Effect of kidney transplantation on right ventricular function, assessment by 2- dimensional speckle tracking echocardiography.

BACKGROUND: Advanced chronic kidney disease often results in adverse cardiovascular outcomes and is the leading cause of mortality in patients with end stage renal diseases (ESRD). There is much information about the effect of chronic kidney diseases (CKD) on the left ventricle (LV) chamber, but the right ventricle (RV) as a neglected chamber had not been evaluated precisely, in spite of its importance. OBJECTIVES: The aim of this study was to evaluate the impact of successful kidney transplants on the RV systolic and diastolic function using the advanced method of 2D speckle tracking echocardiography and comparison with the conventional methods. METHOD: The study included 48 patients with CKD who were eligible for kidney transplantation and underwent successful kidney transplantations. Right ventricular indices were evaluated, while RV function was focused by conventional methods and 2D speckle tracking echocardiography before the successful kidney transplant and 1 week, 1 month, and 3 months after the successful kidney transplant. RESULTS: The results of the study showed that RV global longitudinal strain and RV free wall longitudinal strain improved over the time (P = 0.024, P < 0.001 respectively). It also represented that kidney transplantation did not have significant effect on the RV mid cavity diameter, tissue velocity, Myocardial performance index, RV longitudinal diameter, and Tricuspid annular plane systolic excursion indices, but for other indices this effect was significant. On the differences between the mean slope of regression line of the GLS variable in hypertensive subjects (1.0 ± 0.2) and non-hypertensive subjects (0.36 ± 0.32), an independent t-test showed that between the two groups in terms of the improvement of RVGLS, there was a significant statistical difference (P = 0.0067). CONCLUSION: Most of the ESRD patients had subtle RV dysfunction which could be better detected by recent echocardiography methods than conventional methods. Moreover, kidney transplantation led to considerable improvements in RV function in this population.

The prediction role of D-dimer in recurrence of venous thromboembolism 1-year after anticoagulation discontinuing following idiopathic deep vein thrombosis.

BACKGROUND: After discontinuing oral anticoagulant therapy (OAT), the recurrence of venous thromboembolism (VTE) is greatest in the 1(st) year and gradually diminishes. D-dimer assay was proposed to be effective in selecting patients with idiopathic DVT. The aim of this study was to determine the rate of VTE recurrence after discontinuing OAT according to the results of D-dimer. MATERIALS AND METHODS: This prospective study was conducted in patients with a first episode of symptomatic proximal deep vein thrombosis (DVT) who had received OAT for at least 3 months. Patients were re-evaluated at 1(st), 6(th) and 12(th) months of their follow-up. At the first (T0) and 30-day (T1) visits, venous blood samples were taken for D-dimer test. At each follow-up visit, we examined patients for clinical symptoms or signs of recurrent VTE, bleeding, postthrombotic manifestations, adherence to treatment, and concomitant analgesic or antiinflammatory therapy. The endpoint outcomes were VTE recurrence and complete of this survey follow-ups. RESULTS: A total of 68 eligible patients was enrolled. Four patients (two patients need to use long-term oral anticoagulation, and two patients lost their first follow-up) were excluded. At T0, D-dimer and compression ultrasonongraphy (CUS) was normal in 28 patients (44%). Moreover, 36 patients had abnormal D-dimer but normal CUS. A follow-up of 12 months was available in 44 patients. During the follow-up, three recurrent events were recorded. All Recurrent events were ipsilateral DVT. Among these index cases, all had an abnormal D-dimer at either T0 and/or T1. The recurrence rate was higher in males than in females (8.6% vs. 2.2%, P = 0.04) with an abnormal D-dimer at T0 and/or T1 with a multivariate hazard ratio of 2.1 (95% confidence intervals [CI]: 1.2-5.2; P = 0.02). Patients older than 65 years had a higher rate of events than younger and hazard ratio was about 3.8 (95% CI: 2.1-4.2; P = 0.02). Patients with recurrences had higher mean D-dimer at both T0 and T1 when compared with those without recurrences, but the difference was significant only for D-dimer at T1 (P = 0.03). During the follow-up, two patients died (3%). CONCLUSION: Within 12 months follow-up, the risk of recurrence with an abnormal D-dimer, either during or at 1-month after discontinuing OAT, was 4.6% which is much lower to the annual risk of recurrence in most studies with idiopathic and provoked VTE. D-dimer has an acceptable prognostic value in detecting recurrence of idiopathic VTE before discontinuing the anticoagulant therapy.

Assess the clinical applicability of transthoracic echocardiography in laparotomy patients in a general intensive care unit.

BACKGROUND: Echocardiography is one of the diagnostic tools that can be applied at the bedside, along with avoiding transporting critically ill patients. This prospective observational study was designed to assess the clinical applicability of the transthoracic echocardiography (TTE) device by noncardiologist intensivists. MATERIALS AND METHODS: Intensivists performed a limited TTE examination on critically ill patients admitted to the surgical intensive care unit (ICU). After initial cardiac clinical assessment in 85 critically ill adult patients, a limited TTE was performed by an intensivist to assess left ventricular (LV) function and LV volume status as well as valvular function and qualitative factors. Data were analyzed and presented in proportions using descriptive statistics. The setting was in surgical ICU of an academic medical center. RESULTS: Valvular abnormalities (44.8%) as well as qualitative indices (68.3%) were the most frequently detected abnormalities. The ejection fraction was the only alteration, which was affected by the risk factors (P = 0.05, mean = 55.57). CONCLUSION: Transthoracic approach can provide useful information on cardiac anatomy and function in most ICU patients along with detecting severe previously unknown conditions in some patients.

Evaluation of QTc interval in Iranian causalities (Janbazan) of Iran-Iraq war receiving maintenance methadone treatment.

BACKGROUND: Methadone is a synthetic opioid, used in treatment of chronic pains. The current study was carried out to evaluate the QTc interval in Iranian causalities (Janbazan) of Iran-Iraq war receiving maintenance methadone treatment. MATERIALS AND METHODS: In 2010, one hundred war causalities in Isfahan who chronically take daily dose of 20 mg or more of methadone (more than 2 weeks), and did not have the history of cerebrovascular or coronary artery diseases, cardiac pacemaker, congenital prolonged QTC, or taking drugs affecting QTc, or having electrolyte abnormalities, were selected for the study. An electrocardiogram was taken from each patient using cardiofax instrument, and QTC was calculated manually. The data was analyzed using SPSS software with descriptive statistical methods and Pearson's correlation coefficient. FINDINGS: All patients were male and had the mean age of 45.6 ± 6.1 years. The patients received 20-240 mg methadone daily for 1 to 108 months. The QTc was prolonged in 25% of the patients (QTc 5 450 ms), with the mean of 472.72 ± 18.5 ms (range 450-508 ms) and the mean daily dose of methadone 85.2 ± 59.0 mg. No significant relationship was observed between QTC interval on the one hand, and methadone dose (R = 0.025, P = 0.8), duration of treatment (R =-0.048, P = 0.68), age (R = 0.037, P = 0.71), and weight (R = 0.1, P = 0.21) of the patients, on the other hand. None of the patients had faint, syncope, arrhythmia, or sudden death. CONCLUSION: Oral methadone causes prolongation of QTC interval. However, the dosage of methadone and duration of treatment were not statistically related to QTC interval.

Diffuse and patchy intra-myocardial fat deposition in left ventricle: unclassified cardiomyopathy in an obese woman without pathological condition.

Fat deposition in the left ventricle in patients without proven myocardial diseases has not been sufficiently investigated. In this paper, a case of diffuse and patchy intramyocardial fat deposition in the left ventricular myocardium in a patient with no cardiac disease history has been detected by cardiac magnetic resonance imaging (CMRI). Such a finding would not be considered a usual cardiomyopathy and further studies are needed to investigate its prevalence, pathophysiological mechanisms, and prognosis.

Changes in intraocular pressure after exercise test.

BACKGROUND: The decrease in intraocular pressure (IOP) within exercise has been recently suggested; however, this change remained ambiguous following exercise test. The present study aimed to assess changes in IOP induced by exercise test in patients who suspected to coronary artery disease (CAD) and indicated for exercise test evaluation. METHODS: In a cross-sectional study at the cardiovascular research center of Amin Heart Hospital in Isfahan, 101 eyes from 51 consecutive patients suspected to CAD aged 30-70 years referred for exercise testing were evaluated. IOP was measured at the three time points of before exercise test as well as 5 and 20 min after completing exercise test using Schiotz tonometer. All exercise tests were programmed by the treadmill. RESULTS: The mean IOP in all assessed eyes was 16.12 ± 2.61 mmHg initially that was gradually decreased to 13.79 ± 2.40 mmHg 5 min after the exercise test, but elevated to 15.67 ± 2.26 mmHg 20 min after the test. Assessing IOP following exercise testing showed a significant decrease in IOP in 75 eyes (74.3%), remained unchanged in 19.8% of eyes, and even elevated in 5.9% of eyes. There was a significant direct association between patients' age and IOP changes assessed by the Pearson's correlation test (r = 0.350,P = 0.009). No significant difference was revealed in the trend of the changes in IOP after exercise test between men and women, between left-sided and right-sided eyes as well as between different body mass index subgroups. CONCLUSION: IOP temporarily reduced after exercise test, but return to baseline value shortly after test. This lowering is more evident in advanced aging.

Comparing three clinical prediction rules for primarily predicting the 30-day mortality of patients with pulmonary embolism: The "Simplified Revised Geneva Score," the "Original PESI," and the "Simplified PESI".

BACKGROUND: Patients with suspected pulmonary embolism (PE) should be evaluated for the clinical probability of PE using an applicable risk score. The Geneva prognostic score, the PE Severity Index (PESI), and its simplified version (sPESI) are well-known clinical prognostic scores for PE. The purpose of this study was to analyze these clinical scores as prognostic tools. MATERIALS AND METHODS: A historical cohort study was conducted on patients with acute PE in Al-Zahra Teaching Hospital, Isfahan, Iran, from June 2013 to August 2014. To compare survival in the 1-month follow-up and factor-analyze mortality from the survival graph, Kaplan-Meier, and log-rank logistic regression were applied. RESULTS: Two hundred and twenty four patients were assigned to two "low risk" and "high risk" groups using the three versions of "Simplified PESI, Original PESI, and Simplified Geneva." They were followed for a period of 1 month after admission. The overall mortality rate within 1 month from diagnosis was about 24% (95% confidence interval, 21.4-27.2). The mortality rate of low risk PE patients was about 4% in the PESI, 17% in the Geneva, and <1% in the simplified PESI scales (P < 0.005). The mortality rate among high risk patients was 33%, 33.5%, and 27.5%, respectively. CONCLUSIONS: Among patients with acute PE, the simplified PESI model was able to accurately predict mortality rate for low risk patients. Among high risk patients, however, the difference between the three models in predicting prognosis was not significant.

Design and Implementation of a Portable Impedance Cardiography System for Noninvasive Stroke Volume Monitoring.

Measurement of the stroke volume (SV) and its changes over time can be very helpful for diagnosis of dysfunctions in the blood circulatory system and monitoring their treatments. Impedance cardiography (ICG) is a simple method of measuring the SV based on changes in the instantaneous mean impedance of the thorax. This method has received much attention in the last two decades because it is noninvasive, easy to be used, and applicable for continuous monitoring of SV as well as other hemodynamic parameters. The aim of this study was to develop a low-cost portable ICG system with high accuracy for monitoring SV. The proposed wireless system uses a tetrapolar configuration to measure the impedance of the thorax at 50 kHz. The system consists of carefully designed precise voltage-controlled current source, biopotential recorder, and demodulator. The measured impedance was analyzed on a computer to determine SV. After evaluating the system's electronic performance, its accuracy was assessed by comparing its measurements with the values obtained from Doppler echocardiography (DE) on 5 participants. The implemented ICG system can noninvasively provide a continuous measure of SV. The signal to noise ratio of the system was measured above 50 dB. The experiments revealed that a strong correlation (r = 0.89) exists between the measurements by the developed system and DE (P < 0.05). ICG as the sixth vital sign can be measured simply and reliably by the developed system, but more detailed validation studies should be conducted to evaluate the system performance. There is a good promise to upgrade the system to a commercial version domestically for clinical use in the future.

Comparison of the accuracy of cardiac computed tomography angiography and transthoracic echocardiography in the diagnosis of mitral valve prolapse.

BACKGROUND: Cardiac multidetector computed tomography (MDCT) has been mainly applied in the diagnosis of valvular heart morphology and function along with the assessment of coronary artery disease. This study aimed to evaluate the diagnostic performance of coronary MDCT angiography for the diagnosis of mitral valve prolapse (MVP), as compared to transthoracic echocardiography (TTE). MATERIALS AND METHODS: A total of 40 patients who had undergone both TTE and MDCT within a three-month period were included in the study. Two parameters of mitral valve leaflet thickness and leaflet billowing were measured using both techniques. The MDCT results were compared with those of TTE, which was the reference standard. RESULTS: Implementing the Receiver Operating Characteristic (ROC) test on the data for MDCT-measured leaflet billowing received from MDCT angiography suggests that the area under the ROC curve is 96% for a declared variable, which is absolutely significant (P < 0.001), and MDCT-measured leaflet billowing is an appropriate index for the diagnosis of mitral valve prolapse. On the basis of the achieved cut-off point from the ROC analysis (which equals 2.5 mm leaftlet billowing) the MDCT-measured leaflet billowing takes a sensitivity and specificity of 68.4 and 95.2%. The false positive and false negative results are 4.8 and 31.6%. The positive and negative predictive values (PPV and NPV) of the revealed test indicate 92.9 and 76.9%, respectively. Finally, the consistency of the MDCT measured leaflet billowing for diagnosing the mitral valve prolapse is 82.5%. Based on the mentioned test, the consistency of the MDCT-measured leaflet thickness test is 47.5%. CONCLUSION: Along with the assessment of coronary arteries, the presence or absence of MVP can be reliably evaluated by MDCT angiography.

Postprandial hypertriglyceridemia in non-diabetic patients with coronary artery disease.

BACKGROUND: Hypercholesterolemia has been established as a major independent risk factor for coronary artery disease, but the role of hypertriglyceridemia, is still controversial in this regard. Postprandial hypertriglyceridemia has been reported to be a predisposing factor for coronary events. Present study was undertaken to assess postprandial hypertriglyceridemia in non-diabetic patients with coronary artery disease. METHODS AND RESULTS: 60 subjects aged over 35 years, who had undergone coronary angiography, were included in this case-control study. Subjects having secondary hyperlipidemia were excluded. The case group had significant stenosis in at least one coronary artery while the control group had normal coronary arteries on angiography. Triglyceride level was evaluated in fasting non-stressful situation as well as three hours after a heavy breakfast (bread, butter and jam, approximately 460 kcal). It was defined as normal (<150 mg/dl), borderline (150-200 mg/dl) and high (>200 mg/dl) according to NCEP guidelines, 2001. The mean fasting triglyceride level in control and case group was 141+/-54 v. 162+/-60 mg/dl respectively (statistically not significant). The mean postprandial triglyceride level, in control and case group was 163+/-60 v. 265+/-98 mg/dl, respectively (p<0.05). In the case group, 63.3%, 3.3%, and 33.3%, and in the control group 70%, 16.7% and 13.3% had normal, borderline and high fasting triglyceride levels, respectively (p<0.05). 3.3%, 23.3%, 73.3% of the cases and 50%, 36.7%, 13.3% of the controls had normal, borderline and high postprandial triglyceride levels, respectively (p<0.05). CONCLUSIONS: Considering that the triglyceride levels were higher in postprandial state, fat tolerance test can be used as a complementary test in evaluation of lipid profile in patients with coronary artery disease with normal fasting triglyceride levels.

Case report on the administration of an eighty milligram diazepam injection without respiratory depression.

Nowadays one of the most challenging problems in Medicine is addiction - addiction to sedative drugs such as benzodiazepines. In this article, we are going to describe a case of diazepam addiction that has tolerated a high dose of intravenous diazepam.

Placement of long-term hemodialysis catheter (permcath) in patients with end-stage renal disease through external jugular vein.

BACKGROUND: The number of patients with End-Stage Renal Disease (ESRD) has progressively increased in the population. Kidney transplantation is the specific treatment for such patients; however a majority of patients will require hemodialysis before kidney transplantation. The present study aims to investigate using the external jugular vein (EJV) for Permcath placement in these patients. MATERIALS AND METHODS: This descriptive and analytical study was conducted in Alzahra Medical Center, Isfahan, in 2012. Catheters were inserted by cutting down the right EJV. The patency rate and potential complications were studied. The obtained data was analyzed using SPSS 21.0. RESULTS: Out of 45 live patients, within three months of surgery, 40 patients (81.6%) had no complications and dialysis continued through Permcath. Permcath Thrombosis occurred in two patients (4.4%). Catheter infection led to the removal of it in one patient (2.2%) 1.5 months after surgery. And accidental catheter removal occurred in one patient. CONCLUSION: Placement of the permcath in the external jugular vein can be a safe, uncomplicated, and reliable method for patients requiring hemodialysis, and can be a life-saving alternative in patients without accessible internal jugular vein.

Electrocardiogram abnormalities and risk of cardiovascular mortality and all-cause mortality in old age: the Kahrizak Elderly Study (KES).

Resting electrocardioghic (ECG) abnormalities might be value for mortality prediction. The aim of this study is to evaluate whether ECG abnormalities are associated with increased mortality in older residents of Kahrizak Charity Foundation (KCF). A total of 247 participants ≥60-years of KES were enrolled in this study. Adjudicated all cause mortality was collected over 3 years between 2006 and 2009. The subjects were classified as having major, minor or no ECG abnormalities according to the Minnesota Code. The addition of ECG to risk factors were examined to predict cardiovascular diseases (CVD) and all-cause mortality by using Cox proportional hazards regression models. At baseline, 104(42.1%) had major ECG abnormalities and 73(29.6%) had minor abnormalities. During a median follow-up of 3.2 years, 73 participants died from all-cause mortality and 31 deaths from CVD. Major ECG abnormalities were associated with an increased risk of CVD mortality in all models. The associations between minor ECG abnormalities at baseline and CVD mortality were not statistically significant. After adjustment for age and sex, Body mass index (BMI), smoking, diabetes, hypertension (HTN), hyperlipidemia and history of CVD, the participants with the major ECG abnormalities had higher risks of CVD mortality (HR: 3.12(95% CI, 1.02-9.57) and all-cause mortality (HR: 2.45(95% CI, 1.23-4.85) compared with those with normal ECG.

Association of cardiac autonomic neuropathy with arterial stiffness in type 2 diabetes mellitus patients.

BACKGROUND: Diabetic patients are at the risk of cardiac autonomic neuropathy (CAN) and arterial stiffness. This study aimed to investigate the association of heart rate variability (HRV) as an index for CAN and pulse wave velocity (PWV) as an index for arterial stiffness. METHODS: Uncomplicated diabetes type-2 patients who had no apparent history of cardiovascular condition underwent HRV and PWV measurements and the results were compared with the control group consisting of non-diabetic peers. Also, the findings were adjusted for the cardiovascular risk factors and other confounding factors. RESULTS: A total of 64 diabetic patients (age= 52.08±8.50 years; males=33 [51.6%]) were compared with 57 controls (age= 48.74±6.18 years; males=25 [43.9%]) in this study. Hypertension, dyslipidemia, and thereby systolic blood pressure and statin use were significantly more frequent in the diabetic group, while the serum levels of cholesterol, HDL-C and LDL-C were significantly higher in the controls. Pulse wave was significantly increased in the diabetic patients (p<0.001). Main HRV parameters were significantly lower in diabetics than in controls. After adjustment for the confounders, PWV and HRV remained significantly different between the groups (p=0.01 and p=0.004, respectively). Multiple logistic regression of the association between pulse wave velocity and HRV index was independently significant both in diabetics and controls. CONCLUSIONS: There exists a significant relationship between heart rate variability and arterial stiffness as a measure for atherosclerosis in diabetic patients, although the role of the confounding factors is noteworthy.