The effects of Digoxin use on long-term prognosis in patients with heart failure with reduced ejection fraction.

OBJECTIVE: This study aimed to investigate the effect of digoxin on mortality and rehospitalization in heart failure with reduced ejection fraction (HFrEF) patients. Heart failure is a clinical syndrome that requires frequent rehospitalization and has a high mortality. This study aimed to investigate the effect of digoxin on mortality and rehospitalization in patients with heart failure with reduced ejection fraction. PATIENTS AND METHODS: The study included 326 patients with HFrEF that were hospitalized for decompensation between September 2014 and January 2016. The patients were divided into two groups: digoxin users and a control group. The study's endpoints were cardiovascular death and rehospitalization after 24-month long-term follow-ups. RESULTS: Rehospitalization was lower in patients taking digoxin (25% vs. 47%, p = 0.001). The mean age of patients taking digoxin (n: 78) was 63.7 ± 12.4 years, among which 64% were males. The mean age of the control group was 65.4 ± 11.8 years, among which 74% were males. However, there was no difference in mortality between the two groups (34% vs. 45%, p = 0.10). While Kaplan-Meier curves revealed no significant differences between mortality rates in the groups (log-rank p = 0.508), a statistical difference was found between the groups in rehospitalization rates (log-rank p =  0.013). A multiple linear regression analysis revealed that smoking (HR: 1.97, CI: 1.24-3.11, p = 0.004), systolic blood pressure (HR: 0.983, CI: 0.974-0.992, p < 0.001), atrial fibrillation (HR: 2.09, CI: 1.17-3.72, p = 0.012), C-reactive protein (CRP) (HR: 1.009, CI: 1.003-1.015, p = 0.004), beta-blockers (HR: 0.891, CI: 0.799-0.972, p = 0.009), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (HR: 0.778, CI: 0.641-0.956, p < 0.001), mineralocorticoid receptor antagonists (HR: 0.41, CI:0.26-0.65, p < 0.001), and digoxin use (HR: 0.59, CI: 0.43-0.80, p = 0.001) are independent predictors of rehospitalization in patients with HFrEF. CONCLUSIONS: Our results show that digoxin use does not affect mortality in HFrEF patients. However, rehospitalization decreased in patients taking digoxin in HFrEF.

The magnetic resonance imaging assessment of optic nerve sheath diameter in pediatric acute liver failure patients.

OBJECTIVE: To evaluate the diagnostic value of optic nerve sheath diameter (ONSD) using brain MRI in the pretransplantation period in the pediatric acute liver failure patients, and correlate the ONSD with clinical grade of hepatic encephalopathy (HE) and MRI findings. PATIENTS AND METHODS: Forty acute liver failure patients and 40 control group patients were retrospectively analyzed. The high signal intensities in T2W (T2-weighted image), FLAIR (Fluid Attenuated Inversion Recovery) and DWI (diffusion-weighted imaging) sequences were evaluated and ONSD was measured. The patients were grouped first into 5 according to their West Haven score, and HE grade 0 and grade 1 were accepted as low grade HE, HE grade 2, 3 and 4 were accepted as high grade HE. The patients were grouped to 2 according to the MRI findings as low grade and high grade MRI group. RESULTS: The mean value of ONSD was 6.0 ± 1.80 and 4.94 ± 1.27 in the all patients and in the control group, respectively. There was statistically significant difference between both the ONSD and the low grade-high grade HE groups (p=0.01), and between the ONSD and the low grade-high grade MRI groups (p<0.001). CONCLUSIONS: Although high ONSD values do not make the diagnosis of cerebral edema, it may cause suspicion in the early period. MRI can be helpful in the diagnoses of increased intracranial pressure like ultrasound. Our study is the first study to compare ONSD and MRI findings in addition to HE grades. The widespread use of MRI in children in recent years may help determine the normal range of ONSD values.

Outcomes of Kidney Transplantations From the Same Deceased Donor to Two Different Recipients: A Single-Center Experience.

BACKGROUND: Kidney transplantation is the best treatment method for end-stage renal disease. Technically, left kidney transplantation is easier than right kidney, and the complication rates in the right are higher than the left kidney. We performed 28 kidney transplantations from 14 deceased donors between November 2010 and May 2016. Our aim was to share our outcomes and experiences about these 28 patients. METHODS: We performed 182 kidney transplantations between November 2010 and May 2016. Fifty-four kidney transplantations were performed from deceased donors. Thirty-two of these were performed from 16 of the same donors. These 32 recipients' data were collected and retrospectively analyzed. We excluded the transplantations from two same-donors to their four recipients in this study. The remaining 28 recipients were included in the study. RESULTS: The left and right kidney recipients' numbers were equal (14:14). The left kidney:right kidney rate was 11:3 in the first kidney transplantation recipient group; in the second kidney transplantation recipient group, the rate was 3:11. The difference was statistically significant (P = .002). We found no statistical differences for sex, mean age, and body mass index of recipients, total ischemic time of grafts, hospitalization times, creatinine levels at discharge time, and current ratio of postoperative complications of recipients (P > .05). CONCLUSIONS: There were no differences in the left or the right kidneys or in the first and the second kidney transplantations during the long follow-up period.

Should Interventional Radiology or Open Surgery Be the First Choice for the Management of Ureteric Stenosis After Transplantation? Dual-Center Study.

BACKGROUND: Ureteric stenosis (US) is the most common urologic complication after kidney transplantation. In this dual-center retrospective study we compared the efficacy and safety of open surgery versus interventional radiology for the management of US. METHODS: From 2009 to January 2016, US was treated by surgical revision in 22 (7.8%) out of 281 recipients at one center (group 1) and managed by percutaneous nephrostomy with antegrade nephroureteral stenting (PNAS) in 22 (14.2%) out of 155 recipients at the other center (group 2). RESULTS: Three patients in group 1 required reintervention and again were treated with open surgery. With a mean follow-up of 42.1 ± 38.7 months, graft function improved in all but one patients (95%). Three patients in group 2 were admitted with relapse of US not amenable to 2nd PNAS, and 2 of them were managed with surgery. These 3 and 2 other cases with improved graft function after PNAS lost their grafts and returned to hemodialysis. The remaining 17 patients (77%) still have functioning grafts. There was no statistically significant difference between the efficacy of PNAS and open surgery for the management of post-transplantation US. However; a benefit in favor of open surgery existed for type 2 urinary tract obstruction in terms of decreased reintervention rate and much better protection of the graft function and survival. CONCLUSIONS: Both interventional radiology and open surgery have acceptable efficacy rates in the management of ureteric complications after renal transplantation. Open surgery is a better treatment option for type 2 obstruction.

Intellectuality and attitudes of clergy about organ donation in Turkey: metasynthesis of observational studies.

INTRODUCTION: In Turkey, donation rates remained low despite the efforts of the Religious Affairs Supreme Council. We sought to determine theological perspectives and behaviors of clergy and theology students toward organ donation. METHODS: We conducted a systematic review and metaanalysis of observational studies. RESULTS: There were 2154 participants. Eighty-two percent stated Islam allows organ donation. Nineteen had organ donation card (<1%). Fifty-four percent were reluctant to donate organs themselves, 56% lacked sufficient knowledge. Twenty percent referred to school education and periodicals as the source of information. Sixty-nine percent were act as opinion leaders for organ donation. In curriculums of the Faculties of Theology, organ donation as a separate topic has not been found. No articles regarding organ donation have been published in theology journals in their 60-year publication history. CONCLUSIONS: A discrepancy exists between the resolutions of the Board of Religious Affairs and attitudes of clergy toward organ donation in Turkey. Theology faculties seem not to pay specific attention to this issue. The Directorate of Religious Affairs and the faculty of theology should meet at a common point immediately in terms of training programs and continuing education with strict audit in context of organ transplantation and donation.

Framingham risk score and severity of coronary artery disease.

OBJECTIVES: Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide. Easy-to-perform and reliable parameters are needed to predict the presence and severity of CAD and to implement efficient diagnostic and therapeutic modalities. We aimed to examine whether the Framingham risk scoring system can be used for this purpose. METHODS: A total of 222 patients (96 women, 126 men; mean age, 59.1 ± 11.9 years) who underwent coronary angiography were enrolled in the study. Presence of > %50 stenosis in a coronary artery was assessed as critical CAD. The Framingham risk score (FRS) was calculated for each patient. CAD severity was assessed by the Gensini score. The relationship between the FRS and the Gensini score was analyzed by correlation and regression analyses. RESULTS: The mean Gensini score was 18.9 ± 25.8, the median Gensini score was 7.5 (0-172), the mean FRS was 7.7 ± 4.2, and the median FRS was 7 (0-21). Correlation analysis revealed a significant relationship between FRS and Gensini score (r = 0.432, p < 0.0001). This relationship was confirmed by linear regression analysis (ß = 0.341, p < 0.0001). A cut-off level of 7.5 for FRS predicted severe CAD with a sensitivity of 68 % and a specificity of 73.6 % (ROC area under curve: 0.776, 95 % CI: 0.706-0.845, PPV: 78.1 %, NPV: 62.3 %, p < 0.0001). CONCLUSION: Our work suggests that the FRS system is a simple and feasible method that can be used for prediction of CAD severity. As the sample size was small in our study, further large-scale studies are needed on this subject to draw solid conclusions.

Anemia in living donor kidney transplantation.

BACKGROUND: We evaluated the prevalence of pretransplantation and posttransplantation anemia and its effect on serum creatinine levels among living donor kidney transplant recipients. METHODS: We reviewed retrospectively 170 adult patients who underwent living donor kidney transplantation between 1994 and 2009. We defined anemia as hemoglobin (Hb) ≤12 g/dL for women and ≤13 g/dL for men with severe anemia as Hb <11 g/dL for both men and women (World Health Organization criteria). Patients were also categorized according to Hb levels less than or greater than 10 g/dL for correlation with recipient serum creatinine levels at months 1, 3, 6, and 12. RESULTS: Mean recipient and donor ages were 33 ± 10 and 45 ± 12 years, respectively. Mean cold ischemia time was 76 ± 43 minutes. At the time of transplantation, anemia and severe anemia prevalences were 86.7% and 58.8%, respectively. Anemia was observed in 64 patients (42.1%) at posttransplantation month 3. Pretransplantation severe anemia was a good predictor of both Hb levels and anemia presence posttransplantation. Pretransplantation anemia and severe anemia caused greater requirements for posttransplantation blood transfusions (P < .05). Younger age and female gender were significant risk factors for severe anemia pretransplantation. There was a significant correlation between posttransplantation Hb levels and serum creatinine levels at 12 month (P = .01). Recipient female gender and longer hospital stay were significant risk factors for both anemia and severe anemia posttransplantation. Higher recipient weight and history of acute rejection episode were also significant for posttransplantation severe anemia. CONCLUSION: This study indicated that successful kidney transplantation had a positive effect on Hb levels. Posttransplantation anemia predicted worse graft function in the first month after transplantation.

Comparison of complement-dependent cytotoxic and flow-cytometry crossmatch results before cadaveric kidney transplantation.

AIM: The presence of HLA donor-specific antibodies (DSA) before kidney transplantation decreases graft survival. In this study, we compared crossmatch results of kidney transplantation candidates, for cadaveric renal donation between March 10, 2012, and September 7, 2012. MATERIAL AND METHOD: The 47 kidney transplantation candidates tested for crossmatch included 10 for cadaveric donor organs. Two crossmatch methods were performed: complement-dependent cytotoxic crossmatch (CDCXM) and flow cytometry crossmatch (FCXM). Spleen cells were used as the source of lymphocytes for all crossmatch tests. RESULTS: The T and B cell ratios isolated from spleen were 38.8% and 34.8%, respectively. The concordance ratio of the two methods was 76.6% with 23.4% discordant results. Regarding the discordant results, 4.2% were positive CDCXM but negative FCXM; 191%, negative CDCXM but positive FCXM. All patients displaying positive crossmatches had a previous immunization history. As a result, we speculated that the positive CDCXM but negative FCXM results were due to the washing procedures in the FCXM disturbing antigen-antibody complexes. We suggest at least two different methods to be performed for crossmatch tests before kidney transplantation. CDCXM detects immunoglobulin G1 (IgG1) and IgG3, which are critical for rejection. FCXM is able to detect all IgG subgroups because of its high sensivity. As a result we suggest that both CDCXM and FCXM are preferrable strategies to detect DSAs.

Aortic elastic properties : effects of carvedilol versus nebivolol.

OBJECTIVES: The aim of this study was to compare the effects of the new generation ß-blocker anti-hypertensive drugs carvedilol and nebivolol on aortic elastic properties which are important indicators of hypertension-related morbidity and mortality. METHODS: A total of 50 patients who had been diagnosed with stage 1 hypertension according to the Joint National Committee (JNC) VII criteria and who had not received any anti-hypertensive treatment were enrolled in this study. Patients were randomized to receive either 25 mg/day carvedilol (n=25) or 5 mg/day nebivolol (n=25) for 3 months at the beginning of the study. Three patients (1 in the carvedilol group, 2 in the nebivolol group) who did not attend 3 month follow-up measurements were excluded from the study. The study was completed with 47 patients (25 women; mean age: 49 ± 9 years). The aortic elastic parameters such as aortic strain (AS), aortic distensibility (AD), and aortic stiffness index (ASI) were measured by echocardiography. RESULTS: Carvedilol and nebivolol provided a similar decline in both systolic and diastolic blood pressures (-12/-7 mmHg, p<0.0001 and -12/-7 mmHg, p=0.002, respectively). Both carvedilol and nebivolol induced a significant decrease in heart rate (-15 bpm, p<0.0001, -17 bpm, p<0.0001, respectively). Even though the heart rate at the end of the treatment was lower for the nebivolol group, the rate of decrease of heart rates between carvedilol and nebivolol groups was not statistically significant (p=0.074). Both groups demonstrated improvements in the diastolic functions of the left ventricle where certain values showed more improvement for the nebivolol group. Both groups showed improvements in AS and AD rates compared to basal rates; however, these improvements were not statistically significant. Although the improvement rates in AS, AD, and ASI were higher in the nebivolol group compared to the carvedilol group, the differences were not statistically significant (p=0.091, p=0.095, p=0.259, respectively). CONCLUSION: Both carvedilol and nebivolol induced a decrease in blood pressure and heart rate and showed an improvement in left ventricular diastolic functions. It was observed that both drugs did not cause deterioration in the aortic elastic properties but a slight improvement was seen. However, this improvement was not statistically significant. The improvement was more explicit in the nebivolol group. It may be concluded that nebivolol is slightly superior to carvedilol in reducing heart rate and improving left ventricular diastolic functions. However, further long-term studies with larger sample sizes should be performed in order to better define the effects of both drugs.

Persistent left superior vena cava, absence of the innominate vein, and upper sinus venosus defect : a rare anomaly detected using bubbles.

Superior vena cava anomalies are rare malformations that are typically seen with other congenital cardiac defects. Although a persistent left superior vena cava is the most common anomaly of the systemic venous return in the thorax, its combination with an upper sinus venosus defect and absence of the innominate vein is extremely rare. Here, we report a patient diagnosed with these anomalies based on a bubble study and confirmed with magnetic resonance imaging.

Tirofiban in Takotsubo cardiomyopathy. Atypical broken heart syndrome with extremely fast recovery: a case report.

Takotsubo cardiomyopathy, also known as broken heart syndrome, is similar to acute coronary syndrome. The absence of significant stenosis on coronary angiography and spontaneous improvement of ventricular akinesia are very important features that distinguish this syndrome from acute coronary syndromes. Despite the fact that ST segment elevations are typically encountered, atypical presentation without ECG changes should be kept in mind. We herein report the case of a 61-year-old woman who presented with mid-apical left ventricular akinesia resolving within 24 h.

Assessment of left ventricular systolic and diastolic dyssynchrony with tissue Doppler echocardiography in patients with heart failure and narrow QRS complex.

AIM: Cardiac dyssynchrony is a well known entity in patients with wide QRS complex (>120 ms). Dyssynchrony may also cause ventricular dysfunction in heart failure patients with narrow QRS complexes. In the study, the presence and extent of cardiac dyssynchrony were investigated in patients with heart failure both with narrow and wide QRS complexes using tissue Doppler echocardiography (TDE). METHODS: Forty-nine patients with heart failure, were included to the study. The first group of 30 patients with a QRS duration of <120 ms (23M; mean age, 64±10.1 years) and the second group consisted of 19 patients with a QRS duration of >120 ms (12M; mean age, 65±11.6 years). In order to examine cardiac synchronization, TDE was performed. Systolic and diastolic intraventricular dyssynchrony and interventricular dyssynchrony were calculated. In order to define systolic and diastolic dyssynchrony, intraventricular delay was accepted as >60 ms, and interventricular delay was accepted as >40 ms. RESULTS: Left ventricular systolic dyssynchrony was detected in 18 patients (60%) within the narrow QRS group and in 18 patients (94%) within the wide QRS group. Interventricular dyssynchrony was detected in 17 patients (56%) within the narrow QRS group and in 18 patients (94%) within the wide QRS group. For systolic dyssynchrony, correlations existed between intraventricular delay and QRS duration (r=0.48), left ventricular end diastolic diameter (r=0.62), left ventricular end systolic diameter (r=0.61), and EF (r=-0.63). Similarly, correlations existed between interventricular delay and QRS duration (r=0.58), left ventricular end diastolic diameter (r=0.65), left ventricle end systolic diameter (r=0.64), and EF (r=-0.64). CONCLUSION: The present study suggested that systolic or diastolic dyssynchrony exists despite normal levels of QRS duration.

Effects of impaired fasting glucose on aortic elasticity.

The pathophysiology of atherosclerosis development in patients with diabetes mellitus (DM) is similar to that in nondiabetics. However, atherosclerosis develops earlier and runs a rapid course in patients with diabetes. Aortic stiffness, strain and distensibility are the parameters used to assess an increase in arterial stiffness and can be measured by invasive and non-invasive methods.Aortic elastic properties were compared among patients with normal oral glucose tolerance test but impaired fasting glucose and healthy individuals. The study group consisted of 50 subjects with impaired fasting glucose who had no known risk factors for atherosclerosis. The control group was composed of the same number of volunteers.It was found that aortic strain and distensibility were reduced (8.78±4.3 vs. 10.65±2.6 p<0.01 and 4.1±2.1 vs. 5.1±1.7 p<0.01 respectively) and aortic stiffness index was significantly increased (6.9±3.2 vs. 5.01±1.6, p<0.0001) in patients with impaired fasting glucose compared to those in the control group.It was demonstrated that aortic elasticity was impaired in those with impaired fasting glucose, which indicates that these patients should be kept under close follow-up for cardiovascular events.

Evaluation of P wave and corrected QT dispersion in subarachnoid haemorrhage.

The aim of our study was to investigate P wave dispersion (Pwd), QT corrected QT (QTc), QT dispersion (QTd) and corrected QT dispersion (QTcd) intervals in subarachnoid haemorrhage. Thirty-five subarachnoid haemorrhage patients (Group S) and 35 neurologically normal patients (Group C) were included in this retrospective study. The standard 12 derivations of the electrocardiograms of all patients were analysed and Pwd, QT and QTd intervals were measured. QTc and QTcd intervals were determined with the Bazett formula. There was no significant difference between the study groups according to demographic characteristics, hypertension and diabetes mellutus incidences (P > 0.05). The Pwd, QT, QTc, QTd and QTcd durations of Group S were significantly longer than those of Group C (P < 0.001). Subarachnoid haemorrhage patients may have a higher likelihood of arrhythmia during anaesthesia and in intensive care due to extended QTcd and Pwd durations.