Impaired peripheral microvascular reactivity in patients with nonobstructive coronary artery disease.

OBJECTIVE: This study aimed to determine whether peripheral microvascular reactivity is impaired in patients with nonobstructive coronary artery disease (NOCAD). METHODS: Stable patients presenting with angina were recruited and, based on results from coronary angiography, were categorized into OCAD (coronary stenosis of ≥50%) and NOCAD (stenosis <50%) groups. A control group with no history of angina was also recruited. Forearm skin microvascular reactivity was measured using the laser Doppler blood perfusion monitor and the process of postocclusive skin reactive hyperemia (PORH). RESULTS: Patients were categorized into OCAD (n = 42), NOCAD (n = 40), and control (n = 39) groups. Compared with the control group, the PORH perfusion percent change (PORH% change) was significantly lower in the OCAD and NOCAD groups. No significant differences were noted between the OCAD and NOCAD groups. Additionally, the NOCAD group without any coronary obstruction takes a longer time to reach peak perfusion and had lower PORH% change compared with the nonangina control group. CONCLUSION: Angina patients with NOCAD have microvascular dysfunction as demonstrated by reduced magnitude of reperfusion with an ischemic stimulus. NOCAD patients without coronary obstruction also displayed a slower response to reperfusion.

Diastolic dysfunction in patients with liver cirrhosis: A short-term, observational study at a Malaysian hospital.

Cirrhotic cardiomyopathy is a recognised complication of liver cirrhosis and predicts poor outcomes. Detection of diastolic dysfunction, an early indicator of left ventricular dysfunction can help identify those patients at risk of disease progression. In our study we showed that there was a high prevalence of diastolic dysfunction amongst patients with liver cirrhosis at our outpatient clinic, with the majority being Child-Pugh A/low MELD score. Multiple regression analysis indicated that age and sodium levels were significantly associated with the presence of diastolic dysfunction. This further reinforces the importance of dietary sodium restriction amongst patients with liver cirrhosis.

Diagnostic Performance of Automated Blood Pressure Monitor for Detection of Atrial Fibrillation.

Background Atrial fibrillation (AF) is a type of heart disease characterized by an irregular cardiac rhythm. The complications of AF are associated with significant morbidity, mortality, and medical expenses. This emphasizes the significance of detecting AF early using a feasible device. Methods A total of 123 patients who attended cardiology and INR clinics were enrolled, with 51 of them having AF. The blood pressure of all patients was measured three times using the Rossmax X5, while a single-lead electrocardiogram (ECG) was monitored simultaneously. Following that, a 12-lead ECG was performed on all patients. A cardiologist confirmed the irregular rhythm. Results Compared to the 12-lead ECG method, Rossmax X5 has an accuracy of 99.3%, a sensitivity of 100%, and a specificity of 98.6%. The positive and negative predictive values were also significant, which were 98.1% and 100%, respectively. Conclusion The Rossmax X5 automated blood pressure monitor has a high detection accuracy for AF. Therefore, Rossmax X5 can be recommended for use in the clinical setting as a screening tool for early AF detection.

The Zurkurnai ECG Pattern: A Novel ECG Pattern of the High-Risk Features of Acute Pulmonary Embolism.

Acute pulmonary embolism is an important differential diagnosis in patients presenting with acute shortness of breath. However, the overlapping clinical presentation between acute coronary syndrome, aortic dissection, pneumonia, and heart failure made the diagnosis of pulmonary embolism very challenging in a limited resources center. We present a case of acute pulmonary embolism with an uncommon ECG pattern that was initially misdiagnosed as acute coronary syndrome. The authors made the appropriate diagnosis using the Zurkurnai ECG pattern in acute pulmonary embolism, which is defined as the presence of right axis deviation, deep symmetrical T wave inversion in V1 to V5, II, III, and AVF with the maximum at V3-V4 and poor R wave progression, which indicates the high-risk features of acute pulmonary embolism.

Dizzy spells in pregnancy: successful antenatal removal of a huge left atrial myxoma with mitral valve obstruction.

Diagnosing atrial myxoma in pregnancy is challenging because patients may present with non-specific symptoms that might be overlooked. The timing of non-obstetric operation usually depends on the nature of the disease, after careful consideration of feto-maternal safety, including the use of cardiopulmonary bypass and placental transfer of anaesthetic drug. A woman in her 30s at 18 weeks of pregnancy presented with recurring dizziness. She underwent successful myxoma excision at 20 weeks under general anaesthesia and cardiopulmonary bypass. The 6×5 cm myxoma was histologically confirmed as myxoma. Early detection of atrial myxoma in pregnancy is crucial, and a clinician has to consider the diagnosis of left atrial myxoma with mitral valve obstruction as a cause of severe dizziness. Optimal outcomes require multidisciplinary management. In this case, surgery during the second trimester of pregnancy enabled a full-term pregnancy with the patient's and foetal well-being and normal postprocedural echocardiography.

Adverse Cardiovascular Events Associated With Kopi Jantan.

Energy drinks (EDs) are widely accessible worldwide. In Malaysia, it is common for EDs to be premixed with sexual stimulants. ED consumption has been shown to have an association with cardiac arrest, myocardial infarction, spontaneous coronary artery dissection, and coronary vasospasm. In addition to this, EDs are associated with arrhythmias, which significantly prolong the QTc interval. Myocardial infarction with no obstructive coronary artery disease (MINOCA) is defined as a patient presenting with myocardial infarction with no obstructive coronary artery disease or ≤50% stenosis. It is a challenging and complex pathophysiology compared to obstructive coronary artery disease. MINOCA is more frequently associated with younger patients and women. Here, we report two cases related to a Malaysian local energy drink Kopi Jantan, which presented with atrial flutter and MINOCA.

Posterolateral Premature Ventricular Complex Manifest as Posteroseptal Premature Ventricular Complex: A Case Report.

Premature ventricular complex (PVC) is one of the most common arrhythmias detected in young patients. We report a case of a young patient with symptomatic high-burden PVC suspected to originate from the posterior right ventricular outflow tract (RVOT) who underwent an electrophysiology study (EPS) and was subsequently successfully ablated with markedly reduced PVC burden. The following day, it was noted that there was a change in PVC morphology. A repeat 3D electroanatomical mapping localized the second PVC morphology to posterolateral RVOT and abolished it with radiofrequency ablation (RFA).

24-Hour Holter Monitoring for Identification of an Ideal Ventricular Rate for a Better Quality of Life in Atrial Fibrillation Patients.

Introduction Atrial fibrillation (AF) is the most common persistent cardiac arrhythmia. The impact of AF on quality of life (QoL) is significant, and much has related to the achieved resting ventricular rate (VR). Strategies to control VR can improve QoL in AF patients. However, the ideal VR target remains unclear. Therefore, we aimed to identify the ideal VR target by comparing the QoL of AF patients with different VR cut-off means from the 24-hour Holter (Holter). Methods A cross-sectional study was conducted on AF patients in the international normalized ratio (INR) clinic at Hospital Universiti Sains Malaysia. Patients were fixed with a Holter monitor while QoL was measured using the SF-36v2 Health Survey. Patients were repeatedly divided into mean 24-hour Holter VR above and below 60, 70, 80, 90, and 100 beats per minute (bpm). The differences in the total SF-36v2 score and its components were examined. Results A total of 140 patients completed the study. There was a significant difference in physical role, vitality, mental health, mental component summary, and total SF-36v2 scores for VR above and below 90 bpm. The total SF-36v2 score difference was also significant in the covariate analysis, while other VR cut-offs (60, 70, 80, and 100 bpm) did not show significant changes in total SF-36v2 scores. Conclusion Significant differences were observed in the QoL scores among AF patients, with a cut-off VR of 90 bpm favoring patients with the higher rate. Hence, higher VR is better in terms of QoL among stable AF patients.

Managing a Pseudo-Mobitz Type II Atrioventricular (AV) Block Intrapartum: A Case Report.

Atrioventricular (AV) block in pregnancy is rare, but it is a serious arrhythmia that needs to be carefully managed in pregnancy. However, as of now, there are no clear guidelines or consensus for intrapartum management. Most of the time, an intrapartum AV block is secondary to hypervagatonic sinus node dysfunction and is treated conservatively. Hypervagatonic sinus node dysfunction has a heterogeneous presentation of AV block, and pseudo-Mobitz type II in labor is rarely reported. We report a case of pseudo-Mobitz type II AV block during pregnancy due to labor pain, which is successfully managed conservatively.

An Evaluation of the Role of Oxidative Stress in Non-Obstructive Coronary Artery Disease.

Approximately half of all women presenting to the emergency department with angina chest pain do not have obstructive coronary artery disease (CAD) on coronary angiography. This condition is termed non-obstructive coronary artery disease (NOCAD), and includes ischemia with no obstructive coronary artery disease (INOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA). Oxidative stress has been reported to be involved in the development and progression of CAD. However, a scarcity of studies has assessed a correlation between oxidative stress and NOCAD. Thus, a literature review was performed of available reports on the role of oxidative stress in NOCAD. Possible mechanisms involved in oxidative stress that may contribute to NOCAD were identified and evaluated. A key finding of this literature review was that oxidative stress caused vasoconstriction and endothelial damage, and this results in coronary microvascular dysfunction and vasospasm, which, in turn, lead to the pathogenesis of NOCAD.

Potential of Phage Display Antibody Technology for Cardiovascular Disease Immunotherapy.

Cardiovascular disease (CVD) is one of the leading causes of death worldwide. CVD includes coronary artery diseases such as angina, myocardial infarction, and stroke. "Lipid hypothesis" which is also known as the cholesterol hypothesis proposes the linkage of plasma cholesterol level with the risk of developing CVD. Conventional management involves the use of statins to reduce the serum cholesterol levels as means for CVD prevention or treatment. The regulation of serum cholesterol levels can potentially be regulated with biological interventions like monoclonal antibodies. Phage display is a powerful tool for the development of therapeutic antibodies with successes over the recent decade. Although mainly for oncology, the application of monoclonal antibodies as immunotherapeutic agents could potentially be expanded to CVD. This review focuses on the concept of phage display for antibody development and discusses the potential target antigens that could potentially be beneficial for serum cholesterol management.

The Unusual Cause of Cardiac Tamponade.

We present a previously healthy young man with cardiac tamponade. He underwent emergency pericardiocentesis. The pericardial fluid was exudative, and Salmonella sp. was grown on both pericardial and blood cultures. Further investigations revealed that this patient had classical Hodgkin lymphoma, which explains his immunocompromised state predisposing him to this infection. (Level of Difficulty: Advanced.).

[Urologic complications in 237 recipients of cadaveric kidney transplantation]. / Complicaciones urológicas en 237 receptores de trasplante renal cadavérico.

We describe the urological complications occurred in 237 patients undergoing cadaveric renal transplant in 13 years. Two techniques of extravesical ureterocystoneostomy were used. Thirty patients (13%) presented 35 (15%) urological complications: 23 (9.7%) urinary fistula and 12 (5.1%) ureteral stenosis. The vast majority (80%) were early complications (before 90 days): 82% fistulas and 18% stenosis. All early complications were identified as technical deficiencies; all late complications were obstructive in nature. A new ureteral reimplant was performed in 15 patients, with successful results in 14. Six patients underwent nephrectomy and pyelostomy, 2 of these required a second operation. Seven patients underwent endo-urological procedures with good results. Three patients undergoing conservative treatment for urinary fistula required surgical drainage of an infected urinoma. No statistical difference was observed in the survival rates of both the grafts and the patients presenting or not urinary complications.

[Survival analysis in renal cell carcinoma with invasion of the vena cava]. / Análisis de la supervivencia en el carcioma de células renales con invasión de la vena cava.

Ninety-nine consecutive patients with renal cell carcinoma in stages pT1-4/N0-3/V0-2/M0 were analyzed. Overall 5 year survival was 61%. Factors with greater impact on survival were: 1) degree of anaplasia (DI 73%, DII 47%, DIII 27%; p = 0.0005), 2) pathological stage (pT1-2 87%, pT3 39%; p = 0.0000), 3) perirenal fat invasion (pT1-2 87%, pT3a 60%; p = 0.007), 4) node status (N0 72%, N1-3 17%; p = 0.0000) and 5) veins invasion (V0 74%, V1-2 35%; p = 0.005). No difference in survival between V1 and V2 (40% vs 33%; p0.05) tumours was found. A multivariable study showed that the degree of anaplasia and veins invasion have a significant and separate influence on survival (p = 0.0000). Among patients with vascular invasion, those with no perirenal fat invasion or node damage show better survival rates than patients with capsular infiltration (62% vs 40%; p) and perform significantly better than patients with capsular invasion and nodal implication (62% vs 30%; p). No survival differences were observed between pT3b stages with venous invasion only and pT1-2 stages (p0.05). Venous invasion is not in itself of prognostic relevance; the prognostic significance of vascular invasion is directly related to the presence of perirenal fat invasion and/or nodal implication.

[Monotherapy of ureteral calculi with extracorporeal shockwave lithotripsy]. / Monoterapia de los cálculos ureterales con litotricia extracorpórea por ondas de choque.

We reviewed our experience with ESWL in the treatment of 401 patients with ureteral stones in order to evaluate if a higher disintegration and clearance rates could be achieved without prior manipulation of ureteral calculi, i.e., ESWL used as "in situ" monotherapy. The global stone free rate were 83%, 85% and 91% at 15 days, 1 month and 3 months after ESWL. We also analyzed the results according to the efficiency quotient (EQ).

[Retroperitoneal ganglioneuroma: an infrequent tumor]. / Ganglioneuroma retroperitoneal: un tumor infrecuente.

Presentation of 2 cases of retroperitoneal ganglioneuroma (paravertebral and adrenal, respectively), accidentally diagnosed during ultrasound study. In none of these 2 cases diagnosis by thin-needle puncture-aspiration was possible, therefore, surgical exeresis of the lesion was performed. When diagnosis is made prior to surgery, management can be conservative with close follow-up, unless neuroblastoma is identified or there is other disease-derived pathologies present.

[Primary adrenal carcinoma]. / Carcinoma suprarrenal primario.

A series of 17 patients with primary adrenal cortical carcinoma is presented. Of 14 patients without evidence of disseminated disease prior to radical surgery, 6 developed distant metastases during follow-up. The mean interval free of disease in these patients was 12 months (range 3-40) and the median survival 15 months. Of the six patients in whom adjuvant external beam radiotherapy was delivered, no evidence of local recurrence was observed. Of the patients treated without external beam radiotherapy, 3 local failures were observed. The projected 5 years survival was 35%, which is similar to that reported in the literature. To date, there is no evidence that chemotherapy nor radiotherapy could improve the survival, however, radiotherapy might increase the local control in selected cases.

[Prognostic value of local vascular infiltration in infiltrating transitional carcinoma of the bladder]. / Valor pronóstico de la infiltración vascular local en el carcinoma transicional infiltrante de vejiga.

The present retrospective study analyzes the evolution and survival of 79 patients with bladder infiltrant transitional carcinoma (T2-T3), which were treated with radical cystectomy and bilateral ilio-obturating lymphadenectomy. Pre-operative radiotherapy (57/79) and neo-adjuvant chemotherapy (24/79) was used as supplementary therapy. The univariate analysis showed the relationship between tumour vascular infiltration (TVI) and presence of nodes micrometastasis (p = 0.002). The variables with greater forecast power in the multivariate analysis for survival were a decline in the post-radio and/or neo-adjuvant chemotherapy tumoral stage (p = 0.000) and TVI (p = 0.001). Survival decreased significantly in patients with TVI (p = 0.008), this finding denoting a worse prognosis than the presence of nodular micrometastasis (p = 0.01).

[Infiltrating carcinoma of the bladder: preliminary results of multidisciplinary protocols with radiotherapy and neoadjuvant chemotherapy]. / Carcinoma vesical infiltrante: resultados prelimares de protocolos multidisciplinarios con radioterapia y quimioterapia neoadyuvante.

Report on the evolution of a series of 64 patients with T2-4 N0-3 M0 infiltrant transitional carcinoma of the bladder, treated with TUR and radical cystectomy (28/62) or intra-operative radiotherapy (IOR) 15 Gy and external radiotherapy 40 Gy prior to cystectomy (34/62). The last group including 24 patients which received neo-adjuvant chemotherapy. Seventy percent (15 p0N-, 5 p0N+, 1 p1N-, 3 p1N+) patients treated with radiotherapy, with and without chemotherapy, had local response. Considering just the group which received IOR, external radiotherapy and co-adjuvant chemotherapy (24/34), the local response accounts for 79% (10 p0N-, 5 p0N+, 1 p1N-, 3 p1N+). Current survival of the group receiving concomitant multiple therapy is 92 +/- 5%, 75 +/- 9% and 57 +/- 11% at 1, 3 and 5 years; for equal intervals current survival of the group undergoing cystectomy is 57 +/- 9%, 46 +/- 9% and 40 +/- 10% (p = 0.02). The univariate analysis has confirmed that stage decrease is significantly more frequent in the group receiving radiotherapy with and without chemotherapy (p less than 0.001). Such a decrease significantly biased survival (p = 0.001). In the multivariate analysis, the variables with greater prognostic power were pre-surgical renal function (p less than 0.001), use of radiotherapy (p less than 0.001) and surgical complications (p less than 0.001). Preliminary results show a very high local response to multiple therapy which has been translated so far in increased survival.

[Vascular complications in 237 recipients of renal transplant from cadaver]. / Complicaciones vasculares en 237 receptores de trasplante renal de cadáver.

Between July 1976 and June 1990, 244 transplantations were performed. Of the 237 patients monitored, 13 (5.4%) had vascular complications: 10 (77%) renal artery stenosis, 1 (7.7%) primitive iliac artery stenosis, 1(7.7%) renal artery thrombosis, 1 (7.7%) renal vein thrombosis. Six patients underwent surgery (Angioplasty was performed in three patients, re-anastomosis to the common iliac artery in one, by-pass of saphenous vein in another one, while in the last one it was tried a release of the vascular pediculus). Management with drugs was possible in one case. At present, 11 of the 13 patients are still alive and three of the grafts remain functional after a mean follow-up time of 83 months. According to a univariate study, the influential factors in the development of vascular complications are, the identity of Locus A, the type of extraction in Locus B, the length of cold ischaemia, the type of vascular anastomosis and the number of previous rejections. The factors with maximal influence in the development of complications are the type of vascular suture (with or without patch) and the number of previous rejections (according to a study of log regression models). The study demonstrates the significant influence vascular complications have on the graft's durability (p = 0.005).