Cardiac and renal outcomes of direct oral anticoagulants in patients with atrial fibrillation

BACKGROUND

Oral anticoagulation therapy with warfarin or direct oral anticoagulants (DOACs) is the mainstay for stroke prevention in patients with non-valvular atrial fibrillation (AF). The DOACs might have a lower risk of declining renal function than warfarin. This study aimed to compare renal outcomes among rivaroxaban, edoxaban, dabigatran, and warfarin.

METHOD

This cohort study identified 2203 adults with AF who started anticoagulation therapy between 1 July 2013 and 31 December 2020, in a clinical database at a single centre. Inverse probability of treatment weighting was adopted to balance baseline characteristics among four anticoagulants treatment groups. The primary outcome was a composite of cardiac and renal outcomes, involving a ≥30% decline in estimated glomerular filtration rate (eGFR), renal failure and cardiovascular death.

RESULTS

After propensity score weighting, dabigatran was associated with significantly lower risks of a ≥30% decline in eGFR (hazard ratio [HR]: .69, 95% confidence interval [CI]: .497-.951, p = .0237), doubling of the serum creatinine level (HR: .49, 95% CI: .259-.927, p = .0282) and the cardiac and renal outcome composite (HR: .67, 95% CI: .485-.913, p = .0115) than warfarin. Rivaroxaban and edoxaban did not show significant protective effects on renal outcomes compared to warfarin.

CONCLUSION

In this study, patients treated with dabigatran had significantly reduced risks of declining renal function and composite cardiac and renal events than those treated with warfarin. However, rivaroxaban and edoxaban were not associated with lower risks of any renal outcomes than warfarin. More studies are warranted to investigate and compare the impact of renal function between different DOACs in patients with AF.

Effect of myopia on the progression of normal tension glaucoma

PURPOSE

Identify risk factors of progression in treated normal-tension glaucoma (NTG) in highly myopic and non-highly myopic eyes.

METHODS

This retrospective, observational case series study included 42 highly myopic glaucoma (HMG, <-6D) eyes and 39 non-highly myopic glaucoma (NHG,≧-6D) eyes. Glaucoma progression was determined by serial visual field data. Univariate and multivariate logistic regression method were used to detect associations between potential risk factors and glaucoma progression.

RESULTS

Among 81 eyes from 81 normal-tension glaucoma patients (mean follow-up, 3.10 years), 20 of 42 eye (45.24%) in the HMG and 14 of 39 eyes (35.90%) in the NHG showed progression. The HMG group had larger optic disc tilt ratio (p = 0.007) and thinner inferior macular thickness (P = 0.03) than the NHG group. Changes in the linear regression values for MD for each group were as follows: -0.652 dB/year for the HMG and -0.717 dB/year for the NHG (P = 0.298). Basal pattern standard deviation (PSD) (OR: 1.55, p = 0.016) and post treatment IOP (OR = 1.54, p = 0.043) were risk factors for visual field progression in normal tension glaucoma patients. In subgroup analysis of HMG patients, PSD (OR: 2.77, p = 0.017) was a risk factor for visual field progression.

CONCLUSION

Reduction IOP was postulated to be contributing in the prevention of visual field progression, especially in highly myopic NTG patients with large basal pattern standard deviation.

Comparing the effectiveness and safety of dual antiplatelet with ticagrelor or clopidogrel in elderly Asian patients with acute myocardial infraction

Background

Current guidelines recommend potent P2Y12 inhibitors for patients after acute coronary syndrome. However, the data on the efficacy and safety of potent P2Y12 inhibitors in elderly Asian populations was limited. We aimed to investigate the major adverse cardiovascular events (MACE), bleeding events, and net adverse clinical events (NACE) with ticagrelor and clopidogrel in Taiwanese patients aged 65 and older after acute myocardial infarction (AMI).

Methods

This retrospective population-based cohort study was conducted using data from the National Health Insurance Research Database. The AMI patients aged ≥65 years who underwent percutaneous coronary intervention (PCI) and survived after 1 month were included. The patients were separated into 2 cohorts depending on the type of dual antiplatelet therapy (DAPT) they received: ticagrelor plus aspirin (T + A) or clopidogrel plus aspirin (C + A). We used inverse probability of treatment weighting to balance the difference between these 2 study groups. The outcome included all-cause mortality, MACE (cardiovascular death, nonfatal ischemic stroke, and nonfatal myocardial infarction), intracerebral hemorrhage, major bleeding, and NACE which is composed of cardiovascular death, ischemic and hemorrhagic events. The follow-up period was up to 12 months.

Results

From 2013 to 2017, a total of 14,715 patients who met the eligibility criteria were separated into 2 groups: 5,051 for T + A and 9,664 for C + A. Compared to patients with C + A, patients who received T + A had a lower risk of cardiovascular death and all-cause death, with an adjusted HR of 0.57 [95% confidence interval (CI), 0.38–0.85, p = 0.006] and 0.58 (95% CI 0.45–0.74, p &lt; 0.001), respectively. No differences were found in MACE, intracranial and major bleeding between the 2 groups. In addition, the patients with T + A had a lower risk of NACE with an adjusted HR of 0.86 (95% CI 0.74–1.00, p = 0.045)

Conclusion

Among elderly AMI patients receiving DAPT after successful PCI, ticagrelor was a more favorable P2Y12 inhibitor than clopidogrel because of lowering the risk of death and NACE without increasing the risk of severe bleeding. Ticagrelor is an effective and safe P2Y12 inhibitor in Asian elderly survivors after PCI.

Influenza Vaccination and the Risk of Ventricular Arrhythmias in Patients With Chronic Obstructive Pulmonary Disease: A Population-Based Longitudinal Study

Backgrounds: Influenza vaccination could decrease the risk of major cardiac events in patients with chronic obstructive pulmonary disease (COPD). However, the effects of the vaccine on decreasing the risk of ventricular arrhythmia (VA) development in such patients remain unclear. Methods: We retrospectively analyzed the data of 18,658 patients with COPD (≥55 years old) from the National Health Insurance Research Database from January 1, 2001, to December 31, 2012. After a 1:1 propensity score matching by the year of diagnosis, we divided the patients into vaccinated and unvaccinated groups. Time-varying Cox proportional hazards regression was applied to assess the time to event hazards of influenza vaccination exposure. Results: The risk of VA occurrence was significantly lower in the vaccinated group during influenza season and all seasons [adjusted hazard ratio (aHR): 0.62, 95% CI: 0.41-0.95; aHR: 0.69, 95% CI: 0.44-1.08; and aHR: 0.65, 95% CI: 0.48-0.89, in the influenza season, non-influenza season, and all seasons, respectively]. Among patients with CHA₂DS₂-VASc scores (conditions and characteristics included congestive heart failure, hypertension, diabetes, stroke, vascular disease, age, and sex) of 2-3, receiving one time and two to three times of influenza vaccination were associated with lower risk of VA occurrence in all seasons (aHR: 0.28, 95% CI: 0.10-0.80; aHR: 0.27, 95% CI: 0.10-0.68, respectively). Among patients without stroke, peripheral vascular disease, and diabetes, a lower risk of VA occurrence after receiving one and two to three times vaccination was observed in all seasons. Among patients with a history of asthma and patients without a history of heart failure, ischemic heart disease, angina hypertension, or renal failure, a significantly lower risk of VA occurrence was observed after the first time of vaccination in all seasons. Conclusions: Influenza vaccination may be associated with lower risks of VA among patients with COPD aged 55-74. Further investigation is still needed to resolve this clinical question.

Comparison between ticagrelor versus clopidogrel in long term outcomes of Taiwanese diabetic subjects with acute coronary syndrome undergoing successful revascularization: From TSOC ACS-DM registry

Although previous clinical trials demonstrated that ticagrelor could reduce cardiovascular events and mortality versus clopidogrel in patients with acute coronary syndrome (ACS), the real-world evidence of its clinical impacts on East Asian Diabetic population has rarely been investigated.Between November 2013 and June 2015, 1534 patients were recruited into the Acute Coronary Syndrome-Diabetes Mellitus Registry of the Taiwan Society of Cardiology (TSOC ACS-DM registry). After propensity score matching, a total of 730 patients undergoing successful revascularization and discharged on ticagrelor (N = 365) or clopidogrel (N = 365) were analyzed. The primary and secondary endpoints were all-cause mortality and re-hospitalization, respectively. The all-cause death associated with ticagrelor vs clopidogrel was 3.6% vs 7.4% (adjusted hazard ratio (HR) 0.34 [0.15-0.80]; P = .0138) at 24 months. The re-hospitalization rate at 24 months was 38.9% vs 39.2% (P = .3258).For diabetic patients with ACS, ticagrelor provided better survival benefit than clopidogrel without an increase of re-hospitalization in 24 months after successful percutaneous coronary intervention. This study in real-world circumstance provided valuable complementary data to externally validate platelet inhibition and patient outcomes (PLATO) finding especially in Asian diabetic population.

Comparison of the TIMI, GRACE, PAMI and CADILLAC risk scores for prediction of long-term cardiovascular outcomes in Taiwanese diabetic patients with ST-segment elevation myocardial infarction: From the registry of the Taiwan Society of Cardiology

Acute coronary syndrome (ACS) patients with diabetes have significantly worse cardiovascular outcomes than those without diabetes. This study aimed to compare the performance of The Thrombolysis In Myocardial Infarction (TIMI), Global Registry of Acute Coronary Events (GRACE), Primary Angioplasty in Myocardial Infarction (PAMI), and Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) risk scores in predicting long-term cardiovascular outcomes in diabetic patients with ST-segment elevation myocardial infarction (STEMI). From the Acute Coronary Syndrome-Diabetes Mellitus Registry of the Taiwan Society of Cardiology, patients with STEMI were included. The TIMI, GRACE, PAMI, and CADILLAC risk scores were calculated. The discriminative potential of risk scores was analyzed using the area under the receiver-operating characteristics curve (AUC). In the 455 patients included, all four risk score systems demonstrated predictive accuracy for 6-, 12- and 24-month mortality with AUC values of 0.67–0.82. The CADILLAC score had the best discriminative accuracy, with an AUC of 0.8207 (p<0.0001), 0.8210 (p<0.0001), and 0.8192 (p<0.0001) for 6-, 12-, and 24-month mortality, respectively. It also had the best predictive value for bleeding and acute renal failure, with an AUC of 0.7919 (p<0.05) and 0.9764 (p<0.0001), respectively. Patients with CADILLAC risk scores >8 had poorer 2-year survival than those with lower scores (log-rank p<0.0001). In conclusion, the CADILLAC risk score is more effective than other risk scores in predicting 6-month, 1-year, and 2-year all-cause mortality in diabetic patients with STEMI. It also had the best predictive value for in-hospital bleeding and acute renal failure.

Dysfunctional high density lipoprotein failed to rescue the function of oxidized low density lipoprotein-treated endothelial progenitor cells: a novel index for the prediction of HDL functionality

Lipid metabolic disorders play critical roles in atherogenesis. Traditionally, it has been suggested that reduced high density lipoprotein (HDL) levels might be an important morbidity indicator for cardiovascular diseases. Therefore, it has been argued that therapeutically raising HDL levels may reduce atherogenesis in patients with dyslipidemia. However, recent clinical trials to elevate serum HDL levels by pharmacologic approaches failed to demonstrate clinical efficacy. Thus, to investigate the functionality of HDL and to explore the possible clinical relevance as well as to define an effective indicator that can represent HDL function may provide another key and reference to disclose the clinical treatment of dyslipidemia. We analyzed the association between the data of dichlorofluorescein assay (assay the functionality of HDL), the effect of HDL on oxidized low density lipoprotein (oxLDL)-stimulated endothelial progenitor cells (EPCs) in vitro, levels of circulating EPCs, and ex vitro EPC colony forming units of each case, we defined the indicator (relative HDL index (RHDL index) = dichlorofluorescein assay result of each subject/dichlorofluorescein assay reading of our young healthy controls) that may represent functionality of HDL. HDL from healthy adults protected oxLDL-treated EPCs by modulating p38 mitogen-activated protein kinase and Rho activation and by promoting nitric oxide production. HDL from subject with RHDL index ≧2 also failed to restore the functionality of oxLDL-treated EPCs via cell-signaling pathways in vitro. The RHDL index significantly correlated with patients' circulating EPC number or EPC colony forming units ex vivo. In conclusions, we explored the RHDL index as a score to predict a patient's EPC functions in vivo and ex vitro.

Incidence and risk of major heart diseases in middle-aged adults with moderate to severe vision impairment: a population-based cohort study

BACKGROUND/AIM

To estimate the incidence and risk of major adverse cardiovascular events (MACEs), including heart failure and ischaemic heart disease, among middle-aged people with a visual disability (VD).

METHODS

We used a national health insurance research database to conduct a population-based cohort study from 1 January 2000 to 31 December 2013. Patients with VD aged 35~65 years were recruited. For each VD patient, five age-matched, sex-matched and comorbidity-matched patients were randomly selected and recruited as controls. Control patients had no documented disability.

RESULTS

This study recruited 978 patients with VD (mean age±SD, 55.1±7.8 years; 48.9% male) and 4677 controls. Compared with the same sex of the controls, women with VD had higher incidence of MACE 1 (7.9 vs 2.8/1000 person-years, p<0.001), MACE 2 (27.5 vs 16.9/1000 person-years, p<0.001), MACE 3 (3.7 vs 1.4/1000 person-years, p<0.005) and MACE 4 (4.5 vs 2.5/1000 person-years, p<0.05), and men with VD had higher incidence of MACE 1 (4.6 vs 2.0/1000 person-years, p<0.005). Compared with the controls, patients with VD had lower cumulative MACE 1~MACE 4-free probabilities and had an independently higher risk of MACE 1~MACE 4 during the 13-year study, yielding an adjusted hazard ratio range of 1.31~2.75. Those persons with VD who had diabetes and hypertension had greater risks of MACE 1~MACE 4.

CONCLUSIONS

Middle-aged adults with VD were at risk of MACEs. A programme for MACE prevention is important for middle-aged people with VD. This is especially true for women and for those who also have diabetes and hypertension.

Rapid and Sensitive ELISA Screening Assay for Several Paralytic Shellfish Toxins in Human Urine

Paralytic shellfish poisoning is caused by a group of paralytic shellfish toxins that are produced by dinoflagellates. Toxins in this group include saxitoxin, neosaxitoxin and gonyautoxins. A rapid diagnostic test to identify poisoning by these toxins can be helpful in guiding the appropriate treatment of victims. Additionally, quick receipt of diagnostic results can provide timely proof that shellfish harvesting should be stopped in a given area, thereby preventing additional exposures. We have developed and validated a rapid urinary enzyme-linked immunosorbent assay-based screening test to diagnose exposure to several major paralytic shellfish toxins. The lower limit of detection (LLOD) for multiple paralytic shellfish toxins was characterized as 0.02, 0.10, 0.10, 1.0, 1.0 and 15 ng/mL for saxitoxin, gonyautoxin 2,3, decarbamoyl gonyautoxin 2,3, decarbamoyl saxitoxin, neosaxitoxin and gonyautoxin 1,4, respectively. No interferences were identified in unspiked pooled urine or in specimens collected from unexposed individuals indicating that this method is specific for the paralytic shellfish toxins tested. The accuracy of this test was demonstrated in 10 individual urine specimens with osmolalities ranging from 217 to 1,063 mOsmol/kg and pHs ranging between 5.06 and 7.45. These specimens were spiked with toxins at their LLODs and the presence of toxins at these concentrations was accurately identified in all cases. These results indicate that this diagnostic test can be used to rapidly and accurately screen urine for paralytic shellfish toxins.

Association between renin-angiotensin-aldosterone system blockade and future osteoporotic fracture risk in hypertensive population: A population-based cohort study in Taiwan

Tissue renin-angiotensin-aldosterone system (RAAS) activation in sites of osteoporosis had been demonstrated in animal studies; however, the possibility of RAAS blockade to prevent future osteoporotic fracture had rarely been verified in clinical studies. We Used the Taiwan Longitudinal Health insurance database 2000 to 2008, the cohort study comprised patients age over 40 with a recorded new diagnosis of hypertension between January 1, 2000 to December 31, 2008, in addition, patients who had diagnosis of osteoporosis before the date of cohort enter were excluded. After the definite diagnosis of hypertension, each patient was followed until osteoporotic fracture happened or the end of 2008. The occurrence of osteoporotic fracture was evaluated in patients who either were or without taking RAAS blockade agents. Cox proportional hazard regressions were used to evaluate the osteoporotic fracture incidence after adjusting for known confounding factors. In total, 57,132 hypertensive patients comprised the study cohort. Our study results showed that the incidence of osteoporosis fracture in the whole cohort was significantly higher in the RAAS blockade non-user group than the user group. This phenomenon was observed in both sex and all age categories. Sensitivity analysis further showed the concordant lower osteoporosis fracture risk in patients with various RAAS blockers usage durations; the risk of osteoporosis fracture was the lowest in those drug use >365 days when compared with the non-user cohort. In conclusion, our study result demonstrated the lower future osteoporotic fracture risk in hypertensive subjects who received long term RAAS blocker treatment.

Performance of AHEAD Score in an Asian Cohort of Acute Heart Failure With Either Preserved or Reduced Left Ventricular Systolic Function

Background

AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) score has been related to clinical outcomes of acute heart failure. However, the prognostic value of the AHEAD score in acute heart failure patients with either reduced or preserved left ventricular ejection fraction (HFrEF and HFpEF) remain to be elucidated.

Methods and Results

The study population consisted of 2143 patients (age 77±12 years, 68% men, 38% HFrEF) hospitalized primarily for acute heart failure with a median follow‐up of 23.75 months. The performance of the AHEAD score (atrial fibrillation, hemoglobin <13 mg/dL for men and 12 mg/dL for women, age >70 years, creatinine >130 μmol/L, and diabetes mellitus) was evaluated by Cox's regression analysis for predicting cardiovascular and all‐cause mortality. The mean AHEAD scores were 2.7±1.2 in the total study population, 2.6±1.3 in the HFrEF group, and 2.7±1.1 in the HFpEF group. After accounting for sex, sodium, uric acid, and medications, the AHEAD score remained significantly associated with all‐cause and cardiovascular mortality (hazard ratio and 95% CI: 1.49, 1.38–1.60 and 1.48, 1.33–1.64), respectively. The associations of AHEAD score with mortality remained significant in the subgroups of HFrEF (1.63, 1.47–1.82) and HFpEF (1.34, 1.22–1.48). Moreover, when we calculated a new AHEAD‐U score by considering uric acid (>8.6 mg/dL) in addition to the AHEAD score, the net reclassification was improved by 19.7% and 20.1% for predicting all‐cause and cardiovascular mortality, respectively.

Conclusions

The AHEAD score was useful in predicting long‐term mortality in the Asian acute heart failure cohort with either HFrEF or HFpEF. The new AHEAD‐U score may further improve risk stratification.

Silent and Malignant Early Repolarization Syndrome Mimicking Hyper-Acute ST Elevation Myocardial Infarction

A 55-year-old male with underlying type 2 diabetes mellitus and hypertension presented at our emergency department with ventricular fibrillation-related cardiac arrest. Hyper-acute ST elevation myocardial infarction was the preliminary diagnosis by 12-lead electrocardiography, which simultaneously showed J point ST elevation and tall T waves. However, the echocardiography showed concentric left ventricle hypertrophy and preserved left ventricular systolic function with no regional wall motion abnormalities, and coronary angiography did not show any critical coronary artery lesion. Malignant early repolarization syndrome was diagnosed, and an implantable cardioverter defibrillator was implanted. Early repolarization syndrome is associated with J point elevation, and more involved leads and an increased J point elevation amplitude can increase the risk of arrhythmogenicity. In summary, we report a case with asymptomatic type 3 early repolarization syndrome-induced idiopathic ventricular fibrillation mimicking hyper-acute ST elevation myocardial infarction.

Arterial Stiffness Index and Coronary Artery Plaques in Patients with Subclinical Coronary Atherosclerosis

BACKGROUND

Arterial stiffness is a physiologic quantitative value used to measure arterial compliance. It is predictive of coronary atherosclerosis in patients with intermediate to high cardiovascular risk. However, a correlation between arterial stiffness and subclinical coronary atherosclerosis has yet to be established. Therefore, the purpose of this study was to evaluate arterial stiffness using an arterial stiffness index (ASI) and investigate its association with coronary artery plaque in patients with subclinical coronary atherosclerosis.

METHODS

Our study enrolled 156 consecutive subjects who underwent health screening using a 64-slice cardiac computed tomography angiography (CCTA). Their arterial stiffness index was assessed noninvasively by CardioVision(®) MS-2000. The atheroma on the coronary vessel walls was analyzed.

RESULTS

Of the 156 patients, 53 displayed at least one > 50% stenotic lesion over the coronary arteries in CCTA images. The patients with at least one > 50% coronary stenotic plaque were older and had higher systolic blood pressure and ASI values than patients without > 50% coronary stenotic plaque. After dividing the study population into 2 groups by those patients over and under 50 years of age, the ASI positively correlated with the presentation of at least one > 50% coronary stenotic plaque in patients aged ≥ 50 years (odds ratio = 1.02, 95% confidence interval: 1.00-1.04, p = 0.03).

CONCLUSIONS

The ASI could play a role in risk stratification systems for coronary artery disease in patients with subclinical coronary atherosclerosis, and is a useful clinical marker for the correlation of early coronary plaque.

KEY WORDS

Arterial stiffness; Arterial stiffness index; Atherosclerosis; Coronary artery plaque.

Combined Framingham Risk Score and Coronary Artery Calcium Score Predict Subclinical Coronary Plaque Assessed by Coronary Computed Tomography Angiogram in Asymptomatic Taiwanese Population

BACKGROUND

We sought to determine the predictive value of the combined traditional Framingham risk score (FRS) and coronary artery calcium score (CACS) for subclinical coronary plaque detected by computed tomography coronary angiogram (CTCA) in asymptomatic subjects.

METHOD

We evaluated 167 asymptomatic Taiwanese subjects (mean age, 57 ± 11.2 years), who underwent CTCA as part of a health evaluation. We examined the associations between FRS, CACS, serum biomarkers, and coronary plaque assessed by CTCA.

RESULTS

Out of 167 subjects in the study, 95 had coronary artery atheroma. Of those possible predictors for coronary atherosclerosis, both FRS and CACS were independent predictors for the presence of coronary plaque [relative risk (RR): 1.29, 95% confidence interval (CI): 1.07-1.54, p = 0.006 and RR: 1.42, 95% CI: 1.16-1.75, p = 0.001, respectively]. Receiver operating characteristics curve analysis revealed that CACS and FRS were indicators of the presence of coronary plaque. The area under the curve for FRS and CACS was 0.729 and 0.889, respectively (p < 0.001). Furthermore, the area under the curve for combination of FRS and CACS was 0.936 (95% CI: 0.887-0.969, p < 0.001), and this combination provided a better diagnostic advantage than either FRS or CACS alone (p < 0.001 and p = 0.012 by C-statistic, respectively).

CONCLUSIONS

In asymptomatic Taiwanese subjects with low to intermediate cardiovascular risk, both FRS and CACS were independently related to subclinical atherosclerosis. A combined FRS and CACS evaluation improved the efficacy of prediction for atherosclerotic plaque burden.

KEY WORDS

Atherosclerosis; Computed coronary tomography angiogram; Coronary artery calcium score; Framingham risk score; Subclinical coronary plaque.

Association of clinical symptomatic hypoglycemia with cardiovascular events and total mortality in type 2 diabetes: a nationwide population-based study

OBJECTIVE

Hypoglycemia is associated with serious health outcomes for patients treated for diabetes. However, the outcome of outpatients with type 2 diabetes who have experienced hypoglycemia episodes is largely unknown.

RESEARCH DESIGN AND METHODS

The study population, derived from the National Health Insurance Research Database released by the Taiwan National Health Research Institutes during 1998-2009, comprised 77,611 patients with newly diagnosed type 2 diabetes. We designed a prospective study consisting of randomly selected hypoglycemic type 2 diabetic patients and matched type 2 diabetic patients without hypoglycemia. We investigated the relationships of hypoglycemia with total mortality and cardiovascular events, including stroke, coronary heart disease, cardiovascular diseases, and all-cause hospitalization.

RESULTS

There were 1,844 hypoglycemic events (500 inpatients and 1,344 outpatients) among the 77,611 patients. Both mild (outpatient) and severe (inpatient) hypoglycemia cases had a higher percentage of comorbidities, including hypertension, renal diseases, cancer, stroke, and heart disease. In multivariate Cox regression models, including diabetes treatment adjustment, diabetic patients with hypoglycemia had a significantly higher risk of cardiovascular events during clinical treatment periods. After constructing a model adjusted with propensity scores, mild and severe hypoglycemia still demonstrated higher hazard ratios (HRs) for cardiovascular diseases (HR 2.09 [95% CI 1.63-2.67]), all-cause hospitalization (2.51 [2.00-3.16]), and total mortality (2.48 [1.41-4.38]).

CONCLUSIONS

Symptomatic hypoglycemia, whether clinically mild or severe, is associated with an increased risk of cardiovascular events, all-cause hospitalization, and all-cause mortality. More attention may be needed for diabetic patients with hypoglycemic episodes.

Extracorporeal membrane oxygenation-assisted primary percutaneous coronary intervention may improve survival of patients with acute myocardial infarction complicated by profound cardiogenic shock

PURPOSE

The aim of this study was to evaluate the impact of extracorporeal membrane oxygenation (ECMO) assistance on the clinical outcome of patients with acute myocardial infarction (AMI) that is complicated by profound cardiogenic shock (CS) who received primary percutaneous coronary intervention (PCI).

MATERIALS AND METHODS

We collected patients from January 2004 through December 2006 (stage 1); 25 patients who presented with AMI and received primary PCI and had profound CS were enrolled in the study. Intraaortic balloon counterpulsation (IABP) was the only modality for extracorporeal support in our hospital. From January 2007 through December 2009 (stage 2), 33 patients who presented with AMI and received primary PCI and had profound CS were enrolled; for this stage; both intra-aortic balloon counter-pulsation and ECMO support were available in our facility.

RESULTS

A Kaplan-Meier survival analysis displayed significantly improved survival for patients in stage 2 (P = .001; 1-year survival in stage 1 vs 2; 24% vs 63.64%). Patients presenting with either STEMI (ST segment elevation myocardial infarction) or NSTEMI (Non-ST segment elevation myocardial infarction) benefited from ECMO-assisted PCI (P < .05). In stage 1, patients with refractory ventricular tachycardia/ventricular fibrillation had a very low survival rate; however, in stage 2, the survival rate of patients with and without refractory ventricular tachycardia/ventricular fibrillation was similar (P = .316).

CONCLUSION

Extracorporeal membrane oxygenation-assisted PCI for patients with AMI that is complicated by profound CS may improve the 30-day and 1-year survival rates.

Stress-induced cardiomyopathy caused by heat stroke

Heat stroke is defined by central nervous system abnormalities and failure of proper maintenance of thermoregulation as a result of high core body temperature ensuing from exposure to high environmental temperatures or strenuous exercise. Common complications include acute respiratory distress syndrome, disseminated intravascular coagulation, acute renal injury, hepatic injury, and rhabdomyolysis. Myocardial injury may also occur during heat stroke, resulting in cardiac enzyme increase and ST-segment changes on the ECG. Such findings might behave as diagnostic pitfalls by mimicking the presentation of coronary artery occlusive myocardial infarction. A previous case report described a patient with heat stroke and ST-segment elevation, in which the definite cause of the ST-segment elevation was unclear; however, acute myocardial infarction caused by coronary artery disease was ruled out according to the clinical signs, serial ECG changes, and serum level of cardiac biomarkers. Stress-induced cardiomyopathy (Takotsubo cardiomyopathy) was suspected, but it could not be confirmed because of the lack of coronary angiography. We herein report a case of heat stroke presenting with ST-segment elevation and cardiogenic shock. Coronary angiography was performed and coronary artery occlusive myocardial infarction was ruled out because of the presence of patent coronary arteries. Left ventriculography showed midventricular and apical hypokinesis, and stress-induced cardiomyopathy was then determined to be the appropriate diagnosis. Heat stroke causes increase of serum catecholamine levels, in which oversecretion and abnormal responses to catecholamines are a possible cause of stress-induced cardiomyopathy. Catecholamines may therefore be the key in linking heat stroke and stress-induced cardiomyopathy.

Changes in plasma phenytoin level following craniotomy

Phenytoin is often used to prevent postcraniotomy seizures, but is not always effective. We investigate changes in plasma phenytoin level ([phenytoin]) following craniotomy. The [phenytoin] in 28 patients who were receiving phenytoin (oral/ intravenous) and undergoing a craniotomy were prospectively measured 24 h preoperatively, immediately pre- and postcraniotomy, 24 and 48 h postoperatively. Factors examined included patients' age, sex, pathology, preoperative [phenytoin], operative duration and blood loss. Fifteen patients had [phenytoin] concentrations outside the therapeutic range. Twenty-five patients experienced a decrease in [phenytoin] immediately postcraniotomy: pre-, post- and 24 h postcraniotomy mean [phenytoin] were 13.4, 10.0 and 12.9 mg/l, respectively. Preoperative [phenytoin], operative duration and blood loss had significant correlation with the decrease in [phenytoin] (p < 0.05). In conclusion, < 50% of the patients had therapeutic preoperative [phenytoin]. In most patients, [phenytoin] decreases by 26% after craniotomy and returns to preoperative level within 24 h. These may contribute to early postoperative seizure development.

Spinal sagittal malalignment following surgery for primary intramedullary tumours in children

BACKGROUND/OBJECTIVE

As prior studies analysed predictive factors for various post-laminectomy spinal deformities in mixed spinal regions, age groups or pathologies, their validity and conclusions were unclear. The objective of this study was to determine predictive factors for worsened cervical or thoracic spinal sagittal alignment following laminectomy or laminotomy for primary intramedullary spinal cord tumours in children.

METHODS

In this retrospective study, patients treated between 1980 and 1998 were reviewed. Changes in spinal alignment at the last follow-up compared to the pre-operative state were studied. Factors analysed were age, pre-operative spinal alignment, procedure types (laminectomy or laminoplasty), number of laminae operated, surgery of C2 or T1 laminae, histological grade, presence of post-operative neurological deficit and post-operative radiotherapy.

RESULTS

There were 27 patients. The mean age was 5.6 years (range 1.3-14.0 years), and the mean duration of follow-up was 3.7 years (range 0.075-9.9 years). In the cervical-cervicothoracic surgical group (n = 12), alignment worsened post-operatively in 3 patients. The number of laminae operated upon had a statistically significant impact on the development of post-operative kyphosis (p = 0.07). In the thoracic-thoracolumbar surgical group (n = 15), alignment worsened in 9 patients. Procedure types were statistically significantly different, with laminectomy associated with an increased risk of post-operative kyphosis (p = 0.01). All 5 patients who had spinal fusion for worsened post-operative alignment were in the thoracic-thoracolumbar group; no patients in the cervical-cervicothoracic group required spinal fusion (p = 0.047). Other predictive factors did not reach statistical significance (p > 0.05).

CONCLUSIONS

Worsened spinal sagittal alignment following laminectomy or laminoplasty and the need for spinal fusion is more common in the thoracic-thoracolumbar region than in the cervical-cervicothoracic region. In the cervical-cervicothoracic region, operation on a greater number of laminae tends to increase the risk of worsened alignment. In the thoracic-thoracolumbar region, laminectomy is associated with worsened alignment, while laminoplasty reduces this risk; also, pre-operative kyphotic deformity tends to increase the risk of worsened alignment post-operatively.

The Influence of hair shave on the infection rate in neurosurgery. A prospective study

OBJECTIVE

To investigate whether not shaving hair in neurosurgical operations carries an increased infection rate.

METHODS

Taking advantage of different practices among neurosurgeons in a single institution, we embarked upon a prospective non-randomised study of 100 consecutive neurosurgical procedures involving 90 paediatric patients aged 7 days to 16.8 years. The patients were split into two groups ('hair shave' and 'no hair shave'). The differences with respect to wound complications, positive microbiology on wound culture swabs and wound infection rates were analysed. Other factors considered were the cleansing solution, prophylactic antibiotic regime, duration of the operation, the surgeon's experience and the patient's age.

RESULTS

The only complications observed were 4 incidences of wound dehiscence (2 in the hair shave and 2 in the no hair shave group) and 3 shunt infections (2 in the hair shave and 1 in the no hair shave group). We did not find any significant difference between the two arms for any of the factors assessed. Age was a significant factor in shunt infection, as all shunt infections were seen in patients aged less than 6 months, regardless of whether the hair was shaved or not (p = 0.024, Fisher's exact test).

CONCLUSION

This study confirms our clinical experience that no hair shave is a good alternative to the traditional hair shaving approach, allowing patients to enjoy the psychological benefits of undisturbed body image while recovering from major surgery.

Coexistence of acanthosis nigricans and the sign of Leser-Trélat in a patient with gastric adenocarcinoma: a case report and literature review

The association of acanthosis nigricans (AN) with the sign of Leser-Trélat (LT) and gastric carcinoma is rare. Our patient was a 69-year-old man, who presented with hematemesis; a stage-IV poorly differentiated, diffuse-type, adenocarcinoma of the gastric antrum was diagnosed. The AN was striking, with florid cutaneous papillomatosis that also involved the mucous membranes of the mouth and eyelids, and keratoderma. AN and the sign of LT predated tumor detection by 6 months and regressed after chemotherapy in parallel with reduction of the tumor load, demonstrating the dermatoses as paraneoplastic phenomena. The patient died 7 months after completion of chemotherapy. The coexistence of AN and the sign of LT should prompt a search for underlying malignancy. The pathogenesis of both dermatoses is discussed.

Primary ectopic intramuscular meningioma of the thigh

A case of a primary ectopic intramuscular meningioma of the thigh in a 20-year-old male patient is presented. The possible histogenesis of primary ectopic meningiomas is summarized.

Paraganglioma of the cauda equina: a case report and review of the literature

This case report describes a paraganglioma of the cauda equina in a 57-year-old man. The clinical and pathological features of the 70 cases reported to date are reviewed. The importance of total surgical removal is stressed.

Spinal intramedullary cavernous angioma in a patient with Down's syndrome

A rare case of cervical intramedullary cavernous angioma in a 30-year-old man with Down's syndrome is presented. A review of the literature showed this to be the first reported case. Magnetic resonance imaging was diagnostic. A myelotomy was done and multiple biopsies were taken. The patient deteriorated neurologically and later died due to severe chest infection. The presentation, management and prognosis of this condition are discussed.

Wound infection with meningitis caused by Salmonella typhimurium

We report a case of postoperative wound infection and meningitis with Salmonella typhimurium in a 66-year-old woman who had been operated on for a cerebral meningioma. The diagnostic, therapeutic and prognostic implications are discussed.