Systemic immune inflammation index and its implication on in-stent restenosis among patients with acute coronary syndrome

OBJECTIVE

This study aims to assess the predictive value of the Systemic Immune Inflammation Index (SII) in determining in-stent restenosis (ISR) likelihood in patients with acute coronary syndrome (ACS) who have undergone percutaneous coronary intervention (PCI).

METHODS

The study enrolled 903 ACS patients undergoing PCI, categorized into ISR (+) and ISR (-) groups based on control coronary angiography results. Demographic, clinical, laboratory, and angiographic-procedural characteristics were systematically compared.

RESULTS

The ISR (+) group encompassed 264 individuals (29.2%), while the ISR (-) group comprised 639 individuals (70.8%). Patients had a mean age of 55.8 ± 10.2 years, with 69% being male. The ISR (+) group had higher diabetes and smoking prevalence and notably larger stent dimensions. Lab parameters showed significantly elevated creatinine, total cholesterol, red cell distribution width, white blood cell and neutrophil counts, SII index and C-reactive protein (CRP) in the ISR (+) group, while lymphocyte levels were lower. Binary logistic regression identified stent diameter (odds ratio [OR]: 0.598, 95% confidence interval [CI]: 0.383-0.935; P  = 0.024), stent length (OR: 1.166, 95% CI: 1.132-1.200; P  < 0.001), creatinine (OR: 0.366, 95% CI: 0.166-0.771; P  = 0.003), CRP (OR: 1.075, 95% CI: 1.042-1.110; P  = 0.031), and SII index (OR: 1.014, 95% CI: 1.001-1.023; P  < 0.001) as independent ISR predictors.

CONCLUSION

The SII index exhibits potential as a predictive marker for ISR in ACS patients post-PCI, indicating systemic inflammation and heightened restenosis risk. Integrating the SII index into risk models could identify high-risk patients for targeted interventions.

Predictive value of P wave parameters, indices, and a novel electrocardiographic marker for silent cerebral infarction and future cerebrovascular events

BACKGROUND

Silent cerebral infarction (SCI) is a neuronal injury without a clinically apparent stroke or transient ischaemic attack. Left atrial cardiomyopathy is closely associated with SCI. P wave changes in the electrocardiogram (ECG) provide significant information about the development of atrial cardiomyopathy. This study evaluated the role of P wave parameters and indices and a novel ECG parameter in predicting SCI, future cerebrovascular events, and atrial fibrillation/flutter.

MATERIALS AND METHODS

A total of 272 patients were retrospectively screened and divided into two groups according to SCI. Cerebrovascular events and atrial fibrillation/flutter were defined as the study's outcomes. P wave parameters, indices, and a novel ECG parameter called the P wave ratio (PWR) were calculated from ECGs, and the relationship between SCI and outcomes was investigated.

RESULTS

The maximum P wave duration (PWD), P wave dispersion (PWdisp), PWD measured from the D2 lead (PWDD2), P wave peak time measured from the D2 lead (PWPTD2), PWPT measured from the V1 lead (PWPTV1), and P wave terminal force (PWTFV1) were significantly longer in the SCI group. Both partial and advanced inter atrial block (IAB) were significantly high in the SCI group. The novel parameter P wave ratio (PWR) was significantly longer in the SCI group (0.55 ± 0.08 vs. 0.46 ± 0.09; p < 0.001). In multivariate regression analysis, PWdisp (OR: 1.101, p < 0.001), PWPTD2 (OR: 1.095, p = 0.017), and PWR (OR: 1.231, p < 0.001) were found to be independent predictors of SCI. Cox regression analysis revealed that the PWR (HR 1.077; 95% CI 1.029-1.128; p = 0.001) was associated with cerebrovascular events and atrial fibrillation/flutter.

CONCLUSION

In our study, we observed that PWR could be a valuable parameter for predicting SCI and future cerebrovascular events.

Relationship between platelet mass index and postoperative atrial fibrillation after elective coronary artery bypass surgery: a retrospective study

BACKGROUND

Atrial fibrillation (AF) is the most common complication after cardiac surgery. The pathogenesis of postoperative atrial fibrillation (POAF) is multifactorial and one of the known factors is inflammation. Platelet mass index (PMI) is an indicator of platelet activation and a better inflammatory marker than mean platelet volume (MPV). In this retrospective study, we investigated the relationship between POAF and PMI.

METHODS

The study included 848 consecutive patients (655 male and 193 female) who had elective isolated coronary artery by-pass grafting (CABG) or combined CABG and valvular surgery. Platelet count and MPV were measured from preoperative blood samples to calculate PMI. Post-operative atrial fibrillation was defined as irregular and fibrillatory P waves occurring 48-96 h after cardiac surgery and lasting at least 30 s. The PMI values in patients who developed POAF were compared with those in patients who did not develop POAF.

RESULTS

Patients who developed POAF had higher PMI values (2549.3 ± 1077.1) when compared with patients in sinus rhythm (2248.1 ± 683.4; p < 0.01). In multivariate regression analysis, age (OR: 1.05; 95% CI: 1.02-1.09; p = 0.01), left atrial diameter (OR: 1.05; 95% CI: 1.03-1.09; p = 0.02), hs-CRP (OR: 1.09; 95%CI: 1.05-1.13; p < 0.01), EuroSCORE II (OR: 1.27; 95% CI: 1.14-1.41; p < 0.01), and PMI (OR: 1.01; 95% CI: 1.001-1.02; p < 0.01) were independent predictors of POAF. In ROC analysis, PMI ≥ 2286 predicted POAF development with a sensitivity of 69% and a specificity of 58% (AUC: 0.66; p < 0.01) CONCLUSION: A significant relationship was found between preoperatively calculated PMI and POAF. We showed that PMI may be used to predict patients who are at high risk of developing POAF.

Cardiovascular surgery during the first wave of COVID-19 pandemic

Background

In this study, we aimed to evaluate primary outcomes and main characteristics of emergency and elective/urgent cardiovascular surgeries which were performed in the first three months of the novel coronavirus disease 2019 (COVID-19) pandemic in our center.

Methods

Between March 11th, 2020 and June 11th, 2020, a total of 209 patients (44 males, 165 females; mean age: 57.3±12.8 years; range, 20 to 80 years) who underwent emergency or elective/urgent surgery with cardiovascular pathologies were retrospectively analyzed. The patients were classified as emergency and elective/urgent according to the level of necessity of the surgical procedure at the time of hospital admission. Pre-, intra-, and postoperative data of the patients were recorded.

Results

During the study period, 156 elective/urgent and 74 emergency cardiovascular surgeries were performed. Six COVID-19 (+) patients were operated emergently. The number of acute aortic dissection and peripheral vascular surgery was higher in the emergency group (p<0.05). Two patients who were COVID-19 (-) preoperatively became COVID-19 (+) in the postoperative period. In these patients, acute respiratory distress syndrome developed, and extracorporeal membrane oxygenation support was needed. Four patients who needed post-cardiotomy extracorporeal membrane oxygenation support due to low cardiac output were COVID-19 (-) both in the pre- and postoperative periods. The overall in-hospital mortality rate was 9.1%.

Conclusion

Even during pandemic such as COVID-19, referral centers with experienced personnel can provide non-pandemic healthcare with a quality close to the daily routine.

Extracellular Matrix Collagen Biomarker Levels in Patients who Underwent Pulmonary Endarterectomy

OBJECTIVE

The role of extracellular matrix collagen biomarkers in chronic thromboembolic pulmonary hypertension is not well known. Our aim is to investigate the matrix metalloproteinase-2 and -9 protein levels in patients with chronic thromboembolic pulmonary hypertension.

MATERIALS AND METHODS

This is a prospective and cross-sectional study. Patients with chronic thromboembolic pulmonary hypertension who underwent pulmonary endarterectomy (Group 1) and the control group included patients who underwent lung surgery without pulmonary hypertension (Group 2) between March 2020 and March 2021. In addition to serum levels of matrix metalloproteinase-9, the pulmonary endarterectomy and control pulmonary artery tissue samples were measured by ELISA 4pl, cubic, quadratic and western blot techniques. Levels of matrix metalloproteinase-2 which consist of pro matrix metalloproteinase-2/ß-actin and active matrix metalloproteinase-2/ß-actin and matrix metalloproteinase-9/ß-actin were measured only in the tissue samples.

RESULTS

Forty eight patients were enrolled consecutively in Group 1 (n: 24) and Group 2 (n: 24). The serum concentrations of matrix metalloproteinase-9 were similar in both groups. Similarly, in comparison of tissue sample levels of pro matrix metalloproteinase-2/ß-actin (p: 0.496) and active matrix metalloproteinase-2/ß-actin (p: 0.216) no significant difference was found between the groups. Chronic thromboembolic pulmonary hypertension patients had significantly lower tissue samples of matrix metalloproteinase-9/ß-actin compared to the control group (p: 0.001).

CONCLUSION

This study indicates that serum levels of extracellular matrix collagen biomarkers were similar in patients with chronic thromboembolic pulmonary hypertension who candidates for surgery and non-pulmonary hypertension patients are who undergo lung surgery. Differences in levels of matrix metalloproteinase-9/ß-actin in tissue samples may play a role in pulmonary vascular remodeling in operable patients.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04773028.

Association of Uric Acid Albumin Ratio with Recurrence of Atrial Fibrillation after Cryoballoon Catheter Ablation

Objective: Despite improvements in the technology of catheter ablation of atrial fibrillation (AF), recurrences are still a major problem, even after a successful procedure. The uric acid/albumin ratio (UAR), which is an inexpensive and simple laboratory parameter, has recently been introduced in the literature as a predictor of adverse cardiovascular events. Hence, we aimed to investigate the relationship between the UAR and AF recurrence after catheter ablation. Methods: A total of 170 patients who underwent successful catheter ablation for AF were included. The primary outcome was the late recurrence after treatment. The recurrence (+) and recurrence (−) groups were compared for clinical, laboratory and procedural characteristics as well as the predictors of recurrence assessed by regression analysis. Results: In our study population, 53 (26%) patients developed AF recurrence after catheter ablation. Mean UAR was higher in the recurrence (+) group compared to recurrence (−) group (2.4 ± 0.9 vs. 1.8 ± 0.7, p < 0.01). In multivariable regression analysis, left atrial diameter (HR: 1.08, 95% CI: 1.01−1.16, p = 0.01) and UAR (HR:1.36, 95% CI: 1.06−1.75, p = 0.01) were found to be independent predictors of recurrence. In ROC analysis, the UAR > 1.67 predicted recurrence with a sensitivity of 77% and a specificity of 57% (AUC 0.68, p < 0.01). Conclusion: For the first time in the literature, the UAR were found to be correlated independently with AF recurrence after catheter ablation.

Relation between CRP-Albumin ratio and left atrial volume index for prediction of new onset atrial fibrillation in patients with STEMI treated with percutaneous coronary interventions

New onset atrial fibrillation (NOAF) in the case of acute myocardial infarction appears to be associated with inflammation. However, its influence alongside other risk factors is currently unknown. In this study, the effect of inflammation in predicting NOAF independent of left atrial volume index (LAVi) was investigated with a new marker, the C-reactive protein/Albumin ratio (CAR). We included 945 ST-elevation myocardial infarction (STEMI) patients who underwent pPCI. Two groups were defined according to the presence of NOAF and the groups were compared for demographic, clinical and angiographic findings. Predictors of the NOAF were assessed by multivariable regression analysis. Fifty-five (5.8%) patients had NOAF after the procedures. CAR was substantially higher in patients with NOAF (5.9 [4.9] vs 0.46 [1] p<0.01). CAR was shown as an independent marker for NOAF (OR:1.19 95% CI: 1.11-1.27 p<0.01) development in multivariable regression analysis. In receiver operating curve characteristics, the sensitivity and the specificity of the value CAR>4.2 were 64% and 81% (AUC: 0.86) respectively. In subgroup analysis, OR of CAR in LAVi ≥26.7 ml/m² was 19.5 and 22.1 in LAVi<26.7 ml/m² (p for interaction=0.02). A novel inflammatory marker, CAR has the potential to predict the development of NOAF regardless of LAVi in patients with STEMI treated by PPCI.

Prognostic Significance of Controlling Nutritional Status Score (CONUT) in Patients Undergoing Pericardiocentesis

BACKGROUND

Malnutrition is associated with a poor prognosis in cardiovascular diseases, however the prognostic impact of the Controlling Nutritional Status (CONUT) score in patients with pericardial effusion (PE) is not known.

METHODS

This was a retrospective study conducted among 301 consecutive patients with PE who underwent pericardiocentesis. CONUT score was calculated from serum albumin level, total cholesterol level and lymphocyte count. The prognostic role of admission CONUT score on long-term mortality was evaluated.

RESULTS

The patients were divided into two groups according to long-term mortality. A total of 131 patients died during follow-up. In multivariable regression analysis, chronic heart failure [hazard ratio (HR): 3.21, 95% confidence interval (CI): 1.18-8.70, p < 0.01], malignancy (HR: 5.67, 95% CI: 3.34-9.63, p < 0.01) and CONUT score (HR: 1.21, 95% CI: 1.10-1.33, p < 0.01) were found to be independent predictors of long-term mortality. CONUT score was significantly higher in the patients who died (5.8 ± 2.4 vs. 3.6 ± 2.2, p < 0.01). In receiver operating characteristics analysis, a CONUT score ≥ 4.5 predicted long-term mortality with 66% sensitivity and 69% specificity (area under curve: 0.73, 95% CI: 0.67-0.79, p < 0.01).

CONCLUSIONS

In patients with PE, CONUT score is an independent prognostic factor for mortality.

Prognostic performance of Controlling Nutritional Status score in patients with ST segment elevation myocardial infarction treated with primary percutaneous coronary intervention

OBJECTIVE

The effect of malnutrition in patients with ST segment elevation myocardial infarction (STEMI) is not fully understood. In this study, we tried to investigate the prognostic consequence of the Controlling Nutritional Status (CONUT) score in patients with STEMI.

METHODS

In this study, we evaluated the CONUT scores of 1,028 patients with STEMI and examined its relationship with major adverse cardiovascular events (MACE) (all-cause mortality, myocardial reinfarction, and vessel revascularization) during a period of 19.9±10.3 months. Patients with CONUT score ≥5 were defined as severely malnourished. Predictors of MACE were assessed by Cox regression analysis, and p<0.05 was considered to indicate statistical significance.

RESULTS

MACE was observed in a total of 147 (14.3%) patients. MACE was more frequent in the group with a higher CONUT score (33.3% vs. 10.9%, p<0.001). CONUT score ≥5 was an independent predictor of MACE in the Cox regression analysis (hazard ratio=2.50, 95% confidence interval: 1.61-3.90, p<0.001). Low ejection fraction, Killip class ≥3 at presentation, thrombolysis in myocardial infarction flow grade <3 after intervention, left main artery involvement, and low hemoglobin levels were other independent predictors of MACE in the long-term follow-up. Kaplan-Meier curves showed decreased MACE free survival rates in the high CONUT score group at a mean 19.9±10.3 months' follow-up duration (log-rank p<0.01).

CONCLUSION

Malnutrition was strongly associated with poor outcomes in patients with STEMI treated using primary percutaneous coronary intervention.

Is There Any Role of Pulmonary Endarterectomy in Pulmonary Arterial Hydatidosis?

BACKGROUND

Hydatid Cyst is a zoonosis caused by Echinococcus granulosis. Pulmonary artery involvement is a rare condition. The aim of this study was to review our experience in the surgical treatment of pulmonary arterial hydatidosis.

METHODS

Data were collected prospectively for consecutive patients who underwent pulmonary endarterectomy and had a diagnosis of hydatidosis at or after surgery.

RESULTS

Eight patients (two male, six female, mean age, 31.25±13.68 years) with hydatidosis were defined. Only one patient presented with hemoptysis, while the rest of the patients reported exertional dyspnea as their main symptom. Cardiac hydatidosis associated with pulmonary arterial involvement was noted in one patient. The mean time interval for duration of disease was 12±24.29 months before PEA. Mortality was observed in two patients due to massive hemoptysis in one and right heart failure in one. No anaphylactic reaction was observed. Significant difference was detected in mean pulmonary vascular resistance as decline from 442.38±474.20 to 357.25±285.34 dyn/s/cm^-5 following surgery (p: 0.011). Two patients had recurrence of the disease following a median follow-up of 9.1 months All survivors improved to New York Heart Association functional class I and II.

CONCLUSIONS

Pulmonary arterial hydatidosis may mimic chronic thromboembolic pulmonary hypertension and these patients can be diagnosed with pulmonary endarterectomy. Surgery may be a therapeutic option for patients who do not respond to medical therapy if the cystic lesions are surgically accessible. Pulmonary endarterectomy should be performed only in expert centers because of the high risk of perioperative morbidity, mortality, and postoperative recurrence.

Terapia Trombolítica em Octogenários com Embolia Pulmonar Aguda

Fundamento

Apesar da grande proporção de octogenários com embolia pulmonar aguda, há pouca informação indicando a estratégia de manejo ideal, especialmente medidas terapêuticas, como a terapia lítica.

Objetivos

O número de pacientes idosos diagnosticados com embolia pulmonar aguda aumenta constantemente. Porém, o papel do tratamento trombolítico não está claramente definido entre os octogenários. Nosso objetivo é avaliar a efetividade da terapia lítica em pacientes octogenários diagnosticados com embolia pulmonar.

Métodos

Cento e quarenta e oito indivíduos (70,3% de mulheres, n=104) com mais de 80 anos foram incluídos no estudo. Os pacientes foram divididos em dois grupos: tratamento trombolítico versus não-trombolítico. As taxas de mortalidade hospitalar e episódios de sangramento foram definidos como desfechos do estudo. Valor de p <0,05 foi considerado como estatisticamente significativo.

Resultados

A mortalidade hospitalar reduziu significativamente no grupo trombolítico em comparação ao não-trombolítico (10,5% vs. 24,2%; p=0,03). Episódios de sangramento menores foram mais comuns no braço que recebeu o tratamento trombolítico, mas grandes hemorragias não diferiram entre os grupos (35,1% vs. 13,2%, p<0,01; 7% vs. 5,5% p=0,71, respectivamente). O escore de PESI alto (OR: 1,03 IC95%; 1,01-1,04 p<0,01), a terapia trombolítica (OR: 0,15 IC95%; 0,01-0,25, p< 0,01) e níveis altos de troponina (OR: 1,20 IC95%; 1,01-1,43, p=0,03) estiveram independentemente associados a taxas de mortalidade hospitalar na análise de regressão multivariada.

Conclusão

A terapia trombolítica esteve associada à mortalidade hospitalar reduzida em detrimento do aumento geral das complicações de sangramento em octogenários.

Multimodal Approach of Isolated Pulmonary Vasculitis: A Single-Institution Experience

BACKGROUND

Isolated pulmonary vasculitis (IPV) is a single-organ vasculitis of unknown etiology and may mimic chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this study was to review our clinical experience with pulmonary endarterectomy in patients with CTEPH secondary to IPV.

METHODS

Data were collected prospectively for consecutive patients who underwent pulmonary endarterectomy and had a diagnosis of IPV at or after surgery.

RESULTS

We identified nine patients (six female, median age 48 (23-55) years) with IPV. The diagnosis was confirmed after histopathological examination of all surgical materials. The mean duration of disease before surgery was 88.0 ±70.2 months. Exercise-induced dyspnea was the presenting symptom in all patients. Pulmonary endarterectomy was bilateral in six patients and unilateral in three. No mortality was observed, however, one patient had pulmonary artery stenosis and stent implantation was performed. All patients received immunosuppressive therapies after surgery. Mean pulmonary artery pressure decreased significantly from 30(19-67) mm Hg to 21(15-49) mm Hg after surgery (p <0.05). Pulmonary vascular resistance also improved significantly from 270 (160-1600) to 153 (94-548) dyn/s/cm^-5 (p<0.05). After a median follow-up of 41 months, all but one patient had improved to the New York Heart Association functional class I.

CONCLUSIONS

Isolated pulmonary vasculitis can mimic CTEPH, and these patients can be diagnosed with pulmonary endarterectomy. Furthermore, surgery has not only diagnostic but also therapeutic value for IPV when stenotic and/or thrombotic lesions are surgically accessible. A multidisciplinary experienced CTEPH team is critical for management of these unique patients.

Performance of neutrophil to lymphocyte ratio for the prediction of long-term morbidity and mortality in coronary slow flow phenomenon patients presented with non-ST segment elevation acute coronary syndrome

Introduction: In this study, we aimed to determine if neutrophil to lymphocyte ratio could predict long term morbidity and mortality in patients who hospitalized for non-ST segment elevation acute coronary syndrome (NSTE-ACS) and had coronary slow flow on coronary angiography.

Methods: In this observational study, 111 patients who presented with NSTE-ACS and diagnosed with coronary slow flow phenomenon on angiographic examination were included. Neutrophil to lymphocyte ratio (NLR) calculated as the ratio of the number of neutrophils to the number of lymphocytes. Patients classified into three groups according to NLR values. The term coronary slow flow phenomenon was depicted by calculating Thrombolysis in Myocardial Infarction frame count.Patients were followed up and the occurrence of recurrent angina, recurrent myocardial infarction, and long-term mortality was determined using medical records, phone calls, or face-to-face interviews. P values <0.05 considered to indicate statistical significance.

Results: Recurrent angina and myocardial infarction occurred more frequently in the highest NLR tertile compared with middle and lowest NLR tertiles. High NLR group (NLR≥ 3.88 n=38) was significantly associated with younger age and smoking status. WBC, troponin I and CRP levels increased as the NLR tertile increased. Recurrent myocardial infarction and angina showed strong relationship with increasing NLR values. In multivariate regression analyses smoking and high NLR levels were independent predictors of recurrent myocardial infarction (HR:4.64 95%CI 0.95-22.52 P=0.04, HR: 1.48 95%CI 1.16-1.90 P<0.01 respectively) in the long term follow up.

Conclusion: Our study demonstrated that high NLR values can be a valuable prognostic tool in the long term follow up of patients who presented with NSTE-ACS and diagnosed with slow flow phenomenon on coronary angiography.

A Blockchain-Based Authentication Protocol for Cooperative Vehicular Ad Hoc Network

The efficiency of cooperative communication protocols to increase the reliability and range of transmission for Vehicular Ad hoc Network (VANET) is proven, but identity verification and communication security are required to be ensured. Though it is difficult to maintain strong network connections between vehicles because of there high mobility, with the help of cooperative communication, it is possible to increase the communication efficiency, minimise delay, packet loss, and Packet Dropping Rate (PDR). However, cooperating with unknown or unauthorized vehicles could result in information theft, privacy leakage, vulnerable to different security attacks, etc. In this paper, a blockchain based secure and privacy preserving authentication protocol is proposed for the Internet of Vehicles (IoV). Blockchain is utilized to store and manage the authentication information in a distributed and decentralized environment and developed on the Ethereum platform that uses a digital signature algorithm to ensure confidentiality, non-repudiation, integrity, and preserving the privacy of the IoVs. For optimized communication, transmitted services are categorized into emergency and optional services. Similarly, to optimize the performance of the authentication process, IoVs are categorized as emergency and general IoVs. The proposed cooperative protocol is validated by numerical analyses which show that the protocol successfully increases the system throughput and decreases PDR and delay. On the other hand, the authentication protocol requires minimum storage as well as generates low computational overhead that is suitable for the IoVs with limited computer resources.

Injectable, self-healing mesoporous silica nanocomposite hydrogels with improved mechanical properties

Self-healing hydrogels have emerged as promising biomaterials in regenerative medicine applications. However, an ongoing challenge is to create hydrogels that combine rapid self-healing with high mechanical strength to make them applicable to a wider range of organs/tissues. Incorporating nanoparticles within hydrogels is a popular strategy to improve the mechanical properties as well as to provide additional functionalities such as stimuli responsiveness or controlled drug delivery, further optimizing their use. In this context, mesoporous silica nanoparticles (MSNs) are promising candidates as they are bioactive, improve mechanical properties, and can controllably release various types of cargo. While commonly nanoparticles are added to hydrogels as filler component, in the current study we developed thiol surface-functionalized MSNs capable of acting as chemical crosslinkers with a known hydrophilic polymer, polyethylene glycol (PEG), through dynamic thiol-disulfide covalent interactions. Due to these dynamic exchange reactions, mechanically strong nanocomposites with a storage modulus of up to 32 ± 5 kPa compared to 1.3 ± 0.3 kPa for PEG hydrogels alone, with rapid self-healing capabilities, could be formed. When non-surface modified MSNs were used, the increase in storage modulus of the hydrogels was significantly lower (3.4 ± 0.7 kPa). In addition, the nanocomposites were shown to degrade slowly over 6 weeks upon exposure to glutathione while remaining intact at physiological conditions. Together, the data argue that creating nanocomposites using MSNs as dynamic crosslinkers is a promising strategy to confer mechanical strength and rapid self-healing capabilities to hydrogels. This approach offers new possibilities for creating multifunctional self-healing biomaterials for a wider range of applications in regenerative medicine.

Sleep-wake stage detection with single channel ECG and hybrid machine learning model in patients with obstructive sleep apnea

Sleep staging is an important step in the diagnosis of obstructive sleep apnea (OSA) and this step is performed by a physician who visually scores the electroencephalography, electrooculography and electromyography signals taken by the polysomnography (PSG) device. The PSG records must be taken by a technician in a hospital environment, this may suggest a drawback. This study aims to develop a new method based on hybrid machine learning with single-channel ECG for sleep-wake detection, which is an alternative to the sleep staging procedure used in hospitals today. For this purpose, the heart rate variability signal was derived using electrocardiography (ECG) signals of 10 OSA patients. Then, QRS components in different frequency bands were obtained from the ECG signal by digital filtering. In this way, nine more signals were obtained in total. 25 features from each of the 9 signals, a total of 225 features have been extracted. Fisher feature selection algorithm and principal component analysis were used to reduce the number of features. Finally, features were classified with decision tree, support vector machines, k-nearest neighborhood algorithm and ensemble classifiers. In addition, the proposed model has been checked with the leave one out method. At the end of the study, it was shown that sleep-wake detection can be performed with 81.35% accuracy with only three features and 87.12% accuracy with 10 features. The sensitivity and specificity values for the 3 features were 0.85 and 0.77, and for 10 features the sensitivity and specificity values were 0.90 and 0.85 respectively. These results suggested that the proposed model could be used to detect sleep-wake stages during the OSA diagnostic process.

Association of digoxin therapy with case fatality rate in acute pulmonary embolism

OBJECTIVE

Despite wide usage of digoxin for various diseases in cardiology practice, its benefit is controversial and moreover it had been associated with unfavorable outcomes in some previous studies. The aim of this present study was to demonstrate whether digoxin usage was related with worse outcomes or not in patients with acute pulmonary embolisms.

METHODS

A total number of 1215 patients retrospectively enrolled for the study. Basic demographic features, pulmonary embolism severity index (PESI) scores, laboratory parameters and medications of patients who had been diagnosed with acute pulmonary embolism were recorded. Short (30 days) and long-term mortality were reported as the clinical outcomes.

RESULTS

Total mortality was 15.4% in the study population and 78 of these subjects died within the first 30 days. The frequency of digoxin treatment was 8% and most of these patients were prior users. According to the binary logistic regression analyses the PESI score, right ventricle (RV) diastolic diameter, systolic pulmonary arterial pressure (sPAP), brain natriuretic peptide (BNP), troponin and digoxin therapy (odds ratio, OR: 2.82 95% confidence interval, CI: 1.39-8.31, P = 0.03) were found as independent predictors of short-term mortality. Beside these findings; sPAP, PESI score, RV diastolic diameter and digoxin therapy (hazard ratio, HR: 2.11 95%CI: 1.22-7.31, P = 0.03) were determined as independent predictors of long-term mortality in Cox regression analyses. In subgroup analysis, we determined significantly greater increase in short-term mortality with use of digoxin among patients who had chronic renal disease, among patients under thrombolytic therapy and under high dosage of digoxin therapy and among female patients.

CONCLUSION

Digoxin has been used extensively for decades in the treatment of heart failure and arrhythmias despite some controversies over its benefit. For the first time in the literature, we have demonstrated independent association of digoxin therapy with short-term and long-term mortality in patients with acute pulmonary embolism.

Modified SAMe-TT2R2 score for predicting the therapeutic range of digoxin

BACKGROUND

Digoxin treatment has come under scrutiny in recent years after reports from several studies that it is associated with increased mortality in patients with atrial fibrillation (AF). The clinical effects of digoxin on mortality were closely related to serum digoxin concentrations (SDC) in these studies. In the present work, we evaluated the role of the SAMe-TT₂R₂ and modified SAMe-TT₂R₂ scores in predicting the therapeutic range of digoxin therapy.

METHODS

Medical records from our institution were screened for patients who were under digoxin treatment between 2008 and 2018. A total of 2418 patients for whom SDC were recorded were included in the study. An SDC of <0.5 or >1.2 ng/ml was defined as being out of the therapeutic range (oTR).

RESULTS

In multivariable regression analyses, abnormal body mass index (odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.29-1.95, p < 0.01), white blood cell count (OR: 1.12, 95% CI: 1.01-1.27, p < 0.01), and the modified SAMe-TT₂R₂ score (OR: 4.19 95% CI: 3.71-4.72, p < 0.01) were determined to be independent predictors of oTR. A modified SAMe-TT₂R₂ score greater than 3 predicted oTR with a sensitivity of 86% and a specificity of 65% (AUC: 0.825, p < 0.01).

CONCLUSION

Digoxin is still widely used in the treatment of heart failure and AF despite concerns about the increased risk of mortality when levels are oTR. In the present study, the modified SAMe-TT₂R₂ score was found to be an independent predictor of oTR. This score may aid clinicians in identifying patients who are more likely to benefit from digoxin therapy.

Ethnic differences in bone geometry between White, Black and South Asian men in the UK

Relatively little is known about the bone health of ethnic groups within the UK and data are largely restricted to women. The aim of this study was to investigate ethnic differences in areal bone mineral density (aBMD), volumetric bone mineral density (vBMD), bone geometry and strength in UK men. White European, Black Afro-Caribbean and South Asian men aged over 40years were recruited from Greater Manchester, UK. aBMD at the spine, hip, femoral neck and whole body were measured by DXA. Bone geometry, strength and vBMD were measured at the radius and tibia using pQCT at the metaphysis (4%) and diaphysis (50% radius; 38% tibia) sites. Adjustments were made for age, weight and height. Black men had higher aBMD at the whole body, total hip and femoral neck compared to White and South Asian men independent of body size adjustments, with no differences between the latter two groups. White men had longer hip axis lengths than both Black and South Asian men. There were fewer differences in vBMD but White men had significantly lower cortical vBMD at the tibial diaphysis than Black and South Asian men (p<0.001). At the tibia and radius diaphysis, Black men had larger bones with thicker cortices and greater bending strength than the other groups. There were fewer differences between White and South Asian men. At the metaphysis, South Asian men had smaller bones (p=0.02) and lower trabecular vBMD at the tibia (p=0.003). At the diaphysis, after size-correction, South Asian men had similar sized bones but thinner cortices than White men; measures of strength were not broadly reduced in the South Asian men. Combining pQCT and DXA measurements has given insight into differences in bone phenotype in men from different ethnic backgrounds. Understanding such differences is important in understanding the aetiology of male osteoporosis.

Neurologic outcome in patients with cardiac arrest complicating ST elevation myocardial infarction treated by mild therapeutic hypothermia: The experience of a tertiary institution

OBJECTIVE

Therapeutic hypothermia improves neurologic prognosis after cardiac arrest. The aim of this study was to report clinical experience with intravascular method of cooling in patients with cardiac arrest resulting from ST-segment elevation myocardial infarction (STEMI).

METHODS

Thirteen patients (11 male, 2 famele; mean age was 39.6±9.4 years) who had undergone mild therapeutic hypothermia (MTH) by intravascular cooling after cardiac arrest due to STEMI were included. Clinical, demographic, and procedural data were analyzed. Neurologic outcome was assessed by Cerebral Performance Category (CPC) score.

RESULTS

Anterior STEMI was observed in 9 patients. One patient died of cardiogenic shock complicating STEMI. Mean cardiopulmonary resuscitation (CPR) duration and door-to-invasive cooling were 32.9±20.1 and 286.1±182.3 minutes, respectively. Precooling Glasgow Coma Scale score was 3 in 9 subjects. Twelve patients were discharged, 11 with CPC scores of 1 at 1-year follow-up. No major complication related to procedure was observed.

CONCLUSION

In comatose survivors of STEMI, therapeutic hypothermia by intravascular method is a feasible and safe treatment modality.

Can the T-peak to T-end interval be a predictor of mortality in patients with ST-elevation myocardial infarction?

BACKGROUND

The interval between the peak and the end of the T wave (Tp-e interval) on 12-lead ECG is a measure of transmural dispersion of repolarization and may be related to malignant ventricular arrhythmias. The objective of this study was to investigate whether the Tp-e interval predicts in-hospital and long-term mortality in patients with ST-segment elevation myocardial infarction (STEMI) undergoing a primary percutaneous coronary intervention (pPCI).

METHODS

This study included 488 consecutive patients with STEMI treated with pPCI. Electrocardiograms were obtained after pPCI and the Tp-e interval was measured in leads without ST-segment elevation.

RESULTS

There were 46 (9.4%) deaths in the population, with a mean follow-up time of 21.1±10.2 months. The Tp-e interval was associated with not only in-hospital ventricular tachycardia/fibrillation, target vessel revascularization, and death but also long-term target vessel revascularization and death. Furthermore, the Tp-e interval measured using the tail method was found to be a significant predictor of long-term mortality in multivariable Cox analyses [odds ratio 1.018, 95% confidence interval (1.004-1.033)]. Findings were similar in the Tp-e interval and the heart rate-corrected Tp-e interval (cTp-e).

CONCLUSION

Tp-e and cTp-e measured using the tail method were found to be predictors of both in-hospital and long-term mortality.

Echo-guided pericardiocentesis in patients with clinically significant pericardial effusion. Outcomes over a 10-year period

BACKGROUND

The purpose of the present study is to evaluate current echocardiographically (echo)-guided pericardiocentesis practice with regard to procedural success, complication rate, etiological causes, and outcomes of patients with clinically significant pericardial effusion.

PATIENTS AND METHODS

Patients who underwent echo-guided pericardiocentesis between January 2004 and February 2014 were identified using an institutional code for the procedure. Other complementary data were obtained by interviewing patients or their relatives (directly or by telephone) and by searching the social security death index.

RESULTS

A total of 301 patients were identified. The pericardium was approached via the subcostal (85 %) or apical (15 %) route under echo guidance in all procedures. The success rate was 97 %, with an intervention-requiring complication rate of 1.3 %. No patient died from complications. The most common etiology was malignancy (n = 84, 28 %). Patients were followed-up for a median of 35 months. Median survival for patients with malignant effusion was 5.9 months compared with 54 months for those with nonmalignant effusion.

CONCLUSIONS

Echo-guided pericardiocentesis has a high success and low complication rate in current practice. Among etiologies, malignancy remains the most common cause of clinically significant pericardial effusion and is associated with a poor prognosis.

Neuropeptide y attenuates stress-induced bone loss through suppression of noradrenaline circuits

Chronic stress and depression have adverse consequences on many organ systems, including the skeleton, but the mechanisms underlying stress-induced bone loss remain unclear. Here we demonstrate that neuropeptide Y (NPY), centrally and peripherally, plays a critical role in protecting against stress-induced bone loss. Mice lacking the anxiolytic factor NPY exhibit more anxious behavior and elevated corticosterone levels. Additionally, following a 6-week restraint, or cold-stress protocol, Npy-null mice exhibit three-fold greater bone loss compared to wild-type mice, owing to suppression of osteoblast activity. This stress-protective NPY pathway acts specifically through Y2 receptors. Centrally, Y2 receptors suppress corticotropin-releasing factor expression and inhibit activation of noradrenergic neurons in the paraventricular nucleus. In the periphery, they act to control noradrenaline release from sympathetic neurons. Specific deletion of arcuate Y2 receptors recapitulates the Npy-null stress response, coincident with elevated serum noradrenaline. Importantly, specific reintroduction of NPY solely in noradrenergic neurons of otherwise Npy-null mice blocks the increase in circulating noradrenaline and the stress-induced bone loss. Thus, NPY protects against excessive stress-induced bone loss, through Y2 receptor-mediated modulation of central and peripheral noradrenergic neurons.

Anaphylactic shock associated with intravenous amiodarone

A 64-year-old woman was admitted to our emergency department with shortness of breath and palpitation which started 2 h before her admission. She had a history of rheumatic mitral valve disease and was on drug treatment with warfarin and metoprolol. The patient was orthopneic, blood pressure was 108/68 mmHg with an irregular pulse with a heart rate of 158 beats per minute, and respiratory rate was 23 times per minute. Her electrocardiogram was consistent with atrial fibrillation with rapid ventricular response. For pharmacological cardioversion the patient was given amiodarone intravenous loading dose of 300 mg in 30 min. After 10 min of infusion the patient complained of pruritus and skin rash consistent with urticaria. At the same time the patient had dyspnea and bronchoconstriction was noted on both lung fields. The blood pressure was measured as 64/40 mmHg. The patient was taken to intensive care unit and supportive treatment for anaphylactic shock was given. Amiodarone is a class III antiarrhythmic agent frequently used in the management of atrial fibrillation. This potentially fatal complication of amiodarone should be kept in mind by clinicians and before administration patients should be questioned about previous allergic reactions including previous iodine or iodinated contrast media. Alternative agents should be considered in these conditions. <Learning objective: Anaphylactic shock is a rare complication of amiodarone and it is a commonly used drug. This potentially fatal complication of amiodarone should be kept in mind by clinicians.>.

Neuropeptide Y mediates the short-term hypometabolic effect of estrogen deficiency in mice

BACKGROUND

Estrogen deficiency increases body weight or total and central adiposity and decreases energy expenditure. Hypothalamic neuropeptide Y (NPY) expression is altered by estrogen deficiency in rodents, but the long-term consequences on energy homeostasis are unknown.

OBJECTIVE

To investigate the role of NPY in the changes in energy expenditure and physical activity, as well as the associated changes in body weight and composition in response to short-term and long-term estrogen deficiency.

DESIGN

Sham and ovariectomy (OVX) operations were performed at 8 weeks of age in wild-type (WT) and NPY(-/-) mice. Energy expenditure, physical activity, body composition and weight, as well as food intake were measured at 10-18 days (short-term) and 46-54 days (long-term) after OVX.

RESULTS

OVX influences energy homeostasis differently at early compared with later time-points. At the early but not the late time point, OVX in WT mice reduced oxygen consumption and energy expenditure and tended to reduce resting metabolic rate. Interestingly, these effects of short-term estrogen deficiency were ablated by NPY deletion, with NPY(-/-) mice exhibiting significant increases in energy expenditure and resting metabolic rate. In addition to these hypermetabolic effects, OVX NPY(-/-) mice exhibited significantly lower body weight and whole-body fat mass relative to OVX WT controls at the short-term but not the long-term time point. Food intake and physical activity were unaltered by OVX, but NPY(-/-) mice exhibited significant reductions in these parameters relative to WT.

CONCLUSION

The effects of estrogen deficiency to reduce energy metabolism are transient, and NPY is critical to this effect as well as the early OVX-induced obesity.

Chronic treatment with simvastatin upregulates muscarinic M1/4 receptor binding in the rat brain

Statins are increasingly being used for the treatment of a variety of conditions beyond their original indication for cholesterol lowering. We previously reported that simvastatin affected the dopaminergic system in the rat brain. This study aims to investigate regional changes of muscarinic M1/4 receptors in the rat brain after 4-week administration of simvastatin (1 or 10 mg/kg/day). M1/4 receptor distribution and alterations in the post-mortem rat brain were detected by [(3)H]pirenzepine binding autoradiography. Simvastatin (1 mg/kg/day) increased [(3)H]pirenzepine binding, predominantly in the prefrontal cortex (171%, P<0.001), primary motor cortex (153%, P=0.001), cingulate cortex (109%, P<0.001), hippocampus (138%, P<0.001), caudate putamen (122%, P=0.002) and nucleus accumbens (170%, P<0.001) compared with controls; while lower but still significant increases of [(3)H]pirenzepine binding were observed in the examined regions following simvastatin (10 mg/kg/day) treatment. Our results also provide strong evidence that chronic simvastatin administration, especially at a low dosage, up-regulates M1/4 receptor binding, which is likely to be independent of its muscarinic agonist-like effect. Alterations in [(3)H]pirenzepine binding in the examined brain areas may represent the specific regions that mediate the clinical effects of simvastatin treatment on cognition and memory via the muscarinic cholinergic system. These findings contribute to a better understanding of the critical roles of simvastatin in treating neurodegenerative disorders, via muscarinic receptors.

Asymptomatic neonatal cholelithiasis

Cholelithiasis in neonates and infants has been rarely reported. With the current widespread use of diagnostic ultrasonography, more neonates may be found with gallstones and common bile duct stones. We describe a case of asymptomatic gallstones detected incidentally at the age of four days who presented with early onset of neonatal sepsis and dehydration.

A triterpenoid saponin from Cyclamen coum

A new triterpenoid saponin, coumoside A, has been isolated from the whole plant of Cyclamen coum and the structure of this novel saponin (C58H92O27) has been deduced by NMR methods based on 1H, 13C, DEPT, 1H-1H COSY, HETCOR, NOESY-NMR experiments and the FAB-mass spectrum. It has the structure 3 beta-O-[beta-D-glucopyranosyl-(1-6)-[alpha-L-arabinopyranosyl- (1-2)]-beta-D-glucopyranosyl-(1-4)-[beta-D-glucopyranosyl-(1-2)]-alpha-L -arabinopyranosyl]-16 alpha-hydroxy-30,28 beta-lactone-olean-12-ene and is called coumoside.

Pentacyclic triterpenoid saponin from Cyclamen coum

A new triterpenoid saponin, coumoside B, has been isolated from the whole plant of Cyclamen coum. The structure of the compound 3 (C58H92O27) has been deduced by NMR (400 MHz) methods based on the 1H, 13C, DEPT, 1H-1H COSY, HETCOR, NOESY-NMR experiments, and FAB-mass spectrum. Compound 3 was shown to have the structure 16 alpha-hydroxy-3 beta-[[[[beta-xylopyranosyl-(1-->2)]-[beta-glucopyranosyl-(1-->4)]- [beta-glucopyranosyl-(1-->2)]- alpha-arabinopyranosyl]-oxy]olean-12-eno-30,28-lactone and is named coumoside B.