[Impact of the practice of "Extended Focused Assessment with Sonography for Trauma" (e-FAST) on clinical decision in the emergency department]. / Acil serviste "Genisletilmis Acil Travma Ultrasonografisi" uygulamalarinin klinik karar üzerine etkisi.

BACKGROUND: We aimed to show the sensitivity of Extended Focused Assessment with Sonography for Trauma (e-FAST) for detection of pneumothorax, hemothorax and intraabdominal injury. We also investigated the relationship between e-FAST and need for invasive treatment. METHODS: This study included patients who experienced multiple trauma. The emergency physician, who had no clinical information about the patient, performed e-FAST. Findings on a supine chest X-ray and invasive interventions were recorded. The results of abdomen and thorax computed tomography (CT) were reviewed (the size of the pneumothorax was scored). RESULTS: Compared with CT, the sensitivities of e-FAST for intraabdominal injury and hemothorax were 54.5% and 71%, respectively. The patients with hemothorax and intraabdominal injuries were not identified with e-FAST, didn't need for invasive intervention. Pneumothorax diagnosis was established in 27 patients with e-FAST (sensitivity 81.8%) from among 33 (30.8%) pneumothorax patients. According to the grading on CT, pneumothoraces less than 1 cm in width and not exceeding the midcoronal line in length were not identified. e-FAST was positive for all patients performed with tube thoracostomy. CONCLUSION: e-FAST can be used with high sensitivity for determination of pneumothorax requiring invasive procedure. It has low sensitivity in the diagnosis of intraabdominal injury and hemothorax; however, e-FAST can predict the need for invasive procedures.

[Cardiac rehabilitation in the elderly patient]. / Yasli hastalarda kardiyak rehabilitasyon.

As it is the case globally, cardiovascular diseases (CVD) make up the most frequent cause of death in Turkey also. Due to this fact, cardiac rehabilitation (CR) has gained a highly important role in the treatment of coronary artery diseases. In Turkey, mortality and morbidity rates among the elderly patients are significantly high. Disability due to coronary artery diseases is more frequent in the elderly compared to young patients. So, it is clear that CR has a considerable importance in this special group of patients. CR program consists the following core components; early initial assessment of the patient, nutritional counseling, management of lipid profiles, education to quit smoking, weight control, treatment and control of diabetes, emotional assessment and support, physical activity referral and exercise training. All cardiac patients, both the inpatient and outpatient groups can be recruited in the CR program. It is recommended to keep the exercise intensity between 40-80% of the patient's capacity. Exercise and aerobic training should be given together and while doing this, co-morbidities and the drugs currently used by the patient should be taken into account. In conclusion, CR is recommended to be started just after the acute phase of the disease has resolved or the patient is dismissed from the intensive care unit. Periodic follow up and 30 minute of aerobic exercise which is preffered and can be easily performed by the patient every two or three times a week will be adequate to keep the capacity regained. Especially for the patients over 75 years of age, CR program should be considered as a long-term condition management.

[Dyslipidemia and cardiovascular risk assessment in HIV-positive patients]. / HIV pozitif hastalarda dislipidemi ve kardiyovasküler risk degerlendirilmesi.

OBJECTIVE: Dyslipidemia is a major complication of antiretroviral treatment. Aim of the present study was to screen baseline lipid levels and cardiovascular disease risk in HIV-positive patients and analyze change in those parameters after initiation of antiretroviral treatment (ART). METHODS: HIV-positive patients who presented at our clinic between April 2011 and August 2012 were included. Study included 19 female (22.1%) and 67 male (77.9%) patients (mean age 39.5±10.3 years). Blood pressure, smoking habit, alcohol consumption, serum total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), glucose level, and antiretroviral treatment status data were reviewed retrospectively. Changes in lipid profile and lifetime risk for atherosclerotic cardiovascular disease (ASCVD) according to the American College of Cardiology guidelines were compared with baseline data and analyzed. RESULTS: At baseline, 13 (15.1%) patients were already receiving ART and 73 (84.9%) patients were treatment-naive or had stopped therapy ≥3 months prior to enrollment. At last visit, 73 (84.9%) patients were taking ART. Results of baseline and final visit TC levels were 175.5 mg/dL (range: 90-346 mg/dL) and 196.5 mg/dL (range: 104-317 mg/dL), respectively (p=0.001). HDL levels were 40 mg/dL (range: 21-81 mg/dL) and 35 mg/dL (range: 10-75 mg/dL; p=0.001), and LDL levels were 101.5 mg/dL (range: 32-191 mg/dL) and 120.5 mg/dL (range: 32-250 mg/dL; p<0.001). TG levels were 145.5 mg/dL (range: 43-2580 mg/dL and 152.5 mg/dL (range: 67-884 mg/dL; p=0.102). Baseline ASCVD risk score was 46% (range: 5-69%) while last visit ASCVD risk score was 50% (range: 5-69%; p<0.001). CONCLUSION: HIV infection has adverse effects on lipid profiles and cardiovascular risk of HIV-positive patients. Therefore, patients should be closely monitored for lifestyle interventions and lipid-lowering agents.

A Randomised Comparison of the Effects of Nebivolol and Atenolol with and without Chlorthalidone on the Sexual Function of Hypertensive Men.

BACKGROUND AND OBJECTIVE: Erectile dysfunction, which is common in men with hypertension, has been reported as a common adverse effect of many antihypertensive drug classes, including beta-blockers and diuretics. Atenolol and nebivolol are both beta(1)-selective blockers, but nebivolol is a new-generation compound with nitric oxide-mediated vasodilating activity. The aim of the study was to compare the effects of nebivolol and atenolol +/- chlorthalidone on the sexual function of hypertensive men. METHODS: A total of 131 male patients (mean age 47.3 +/- 4.6 years) with newly diagnosed hypertension were included in the study. All the patients were married and had not previously experienced any erectile dysfunction. After a 4-week placebo run-in period, patients were randomised to receive 12 weeks' therapy with nebivolol 5 mg/day (n = 43), atenolol 50 mg/day (n = 44), or atenolol 50 mg/day + chlorthalidone 12.5 mg/day (n = 44), according to a double-blind design. After 4 weeks of treatment, drug dosage could be doubled in patients not responding to therapy. Erectile function (instances of successful intercourse/month) was assessed by means of a questionnaire at the end of the placebo run-in period (baseline) and at the end of double-blind treatment. Blood pressure was also assessed at these times. RESULTS: At the end of the 12-week, double-blind treatment period, the mean number of episodes of satisfactory sexual intercourse per month was significantly decreased from baseline in the groups receiving atenolol (from 7.0 to 3.7; p < 0.01) and atenolol + chlorthalidone (from 6.4 to 2.8; p < 0.01). In contrast, the mean number of episodes of satisfactory sexual intercourse per month remained constant in the group of patients receiving nebivolol (6.4 during the baseline assessment and 6.0 during the last month of treatment). Blood pressure and heart rate were significantly decreased from baseline in all treatment groups. CONCLUSION: Increased release of nitric oxide associated with nebivolol may counteract the detrimental effect of beta-blockade on penile erection, thereby allowing maintenance of sexual activity in previously untreated hypertensive men compared with a significant decrease observed in the sexual activity of men receiving atenolol-based treatment.

Comparison of Conventional Radiography and Digital Computerized Radiography in Patients Presenting to Emergency Department.

OBJECTIVES: To compare the differences between conventional radiography and digital computerized radiography (CR) in patients presenting to the emergency department. METHODS: The study enrolled consecutive patients presenting to the emergency department who needed chest radiography. Quality score of the radiogram was assessed with visual analogue score (VAS-100 mm), measured in terms of millimeters and recorded at the end of study. Examination time, interpretation time, total time, and cost of radiograms were calculated. RESULTS: There were significant differences between conventional radiography and digital CR groups in terms of location unit (Care Unit, Trauma, Resuscitation), hour of presentation, diagnosis group, examination time, interpretation time, and examination quality. Examination times for conventional radiography and digital CR were 45.2 and 34.2 minutes, respectively. Interpretation times for conventional radiography and digital CR were 25.2 and 39.7 minutes, respectively. Mean radiography quality scores for conventional radiography and digital CR were 69.1 mm and 82.0 mm. Digital CR had a 1.05 TL cheaper cost per radiogram compared to conventional radiography. CONCLUSIONS: Since interpretation of digital radiograms is performed via terminals inside the emergency department, the patient has to be left in order to interpret the digital radiograms, which prolongs interpretation times. We think that interpretation of digital radiograms with the help of a mobile device would eliminate these difficulties. Although the initial cost of setup of digital CR and PACS service is high at the emergency department, we think that Digital CR is more cost-effective than conventional radiography for emergency departments in the long-term.

Association between serum paraoxonase activity and oxidative stress in acute coronary syndromes.

OBJECTIVE: The oxidation of low-density lipoprotein (LDL) is believed to have a central role in atherogenesis. Under oxidative stress not only LDL, but all other serum lipids are exposed to oxidation. High-density lipoprotein (HDL)-associated paraoxonase (PON1) was shown to inhibit LDL and HDL oxidation. We investigated the relationship between PON1 and oxidative stress in acute myocardial infarction and unstable angina in a comparative fashion. METHODS AND RESULTS: Activities of PON1, concentrations of malondialdehyde (MDA), lipids and lipoproteins were measured in patients (38 subjects with acute myocardial infarction and 33 subjects with unstable angina pectoris) and in age- and sex-matched controls (32 subjects). Serum PONI activity was significantly lower in patients than in controls (p < 0.001). Patients had significantly increased serum MDA concentrations (p < 0.001) and there were strong negative correlations (p < 0.001) between serum PON1 and MDA levels in the acute myocardial infarction group (r = -0.673), in the unstable angina pectoris group (r = -0.868) and in healthy controls (r = -0.778). Serum HDL-cholesterol (HDL-C) concentrations were lower in patients than controls (p < 0.05). No correlation was observed between PON1 and HDL-C levels in patients or controls. Apo A I concentrations were significantly lower in the patient groups (p < 0.01), but were insignificant between patients with AMI and UAP. Apo A-I and PON1 levels did not show any correlation. Apo B concentrations were lowest in the healthy controls, higher in the UAPgroup and highest in the AMI group (p < 0.001). In the acute myocardial infarction group LDL/apo B ratio was lower than in healthy controls and in the UAP group, suggesting smaller LDL particle size. CONCLUSIONS: Results of this study indicate that lower serum PON1 activity is associated with oxidative stress and the activity of PON1 is not related to HDL-cholesterol.

Comparison of candesartan and felodipine alone and combined in the treatment of hypertension: a single-center, double-blind, randomized, crossover trial.

BACKGROUND: In the past decade, many studies have indicated that the combination of low doses of different classes of antihypertensive agents may be more efficacious than monotherapy while minimizing the likelihood of dose-dependent adverse effects (AEs). OBJECTIVE: The aim of this study was to determine whether combination therapy with lower doses of candesartan and a calcium antagonist, felodipine, would be more effective and tolerable in controlling mild to moderate hypertension compared with either drug used alone. METHODS: In this 18-week, single-center, double-blind, crossover study, patients with mild to moderate essential hypertension were randomized to 1 of 2 treatment groups after a 2-week placebo washout period. Patients in group 1 received candesartan 16 mg once daily and patients in group 2 received felodipine 5 mg once daily, for 6 weeks. All patients then received half-dose combination therapy (candesartan 8 mg plus felodipine 2.5 mg, once daily) for 6 weeks. Finally, patients received 6 weeks of monotherapy with the alternate medication (group 1 received felodipine 5 mg once daily and group 2 received candesartan 16 mg once daily). RESULTS: Thirty patients (18 men, 12 women; mean [SD] age, 54.0 [4.9] years; range, 39-62 years) were included in the study. During both monotherapy periods, candesartan and felodipine significantly reduced blood pressure (BP) (both P<0.001). BP further decreased with combination therapy (P<0.001 in both groups). Overall, 90.0% (27/30) of the patients achieved the target BP at the end of combination therapy. The incidence of AEs was similar with combination therapy compared with either monotherapy. CONCLUSIONS: In this study population, candesartan and felodipine had additive effects when used in combination, even at low doses, in the treatment of hypertension. Therefore, the combination of candesartan and felodipine is an effective alternative to that of candesartan and hydrochlorothiazide.

Structure of the human tricuspid valve leaflets and its chordae tendineae in unexpected death. A forensic autopsy study of 400 cases.

OBJECTIVE: Congenital variations are known to be potential candidates for mechanical trauma leading to tricuspid valve lesions. For this reason, a detailed examination of heart valves as well as chordae tendineae should carefully be performed to clarify the reason of sudden death with no apparent cause. The aim of this study is to investigate the relationship of valvachordal anatomy in tricuspid valve in sudden deaths, and mainly cardiac disease in connection with its structure as well as leading congenital changes. METHODS: The 400 human hearts were collected between 2000 and 2002 from 400 autopsy cases during a medicolegal autopsy with permission from the Council of Forensic Medicine, Izmir, Turkey. Morphometric and morphological data were obtained in Ege University Faculty of Medicine, Department of Anatomy from each valve namely area, basal width, depth of leaflets, depth of commissure, number of chordae tendineae and their relation to the leaflets. These data were correlated for cardiac and noncardiac death cases. RESULTS: The results of this anatomical study may explain the increased incidence in wide variations of chordae tendineae in deaths of cardiac origin. In 40 hearts, we found 2 leaflets (20%), in 140 (70%) 3 leaflets and in 20 hearts there were 4 leaflets (10%) in deaths of noncardiac origin. We found 2 leaflets in 36 hearts (18%), 3 leaflets in 130 hearts (65%) and there were 4 leaflets in 34 hearts (17%) in deaths of cardiac origin. Although chordal abnormalities were extremely rare in cardiac death cases, some chordae tendineae retained a normal or near-normal appearance, while others were thickened and shortened in cardiac death cases. Higher ratio of abnormal chordae that were too short and too thick was also significant. CONCLUSION: This condition negatively affects the feeding of chordae and leaflets and acts as a culprit of cardiac deaths, since aging starts at an early stage. This situation changes the verdict in legal affairs. For this reason, the valvachordal structure should be carefully examined prospectively in autopsies.

Variations in the papillary muscles of normal tricuspid valve and their clinical relevance in medicolegal autopsies.

OBJECTIVE: In our study, tricuspid valves in cases of sudden death secondary to congenital differences of the tricuspid valve with significant papillary muscle anatomy were investigated. No studies of papillary muscle anatomy of the tricuspid valve have been found in medicolegal autopsies in literature. The purpose of our study is to investigate the relationship of papillary muscle in tricuspid valve in cases of sudden deaths, especially those resulting from cardiac disease, with the muscle structure, as well as the number of the muscle leading congenital changes. METHODS: The study was carried out in the Department of Anatomy, Faculty of Medicine, Ege, University, Izmir, Turkey and comprised of 400 human hearts obtained between 2000 and 2002 from 400 autopsy cases during a medicolegal autopsy with permission from the Council of Forensic Medicine, Izmir. Quantitative and morphological aspects of the papillary muscles of the right ventricle were evaluated. The criteria such as number, incidence, length and shape of the anterior, (APM) septal (SPM) and posterior papillary muscles (PPM) have been observed. RESULTS: Although the papillary muscle presented great variability in numbers, with a minimum of 2 and a maximum of 9 papillary muscles in the right ventricle, there were usually 3 papillary muscles in the right ventricle; APM, PPM and SPM. The one headed APM was found to be more often in cardiac deaths. However, observing more frequent conical and flat topped configurations in all PPM was striking. The absence or lower ratio, or both of attachment bridges of SPM and APM/PPM in deaths of cardiac origin is also significant. We have found that the presence of this attachment is higher in deaths of noncardiac origin. CONCLUSION: This anatomical study may explain the increased in incidence wide variations of papillary muscle tricuspid valve in deaths of cardiac origin. The verdict in legal affairs may change with this. The knowledge regarding wide variations and minor anatomical abnormalities of papillary muscle helps forensic examiners not to get confused at unexpected deaths.

The effect of combination therapy on regression of left ventricular hypertrophy in cases with hypertension.

OBJECTIVE: Up to this date, it is well shown that several antihypertensive drugs have different regressive effect on left ventricular hypertrophy (LVH). However, there are different studies regarding the effect of antihypertensive combination therapies on regression of LVH. In this study, 2 different combinations ACE-I plus calcium channel blocker and ACE-I plus diuretic were compared in cases with hypertension whose BPs were not controlled by ACE-I alone. METHODS: Forty patients with mild to moderate hypertension were included in this study. The treatment was continued for 6 months in the Faculty of Medicine at Ege University, Turkey, between January and December 2003. Adequate response with lisinopril 20 mg/daily failed to be achieved in all patients. Patients divided into 2 groups. There were no differences between the groups in patients' age, blood pressure (BP) and other clinical and laboratory range. First group patients received lisinopril 20 mg + nifedipine GITS 30 mg and second group patients received lisinopril 20 mg + hydrochlorothiazide 25 mg. The treatment was continued for 6 months. Blood pressure were measured every 2 weeks, echocardiographic findings, and blood and urinary analysis were performed before and at the end of treatment. RESULTS: Systolic and diastolic BP decreased significantly in both groups and no significant difference regarding BP was found between the 2 groups. Left ventricular mass index also decreased significantly in both groups. However, in the first group left ventricular mass index decreased more compared to the second group. CONCLUSION: The effect of combination therapies with angiotensin converting enzyme inhibitor (ACE-I) plus diuretic and ACE-I plus calcium channel blocker on systolic and diastolic BP are similar. However, when LVH is present, regressive effect of the combination of ACE-I plus calcium channel blocker is superior to the combination of ACE-I plus diuretic.

Anatomic variability of the coronary arterial orifices.

OBJECTIVE: Anatomical differences in coronary orifices (CO) are important as they are associated with myocardial ischemia and sudden death. The location of coronary orifices to the aortic valve has been studied since it is a determining point in surgical and radiological attempts. METHODS: The number, position, and shape of the CO, and their relation to the sinotubular junction (SJ), were studied in 100 normal adult hearts. Student-t test, one- and two-way ANOVA with posthoc Tukey's HSD tests were applied for statistical analysis. RESULTS: The mean height of the right, non- and left coronary sinuses were 18.75+/- 1.71, 17.86+/- 1.55 and 16.41+/- 1.21 mm, respectively. The mean height of the right, non- and left coronary cusps were measured as 16.2+/- 1.2, 15.9+/- 1.1 and 12.3+/- 2.1 mm, respectively. The left coronary artery (LCA) was observed to arise from the lower part of the SJ in 58% of the patients, while in 29% of them it originated from the SJ, and in 13% of the cases it arose from the upper part of the SJ. The right coronary artery (RCA) arising from the lower part of the SJ was seen in 78% of the patients, while it originated from the SJ in 13% of the patients, and it was observed to arise from the upper part of the SJ in 9 specimens. The diameters of the LCA and RCA were measured as 4.22+/- 0.72 and 3.32+/- 0.82 mm, respectively. An accessory orifice was found on the left in 47 specimens, while it was seen on the right in 54 of them. CONCLUSIONS: The location of the CO should be identified according to the vertical and horizontal surfaces of the sinus. In this study, the frequency of the coronary artery orifices with different locations was provided. Such data will increase the success of coronary interventions and decrease complication rate.