Improved cardiac function in patients with obstructive jaundice after internal biliary drainage: hemodynamic and hormonal assessment

OBJECTIVE

To investigate myocardial function in patients with obstructive jaundice before and after internal biliary drainage.

SUMMARY BACKGROUND DATA

Increased plasma levels of atrial natriuretic peptide (ANP) have been found in patients with biliary obstruction.

METHODS

Thirteen patients with newly diagnosed obstructive jaundice and no previous heart, lung, or renal disease were studied using a Swan-Ganz catheter. Hemodynamic measurements were taken before and 4 days after internal biliary drainage. Levels of ANP and brain natriuretic peptide (BNP) were obtained and liver function tests were also determined.

RESULTS

Plasma levels of ANP and BNP were increased twofold to fourfold in the basal state and declined after biliary drainage. Independent variables predicting left ventricular systolic work were total bilirubin concentrations, duration of jaundice, and BNP. In addition, bilirubin concentrations correlated with pulmonary vascular resistance, mean arterial pulmonary pressure, and right ventricular systolic work. Internal biliary drainage resulted in an improvement in left ventricular systolic work. A correlation was found between decreasing ANP concentrations and increasing cardiac output.

CONCLUSIONS

Increased plasma levels of natriuretic peptides in patients with obstructive jaundice may reflect a subclinical myocardial dysfunction correlating with the degree of jaundice. After internal biliary drainage, there is a measurable improvement of cardiac function.

DNA clustering and genome complexity

Early global measures of genome complexity (power spectra, the analysis of fluctuations in DNA walks or compositional segmentation) uncovered a high degree of complexity in eukaryotic genome sequences. The main evolutionary mechanisms leading to increases in genome complexity (i.e. gene duplication and transposon proliferation) can all potentially produce increases in DNA clustering. To quantify such clustering and provide a genome-wide description of the formed clusters, we developed GenomeCluster, an algorithm able to detect clusters of whatever genome element identified by chromosome coordinates. We obtained a detailed description of clusters for ten categories of human genome elements, including functional (genes, exons, introns), regulatory (CpG islands, TFBSs, enhancers), variant (SNPs) and repeat (Alus, LINE1) elements, as well as DNase hypersensitivity sites. For each category, we located their clusters in the human genome, then quantifying cluster length and composition, and estimated the clustering level as the proportion of clustered genome elements. In average, we found a 27% of elements in clusters, although a considerable variation occurs among different categories. Genes form the lowest number of clusters, but these are the longest ones, both in bp and the average number of components, while the shortest clusters are formed by SNPs. Functional and regulatory elements (genes, CpG islands, TFBSs, enhancers) show the highest clustering level, as compared to DNase sites, repeats (Alus, LINE1) or SNPs. Many of the genome elements we analyzed are known to be composed of clusters of low-level entities. In addition, we found here that the clusters generated by GenomeCluster can be in turn clustered into high-level super-clusters. The observation of 'clusters-within-clusters' parallels the 'domains within domains' phenomenon previously detected through global statistical methods in eukaryotic sequences, and reveals a complex human genome landscape dominated by hierarchical clustering.

[Primary stent treatment in the acute phase of myocardial infaction]

INTRODUCTION

Although direct balloon angioplasty has emerged as an alternative to thrombolytic therapy in patients with acute myocardial infarction, reocclusion and restenosis rates are limiting factors. We postulated that these limitations could be partly overcome by primary stenting of the responsible lesion.

MATERIAL AND METHODS

Since January/94 we have studied 59 patients with acute myocardial infarction who were treated in the early phase (3.1 +/- 2 hours since the onset of symptoms) by elective Palmaz-Schatz stent implantation. No adjunctive thrombolytic therapy was associated. Two patients were in cardiogenic shock and were treated under percutaneous cardiopulmonary support. At cardiac catheterization a left ventriculography and coronary angiograms were obtained. Then, mechanical recanalization of the responsible lesion was performed. If the angiographic anatomy was considered suitable, a stent was implanted at the lesion.

RESULTS

The infarct related artery was the left anterior descending in 29 patients, the circumflex in 14 and the right coronary artery in 16. At baseline conditions, 40 patients had a totally occluded artery and 19 showed a TIMI-grande 1 antegrade flow. One patient had an early clinical recurrence 4 days later, which required an additional divided Palmaz-Schatz stent at the distal portion of the lesion, in order to seal a residual dissection. All remaining patients had a favourable clinical course without major complications. Immediately after treatment the minimal lumen diameter was 3.2 +/- 0.4 mm and no residual stenosis was detectable at the treated segment. Six-month angiographic reevaluation was performed in all 29 (49%) eligible patients. Restenosis (> 50% stenosis) was detected in 6 out of the 29 evaluated patients (21%).

CONCLUSIONS

Primary stent implantation in selected patients with an evolving myocardial infarction provides good initial and 6-month results.

[Patients with an acute myocardial infarct treated in a coronary unit or in a general cardiology ward A comparative study]

INTRODUCTION AND OBJECTIVES

Coronary care units have been accepted as the standard location for treatment for patients with acute myocardial infarction. Nevertheless, controversy over their clinical impact, current role and cost-effectiveness still remains. Due to the increased incidence of coronary artery disease in Spain, coronary care units are often full, and patients with acute myocardial infarction must be cared for in a general cardiology ward.

METHODS

We have studied the features and results of 420 patients with acute myocardial infarction consecutively admitted to our hospital and compared patients cared for in the coronary care unit (329 [78%]) with those cared for in the cardiology ward (91 [22%]). Admission to cardiology ward or coronary care unit was based on the clinical judgment of emergency room physicians and the bed availability. No differences in age, sex, risks factors, prior history of coronary heart disease, blood pressure on admission, extension and complications of myocardial infarction were found between both groups.

RESULTS

The percentage of patients with evolved and non-Q wave acute myocardial infarction, and admission electrocardiogram not suggestive of infarction was significantly higher in ward group (23 versus 2.4%, p < 0.001; 19 versus 11%, p < 0.01; and 43 versus 15%, p < 0.01; respectively). Although patients admitted to the coronary care unit underwent intravenous thrombolysis and coronary artery revascularization procedures in a higher proportion, mortality was similar in both groups (14% for ward patients and 17% for coronary care unit patients). When patients with evolved or non-Q wave infarctions and those with admission electrocardiograms not suggestive of infarction were excluded from the analysis, mortality rates remained similar. Subgroups mortality was in general similar for patients cared for in cardiology ward or in coronary care unit, although patients without shock, with Killip class I or II, and older than 70 years, had a slightly lesser mortality when treated in the Cardiology ward (5 versus 11%, 6 versus 11%, and 14 versus 28%, respectively). By contrast, patients with shock, Killip class III or IV, and electrocardiogram at admission not suggestive of infarction, had a lesser mortality when cared for in coronary care unit.

CONCLUSIONS

We conclude that some subgroups of patients with acute myocardial infarction can be, if needed, effective and safely cared for in cardiology ward.