Antiplatelet and invasive treatment in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency and acute coronary syndrome. The safety of aspirin.

WHAT IS KNOWN AND OBJECTIVE: Aspirin is an important drug in acute coronary syndromes (ACS) and percutaneous coronary interventions (PCI). However, its use is contraindicated in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency (risk for haemolytic anaemia). We report the management of 2 patients with class II G6PD deficiency and non-ST-segment elevation ACS (NSTE-ACS). CASE DESCRIPTION: The two patients were safely and efficiently treated with dual antiplatelet treatment (DAPT, aspirin plus ticagrelor) and PCI using new-generation drug-eluting stent (DES) despite G6PD deficiency. WHAT IS NEW AND CONCLUSION: NSTE-ACS management with DAPT and DES is probably safe and effective in class II G6PD-deficient patients.

Cardiovascular risk factor(s) prevalence in Greek hypertensives. Effect of gender and age.

The aim of this study was to determine cardiovascular (CV) risk factors (RFs) and target organ damage clustering in 21280 Greek hypertensives stratified by gender and age. Glycemic and lipid profile were determined, left ventricular mass index, estimated gromerular filtration rate (eGFR), 10-years CV risk according to Framingham risk score (FRS) and HeartScore (HS) were calculated. Only 10.2% of patients had no concomitant RFs, 53.1% had one (48.8% dyslipidemia, 3.4% smoking, 0.9% diabetes), 32.9% had two (26% dyslipidemia and smoking, 6.6% dyslipidemia and diabetes, 0.3% smoking and diabetes) and 3.7% had all four traditional RFs. Obesity was present in 30%, metabolic syndrome in 38%, low eGFR in 24% and left ventricular hypertrophy in 49%. Mean FRS risk was 35% for males, 24.1% for females whereas in high risk (>20%) were 68.7 and 50.7%, respectively (P<0.0001). Mean HS risk was 8.4% for males, 6.2% for females whereas in high risk (>5%) were 48.6 and 36.2%, respectively (P<0.0001). Age was correlated to pulse pressure, eGFR, left ventricular mass index and CV risk (P<0.0001). Ageing increased the risk difference between genders for total (P=0.001) but not for fatal events (P=nonsignificant). In conclusion, as RFs cluster in hypertensives, CV risk calculation should guide treatment decisions.

Exercise duration as a determinant of vascular function and antioxidant balance in patients with coronary artery disease.

BACKGROUND: Exercise improves the clinical outcome of patients with coronary artery disease (CAD); however, the ideal exercise duration for each patient remains unclear. OBJECTIVE: To investigate the effects of exercise duration on arterial elastic properties and antioxidant/pro-oxidant mechanisms in patients with CAD. DESIGN, SETTING, PATIENTS, INTERVENTIONS: Sixty male patients with CAD were randomised into two groups, and underwent exercise for 30 min or 60 min in a crossover design with 2 weeks' wash-out period. In all participants aortic and radial blood pressures (BP) and arterial elastic properties (augmentation index (AIx)/pulse wave velocity (PWV)) were determined at baseline and 24 h after exercise. Plasma malonyldialdehyde (MDA) and superoxide dismutase (SOD)1 and SOD2 levels were also measured. RESULTS: Exercise had no effect on aortic and radial BP (p=NS for all). Walking for 30 min improved AIx (from 33.79 ± 0.91% to 31.73 ± 0.86%, p<0.001) and PWV (from 9.26 ± 0.95 m/s to 9.06 ± 0.21 m/s, p<0.001), while exercise for 60 min had adverse effects on vascular stiffness (for AIx: from 33.37 ± 0.93% to 33.73 ± 1.05%, p=NS and for PWV: from 9.25 ± 0.19 m/s to 9.37 ± 0.21 m/s, p < 0.05 mainly in older patients). Exercise for 60 min was associated with a significant 20% increase in MDA levels (p<0.05). Exercise had no effects on SOD1 levels, however it significantly increased SOD2 levels after 30 min (from 2.26 ± 0.22 ng/mL to 2.36 ± 0.18 ng/mL, p < 0.05) but not after 60 min (p=NS). Conclusion Shorter exercise duration was associated with favourable antioxidant and vascular effects, while longer exercise blunted these beneficial effects and was accompanied by adverse effects on vascular function, mainly in older coronary patients. Further studies are required to explore the hypothesis that a more individualised approach to the selection of the appropriate exercise programme should be considered for patients with CAD.

Laparoscopic versus open cholecystectomy. An analysis of clinical and financial aspects.

BACKGROUND: The aim of this study is to assess the clinical and financial aspects of laparoscopic cholecystectomy (LC) compared to open cholecystectomy (OC). METHODS: Thirty-six patients treated with LC were prospectively, not randomized, compared with 35 patients that underwent OC. The data used were taken from local registers, patient-statistics and hospital accounting systems. We evaluated the costs, morbidity and mortality for both surgical procedures. RESULTS: Significant differences were observed concerning the number of days that pain was suffered (mean 7.6 days in LC versus 18.5 days in OC), the duration of postoperative hospitalization (LC mean 2-3 days; OC 7-9 days), the extent of postoperative monitoring performed, and the number of days in order to return to normal activity (mean 4.4 days in LC; mean 7.6 days in OC). Calculation of the costs was based on the Diagnosis Related Groups (DRG). The profit for a DRG is the result of the difference between the reimbursement obtained from the execution of the operation and the cost in order to carry it out. The total cost for the execution of LC is Italian 3,332,632 pound sterling with a profit of Italian 1,208,807 pound sterling while for OC the cost is 4,007,359 pound sterling and the profit is 347,041 pound sterling. CONCLUSIONS: The results of our study is that, clinically and financially, LC has obvious advantages over OC.

Acute biliary pancreatitis: staging and management.

BACKGROUND/AIMS: Acute biliary pancreatitis is a clinical entity with a high morbidity rate (15-50%) and mortality rate (20-35%). Early diagnosis has a primary importance for an appropriate treatment (75% of cases of idiopathic acute pancreatitis are of biliary origin). METHODOLOGY: Diagnosis of acute biliary pancreatitis in 78 patients was based on careful clinical and instrumental assessment: ultrasonography (76.9% of cases) and laboratory tests in 23.1% of cases. In our study we used the Ranson and APACHE II scores and 24 of the cases (30.7%) were classified as severe, while 54 (69.2%) were mild. All patients with severe acute biliary pancreatitis underwent emergency endoscopic retrograde cholangiopancreatography + endoscopic sphincterotomy (within 24-48 hours) followed by laparoscopic cholecystectomy (10 days). Patients with mild acute biliary pancreatitis underwent laparoscopic cholecystectomy associated with intraoperative cholangiography, within 10 days. RESULTS: In 19 patients with severe acute biliary pancreatitis operative endoscopy was curative. Subsequent laparoscopic cholecystectomy provoked subcutaneous emphysema only in one case but did not show any other serious morbidity. In the remaining 5 cases laparotomy was required because of necrosis, with a mortality rate of 60%. In all cases of mild acute biliary pancreatitis, laparoscopic cholecystectomy was successfully performed with a morbidity rate of 7.3%. Common bile duct stones were revealed with intraoperative cholangiography in 31.4% of the mild cases and in 75% of the severe cases. CONCLUSIONS: In conclusion acute biliary pancreatitis treatment is always surgical; in almost all severe cases it is performed with minimally invasive procedures (endoscopic retrograde cholangiopancreatography + endoscopic sphincterotomy with laparoscopic cholecystectomy < or = 10 days) if surgery is carried out within 24-48 hrs, as well in the mild cases (laparoscopic cholecystectomy + intraoperative cholangiography) when surgery is performed within 10 days.

[Inflammatory markers after laparoscopy versus laparotomy cholecystectomy]. / Markers infiammatori post colecistectomia laparoscopica versus laparotomica.

OBJECTIVE: The study is carried out to determine whether the level of IL-6 is altered and in what way after surgery as well as if such a change could be an indicator of increased morbidity after surgical treatment. MATERIALS OF THE STUDY: Chemiluminesence immunoeassay system was used in order to establish IL-6 level in blood samples of 71 patients that underwent abdominal surgery, 36 Laparoscopic Cholecystectomy (LC) and 35 Open Cholecystectomy (OC) at time 0 (before the operation), 1 h, 2 h, 3 h, 6 h, 24 h and 48 h after the operation. RESULTS: Plasma IL-6 levels are significantly increased after OC; we observed 3 cases of post-operative infections, in which IL-6 returned to normal levels 6 days after surgery. Analogous variation to the IL-6 levels was noted for the C-reactive protein levels. DISCUSSION: Laparoscopic cholecystectomy, a so called mini-invasive surgical procedure, is associated to a small increase of IL-6 serum levels and provides better post-operative conditions to the patients by reducing surgical stress and the infectious complications correlated to the surgical procedure. CONCLUSIONS: During OC there is a significant higher elevation of IL-6 serum levels than after laparoscopic cholecystectomy. Variation of C-reactive protein serum levels after surgery is analogous to variation of IL-6 levels.

Prevalence of autoantibodies against contractile proteins in coronary artery disease and their clinical implications.

In this initial study, we found that autoantibodies against actin and myosin were present during and after an acute coronary syndrome. Moreover, they correlated with persistent troponin-I elevation at follow-up, and with late myocardial infarction.

[Structure, function, and levels of neutrophil elastase after laparoscopic cholecystectomy]. / Struttura, funzione e livelli dell'elastasi neutrofila dopo videolaparocolecistectomia.

Neutrophil elastase is a neutral proteinase present mainly in the azurophilic granules of segmented granulocytes, the main cells involved in the inflammatory response reaction. In our study we attempted to determine whether an enzyme such as neutrophil elastase produced by polymorpho-nuclear leukocytes could be an indicator capable of determining the degree of surgical trauma, comparing two surgical approaches, namely, laparoscopic cholecystectomy and open cholecystectomy. Plasma neutrophil elastase was determined photometrically, using an immune-activation immunoassay, in 66 patients (32 patients underwent open cholecystectomy and 34 laparoscopic cholecystectomy) 1 day before surgery and 1, 3, 6 and 12 days after surgery. We established a reference range for elastase by measuring the serum elastase concentration in 48 healthy control patients. A significant increase (p < 0.05) in plasma neutrophil elastase levels was observed on days 1, 3 and 6 after surgery in patients undergoing open cholecystectomy, whereas the levels of the enzyme were almost stable in patients undergoing laparoscopic cholecystectomy. We recorded two cases (6.2%) of respiratory tract infections in the "open" group. Neutrophil elastase is a good indicator for discriminating the severity of the surgical trauma, which is certainly more severe in laparotomy than in laparascopic cholecystectomy. Peripheral leukocyte function seems to be better preserved after laparoscopic surgery than after laparotomy.