Perspectives on the use of digital health technologies in cardiology among specialists from an ESC member country: results from a survey

Background

Digital health technologies (DHTs) have the potential of facilitating both physicians' and patients' lives with regards to the diagnosis, treatment and follow-up of cardiovascular disease. A huge acceleration in relevant research has been noted particularly after the COVID-19 pandemic.

Purpose

The goal of this study was to determine the reasons for using DHTs in cardiology, as well as the perceived barriers to its use.

Methods

An electronic survey with 43 question multiple-choice questionnaire was conducted between January 10-March 3, 2022. National cardiac society member cardiology fellows in training and specialists were contacted via e-mail (n=2789).

Results

308/2789 (11.04%) subjects responded to the survey (72.40% males, 62.01% aged 30–44 years). 42.53% and 44.81% were affiliated with university hospitals and state hospitals, respectively. 88/297 (29.63%) stated having at least good understanding of DHTs in cardiology. 44.16% utilized smart devices to track their own health status. 117/290 (40.34%) and 193/299 (64.55%) used social media platforms to share medical information with their patients and other physicians, respectively. WhatsApp and Instagram were the most popular platforms for sharing with patients (92/117, 78.63% and 48/117, 41.03%), while WhatsApp and Twitter were the most popular platforms for sharing with other physicians (151/193, 78.24% and 91/193, 47.15%). Considerations and recommendation/utilization patterns of DHTs by physicians are summarized in Table 1. Perceived barriers to the use of DHTs in cardiology is shown on Figure 1 (A: physician-related, B: patient-related, C: technical).

Conclusion

Findings suggest that nearly half of the physicians use DHTs to collect their own health data and use social media to disseminate health information. The majority of physicians believe that DHT is beneficial to both themselves and their patients, and that DHT use in cardiology has increased as a result of the COVID-19 pandemic. To overcome the challenges to the use of DHTs in cardiology, a multilayered collaborative effort involving patient and professional organizations, as well as technical stakeholders and lawmakers, is required.

Funding Acknowledgement

Type of funding sources: None.

Elevated circulating levels of secreted frizzled-related protein 4 in relation to insulin resistance and androgens in women with polycystic ovary syndrome

PURPOSE

Secreted frizzled-related protein 4 (SFRP4) is an adipokine involving in apoptotic process during ovulation and energy metabolism. Polycystic ovary syndrome (PCOS) is a common reproductive and metabolic disorder associated with insulin resistance and impaired oocyte maturation as well as apoptotic dysfunctions through oocyte development. Our aim was to determine whether there was an alteration in levels of SFRP4 and if there was an association between metabolic or hormonal parameters and SFRP4 in women with PCOS.

METHODS

We enrolled 80 subjects with PCOS and 80 age- and body mass index (BMI)-matched subjects with normal menstrual cycle into current case-control study. Metabolic and hormonal parameters of enrolled subjects were determined. Circulating SFRP4 levels were measured with ELISA method.

RESULTS

We found that circulating SFRP4 levels were elevated in women with PCOS with respect to controls (5.87 ± 1.91 vs. 3.72 ± 1.29 ng/ml, P < 0.001). We also found a positive association between SFRP4 and insulin resistance, androgens, ovarian follicular number or ovarian volume in women with PCOS. Binary logistic regression analysis revealed that subjects with the highest tertile of SFPR4 levels displayed increased possibility of having PCOS risk compared to those subjects with the lowest tertile of SFRP4 levels.

CONCLUSIONS

Increased SFRP4 levels were not only associated with higher possibility of having PCOS but also related to insulin resistance, hyperandrogenism, ovarian follicular number and ovarian volume, suggesting that SFPR4 could be a player in different pathophysiologic pathways of PCOS.

Assessment of ventricular tachyarrhythmia in patients with hypertrophic cardiomyopathy with machine learning-based texture analysis of late gadolinium enhancement cardiac MRI

OBJECTIVE

To assess the diagnostic value of machine learning-based texture feature analysis of late gadolinium enhancement images on cardiac magnetic resonance imaging (MRI) for assessing the presence of ventricular tachyarrhythmia (VT) in patients with hypertrophic cardiomyopathy.

MATERIALS AND METHODS

This retrospective study included 64 patients with hypertrophic cardiomyopathy who underwent cardiac MRI and 24-hour Holter monitoring within 1 year before cardiac MRI. There were 42 men and 22 women with a mean age of 48.13±13.06 (SD) years (range: 20-70 years). Quantitative textural features were extracted via manually placed regions of interest in areas with high and intermediate signal intensity on late gadolinium-chelate enhanced images. Feature selection and dimension reduction were performed. The diagnostic performances of machine learning classifiers including support vector machines, Naive Bayes, k-nearest-neighbors, and random forest for predicting the presence of VT were assessed using the results of 24-hour Holter monitoring as the reference test. All machine learning models were assessed with and without the application of the synthetic minority over-sampling technique (SMOTE).

RESULTS

Of the 64 patients with hypertrophic cardiomyopathy, 21/64 (32.8%) had VT. Of eight machine learning models investigated, k-nearest-neighbors with SMOTE exhibited the best diagnostic accuracy for the presence or absence of VT. k-nearest-neighbors with SMOTE correctly identified 40/42 (95.2%) VT-positive patients and 40/43 (93.0%) VT-negative patients, yielding 95.2% sensitivity (95% CI: 82.5%-99.1%), 93.0% specificity (95% CI: 79.8%-98.1%) and 94.1% accuracy (95% CI: 88.8%-98%).

CONCLUSION

Machine learning-based texture analysis of late gadolinium-chelate enhancement-positive areas is a promising tool for the classification of hypertrophic cardiomyopathy patients with and without VT.

Frequency, characteristics, and clinical determinants of 'prodrome' in familial Mediterranean fever patients

Objective: Prodrome is defined by manifestations that precede a familial Mediterranean fever (FMF) attack and predict its emergence. We aimed to determine the frequency, characteristics, and clinical determinants of prodrome in patients with FMF.Method: This cross-sectional study was conducted in a tertiary rheumatology clinic. During the clinical interview, all patients completed a standardized questionnaire about the pre-attack period. Prodrome was defined as the presence of any recurrent pre-attack manifestation occurring at least 4 h before an attack. Patients were classified according to whether they had prodrome of any kind of attack.Results: The study enrolled 401 patients aged 37.7 ± 11.0 years (mean ± sd). Male gender, M694V/M694V, homozygous MEFV mutation, peritonitis, pleuritis, and arthritis were more frequent in prodrome-positive patients. Altogether, 141 patients (35.2%) had prodrome. Male gender and ever having attack types of peritonitis or arthritis were independent clinical determinants of prodrome [relative risk (95% confidence interval): 1.72 (1.07-2.76), p = 0.02; 4.27 (1.80-10.1), p = 0.001; 1.77 (1.04-3.04), p = 0.04, respectively]. Age, MEFV mutations, pleuritis, and erysipelas-like erythema were not clinical determinants.Conclusions: All FMF patients, particularly males and patients who had peritonitis or arthritis at any time, should be questioned about prodrome. Prodrome should be analysed in terms of elucidating the pathogenesis of FMF and as an opportunity for a secondary prevention strategy for impending attacks. This study may shed light on prodrome for future cytokine or drug studies with the purpose of developing new cost-effective treatment protocols irrespective of colchicine resistance.

Circulating insulin-like peptide 5 levels and its association with metabolic and hormonal parameters in women with polycystic ovary syndrome

PURPOSE

Insulin-like peptide 5 (INSL5) is a gut peptide hormone that is a member of relaxin/insulin superfamily. Growing evidence implicates the crucial role of the peptide in some metabolisms including food intake, glucose homeostasis and reproductive system. Polycystic ovary syndrome (PCOS) is involved in both reproductive and metabolic issues. The aim of the study was determination of circulating levels of INSL5 alteration in women with PCOS and evaluation of the relationship between INSL5 and hormonal-metabolic parameters as well as carotid intima media thickness (cIMT).

METHODS

A total of 164 subjects were recruited in this cross-sectional study (82 women with PCOS and 82 age- and BMI-matched controls). Circulating INSL5 levels were assessed via ELISA method. High-resolution B-mode ultrasound was used to measure cIMT. The hormonal and metabolic parameters of the recruited subjects were determined.

RESULTS

Circulating INSL5 levels were significantly elevated in women with PCOS compared to controls (27.63 ± 7.74 vs. 19.90 ± 5.85 ng/ml, P < 0.001). The mean values of INSL5 were significantly higher in overweight subjects compared to lean weight subjects in both groups. The women with PCOS having insulin resistance have increased INSL5 compared to those of PCOS subjects without insulin resistance. INSL5 is associated with insulin resistance, BMI, luteinizing hormone and free androgen index. Multivariate logistic regression analyses revealed that the odds ratio for having PCOS in the highest tertile of INSL5 was higher than in the lowest tertile.

CONCLUSIONS

PCOS subjects exhibited an elevation in circulating INSL5 levels along with a link between INSL5 level induction and metabolic-hormonal parameters.

Is elevated urotensin II level a predictor for increased cardiovascular risk in subjects with acromegaly?

PURPOSE

Acromegaly is a rare disorder existed in the result of overproduction of growth hormone (GH). The disorder is associated with increased cardiovascular risk factors and metabolic abnormalities. Urotensin II (UII), a secreted vasoactive peptide hormone, belonging somatostatin superfamily, plays an essential role in atherosclerosis and glucose metabolism. The aim of this study was to ascertain whether circulating UII levels are altered in subjects with acromegaly, and to describe the relationship between UII and hormonal or cardiometabolic parameters.

METHODS

This cross-sectional study included 41 subjects with active acromegaly, 28 subjects with controlled acromegaly, and 37 age- and BMI-matched controls without acromegaly. Hormonal and metabolic features of the subjects as well as carotid intima media thickness (cIMT) and epicardial fat thickness (EFT) were defined. Circulation of UII levels was determined via ELISA.

RESULTS

Both active and controlled acromegalic subjects showed a significant elevation of circulating levels of UII with respect to controls. There was no remarkable difference in circulating levels of UII between active and controlled acromegalic groups. Both cIMT and EFT were remarkably increased in acromegaly subjects comparing to controls. UII positively correlated with cIMT, EFT, BMI, and HOMA-IR. There was no correlation between UII and GH, insulin-like growth factor-1. According to the results obtained from regression models, UII levels independently predicted cIMT and EFT.

CONCLUSION

Elevated UII levels are associated with severity of cardiovascular risk factors including cIMT and EFT in acromegalic subjects.

Serum endocan levels in patients with cardiac syndrome X

BACKGROUND

Endocan is a recently introduced marker of endothelial dysfunction and is also associated with inflammation and atherosclerosis. To date, the relationship between cardiac syndrome X (CSX) and endocan has not been studied. The objective of this study was to compare the serum endocan levels of patients with CSX with those of control subjects.

PATIENTS AND METHODS

In this study, 50 patients were included in the CSX group and 28 patients in the control group. Patients with pathological conditions that could potentially influence endothelial functions were excluded. Endocan serum concentrations were measured using an enzyme-linked immunosorbent assay.

RESULTS

The mean endocan level of the CSX group was significantly higher than that of the control group (3051.3 ± 1900.5 ng/l vs. 2088.1 ± 522.2 ng/l; p = 0.002). There was no difference between the two groups in terms of age, gender, hypertension, diabetes mellitus, dyslipidemia, and smoking status. In receiver operating characteristic (ROC) curve analysis, endocan levels greater than 2072 ng/l had a 72% sensitivity and 54% specificity (p = 0.002) for accurately predicting a diagnosis of CSX.

CONCLUSION

The results of this study suggest that patients with CSX have higher endocan levels. Therefore, endocan may be valuable in helping uncover the underlying pathogenesis of CSX.

Clinical, angiographic and procedural characteristics of longitudinal stent deformation

Recently, longitudinal stent deformation (LSD) has been reported increasingly. Even though the reported cases included almost all stent designs, most cases were seen in the Element™ stent design (Boston Scientific, Natick, MA, USA). It is considered that stent design, lesion and procedural characteristics play a role in the etiology of LSD. Yet, the effect of LSD on long-term clinical outcomes has not been studied well. Element stents implanted between January 2013 and April 2015 in our hospital were examined retrospectively. Patients were grouped into two according to the presence of LSD, and their clinical, lesion and procedural characteristics were studied. Twenty-four LSD's were detected in 1812 Element stents deployed in 1314 patients (1.83 % of PCI cases and 1.32 % of all Element stents). LMCA lesions (16.7 % vs 1.6 %, p < 0.001), complex lesions (75 % vs 35.1 %, p < 0.001), bifurcation lesions (37.5 % vs 18.3 %, p = 0.017), ostial lesions (33.3 % vs 12.8 %, p = 0.003), using of extra-support guiding catheter (54.2 % vs 22.3 %, p < 0.001) and extra-support guidewire (37.5 % vs 16.2 %, p = 0.005) were found to be more frequent in cases with LSD than in cases without it. In addition, the number of stents, stent inflation pressure and the use of post-dilatation were significantly different between the two groups. Two patients had an adverse event during the follow-up period. LSD is a rarely encountered complication, and is more common in complex lesions such as ostial, bifurcation and LMCA lesions. The use of extra-support guiding catheter, extra-support guidewires and low stent inflation pressure increases the occurrence of LSD. Nevertheless, with increased awareness of LSD and proper treatment, unwanted long-term outcomes can be successfully prevented.

CEREBRAL VENOUS THROMBOSIS AND TURNER SYNDROME: A RARE REPORTED ASSOCIATION

Turner Syndrome is the only known viable chromosomal monosomy, characterised by the complete or partial absence of an X chromosome. It's the most common chromosomal abnormality in females. Apart from the well known dysmorphic features of the syndrome, it has been associated with a number of vascular pathologies; mainly involving the cardiovascular, renovascular, peripheral vascular and cerebrovascular system. It seems striking that thromboembolism is not considered as a feature of the syndrome. Most of the thromboembolism cases are related to the arterial vascular system; except for some rare reported portal venous thrombosis cases, peripheral venous thrombosis cases and to the best of our knowledge a single case of cerebral venous thrombosis with Dandy Walker malformation and polymicrogyria. We herein report a cerebral venous thrombosis case with Turner Syndrome. With no other found underlying etiology, we want to highlight that Turner Syndrome, itself, may have a relationship not only with the cerebral arterial vascular system pathologies but also with the cerebral venous thrombosis.

An evaluation of combat application tourniquets on training military personnel: changes in application times and success rates in three successive phases

INTRODUCTION

Haemorrhage from the injured extremity is a significant cause of preventable death in military settings. This study evaluated the effect of training on the efficacy of the combat application tourniquet (CAT) and to define standards for military personnel.

METHOD

Participants from a training tank battalion were randomised. Data collected included age, body mass index, mean arterial pressure, hand dominance, femoral artery diameter and skin thickness. The study involved tourniquet application times (AT) and application success rates in basic, after-training and eyes-closed phases. Doppler ultrasound was used to identify the presence or absence of popliteal, radial and ulnar artery pulses.

RESULTS

A total of 102 trainees participated. In the after-training phase, the left and right upper extremity ATs were 35 ± 13.1 s, and 34.8 ± 13.5 s and the right and left lower extremity ATs were 20.6 ± 6.0 s and 20.5 ± 5.5 s, respectively. The overall tourniquet success rates in three successive study phases were 69.6%, 82.4% and 91.2%, respectively. A negative significant relationship was found between extremity circumference and tourniquet success.

DISCUSSION

The results show that the efficacy of CAT application increases with training. Further studies are required to investigate the reasons underlying application failures. This single group prospective randomised study involves level of evidence 4.

Contrast-induced neurotoxicity after coronary angiography

BACKGROUND

Contrast-induced neurotoxicity (CIN) is a very rare complication of coronary angiography. Clinical presentations include encephalopathy, seizures, cortical blindness, and focal neurological deficits. An inherent difficulty in understanding the natural history of the condition as well as its risk factors and prognosis is the rarity of its occurrence. To date, there are only case reports published on this complication.

PATIENTS AND METHODS

This was a retrospective analysis of 9 patients with CIN (8 men, 1 woman; mean age, 64.6 ± 7.8 years; range, 47-72 years) and coronary artery disease who were administered iopromide contrast agent.

RESULTS

In the last 3 years, we diagnosed 9 patients with CIN. Of these, 8 patients (89 %) had hypertension. The clinical presentations of the patients were different on admission: 6 patients had acute coronary syndrome and 3 patients had stable angina pectoris. One patient had history of previous contrast agent exposure. All patients underwent coronary angiography with a low-osmolar nonionic monomer contrast agent (iopromide; Ultravist®-300, Bayer Healthcare). The mean volume of contrast injected was 177 ± 58 ml. The mean time between contrast agent administration and clinical symptoms was 100 ± 71 min (range, 30-240 min). While in 5 of the patients (56 %) the clinical sign of CIN was confusion, 2 had ophthalmoplegia, 1 had cerebellar dysfunction, and 1 had monoplegia. In 8 of 9 patients (89 %), neurological symptoms resolved after giving supportive medication and hydration. Only 1 female patient, who had bilateral ophthalmoplegia, did not recover. Neurological recovery occurred at a mean time of 14.2 ± 6.7 h (range, 8-30 h).

CONCLUSION

CIN is a very rare condition. Advanced age, male gender, and hypertension are the greatest risk factors for CIN. Although the prognosis of CIN is benign, it can potentially cause permanent neurological deficits or death. We found that patients with ophthalmic involvement had a higher propensity for persistent deficit. On the basis of the current data, we propose 170 ml as the maximal recommended dose for coronary procedures.

Complete A-V block: incidental or a part of cor triatriatum dexter

Cor triatriatum dexter (CTD) is an extremely rare cardiac anomaly in which the right atrium is divided into two distinct chambers by a membrane. The persistence of the right valve of sinus venosus results in a complete septation of the right atrium. This anomaly is frequently associated with other right-sided cardiac abnormalities. Its clinical manifestation and the need for intervention are determined by the number and the size of the fenestrations on the membrane, associated cardiac anomalies and arrhythmias. We describe a case of CTD in a patient with complete atrioventricular (A-V) block.

Can cardiac surgery be performed safely on patients with haematological malignancies

Introduction

Surgical strategy in patients with haematological malignancies must be planned and carried out with the specific aim of decreasing postoperative complications. The aim of this study was to present our experience on patients previously diagnosed with haematological malignancies who subsequently underwent cardiac surgery. We include data to assist other surgeons predict factors affecting postoperative morbidity and mortality in this group of patients.

Methods

Fifteen patients diagnosed with haematological malignancies who had cardiac surgery were retrospectively analysed. Eight patients had chronic lymphocytic leukaemia, six had non-Hodgkin’s lymphoma and the rest had chronic myelocytic leukaemia. Coronary artery bypass graft surgery was performed on all of them.

Results

There were no hospital mortalities. The average follow-up period was 35 ± 11 (23–56) months. Three patients required early postoperative re-operation because of excessive bleeding. No mortalities were seen in the early postoperative period. There were five (33%) deaths during the late follow-up period. Three patients were lost due to intracranial bleeding (confirmed by autopsy) in the 16th, 23rd and 38th months after surgery. The remaining two patients had sudden death in the eighth and 55th months from non-detectable causes.

Conclusion

Conclusion: Cardiac surgery can be performed with acceptable early postoperative outcomes in patients with haematological malignancies. Intracranial bleeding is an important factor contributing to late mortality and patient selection and risk stratification are crucial to improving surgical benefits.

A rare complication after coronary artery bypass graft surgery: Ogilvie's syndrome

Gastrointestinal (GI) complications occur in less than 2% of patients undergoing open-heart surgery. Acute colonic pseudo-obstruction, known as Ogilvie's syndrome, is also a rare complication encountered in 0.046% of patients undergoing coronary artery bypass graft surgery. It is characterised by massive colonic dilatation without mechanical obstruction in patients with underlying medical or surgical conditions. In this report we describe a patient who suffered from acute renal failure requiring haemodialysis, and subsequently Ogilvie's syndrome, which was treated with high-dose neostigmine.

Successful percutaneous closure in patients with difficult atrial septal defects: case series and review of literature

Atrial septal defect is a common form of congenital heart disease. Percutenous closure is an important treatment option for these patients. In this case series, we intend to share the percutaneous closure of the difficult types of secundum atrial septal defects.

A successful septal ablation of the first septal perforator artery arising from the circumflex artery

Congenital coronary anomalies are usually incidental, uncommon and asymptomatic. We present a case of a successful septal ablation of the first septal perforator artery arising from the circumflex artery in a patient with symptomatic hypertrophic cardiomyopathy.

Noncompaction cardiomyopathy. Is it more than noncompaction?

Noncompaction cardiomyopathy, a rare congenital cardiomyopathy, is characterized by increased trabeculation in one or more segments of the ventricle. The coexistence of other cardiac anomalies such as coronary-cameral fistula, bicuspid aortic valve, ventricular septal defect, patent ductus arteriosus and bradyarrhythmias make noncompaction cardiomyopathy resemble the reptile heart. The defect in myocardial compaction and the frequently seen accompanying anomalies may share a common causative factor during embryogenesis.

A successful percutaneous closure of ventricular septal defect following septal myectomy in patients with hypertrophic obstructive cardiomyopathy

Postoperative ventricular septal defect (post-op VSD) after septal myectomy in patients with hypertrophic obstructive cardiomyopathy is a rare and unexpected complication. We report a case of successful percutaneous closure of VSD following septal myectomy and mitral valve replacement in a patient with intrinsic mitral valve disease and severe mitral valve regurgitation together with hypertrophic obstructive cardiomyopathy.

Is 5-fluorouracil-induced vasospasm a Kounis syndrome? A diagnostic challenge

Cardiovascular hypersensitivity is a rare and well-documented side-effect of 5-FU (5-fluorouracil). Besides the common complications such as angina pectoris and myocardial infarction, it can also cause cardiogenic shock, and supraventricular and ventricular arrhythmias. Studies have reported that FU-induced angina most commonly occurred due to vasospasm. In our case, 9 hours after stopping the infusion of 5-FU, the patients developed symptoms and electrocardiographic (ECG) findings consistent with acute myocardial infarction. We intend to share this rare case and discuss whether this late complication after 5-FU infusion is an FU-induced vasospasm or rather an allergic reaction leading to Kounis syndrome.

Mitral valve replacement in a patient with situs inversus and dextrocardia

Dextrocardia is a rarely seen cardiac malposition, often associated with multiple and complex congenital cardiac anomalies. Valve surgery for acquired valvular lesions in dextrocardia with situs inversus is rare. A 65-year-old man was admitted to our department with palpitation and dyspnea. Chest X-ray showed dextrocardia, and echocardiography revealed severe mitral regurgitation due to rheumatic valve degeneration. Prosthetic mitral valve replacement using a transseptal approach via a median sternotomy was successfully performed in the patient.

Repair of sternal dehiscence with titanium mesh plates: the sandwich technique

Sternal dehiscence after cardiac surgery occurs infrequently and can lead to mediastinitis and prolonged hospital stay and may even result in death. The most common treatment for mechanical sternal instability is rewiring with wound debridement. We present a case in which a modified titanium mesh plate fixation technique was used. A safe and easy to perform technique, this method can be an alternative option to wire closure in a sternum with fractures, instability or poor bone quality.

Co-existence of gastrointestinal stromal tumors with malign epithelial tumors: a report of two cases

AIM

To emphasize the importance of a detailed observation for incidental simultaneous tumoral masses during surgery for gastrointestinal stromal tumors (GISTs) at any location in the gastrointestinal system.

CASE PRESENTATIONS

Case 1: a 39-year-old female patient with an esophageal squamous cell carcinoma and a synchronous small intestinal GIST discovered incidentally during esophagectomy. Case 2: a 73-year-old female patient with a gastric GIST and a synchronous colorectal cancer detected incidentally during gastrectomy. In both cases, immunohistochemical examinations of the resected specimens confirmed the coexistences of GISTs and epithelial malignancies.

CONCLUSION

The coexistences of GISTs with epithelial tumors have been increasing in recent years. In any case of a GIST or gastrointestinal adenocarcinoma, the surgeon should be alert to recognize a possible coexistent tumor with different histological origin.

A retrospective comparison of bovine pericardium and polytetrafluoroethylene patch for closure of ventricular septal defects

This retrospective study compared the immediate post-operative (first month) and mid-term (up to 5 years post-operation) results of 22 patients with isolated ventricular septal defects who underwent surgical correction with bovine pericardium with 57 similar patients who received a polytetrafluoroethylene (PTFE) patch. There were no cases of early (in the first month) mortality in either group and the 3-month post-operative echocardiographical studies showed no evidence of calcification or aneurysm formation around the patch. Recurrent ventricular septal defects due to dehiscence of the patch occurred in the early follow-up period in four patients who had the PTFE patch but this was not statistically significant. Annual echocardiographical examination revealed some calcification in both groups. We conclude that although there are no significant differences between the two materials in outcome after ventricular septal defects closure, we prefer bovine pericardium because of its handling characteristics, elasticity and the lower risk of endocarditis.

Orthodontic and prosthodontic treatment of ectodermal dysplasia--a case report

In addition to its other symptoms, ectodermal dysplasia causes anodontia and hypodontia intraorally. Partial or total anodontia results in some loss of function, such as chewing, and affects aesthetics. Prosthodontic rehabilitation can be accomplished with fixed, overdenture, complete, or implant-retained prostheses. For rehabilitation, it is crucial to know the age, number and condition of present teeth, and the state of growth of the patient. A 10-year-old male patient who visited our clinic was treated by a multi-disciplinary team of surgeons, orthodontists, and prosthodontists. An overdenture was planned, and an implant-supported prosthesis was considered for when the patient had finished growing. A clasp retained over the denture was planned for prosthetic rehabilitation after considering his growth and the number and condition of his present teeth.

Effect of growth factors, EGF and IGF-I, and estradiol on in vitro maturation of sheep oocytes

The objective of these experiments was to determine the effect of exogenous addition of insulin-like growth factor-I (IGF-I, 100 ng/mL), epidermal growth factor (EGF, 10 ng/mL) and estradiol (E2, 100 ng/mL) to the maturation medium of sheep oocytes on their subsequent development in vitro. Addition of IGF-I to the maturation medium did not improve nuclear or cytoplasmic maturation of sheep oocytes at the concentration tested. However, EGF improved significantly the resumption of meiosis (84% oocytes in metaphase II stage after IVM vs. 59% in medium alone). Cleavage rate and blastocyst development rates were improved (P<0.01) after addition of EGF (60% and 29%, respectively), as compared with maturation in TCM 199 alone (39% and 19%, respectively), but remained lower than rates observed after maturation in complete medium containing follicular fluid (FF, 10%) and FSH (81% and 35%, respectively). No additive effect of EGF over FSH was observed during these experiments. Addition of FF to FSH containing maturation medium improved significantly both cleavage (P<0.001) and blastocyst rates (P<0.05). Addition of E2 to the IVM medium is not required when medium already contains FF. However, in defined conditions supplementation of maturation medium with E2 had a positive effect. These results suggest that EGF, FSH and E2 may play an important role in the nuclear and cytoplasmic maturation of sheep oocytes in vitro.

Effect of GnRH antagonist-induced prolonged follicular phase on follicular atresia and oocyte developmental competence in vitro in superovulated heifers

A GnRH antagonist (Antarelix) was used to suppress endogenous pulsatile secretion of LH and delay the preovulatory LH surge in superovulated heifers to study the effect of a prolonged follicular phase on both follicle and oocyte quality. Oestrous cycles were synchronized in 12 heifers with progestagen (norgestomet) implants for 10 days. On day 4 (day 0 = day of oestrus), heifers were stimulated with 24 mg pFSH for 4 days and luteolysis was induced at day 6 with PGF2 alpha (2 ml Estrumate). Animals in the control group (n = 4) were killed 24 h after the last FSH injection. At this time, heifers in group A36h (n = 4) and group A60h (n = 4) were treated with 1.6 mg of Antarelix every 12 h for 36 and 60 h, respectively, and then killed. After dissection of ovarian follicles, oocytes were collected for individual in vitro maturation, fertilization and culture; follicular fluid was collected for determination of steroid concentrations, and granulosa cells were smeared, fixed and stained for evaluation of pycnosis rates. Granulosa cell smears showed that 90% of follicles were healthy in the control group. In contrast, 36 and 58% of the follicles in group A36h showed signs of early or advanced atresia, respectively, while 90% of the follicles in group A60h showed signs of late atresia. Intrafollicular concentrations of oestradiol decreased (P < 0.0001) from healthy follicles (799.14 +/- 40.65 ng ml-1) to late atretic follicles (3.96 +/- 0.59 ng ml-1). Progesterone concentrations were higher (P < 0.0001) in healthy follicles compared with atretic follicles, irrespective of degree of atresia. Oestradiol:progesterone ratios decreased (P < 0.0001) from healthy (4.58 +/- 0.25) to late atretic follicles (0.07 +/- 0.009). The intrafollicular concentrations of oestradiol and progesterone were significantly higher (P < 0.0001) in the control than in the treated groups. The oestradiol:progesterone ratio was higher (P < 0.0001) in the control (4.55 +/- 0.25) than in the A36h (0.40 +/- 0.05) and A60h (0.07 +/- 0.009) groups. Unexpectedly, the cleavage rate of fertilized oocytes, blastocyst rate and number of cells per blastocyst were not significantly different among control (85%, 41% and 95 +/- 8), A36h (86%, 56% and 93 +/- 5) and A60h (88%, 58% and 79 +/- 4) groups. In addition, there were no significant differences in the blastocyst rates from oocytes derived from healthy (45%), early atretic (54%), advanced atretic (57%) and late atretic follicles (53%). In conclusion, the maintenance of the preovulatory follicles in superovulated heifers with a GnRH antagonist induced more atresia and a decrease in oestradiol and progesterone concentrations. However, the developmental potential in vitro to day 8 of the oocytes recovered from these atretic follicles was not affected.

Effect of GnRH antagonist-induced prolonged follicular phase on follicular atresia and oocyte developmental competence in vitro in superovulated heifers

A GnRH antagonist (Antarelix) was used to suppress endogenous pulsatile secretion of LH and delay the preovulatory LH surge in superovulated heifers to study the effect of a prolonged follicular phase on both follicle and oocyte quality. Oestrous cycles were synchronized in 12 heifers with progestagen (norgestomet) implants for 10 days. On day 4 (day 0 = day of oestrus), heifers were stimulated with 24 mg pFSH for 4 days and luteolysis was induced at day 6 with PGF2 alpha (2 ml Estrumate). Animals in the control group (n = 4) were killed 24 h after the last FSH injection. At this time, heifers in group A36h (n = 4) and group A60h (n = 4) were treated with 1.6 mg of Antarelix every 12 h for 36 and 60 h, respectively, and then killed. After dissection of ovarian follicles, oocytes were collected for individual in vitro maturation, fertilization and culture; follicular fluid was collected for determination of steroid concentrations, and granulosa cells were smeared, fixed and stained for evaluation of pycnosis rates. Granulosa cell smears showed that 90% of follicles were healthy in the control group. In contrast, 36 and 58% of the follicles in group A36h showed signs of early or advanced atresia, respectively, while 90% of the follicles in group A60h showed signs of late atresia. Intrafollicular concentrations of oestradiol decreased (P < 0.0001) from healthy follicles (799.14 +/- 40.65 ng ml-1) to late atretic follicles (3.96 +/- 0.59 ng ml-1). Progesterone concentrations were higher (P < 0.0001) in healthy follicles compared with atretic follicles, irrespective of degree of atresia. Oestradiol:progesterone ratios decreased (P < 0.0001) from healthy (4.58 +/- 0.25) to late atretic follicles (0.07 +/- 0.009). The intrafollicular concentrations of oestradiol and progesterone were significantly higher (P < 0.0001) in the control than in the treated groups. The oestradiol:progesterone ratio was higher (P < 0.0001) in the control (4.55 +/- 0.25) than in the A36h (0.40 +/- 0.05) and A60h (0.07 +/- 0.009) groups. Unexpectedly, the cleavage rate of fertilized oocytes, blastocyst rate and number of cells per blastocyst were not significantly different among control (85%, 41% and 95 +/- 8), A36h (86%, 56% and 93 +/- 5) and A60h (88%, 58% and 79 +/- 4) groups. In addition, there were no significant differences in the blastocyst rates from oocytes derived from healthy (45%), early atretic (54%), advanced atretic (57%) and late atretic follicles (53%). In conclusion, the maintenance of the preovulatory follicles in superovulated heifers with a GnRH antagonist induced more atresia and a decrease in oestradiol and progesterone concentrations. However, the developmental potential in vitro to day 8 of the oocytes recovered from these atretic follicles was not affected.