Anesthetic ointment only (lidocaine/prilocaine) instead of injectable local lidocaine in trans-radial catheterization: A viable no-needle alternative.

OBJECTIVE: The aim of the present study was to assess the level of access site pain in patients undergoing transradial coronary catheterization by using topical application of an anesthetic ointment (lidocaine/prilocaine-AO) compared to standard local anesthesia (LA) by means of injectable lidocaine. METHODS: We prospectively studied 444 patients undergoing elective trans-radial coronary angiography. The quality of analgesia was assessed using a visual analogue scale (VAS) immediately after the puncture and 30 min after the removal of the sheath. The number and duration of attempts before successful sheath insertion, as well as artery spasm, were compared between the two groups. RESULTS: Pain levels measured by VAS were found to be similar between the two groups during sheath insertion (VAS: AO: 4.84 ± 1.0 vs 4.82 ± 1.2, P = NS), as well as 30 min after sheath removal (VAS: AO: 0.07 ± 0.5 vs LA: 0.15 ± 0.6, P = NS). The time to obtain radial access was also not affected by the use of anesthetic ointment (AO: 62.24 ± 25.7 s vs LA: 64.04 ± 18.78 sec, P = NS). The rate of clinical or angiographic radial artery spasm was similar (8-10%) between the groups (P = NS) CONCLUSION: Use of a local anesthetic ointment, versus injectable lidocaine, in trans-radial cardiac catheterization as means of local anesthesia, was found to be equally effective in terms of pain, artery spasm, or artery cannulation speed.

Trans-femoral TAVI: Successful hemostasis of a totally calcified femoral artery ("calcium tube") with the Manta© device.

We describe a case of trans-femoral trans-catheter aortic valve implantation (TF-TAVI) wherein the use of a novel collagen plug-based device (i.e. Manta© device) was very successful in arterial 16 French sheath hemostasis despite an extremely hostile peripheral vessel anatomy due to calcification.

Emergency room management of trauma patients in Greece: preliminary report of a national study.

AIM OF THE STUDY: The aim of this study was to record and to evaluate the epidemiology of trauma in Greece and to assess the quality of management provided for trauma patients in the emergency department in Greek hospitals. METHODS: The Hellenic Society of Trauma and Emergency Surgery invited all the official representatives of the society throughout the country to participate in the study. The representatives that responded positively, met with the Board of the society in succeeding meetings to establish the reporting form and the inclusion criteria. Inclusion criteria were defined as trauma patients requiring admission, transfer to a higher level center or arrived dead or died in the emergency department of the reporting hospital. All reports were accumulated by the Hellenic Trauma society, imported in an electronic data base and analyzed. The design of the study was prospective and observational. RESULTS: In total 8862 patients were included in the study in 12 months time. Of them 68.7% (n=6084) were male, aged 41.8+/-20.6 (mean+/-S.D.) and 31.3% were female (n=2778), aged 52.7+/-24.1 (mean+/-S.D.). The mean duration of treatment in the emergency room department was 1h and 28min. Of the total number of patients, 2312 (26.1%) were initially assessed and managed by a specialist and 6249 (70.5%) were initially assessed and managed by a resident. CONCLUSIONS: Data from this study show that there is substantial room for improvement in the patient care in the emergency department following trauma. Further evaluation will be required to identify particular management patterns that can be readily altered.

The implementation of a national trauma registry in Greece. Methodology and preliminary results.

BACKGROUND: Trauma is a leading cause of death worldwide and a major health problem of the modern society. Trauma systems are considered the gold standard of managing patients with trauma. An integral part of any trauma system is a trauma registry. In Europe, and particularly in Greece, trauma registries and systems are in an embryonic stage. In this study, we present an attempt to record trauma in Greece. METHODS: The Hellenic Society of Trauma and Emergency Surgery invited all the official representatives of the society throughout the country to participate in the study. In succeeding meetings of the representatives, the reporting form was developed and the inclusion criteria were defined meticulously. Inclusion criteria were defined as patients with trauma requiring admission, transfer to a higher level center, or arrived dead or died in the emergency department of the reporting hospital. All reports were accumulated by the Hellenic Trauma society, imported in an electronic database, and analyzed. RESULTS: Thirty-two hospitals receiving patients with trauma participated in the country, representing 40% of the country's healthcare facilities and serving 40% of the country's population. In 12 months time, (October 2005 to September 2006), 8,862 patients were included in the study. Of them, 66.9% were men and 31.3% were women. The compilation rate of the reporting forms was surprisingly high, considering that the final reporting form included 150 data points and that there were no independent personnel in charge of filling the forms. CONCLUSIONS: Trauma registries are feasible even in health care systems where funding of medical research is sparse.

Selective serotonin reuptake inhibitors modify the effect of beta-blockers on long-term survival of patients with end-stage heart failure and major depression.

BACKGROUND: Major depression (MD) is a key feature in heart failure (HF), and it is unclear whether common antidepressive medications interact with cardiovascular drugs used for the treatment of patients with MD and HF, affecting their efficacy. We examined the impact of MD on long-term survival of patients with end-stage severe HF. We also evaluated the interaction between antidepressive medication and beta-blockers on the clinical outcome of these patients. METHODS AND RESULTS: The study population consisted of 250 patients with end-stage severe HF. Sixty-one percent of these patients suffered MD and were receiving selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), or tricyclic antidepressants (TCA). All patients were followed prospectively for 18 months. The primary end point was cardiovascular death. At baseline, patients with severe MD had higher serum interleukin 6 (P < .05) and soluble vascular cell adhesion molecule (P < .01). During the follow-up, 167 cardiovascular deaths were reported, and MD was 1 of the major predictors of cardiovascular death (P = .031), whereas treatment with angiotensin receptor inhibitors and statins were also important negative predictors of mortality (P = .036 and P = .039, respectively). Although beta-blockers had a borderline nonsignificant effect on cardiovascular mortality in the overall population, they had a striking beneficial effect among those patients with major depression receiving SSRIs (P = .006), whereas they had a negative effect on mortality in those patients receiving SNRIs/TCAs (P = .025). CONCLUSIONS: MD is an independent predictor of cardiovascular death in patients with end-stage HF. beta-blockers are associated with lower cardiovascular mortality in patients with end-stage HF and depression only when they are combined with SSRIs.

Methionine-loading rapidly impairs endothelial function, by mechanisms independent of endothelin-1: evidence for an association of fasting total homocysteine with plasma endothelin-1 levels.

OBJECTIVE: Homocysteinemia is associated with elevated oxidative stress and impaired endothelial function. In the present study we examined the impact of oxidative stress in the development of endothelial dysfunction in both chronic and acute (methionine-induced) homocysteinemia in humans. We also examined the role of endothelin-1 (ET-1) in the development of endothelial dysfunction in these two conditions. METHODS: In this double-blind placebo controlled study, 28 subjects of both genders (14 with homocysteinemia and 14 healthy controls) underwent methionine-loading (100mg/Kg body weight) in a standard juice, containing vitamins C (2g) plus E (800IU) (n = 14) or no vitamins (placebo group, n = 14). Forearm vasodilatory response to reactive hyperemia, plasma total homocysteine (tHcy), oxidized LDL (ox-LDL), ET-1 and soluble vascular cell adhesion molecule (sVCAM-1), were evaluated at baseline and 4 hours post methionine loading (4hPML). RESULTS: Chronic homocysteinemia was associated with increased oxLDL (p < 0.01), higher ET-1 (p < 0.05) and impaired endothelial function (p < 0.01). However, oxLDL (but not ET-1) was increased 4hPML in the placebo group, an effect prevented by antioxidant vitamins. The development of severe endothelial dysfunction 4hPML was not however prevented by antioxidants. In linear regression analysis, fasting tHcy was an independent predictor of baseline oxLDL (p = 0.0001), but not of ET-1 levels. On the contrary, oxLDL was the main predictor of ET-1 (p = 0.008), suggesting that tHcy may increase ET-1 by enhancing the production of oxLDL. CONCLUSIONS: Both chronic and acute methionine-induced homocysteinemia are associated with elevated oxidative stress status. Although ET-1 is increased in chronic homocysteinemia, it does not participate in the rapid development of endothelial dysfunction after methionine loading. These findings suggest that despite its potential role in chronic homocysteinemia, ET-1 has a limited contribution to the development of endothelial dysfunction in acute, methionine-induced homocysteinemia in humans.

A novel hybrid approach for reconstruction of coronary bifurcations using angiography and OCT.

The aim of this study is to present a new method for three-dimensional (3D) reconstruction of coronary bifurcations using biplane Coronary Angiographies and Optical Coherence Tomography (OCT) imaging. The method is based on a five step approach by improving a previous validated work in order to reconstruct coronary arterial bifurcations. In the first step the lumen borders are detected on the Frequency Domain (FD) OCT images. In the second step a semi-automated method is implemented on two angiographies for the extraction of the 2D bifurcation coronary artery centerline. In the third step the 3D path of the bifurcation artery is extracted based on a back projection algorithm. In the fourth step the lumen borders are placed onto the 3D catheter path. Finally, in the fifth step the intersection of the main and side branches produces the reconstructed model of the coronary bifurcation artery. Data from three patients are acquired for the validation of the proposed methodology and the results are compared against a reconstruction method using quantitative coronary angiography (QCA). The comparison between the two methods is achieved using morphological measures of the vessels as well as comparison of the wall shear stress (WSS) mean values.

Randomized comparison of the effects of ASA plus clopidogrel versus ASA alone on early platelet activation in acute coronary syndromes with elevated high-sensitivity C-reactive protein and soluble CD40 ligand levels.

BACKGROUND: High-sensitivity C-reactive protein (hsCRP) and soluble cluster of differentiation 40 ligand (sCD40L) have been established as effective markers of inflammation in predicting the risk for adverse outcomes in patients with acute coronary syndromes (ACSs). Activated platelets secrete certain inflammatory mediators such as P-selectin and sCD40L, which play a role in the pathogenesis of ACSs. Although acetylsalicylic acid (ASA) has been found to be an effective treatment of ACSs, the addition of clopidogrel bisulfate has been found tofurther improve clinical outcomes as a result of additional antiplatelet and anti-inflammatory action. Few data exist concerning the effects of dual antiplatelet therapy on these markers in patients with ACSs. OBJECTIVE: The aim of this study was to assess the effectiveness and clinical significance of clopidogrel administration in patients with ACSs without ST segment elevation treated with ASA. METHODS: This randomized, single-blind, controlled trial was conducted at the First Department of Cardiology, Hippokration Hospital, Athens, Greece. Inpatients aged>or=21 years with ACSs without ST segment elevation were randomly assigned to 1 of 2 groups: ASA 325 mg/d for 1 week, followed by ASA (100 mg/d) plus clopidogrel (300-mg loading dose followed by 100 mg/d) for 36 weeks (ASA+Clop group) or ASA alone (325 mg/d for 1 week, followed by 75 mg/d for 36 weeks) (ASA group). Levels of serum sCD40L, hsCRP, and P-selectin were determined on admission and at 8 hours, 48 hours, and 6 days of treatment. By means of clinical follow-up, Kaplan-Meier free-of-major adverse cardiovascular events (MACES) plots were used to assess the prevalence of MACES, including cardiovascular-related death, in patients with and without high levels of hsCRP (>or=3 mg/L) and sCD40L (>or=5 microg/L) for 52 weeks. RESULTS: A total of 86 patients were enrolled (71 men, 15 women; mean [SD] age, 68 [3] years; mean [SD] weight, 86 [18] kg; white race, 86 [100%]; 43 patients per group). Both groups had similar initial clinical characteristics and P-selectin levels. Baseline hsCRP and sCD40L levels were correlated with baseline P-selectin levels (hsCRP, r2=0.099 CONCLUSIONS: The results of this small study suggest that early activation of platelets, as measured using P-selectin levels, was effectively inhibited by the addition of clopidogrel to a regimen of ASA in the subgroup of patients with ACSs and intense activation of platelets (defined as high hsCRP and sCD40L levels). In patients without high hsCRP and sCD40L levels, the addition of clopidogrel did not have a significant effect on P-selectin levels.

Cardio-anesthesiology considerations for the trans-catheter aortic valve implantation (TAVI) procedure.

Transcatheter aortic valve implantation (TAVI) has become the mainstay for high-risk or inoperable patients with symptomatic aortic valve stenosis, and research regarding the use of transcatheter valves in intermediate or low-risk patients is currently ongoing. The aim of this article is to provide comprehensive insight into the anesthetic management of patients undergoing TAVI and to highlight possible gaps in the current knowledge. One important procedural characteristic that is imperative to consider is the type of anesthesia being used and its possible complications. Increasingly, experienced centers have changed from general anesthesia with endotracheal intubation to local anesthesia with sedation, especially when the transfemoral access route is used for TAVI. There is still debate regarding what type of anesthesia should be used in the procedure, and the lack of randomized data makes it even more challenging for the operators.

Occidental beriberi and sudden death.

Beriberi, thiamine deficiency, is classified as "dry" (neurologic) or "wet" (cardiovascular) and may be mixed. Deficiency of this vitamin may be nutritional or secondary to alcohol intoxication. In Western societies (occidental beriberi), the disorder is more commonly observed in long-term alcohol abusers. However, it may go undiagnosed because it is relatively uncommon. In some cases (acute cardiovascular beriberi), early treatment with parenteral vitamin B1 is required to prevent the development of low-output state and sudden death. We report a case of occidental beriberi with fatal outcome despite therapy.

Targeting myocardial metabolism for the treatment of stable angina.

The goals of pharmacological treatment of stable angina pectoris are to improve quality of life by reducing the severity and/or frequency of symptoms and also the long-term prognosis. Patients with coronary artery disease have viable but dysfunctional myocardium. The metabolism of the ischemic myocardium is characterized by a shift from fatty acid to glucose as a preferred substrate and a decline in the levels of ATP. Targeting myocardial metabolism as a pharmacologic approach for chronic angina is based on the concept that metabolic adaptive mechanisms during ischemia resemble fetal energy metabolism by shifting substrate use towards glucose metabolism. Potential pharmacologic approaches should target i) the suppression of lipolysis and the plasma fatty acid levels and subsequent uptake and oxidation by the heart, ii) direct inhibition of the enzymes of fatty acid beta-oxidation, iii) inhibition of carnitine palmitoyl transferase- I (CPT-1). Currently, there are no approved medications directly targeting myocardial metabolism. However, in the last two years a number of medications indirectly targeting cardiac metabolism have been tested in small clinical trials, and some of them appear to be promising potential therapies for stable angina. This review summarizes the main aspects of myocardial metabolism and focuses on the therapeutic approaches that could offer clinical benefit in patients with stable angina.

Novel risk factors related to stable angina.

Stable angina (SA) pectoris is a common and disabling disorder in patients with coronary artery disease (CAD), with increasing epidemiology and is associated with myocardial infarction and increased mortality. However, within the population of SA patients, an individual's prognosis can vary considerably. Except from conventional risk factors a variety of biomarkers have been evaluated for their prognostic significance in the settings of SA. Novel biomarkers associated with inflammatory status, such as C reactive protein and tumor necrosis factor alpha, with myocardial performance, such as B-type natriuretic peptide, with extracellular matrix remodeling, with vascular calcification such as osteoprotogerin and osteopontin, with myocardial ischemia, such as ischemia modified albumin have been associated with the progression of CAD and with the prognosis of SA patients. Despite the multiplicity of novel biomarkers there is lack of a clinical useful, highly specific for CAD biomarker with the ability to guide treatment decisions. In the context of this evidence in this review article we summarize the so far acquired knowledge of the most promising biomarkers and we discuss the major clinical correlations of novel risk factors with SA physical history, their predictive value for future cardiovascular events and their use in the treatment monitoring of this population.

Oxidative stress and endothelial function: therapeutic interventions.

Cardiovascular risk factors, such as hypertension, hypercholesterolemia, diabetes mellitus, or chronic smoking, stimulate the production of reactive oxygen species (ROS) in the vascular wall. Oxidative stress and endothelial dysfunction in the coronary and peripheral circulation have important prognostic implications for subsequent cardiovascular events. The pathophysiologic causes of oxidative stress are likely to involve changes in a number of different enzyme systems. Reactive oxygen species (ROS) are produced by various oxidase enzymes, including nicotinamide-adenine dinucleotide phosphate (NADPH) oxidase, xanthine oxidase, uncoupled endothelial NO synthase (eNOS), cyclooxygenase, glucose oxidase, and lipooxygenase, and mitochondrial electron transport. Decreased NO production due to changes in the expression and activity of eNOS and increased degradation of NO, by reaction with superoxide account for the reduction in endothelium-dependent vascular relaxation. Recently, a variety of antioxidants have been extensively studied in clinical trials for the prevention and treatment of atherosclerosis. In small clinical studies both vitamins C and E may improve endothelial function in high-risk patients. However, larger interventional trials have been controversial, suggesting potential harm in certain high-risk populations. Antihypertensive and hypolipidemic medications exhibit well-documented antioxidant effects and improve endothelial function. However, the discussion of recent patents with the novel antioxidant strategies are required to clarify the role of antioxidant intervention in vascular diseases.

Intramuscular myxoma associated with an increased carbohydrate antigen 19.9 level in a woman: a case report.

INTRODUCTION: Intramuscular myxoma is a rare benign soft tissue tumor. The lack of specific symptoms and widely used laboratory tests makes the diagnosis quite difficult. We present a case of an Intramuscular myxoma associated with an increased carbohydrate antigen 19.9 level. To the best of our knowledge, there have not been any reported cases of an association of Intramuscular myxoma with tumor markers in the literature. CASE PRESENTATION: A 45-year-old Caucasian woman presented to our department for resection of a mass in her left groin area, discovered incidentally on a triplex ultrasonography of her lower extremities. The diagnosis of Intramuscular myxoma was confirmed on histopathology after the complete surgical excision of the tumor. On laboratory examination, the serum level of carbohydrate antigen 19.9 was found to be elevated, but it returned to normal six months after resection of the mass. CONCLUSION: Carbohydrate antigen 19.9 is a tumor marker that increases in a variety of malignant and benign conditions. After the exclusion of all other possible reasons for carbohydrate antigen 19.9 elevation, we assumed a possible connection of carbohydrate antigen 19.9 elevation and Intramuscular myxoma, an issue that requires needs further investigation.