described, other sites, such as gastroduodenal, are more common. Direct gastrojejunal fistulization is less favorable due to the anatomy of the mesentery. The literature reports only 13 gastrojejunal fistulas complicating benign ulcers. In other cases, unique risk factors are reported (malignancy, prior gastric surgery). Only 3 of 13 reported cases resolved with medication alone. The overwhelming majority required surgery. Notably, many of the case reports pre-date the introduction of proton-pump inhibitors.

The etiology of our patient’s ulcer was benign but remains undefined. ASA use was excluded on history, and H. pylori sampling was negative. We speculate profound malnutrition placed her at risk for poor healing and thus contributed to the extensive disease complicated by fistula.

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Disclosure of Interest

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Exploring the Challenges of Frailty in Medical Education

Frailty is common, and medical students and doctors across all specialties will look after patients with frailty. The General Medical Council requires UK medical schools to teach and assess on frailty, and national geriatric societies across the globe include frailty in their recommended undergraduate curricula. However, frailty in medical education is challenging; there is uncertainty around what frailty is in medical education, including how and when to teach it; controversies in mapping teaching and assessments to recommended curricula; patients with frailty can be challenging to include in teaching and assessments due to functional, sensory, and/or cognitive impairments; an individual with frailty is likely to present atypically, with less predictable recovery, introducing complexities into clinical reasoning that can be challenging for students; the term frailty is often negatively perceived, used colloquially and avoided in educational interactions. This commentary discusses these challenges around frailty in undergraduate medical education and serves to provoke discussion about why frailty is so challenging to teach and learn about, including recommendations for how frailty education could be improved.

Altered Aortic Hemodynamics and Relative Pressure in Patients with Dilated Cardiomyopathy

Ventricular-vascular interaction is central in the adaptation to cardiovascular disease. However, cardiomyopathy patients are predominantly monitored using cardiac biomarkers. The aim of this study is therefore to explore aortic function in dilated cardiomyopathy (DCM). Fourteen idiopathic DCM patients and 16 controls underwent cardiac magnetic resonance imaging, with aortic relative pressure derived using physics-based image processing and a virtual cohort utilized to assess the impact of cardiovascular properties on aortic behaviour. Subjects with reduced left ventricular systolic function had significantly reduced aortic relative pressure, increased aortic stiffness, and significantly delayed time-to-pressure peak duration. From the virtual cohort, aortic stiffness and aortic volumetric size were identified as key determinants of aortic relative pressure. As such, this study shows how advanced flow imaging and aortic hemodynamic evaluation could provide novel insights into the manifestation of DCM, with signs of both altered aortic structure and function derived in DCM using our proposed imaging protocol.

Care navigation increases initiation of hepatitis C treatment following release from prison in a prospective randomised controlled trial: The C-LINK Study

Background

Prison-based hepatitis C treatment is safe and effective; however, many individuals are released untreated due to time or resource constraints. On community re-entry, individuals face a number of immediate competing priorities, and in this context, linkage to hepatitis C care is low. Interventions targeted at improving healthcare continuity after prison release have yielded positive outcomes for other health diagnoses; however, data regarding hepatitis C transitional care are limited.

Methods

We conducted a prospective randomized controlled trial comparing a hepatitis C care navigator intervention with standard of care for individuals released from prison with untreated hepatitis C infection. The primary outcome was prescription of hepatitis C direct-acting antivirals (DAA) within 6 months of release.

Results

Forty-six participants were randomized. The median age was 36 years and 59% were male. Ninety percent (n = 36 of 40) had injected drugs within 6 months before incarceration. Twenty-two were randomized to care navigation and 24 were randomized to standard of care. Individuals randomized to the intervention were more likely to commence hepatitis C DAAs within 6 months of release (73%, n = 16 of 22 vs 33% n = 8 of 24, P < .01), and the median time between re-entry and DAA prescription was significantly shorter (21 days [interquartile range {IQR}, 11–42] vs 82 days [IQR, 44–99], P = .049).

Conclusions

Care navigation increased hepatitis C treatment uptake among untreated individuals released from prison. Public policy should support similar models of care to promote treatment in this high-risk population. Such an approach will help achieve hepatitis C elimination as a public health threat.

Gelation Dynamics upon Pressure-Induced Liquid-Liquid Phase Separation in a Water-Lysozyme Solution

Employing X-ray photon correlation spectroscopy, we measure the kinetics and dynamics of a pressure-induced liquid-liquid phase separation (LLPS) in a water-lysozyme solution. Scattering invariants and kinetic information provide evidence that the system reaches the phase boundary upon pressure-induced LLPS with no sign of arrest. The coarsening slows down with increasing quench depths. The g₂ functions display a two-step decay with a gradually increasing nonergodicity parameter typical for gelation. We observe fast superdiffusive (γ ≥ 3/2) and slow subdiffusive (γ < 0.6) motion associated with fast viscoelastic fluctuations of the network and a slow viscous coarsening process, respectively. The dynamics age linearly with time τ ∝ t_w, and we observe the onset of viscoelastic relaxation for deeper quenches. Our results suggest that the protein solution gels upon reaching the phase boundary.

Micro-elimination of hepatitis C among people with HIV coinfection: declining incidence and prevalence accompanying a multi-center treatment scale-up trial

BACKGROUND

Gay and bisexual men (GBM) are a key population affected by HIV and hepatitis C (HCV) co-infection. Providing HCV treatment scale-up across specialist and non-hepatitis specialist settings may eliminate HCV in this population. We aimed to (1) deliver and measure HCV treatment effectiveness, and (2) determine the population impact of treatment on HCV prevalence and incidence longitudinally.

METHODS

The co-EC Study (Enhancing care and treatment among HCV/HIV co-infected individuals to Eliminate Hepatitis C transmission) was an implementation trial providing HCV direct-acting antiviral treatment in Melbourne, Australia, from 2016-2018. Individuals with HCV/HIV co-infection were prospectively enrolled from primary and tertiary-care services providing care for 85% of GBM with HIV in our jurisdiction. HCV-viraemic prevalence and HCV-antibody/viraemic incidence were measured using a state-wide, individually-linked, electronic surveillance system.

RESULTS

Among 200 participants recruited, 186 initiated treatment during the study period. Sustained virological response among primary care participants (98%, 95%CI:93-100%) was not different to tertiary care (98%, 95%CI:86-100%). From 2012-2019, between 2434 and 3476 GBM with HIV-infection attended our primary-care sites annually providing 13,801 person-years of follow-up; 50-60% received an HCV test annually, 10-14% were anti-HCV positive. Among those anti-HCV positive, viraemic prevalence declined 83% during the study (54% to 9%; 2016 to 2019). HCV incidence decreased 25% annually from 1.7/100 person-years in 2012 to 0.5/100 person-years in 2019 (incidence rate ratio 0.75; CI:0.68-0.83;p<0.001).

CONCLUSION

High treatment effectiveness by non-specialists demonstrates the feasibility of treatment scale-up in this population. Substantial declines in HCV incidence and prevalence among GBM with HIV-infection provides proof-of-concept for HCV micro-elimination.

REGISTRATION

ClinicalTrials.gov (Identifier: NCT02786758).

Influence of thermally induced structure changes in diluted β-lactoglobulin solutions on their surface activity and behavior in foam fractionation

Surface activity is an intrinsic protein feature, leading to the capability of aqueous protein solutions to form foam. This feature provides opportunities for downstream processing, such as usage of foam fractionation for purification. In order to investigate the impact of the surface activity on the performance of the foam fractionation process, protein solutions with different surface activity were produced by different thermal denaturation of aqueous β-lactoglobulin solutions. The effectiveness of the denaturation procedure was verified with circular dichroic spectroscopy, and the impact on surface activity was determined via dynamic surface tension measurement. The increased surface activity resulted in higher foamate flow rates. Furthermore, the effects could be correlated with secondary structure changes and with the dynamic surface pressure. The new result of this study is that the effect of the denaturation of a protein on foam fractionation depends on the protein concentration. At the lower feed concentration, effects became visible, which could not be observed at the higher concentration.

High seroprevalence of SARS-CoV-2 in elderly care employees in Sweden

The COVID-19 pandemic is growing and spread in the Swedish elderly care system during April 2020. The increasing number of employees on sick-leave due to COVID-19 created severe logistic problems. Some elderly care homes therefore started to screen their personnel to secure the safety of the elderly and to avoid unnecessary quarantine of potentially immune employees.

Secondary data from a screening with a COVID-19 rapid test for detection of SARS-CoV-2-specific IgM and IgG of 1,005 employees in 22 elderly care homes in Stockholm, Sweden, were analyzed. Seropositive employees were found in 21 out of the 22 care homes. In total, 23% (231/1,005) of the employees tested positive for antibodies against SARS-CoV-2, and 14.3% (144/1,005) were found positive for IgM (either alone or combined with IgG), indicating recent or present infection. Of those that tested seropositive, 46.5% did not report any clinical symptoms, indicating pre- or asymptomatic infections. Reported symptoms with the highest correlation with seropositivity were fever and loss of smell and taste.

These results suggest that antibody testing of employees in elderly care homes is valuable for surveillance of disease development and a crucial screening tool in the effort to decrease the death toll in this pandemic.

Combined spatiotemporal and frequency-dependent shear wave elastography enables detection of vulnerable carotid plaques as validated by MRI

Fatal cerebrovascular events are often caused by rupture of atherosclerotic plaques. However, rupture-prone plaques are often distinguished by their internal composition rather than degree of luminal narrowing, and conventional imaging techniques might thus fail to detect such culprit lesions. In this feasibility study, we investigate the potential of ultrasound shear wave elastography (SWE) to detect vulnerable carotid plaques, evaluating group velocity and frequency-dependent phase velocities as novel biomarkers for plaque vulnerability. In total, 27 carotid plaques from 20 patients were scanned by ultrasound SWE and magnetic resonance imaging (MRI). SWE output was quantified as group velocity and frequency-dependent phase velocities, respectively, with results correlated to intraplaque constituents identified by MRI. Overall, vulnerable lesions graded as American Heart Association (AHA) type VI showed significantly higher group and phase velocity compared to any other AHA type. A selection of correlations with intraplaque components could also be identified with group and phase velocity (lipid-rich necrotic core content, fibrous cap structure, intraplaque hemorrhage), complementing the clinical lesion classification. In conclusion, we demonstrate the ability to detect vulnerable carotid plaques using combined SWE, with group velocity and frequency-dependent phase velocity providing potentially complementary information on plaque characteristics. With such, the method represents a promising non-invasive approach for refined atherosclerotic risk prediction.

Comparison of right ventricular function after ministernotomy and full sternotomy aortic valve replacement: a randomized study

OBJECTIVES

Right ventricular (RV) function is impaired after cardiac surgery, possibly because of the opening of the pericardium. In minimally invasive aortic valve replacement, the pericardium is only partially incised.

METHODS

A randomized trial compared RV function after ministernotomy versus full sternotomy in 40 adults undergoing aortic valve replacement at the Karolinska University Hospital. Primary outcomes were tricuspid annular plane systolic excursion, RV pulsed-wave tissue Doppler velocity, RV fractional area change and basal and mid-RV transversal diameters on postoperative Days 4 and 40.

RESULTS

On postoperative Day 4, the tricuspid annular plane systolic excursion had decreased in both groups [ministernotomy: median (Q1-Q3) 25 (21-28) vs 16 (11-18), P < 0.001; sternotomy: 22.5 (22-22.5) vs 8 (7-12) mm, P < 0.001] but was higher in the ministernotomy group (P < 0.001). Pulsed-wave tissue Doppler RV velocity decreased significantly in patients who underwent sternotomy [10.5 (10-12) vs 6.5 (5-8) cm/s, P < 0.001] but did not decrease significantly in patients who underwent ministernotomy [11.5 (11-12) vs 10 (9-11) cm/s, P = 0.054]. Fractional area change was equally decreased in both groups [ministernotomy: 46 (39-51) vs 38 (34-44)%, P < 0.001; sternotomy: 45 (40-49) vs 37 (25-39.5)%, P = 0.003]. RV dimensions did not change on postoperative Day 4 in both groups. The differences between the 2 groups were similar 40 days postoperatively.

CONCLUSIONS

RV long-axis function was reduced after both ministernotomy and full sternotomy aortic valve replacement, but the reduction was more pronounced in the full sternotomy group. Global RV function was equally impaired in both groups postoperatively.

Clinical trial registration

http://www.clinicaltrials.gov. Unique identifier: NCT01972555.

Right ventricular mechanics and contractility after aortic valve replacement surgery: a randomised study comparing minimally invasive versus conventional approach

Objective

Minimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.

Methods

A predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery.

Results

Comparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, p<0.01). RV longitudinal strain reduced following AVR (−27.4±2.9% vs −18.8%±4.7%, p<0.001) and MIAVR (−26.5±5.3% vs −20.7%±4.5%, p<0.01). Peak systolic velocity of the lateral tricuspid annulus reduced by 36.6% in the AVR group (9.3±2.1 vs 5.9±1.5 cm/s, p<0.01) and 18.8% in the MIAVR group (10.1±2.9 vs 8.2±1.4 cm/s, p<0.01) when comparing preoperative values with postoperative values.

Conclusions

RV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. A decline in RV longitudinal function was also observed following MIAVR, however, to a much lesser extent.

Test of simulator-based assessment of psychomotor skill in transthoracic echo

BACKGROUND

We developed a transthoracic echo simulator that measures technical skill in image acquisition in terms of the deviation angle between an acquired image and the anatomically correct plane for that view. We studied whether this metric reflects the clinical experience of providers.

METHODS

Attendees at an echo course or at the annual meeting of the Swedish Heart Association were invited to test themselves on the simulator by scanning a mannequin and acquiring four views in 15 min: parasternal long axis (pLAX) in patient 1, apical four chamber and apical long axis (aLAX) in patient 2 and pLAX in patient 3. Their experience with echo was assessed from duration in years and procedure volume in the past year. Image acquisition error was assessed from the deviation angle.

RESULTS

Of 61 participants, there were 37 physicians and 24 non-physicians (22 sonographers and two nurses). Non-physicians had higher procedure volume than physicians (850 ± 599 versus 312 ± 393 tests year-1 , P<0·001); both had similar duration of experience (9 ± 8 versus 12 ± 11 years, P = NS). The deviation angle for aLAX (55 ± 37 degrees) was higher than for any other view (P<0·00001). aLAX was the only view whose deviation angle correlated significantly with experience and only with procedure volume (r = -0·357, P = 0·008).

CONCLUSIONS

These results demonstrate that deviation angle, a novel metric of technical skill in image acquisition, reflects clinical experience. Simulator-based testing provides objective and quantitative assessment that may be of value in the certification of trainees and for maintenance of certification.

Influence of cosolvents, self-crowding, temperature and pressure on the sub-nanosecond dynamics and folding stability of lysozyme

We studied the effects of temperature and hydrostatic pressure on the dynamical properties and folding stability of highly concentrated lysozyme solutions in the absence and presence of the osmolytes trimethylamine-N-oxide (TMAO) and urea. Elastic incoherent neutron scattering (EINS) was applied to determine the mean-squared displacement (MSD) of the protein's hydrogen atoms to yield insights into the effects of these cosolvents on the averaged sub-nanosecond dynamics in the pressure range from ambient up to 4000 bar. To evaluate the additional effect of self-crowding, two protein concentrations (80 and 160 mg mL^-1) were used. We observed a distinct effect of TMAO on the internal hydrogen dynamics, namely a reduced mobility. Urea, on the other hand, revealed no marked effect and consequently, no counteracting effect in an urea-TMAO mixture was observed. Different from the less concentrated protein solution, no significant effect of pressure on the MSD was observed for 160 mg mL^-1 lysozyme. The EINS experiments were complemented by Fourier-transform infrared (FTIR) spectroscopy measurements, which led to additional insights into the folding stability of lysozyme under the various environmental conditions. We observed a stabilization of the protein in the presence of the compatible osmolyte TMAO and a destabilization in the presence of urea against temperature and pressure for both protein concentrations. Additionally, we noticed a slight destabilizing effect upon self-crowding at very high protein concentration (160 mg mL^-1), which is attributable to transient destabilizing intermolecular interactions. Furthermore, a pressure-temperature diagram could be obtained for lysozyme at these high protein concentrations that mimics densely packed intracellular conditions.

Method comparison for cardiac image registration of coronary computed tomography angiography and 3-D echocardiography

Treatment decision for coronary artery disease (CAD) is based on both morphological and functional information. Image fusion of coronary computed tomography angiography (CCTA) and three-dimensional echocardiography (3DE) could combine morphology and function into a single image to facilitate diagnosis. Three semiautomatic feature-based methods for CCTA/3DE registration were implemented and applied on CAD patients. Methods were verified and compared using landmarks manually identified by a cardiologist. All methods were found feasible for CCTA/3DE fusion.

Co-solvent effects on reaction rate and reaction equilibrium of an enzymatic peptide hydrolysis

This work presents an approach that expresses the Michaelis constant KaM and the equilibrium constant K_th of an enzymatic peptide hydrolysis based on thermodynamic activities instead of concentrations.

Patient-Specific Left Ventricular Flow Simulations From Transthoracic Echocardiography: Robustness Evaluation and Validation Against Ultrasound Doppler and Magnetic Resonance Imaging

The combination of medical imaging with computational fluid dynamics (CFD) has enabled the study of 3-D blood flow on a patient-specific level. However, with models based on gated high-resolution data, the study of transient flows, and any model implementation into routine cardiac care, is challenging. This paper presents a novel pathway for patient-specific CFD modelling of the left ventricle (LV), using 4-D transthoracic echocardiography (TTE) as input modality. To evaluate the clinical usability, two sub-studies were performed. First, a robustness evaluation was performed, where repeated models with alternating input variables were generated for six subjects and changes in simulated output quantified. Second, a validation study was carried out, where the pathway accuracy was evaluated against pulsed-wave Doppler (100 subjects), and 2-D through-plane phase-contrast magnetic resonance imaging measurements over seven intraventricular planes (6 subjects). The robustness evaluation indicated a model deviation of <12%, with highest regional and temporal deviations at apical segments and at peak systole, respectively. The validation study showed an error of <11% (velocities <10 cm/s) for all subjects, with no significant regional or temporal differences observed. With the patient-specific pathway shown to provide robust output with high accuracy, and with the pathway dependent only on 4-D TTE, the method has a high potential to be used within future clinical studies on 3-D intraventricular flow patterns. To this, future model developments in the form of e.g., anatomically accurate LV valves may further enhance the clinical value of the simulations.

Heart rate and dyssynchrony in patients with cardiac resynchronization therapy: a pilot study

OBJECTIVES

The objective of this pilot study was to describe the impact of paced heart rate on left ventricular (LV) mechanical dyssynchrony in synchronous compared to dyssynchronous pacing modes in patients with heart failure.

METHODS

Echocardiography was performed in 14 cardiac resynchronization therapy (CRT) patients at paced heart rates of 70 and 90 bpm in synchronous- (CRT), and dyssynchronous (atrial pacing + wide QRS activation) pacing modes. LV dyssynchrony was quantified using the 12-segment standard deviation model (Ts-SD) derived from Tissue Doppler Imaging. In addition, cardiac cycle intervals were assessed using cardiac state diagrams and stroke volume (SV) and filling pressure were estimated.

RESULTS

Ts-SD decreased significantly with CRT at 90 bpm (25 ± 12 ms) compared to 70 bpm (35 ± 15 ms, p = .01), but remained unchanged with atrial pacing at different paced heart rates (p = .96). The paced heart rate dependent reduction in Ts-SD was consistent when Ts-SD was indexed to average Ts and systolic time interval. Cardiac state diagram derived analysis of cardiac cycle intervals demonstrated a significant reduction of the pre-ejection interval and an increase in diastole with CRT compared to atrial pacing. SV was maintained at the higher paced heart rate with CRT pacing but decreased with atrial pacing.

DISCUSSION

Due to the small sample size in this pilot study general and firm conclusions are difficult to render. However, the data suggest that pacing at higher heart rates acutely reduces remaining LV dyssynchrony during CRT, but not during atrial pacing with dyssynchronous ventricular activation. These results need confirmation in a larger patient cohort.

Coronary flow velocity reserve reduction is comparable in patients with erectile dysfunction and in patients with impaired fasting glucose or well-regulated diabetes mellitus

BACKGROUND

There is growing evidence that erectile dysfunction is a sentinel for future coronary artery disease. Recently published studies have shown signs of impaired coronary endothelial function in patients with erectile dysfunction, without clinical cardiovascular disease and diabetes. We evaluated the magnitude of coronary vasodilatory dysfunction in men with erectile dysfunction, as compared with men with impaired glucose metabolism (impaired fasting glucose or diabetes) and healthy controls.

METHODS

We investigated men aged 68-73 years with erectile dysfunction (n=12), age-matched men with impaired glucose metabolism, who all proved to have erectile dysfunction (n=15), and age-matched male controls (n=12). Erectile dysfunction was evaluated using the International Index of Erectile Function (IIEF)-5 questionnaire. Coronary flow velocity reserve in the left anterior descending artery was examined using Doppler ultrasound and intravenous adenosine provocation.

RESULTS

Coronary flow velocities at rest did not differ between the three groups, but maximum coronary flow velocity was significantly lower in the erectile dysfunction group (P=0.004) and in the impaired glucose metabolism group (P=0.019), as compared with controls. There was no difference between the erectile dysfunction and impaired glucose metabolism groups. Coronary flow velocity reserve was reduced in the erectile dysfunction group (P=0.026) compared to controls, but was similar compared to the impaired glucose metabolism group. In multivariate analysis including all groups, erectile dysfunction score was the only independent predictor of reduced coronary flow velocity reserve (P=0.020).

CONCLUSIONS

The magnitude of early coronary endothelial and smooth muscle cell dysfunction in otherwise healthy men with erectile dysfunction was comparable to that of patients with impaired glucose metabolism: a well known risk factor for coronary artery disease.