Application of a topical vapocoolant spray decreases pain at the site of initial intradermal anaesthetic injection during ultrasound-guided breast needle biopsy.

AIM: To assess whether the application of a topical vapocoolant spray immediately prior to initial intradermal anaesthetic injection during ultrasound-guided breast biopsy decreases pain at the site of the initial injection. MATERIALS AND METHODS: In this institutional review board-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study, 50 women aged 49.1 ± 1.6 years (mean ± standard error) were recruited and provided written informed consent. Participants served as their own controls and were blinded as to whether a topical vapocoolant spray or a placebo was used immediately prior to the initial local anaesthetic injection at two separate biopsy sites. With the exception of the application of vapocoolant or placebo, the entire ultrasound-guided procedure was performed according to a routine protocol. Participants recorded pain at initial injection site on a visual analogue scale. General linear mixed models for repeated measures analysis of variance and a 0.05 significance level were used. RESULTS: Application of topical vapocoolant spray was shown to significantly decrease pain at the site of initial intradermal anaesthetic injection as compared to placebo (p<0.001). Treatment effect was independent of age of the subject, race/ethnicity, operator, type of biopsy device, and histopathology result. No complications from vapocoolant spray use were reported. CONCLUSION: Application of a topical vapocoolant spray immediately prior to initial intradermal anaesthetic injection during ultrasound-guided breast biopsy significantly decreases pain at the site of the initial injection and could contribute to improve the patient's overall procedural experience.

Illicit drug use and cardiometabolic disease risk: an analysis of 2005-2008 National Health and Nutrition Examination Survey data.

PURPOSE: To explore the association between illicit drug use (IDU) and cardiometabolic disease risk factors (CDRF) in a nationally representative sample of adults. METHODS: The 2005-2008 National Health and Nutrition Examination Surveys data from 20- to 45-year-old adults (n = 8738) were utilised to analyze the relationship between IDU (ever used, repeated use and current use) and CDRF (hyperlipidemia, hyperinsulinemia, hypertension, elevated C-reactive protein, body mass index, waist circumference and cigarette use) via chi square and logistic regression analyses. Age, gender, race/ethnicity, education level, poverty to income ratio (PIR), and alcohol use were included as confounders in the models. RESULTS: Individuals who reported drug use (DU) at least once in lifetime were more likely to have CDRF than non-DU (NDU) (OR = 1.3, p = 0.004). Females with DU, IDU at least once in lifetime, and with repeated IDU were about 1.5 times more likely than their NDU counterparts to have CDRF (p < 0.0001, p = 0.02, p = 0.02, respectively). CONCLUSION: Results from this study suggest that healthcare professionals should be aware that patients with a history of DU may be at heightened risk for cardiometabolic disease. Females in particular have a heightened cluster of CDRF across drug-use categories.

Duration of analgesia and pruritus following intrathecal fentanyl for labour analgesia: no significant effect of A118G µ-opioid receptor polymorphism, but a marked effect of ethnically distinct hospital populations.

BACKGROUND: Genetic polymorphism (A118G) in the µ-opioid receptor has been reported to affect systemic opioid analgesia. However, reported pharmacogenetic effects on spinal opioid analgesia, particularly in labour, have been equivocal. METHODS: We prospectively assessed effects of the µ-opioid receptor A118G single nucleotide polymorphism (SNP) on analgesia after 20 µg of spinal fentanyl. We studied two ethnically distinct hospital populations (Miami and Jerusalem). Independent variables were A118G, ethnicity, and hospital. Primary outcome was time from spinal analgesia until analgesic request. Secondary outcomes were pain and pruritus, assessed at repeated intervals until analgesia request. RESULTS: One hundred and twenty-five nulliparous parturients in early labour were analysed. The allelic frequency of A118G was 14.8% (14.4% in Miami; 15.5% in Jerusalem). Time to analgesia request (sd) in Miami was 122 (44) min and in Jerusalem was 87 (32) min, P<0.001; Hispanic 123 (46) min vs Jew/Arab 87 (32) min, P<0.001; Black 121 (41) min vs Jew/Arab 87 (32) min, P=0.015. There was no significant effect of A118G. Survival analysis showed Miami > Jerusalem, P<0.001; Hispanics and Black > Jew/Arab, P<0.001; no effect of A118G. Within hospital groups, A118G had no effect on time to analgesic request; within genomic groups there was a significant difference between hospitals. The time-course for pruritus exactly paralleled the time-course for analgesia and was affected by hospital (P=0.006) and by ethnic group (P=0.03), but not by A118G. CONCLUSIONS: We found no significant effect for the A118G single nucleotide polymorphism (SNP) on analgesic duration after spinal fentanyl for labour. In contrast, ethnically distinct hospital population groups exerted a marked effect on the time-course of both analgesia and pruritus.

Aerobic training does not alter CRP in apparently healthy, untrained men.

AIM: Regular aerobic exercise may reduce cardiovascular disease (CVD) risk by lowering the concentration of inflammatory markers, such as C-reactive protein (CRP). While studies in diseased populations have shown significant decreases in CRP concentrations with regular aerobic training, little has been conclusively determined regarding the effects of aerobic training on CRP concentrations in apparently healthy, untrained populations. Aim of the study was to examine the effects of a 17-wk half marathon training program (TP) on CRP concentrations, aerobic fitness, and body composition in apparently healthy, untrained men. METHODS: Twenty men (29.3±1.0 y) enrolled as training subjects (TRN) in a 17-wk half marathon TP. An additional 22 men (27.8±1.4 y) served as controls (CON). Fasting blood samples were taken at four time points over the TP and were analyzed for CRP and interleukin-6 (IL-6) concentrations. Aerobic capacity (VO2max) and body fat percent (BF%) were measured before and after the TP. RESULTS: No significant post-training changes in CRP (P=0.70) or IL-6 concentrations (P=0.67) were seen in TRN as a result of the TP, despite significant improvements in VO2max (42.2±1.9 ml∙kg-1∙min⁻¹, P<0.0001) and significant reductions in resting heart rate (P=0.004), BF% (P=0.03), and body mass index (BMI, P=0.05). No significant changes in CRP, VO2max, BMI, or BF% were detected in CON over time. CONCLUSION: Regular aerobic training does not appear to affect CRP concentrations in apparently healthy, untrained men despite significant improvements in bodyweight, BF%, BMI, and VO2max.

Associations of age, gender and body mass with 1H MR-observed brain metabolites and tissue distributions.

Recent reports have indicated that a measure of adiposity, the body mass index (BMI), is associated with MR-observed brain metabolite concentrations and tissue volume measures. In addition to indicating possible associations between brain metabolism, BMI and cognitive function, the inclusion of BMI as an additional subject selection criterion could potentially improve the detection of metabolic and structural differences between subjects and study groups. In this study, a retrospective analysis of 140 volumetric MRSI datasets was carried out to investigate the value of including BMI in the subject selection relative to age and gender. The findings replicate earlier reports of strong associations of N-acetylaspartate, creatine, choline and gray matter with age and gender, with additional observations of slightly increased spectral linewidth with age and in female relative to male subjects. Associations of metabolite levels, linewidth and gray matter volume with BMI were also observed, although only in some regions. Using voxel-based analyses, it was also observed that the patterns of the relative changes of metabolites with BMI matched those of linewidth with BMI or weight, and that residual magnetic field inhomogeneity and measures of spectral quality were influenced by body weight. It is concluded that, although associations of metabolite levels and tissue distributions with BMI occur, these may be attributable to issues associated with data acquisition and analysis; however, an organic origin for these findings cannot be specifically excluded. There is, however, sufficient evidence to warrant the inclusion of body weight as a subject selection parameter, secondary to age, and as a factor in data analysis for MRS studies of some brain regions.

Mapping of brain metabolite distributions by volumetric proton MR spectroscopic imaging (MRSI).

Distributions of proton MR-detected metabolites have been mapped throughout the brain in a group of normal subjects using a volumetric MR spectroscopic imaging (MRSI) acquisition with an interleaved water reference. Data were processed with intensity and spatial normalization to enable voxel-based analysis methods to be applied across a group of subjects. Results demonstrate significant regional, tissue, and gender-dependent variations of brain metabolite concentrations, and variations of these distributions with normal aging. The greatest alteration of metabolites with age was observed for white-matter choline and creatine. An example of the utility of the normative metabolic reference information is then demonstrated for analysis of data acquired from a subject who suffered a traumatic brain injury. This study demonstrates the ability to obtain proton spectra from a wide region of the brain and to apply fully automated processing methods. The resultant data provide a normative reference for subsequent utilization for studies of brain injury and disease.

Suppression of insulin secretion is associated with weight loss and altered macronutrient intake and preference in a subset of obese adults.

PURPOSE: Hyperinsulinemia is a common feature of many obesity syndromes. We investigated whether suppression of insulin secretion, without dietary or exercise intervention, could promote weight loss and alter food intake and preference in obese adults. METHODS: Suppression of insulin secretion was achieved using octreotide-LAR 40 mg IM q28d for 24 weeks in 44 severely obese adults (89% female, 39% minority). Oral glucose tolerance testing was performed before and after treatment, indices of beta-cell activity (CIRgp), insulin sensitivity (CISI), and clearance (CP/I AUC) were computed, and leptin levels, 3-day food records and carbohydrate-craving measurements were obtained. DEXA evaluations were performed pre- and post-therapy in an evaluable subgroup. RESULTS: For the entire cohort, significant insulin suppression was achieved with simultaneous improvements in insulin sensitivity, weight loss, and body mass index (BMI). Leptin, fat mass, total caloric intake, and carbohydrate craving significantly decreased. When grouped by BMI response, high responders (HR; DeltaBMI<-3 kg/m(2)) and low responders (LR; DeltaBMI between -3 and -0.5) exhibited higher suppression of CIRgp and IAUC than nonresponders (NR; DeltaBMI-0.5). CISI improved and significant declines in leptin and fat mass occurred only in HR and LR. Conversely, both leptin and fat mass increased in NR. Carbohydrate intake was markedly suppressed in HR only, while carbohydrate-craving scores decreased in HR and LR. For the entire cohort, DeltaBMI correlated with DeltaCISI, Deltafat mass, and Deltaleptin. DeltaFat mass also correlated with DeltaIAUC and DeltaCISI. CONCLUSIONS: In a subcohort of obese adults, suppression of insulin secretion was associated with loss of body weight and fat mass and with concomitant modulation of caloric intake and macronutrient preference.

The "differential diagnosis" for multiple diseases: comparison with the binary-truth state experiment in two empirical studies.

RATIONALE AND OBJECTIVES: In practice readers must often choose between multiple diagnoses. For assessing reader accuracy in these settings. Obuchowski et al have proposed the "differential diagnosis" method, which derives all pairwise estimates of accuracy for the various diagnoses, along with summary measures of accuracy. The current study assessed the correspondence between the differential diagnosis method and conventional binary-truth state experiments. MATERIALS AND METHODS: Two empirical studies were conducted at two institutions with different readers and diagnostic tests. Readers used the differential diagnosis format to interpret a set of cases. In subsequent readings they interpreted the cases in binary-truth state experiments. Spearman rank correlation coefficients and the percentages of agreement in scores were computed, and the areas under the receiver operating characteristic curves were estimated and compared. RESULTS: The between-format Spearman rank correlation coefficients were 0.697-0.718 and 0.750-0.780 for the two studies; the between-reader correlations were 0.417 and 0.792, respectively. The percentages of agreement between formats for the two studies were 50.0%-51.7% and 72.9%-78.8%; the percentages of agreement between readers were 45.0% and 80%, respectively. In the first study there were several significant differences in the areas under receiver operating characteristic curves; in the second study these differences were small. CONCLUSION: The differences observed between the two formats can be attributed to within-reader variability and inherent differences in the questions posed to readers in the multiple-diagnoses versus binary-truth state reading sessions. The differential diagnosis format is useful for estimating accuracy when there are multiple possible diagnoses.

Combined spinal and epidural anesthesia with low doses of intrathecal bupivacaine in women with severe preeclampsia: a preliminary report.

BACKGROUND AND OBJECTIVES: The purpose of our study was to evaluate the quality of anesthesia for cesarean delivery (CD), analgesia for labor (LA), hemodynamic changes, and neonatal effects of combined spinal and epidural anesthesia (CSE) with low intrathecal doses of bupivacaine and fentanyl in patients with severe preeclampsia. METHODS: Of the 85 patients with severe preeclampsia (systolic pressures [SBP] > or = 160 mm Hg or diastolic pressures [DBP] > or = 110 mm Hg, and proteinuria > or = 100 mg/dL), 46 underwent CD and 39 delivered vaginally. The CD group received 7.5 mg of hyperbaric bupivacaine and 25 microg fentanyl intrathecally with a goal of obtaining a T4 sensory block. Those with levels less than T4 received 2% lidocaine epidurally to extend the block. In the LA group, the intrathecal dose was 1.25 mg of plain bupivacaine with 25 microg of fentanyl, followed by epidural infusion of 0.0625% to 0.125% bupivacaine with 2 to 4 microg fentanyl/mL at 12 to 15 mL/h. RESULTS: In the CD group, all but 4 patients had > or = T4 block, and these 4 patients received 2% lidocaine epidurally. None required conversion to general anesthesia. In the LA group, sensory levels were T10 (range, T6-L2) with adequate analgesia. The baseline mean arterial pressure (MAP) was 122 +/- 13 mm Hg in the CD group and 117 +/- 12 mm Hg in the LA group. After CSE, MAP decreased significantly and reached a nadir within 5 minutes in both groups (103 +/- 12 mm Hg in the CD group and 96 +/- 13 mm Hg in the LA group, P <.05). The maximum decrease in MAP was similar in the 2 groups (-15% +/- 8% in the CD group and -16% +/- 9% in the LA group). The neonatal Apgar scores and umbilical artery (UA) pH were similar, and there were no significant correlations between UA pH and lowest MAP before delivery or the maximum percentage change in MAP in either group. CONCLUSIONS: The results indicate that CSE with low intrathecal doses of bupivacaine and epidural supplementation, when needed, produces adequate anesthesia for CD and analgesia for labor in patients with severe preeclampsia. The maximum decreases in MAP after CSE were modest and quite similar in the 2 groups.

Results of the 4th ABFO Bitemark Workshop--1999.

Thirty-two certified diplomates of the American Board of Forensic odontology (ABFO) participated in a study of the accuracy of bitemark analysis. Examiner experience as board-certified odontologists ranged from 2 to 22 years. Examiners were given sets of photographs (a cast in 1 case) of 4 bitemark cases and asked to report their certainty that each case was truly a bitemark and the apparent value of the case as forensic evidence. Participants also received 7 occluding sets of dental casts, 1 correct dentition for each case and three unrelated to any of the cases, and asked to rate how certain they were that each set of teeth had made each bitemark. Receiver operating characteristic (ROC) analysis resulted in an accuracy score of 0.86 (95% CI=0.82-0.91). Youden's index was used to determine a cutoff point for determining an accuracy score for each case. Accuracy scores were significantly correlated with bitemark certainty and forensic value (P<0.001 in both cases) but not with examiner experience (P=0.958). The use of individual ROC analysis with weighted Youden's index to calibrate individual accuracy was also demonstrated.

Comparative pharmacokinetics of submucosal vs. intravenous flumazenil (Romazicon) in an animal model.

PURPOSE: This study was performed to determine the bioavailability and local tissue toxicological safety of flumazenil (Romazicon) when administered by oral submucosal (SM) as opposed to intravenous (i.v.) injection. METHODS: Six dogs each received SM flumazenil (0.2 mg), and their serum was collected at predetermined time intervals (0-2 h) and frozen (-70 degrees C). Seven days later, the dogs received an identical dose of i.v. flumazenil, and serum samples were again collected, as above. Comparative quantitation of flumazenil levels (i.v. vs. SM) was made using a sensitive HPLC assay (UV detection). Direct/local drug toxicity was visually scored by unbiased raters of color photographs (test and control mucosa) taken at 1, 2, and 7 days following SM flumazenil injection. An oral pathologist examined slides processed from control and treatment tissues (hematoxylin and eosin staining) taken (punch biopsy) 1 week following SM injection to compare with direct clinical scores. RESULTS: Serum flumazenil levels reached a plateau (8.5 +/- 1.5 ng/mL, mean +/- SD) within 4 min of SM drug injection and declined thereafter to -2 ng/mL by 2 h. Bioavailability of SM flumazenil was 101 +/- 14%, based upon measuring the area under the serum concentration-time curves over 1.5 h (AUC 0-1.5 h, SM vs. i.v. drug). Thus, serum drug levels following SM drug administration were broadly comparable to those obtained during the elimination phase of corresponding i.v. drug delivery. Regarding drug tissue toxicity, no evidence of direct drug toxicity was observed by unbiased raters of color photographs (test and control mucosa) taken at 1, 2, and 7 days following SM flumazenil injection. Following pathologic review, no difference was seen in the degree of inflammation between treatment and control tissue. CONCLUSION: At the quantity and concentration used, SM drug flumazenil administration appears to be both a safe and a viable alternative to bolus i.v. drug delivery and worthy of further investigation.

Role of transesophageal echocardiography in assessing diastolic dysfunction in a large clinical practice: a 9-year experience.

BACKGROUND: Two-dimensional transthoracic echocardiography with respiratory monitoring has been used to characterize diseases that impair diastolic function. Transesophageal echocardiography (TEE) has emerged as a complementary technique to evaluate patients with these diseases. The purpose of this study was to evaluate in a large clinical practice the utility of TEE with respiratory monitoring for classification of patients with diastolic dysfunction. METHODS: Over a 9-year period TEE was used to examine 192 patients referred to an echocardiography laboratory for additional evaluation of abnormal diastolic function. We performed pulsed-wave Doppler TEE of the left ventricular inflow and pulmonary veins and respiratory monitoring to categorize patients as showing restrictive physiologic features, constriction with or without effusion, mixed constriction and restriction, abnormal relaxation, pseudonormalization, large pericardial effusion or tamponade, or normal diastolic function. RESULTS: Patients with diastolic dysfunction underwent 3% of the total number of transesophageal studies conducted during the study period. Among the 192 patients referred for TEE, abnormal diastolic function was found in 181 (94%); 11 (6%) had normal diastolic function. Seventy-one (39%) of the 181 patients had restrictive physiologic features. Constrictive pericarditis was found in 54 (30%) of the patients and was confirmed for all 31 patients who underwent pericardiectomy. Mixed constriction and restriction was present in 21 (12%) of the patients. The other 35 patients (19%) had abnormal relaxation, pseudonormalization, or large pericardial effusion or tamponade. The cause of diastolic dysfunction was idiopathic for 32% of the patients, previous cardiac operation for 26%, cardiac amyloidosis for 23%, radiation therapy for 11%, and hypertension or advanced ischemic heart disease for 8%. CONCLUSION: Two-dimensional and Doppler TEE with respiratory monitoring is useful in categorizing patients with impaired diastolic function, primarily into those with restrictive physiologic features or constrictive pericarditis.

Radiation exposure to children during coil occlusion of the patent ductus arteriosus.

The risks of excessive exposure to ionizing radiation are well described and measures are routinely taken to limit such exposure to both patient and personnel in the catheterization laboratory. Coll occlusion of the patent ductus arteriosus (PDA) as well as other more complex pediatric interventions has raised concern regarding radiation exposure, particularly as minimally invasive surgical techniques are being developed which lack such exposure risk. In eight consecutive patients, aged 0.7-7 years (median, 2.3 years), coil occlusion of a PDA was performed and surface entrance radiation dose determined by thermoluminescent dosimetry (TD). Total cumulative doses (PA + lateral dose) were also calculated for each patient. Entrance and cumulative dose was likewise measured in 12 patients undergoing standard diagnostic catheterization (DC) and in 5 consecutive patients undergoing pulmonary balloon valvuloplasty (PBV). The groups were comparable in age, weight, and body surface area (BSA). Total cumulative dose in the PDA patients was 97 +/- 25 mGy (mean +/- SE). There was no significant difference between the three groups in entrance dose absorbed at each location or in total cumulative dose. The mean total fluoroscopy time in the PDA occlusion group was significantly less than that of the PBV group (10.1 +/- 1.81 min vs. 19.3 +/- 2.29 min, P < 0.05) but was comparable to the DC group (13.2 +/- 1.5 min, P = NS). When the subjects were analyzed collectively, no correlation between fluoroscopy time and measured entrance dose was observed. The strongest correlates of total cumulative dose were patient weight (r = 0.67, P < 0.001) and BSA (r = 0.62, P = 0.001). Patients undergoing coil occlusion of a PDA are not exposed to increased radiation entrance dose compared to those undergoing standard DC and PBV. Furthermore, surface entrance radiation dose as determined by TD varies according to patient size for a given fluoroscopy time.

Atrial fibrillation early postoperatively following minimally invasive cardiac valvular surgery.

We report a cohort of our first 100 minimally invasive cardiac valvular operations matched 1:1 by age and valvular surgery type with patients undergoing a traditional midline sternotomy approach. The prevalence of postoperative atrial fibrillation among patients with minimally invasive procedures versus traditional midline sternotomy was 26.3% versus 38.0%, respectively (p = 0.08). Neither multiple logistic regression nor Kaplan-Meier distribution analysis identified differences in postoperative atrial fibrillation between the 2 surgical techniques.

Diagnostic accuracy of colposcopic photographs in child sexual abuse evaluations.

STUDY OBJECTIVE: To evaluate the utility of colposcopic photographs in child sexual abuse evaluations and to assess whether such photographs can be reliably used for peer review, second opinion, and court testimony. METHODS: A prospective review of colposcopic photographs at the Pediatric and Adolescent Gynecology Clinic in Louisville, Kentucky. Participants were 189 girls who were referred for evaluation for possible sexual abuse. Interventions used included gynecologic evaluation, colposcopic photographs, and review of photographs. The main outcome measure was the degree of agreement between the examining physician and the reviewers. RESULTS: The reviewers' accuracy for the entire set of 189 cases is uniformly high (93%-95%). Accuracy rates are significantly lower for pubertal girls (83%-90%) and for girls with signs of abuse (58%-88%). CONCLUSIONS: The diagnostic accuracy of the colposcopic photographs is sufficiently high to warrant continued use of medical photography for documentation and peer review. One should anticipate some disagreements between the examining physician and the reviewers, and contradictory opinions are more likely to occur with girls exhibiting physical signs of abuse and with pubertal girls.

Prevalence and determinants of hyperhomocysteinemia in hemodialysis and peritoneal dialysis.

BACKGROUND: Hyperhomocysteinemia is an independent risk factor for atherosclerotic complications in patients with end-stage renal disease, although the mechanisms remain unclear. The major determinants of plasma homocysteine concentration are usually folate, vitamin B12, pyridoxal 5'-phosphate (vitamin B6), and glomerular filtration rate. METHODS: We measured factors, including plasma folate, vitamin B12, vitamin B6, creatinine, as well as the dose and duration of dialysis, that might affect plasma homocysteine concentrations in 130 patients on hemodialysis (HD) and compared these observations with those in 46 patients on peritoneal dialysis (PD). Independent determinants of total homocysteine were identified using a multiple logistical regression analysis. RESULTS: Total homocysteine values averaged 29.8 mumol/liter in HD patients, significantly higher than the mean value of 19.9 mumol/liter observed in patients on PD (P < 0.001). The prevalence of hyperhomocysteinemia was 90.8% among HD patients, significantly higher than the prevalence of 67.4% among PD patients. Folate values in HD patients averaged 45.5 nmol/liter and were significantly lower than in PD patients (104.2 nmol/liter, P < 0.001). For patients on HD, the only determinant of total homocysteine concentration was plasma folate (r = -0.31, P < 0.001). In contrast, for PD patients, total homocysteine did not correlate with plasma folate, vitamin B12, or vitamin B6. CONCLUSIONS: Hyperhomocysteinemia is more prevalent and intense in HD patients compared with those on PD. The homocysteine response may become refractory to excess folate supplementation in PD patients.

Reduction of homocysteine levels in coronary artery disease by low-dose folic acid combined with vitamins B6 and B12.

An increased plasma homocysteine concentration is a risk factor for atherosclerosis. Folic acid lowers homocysteine but the optimal dose in patients with coronary artery disease (CAD) is unclear. This placebo-controlled, single-blind, dose-ranging study evaluates the effect of low-dose folic acid on homocysteine levels in 95 patients aged 61 +/- 11 years (mean +/- SD) with documented CAD. Patients in each group were given either placebo or 1 of 3 daily supplements of folic acid (400 microg, 1 mg, or 5 mg) for 3 months. Each active treatment arm also received 500 microg vitamin B12 and 12.5 mg vitamin B6. Total plasma homocysteine levels were measured after 30 and 90 days. Folic acid 400 microg reduced homocysteine levels from 13.8 +/- 8.8 to 9.6 +/- 2.0 micromol/L at 90 days (p = 0.001). On 1- and 5-mg folic acid, levels decreased from 13.0 +/- 6.4 to 9.8 +/- 4.0 micromol/L (p = 0.001) and from 14.8 +/- 6.9 to 9.7 +/- 3.3 micromol/L (p < 0.001), respectively. The decrease was similar in all treatment groups. There was no significant change with placebo. Although the sample size is small, these findings suggest that daily administration of 400 microg/day folic acid combined with vitamin B12 and vitamin B6 may be equivalent to higher doses in reducing homocysteine levels in patients with CAD.

Prognosis of patients with vascular disease after clinical evaluation and dobutamine stress echocardiography.

BACKGROUND: Coronary disease is an important cause of long-term morbidity in patients needing major vascular surgery. We sought to assess the efficacy of preoperative clinical evaluation and the detection of inducible ischemia for prediction of immediate and long-term cardiac outcomes of patients undergoing vascular surgery. METHODS: In 233 patients undergoing vascular procedures, we assessed risk clinically on the basis of Eagle's criteria. Dobutamine echocardiography was performed with a standard protocol and results were classified as showing ischemia, scar, or a normal response. Patients were observed perioperatively, and late follow-up (28 +/- 13 months) was completed in all surgical survivors. A composite end point of cardiac death, myocardial infarction, and unstable and progressive angina requiring late revascularization was used to judge event-free survival. RESULTS: Of 233 patients undergoing preoperative dobutamine echocardiography, 39 (17%) had inducible ischemia and 36 (15%) had scar. Perioperative events occurred in 8 patients (3%). None of the patients with ischemia had perioperative events, reflecting the effect of revascularization in 9 patients. Late events occurred in 36 patients; ischemia on preoperative stress testing was a predictor of these events even after adjusting for clinical variables and left ventricular dysfunction (relative risk = 3.3; 95% confidence interval 1.6 to 6.8; P =.001). The association of ischemia with clinical predictors was associated with incrementally worse outcome. CONCLUSION: In addition to perioperative assessment, the combined use of clinical and dobutamine echocardiographic evaluation may stratify the risk of late cardiac events.

Tricuspid valve surgery and intraoperative echocardiography: factors affecting survival, clinical outcome, and echocardiographic success.

BACKGROUND: The impact of echocardiographic-guided treatment on outcome after tricuspid valve (TV) surgery is not well defined. OBJECTIVES: The purpose of this study was to determine clinical and echocardiographic factors associated with adverse outcomes after TV surgery and determine the role of intraoperative echo (IOE) in facilitating successful outcomes after TV surgery. METHODS: Four hundred and one patients (279 females, mean age 60 years) underwent TV surgery and other concomitant cardiac surgery at a single institution and were followed clinically and by echocardiography during a 10-year period. RESULTS: Decreased survival after TV surgery was associated with: preoperative increased New York Heart Association (NYHA) functional classification (relative risk [RR]=2.02), increased left ventricular dysfunction by echocardiography (RR=1.28), and use of a TV replacement strategy (RR=2.92). Decreased event-free survival after TV surgery was associated with concomitant coronary artery bypass grafting (RR=2.97). Late echocardiographic failure (3 to 4+ tricuspid valve regurgitation [TR]) after TV surgery was associated with increased severity of TR on preoperative echocardiogram (odds ratio [OR]=1.91). Decreased late echocardiographic failure after TV surgery was associated with the use of a TV annuloplasty ring with a repair strategy (OR=0.40). The surgical plan was altered at the time of surgery to insure a successful outcome in 32 (10%) of 335 patients based on IOE findings. CONCLUSIONS: Adverse outcomes after TV surgery can be predicted by several preoperative clinical and echocardiographic variables. IOE is useful in improving immediate, but not late, outcomes after TV surgery.

Aortic valve replacement for octogenarians: are small valves bad?

BACKGROUND: As the population ages, more octogenarians become candidates for aortic valve replacement. Many octogenarians, particularly women, have a small aortic annulus and there is uncertainty as to the optimal management of this situation in that age group. METHOD: To examine this issue, we reviewed 248 octogenarians (mean age, 82.6 +/- 2.3 years; 58% men) who underwent primary isolated aortic valve replacement (n = 99), or aortic valve replacement and coronary revascularization (n = 149), between 1980 and 1995. Nineteen-millimeter valves were used in 26% of the patients. RESULTS: In-hospital mortality was 8.9%, 5% for aortic valve replacement alone and 11.4% for aortic valve replacement and coronary revascularization. It was 12.5% for the 19-mm size valves compared with 7.7% for the bigger size valves (p = 0.24). Follow-up (mean interval, 4.4 years) demonstrated survival for all patients of 85%, 60%, and 30% and survival free from cardiovascular events of 80%, 45%, and 21% at 1, 5, and 10 postoperative years, respectively. Multivariate analysis identified triple-vessel disease and preoperative congestive heart failure as associated with increased risk for both in-hospital and late mortality (p < 0.05). Valve size did not influence late survival or event-free survival regardless of body surface area. CONCLUSIONS: The use of small aortic valve prostheses in octogenarians does not adversely affect the incidence of early or late mortality or cardiac events.