Echocardiographic predictors of exercise intolerance in patients with heart failure with severely reduced ejection fraction.

Decreased exercise capacity (EC) is an established predictor of cardiac and all-cause mortality in patients with chronic heart failure (HF). No correlation has been found between EC and left ventricular (LV) ejection fraction. Moreover, data about the effect of right ventricular (RV) function on EC in HF with severe LV dysfunction are limited and contradictory. In this study, we aimed to investigate the relationship between EC and myocardial mechanics in patients with HF with reduced ejection fraction.Consecutive patients with symptomatic HF and LV ejection fraction ≤35% were prospectively assessed. All patients were evaluated with enhanced echocardiography. A symptom-limited treadmill cardiopulmonary exercise test (CPX) was performed within 24-hour interval. Patients were stratified into 4 groups according to their EC defined by Weber's classification. Prognosis of EC, expressed as oxygen uptake at peak exercise (peak VO2), was evaluated in multivariate linear regression analysis model.Sixty-seven patients with New York Heart Association classes II to III and a mean LV ejection fraction of 26 ±â€Š7% were enrolled. A wide range of peak VO2 was observed in CPX with patient exercise performance distributed to all classes according to Weber's classification. Significant differences were found in RV systolic and diastolic functions between groups with different classes of EC: RV peak systolic myocardial velocity (S') (P < .001), tricuspid annular plane systolic excursion (TAPSE) (P = .003), RV E' (P = .003). In patients with functional decline, systolic pulmonary artery pressure (PASP) was higher (P = .029) and TAPSE/PASP ratio was lower (P = .006). No significant differences were found in LV diameter, systolic and diastolic function, and degree of mitral regurgitation. Thirty three patients with RV systolic dysfunction showed lower peak VO2 and oxygen uptake at anaerobic threshold (P = .008, P = .006, respectively), shorter exercise time (P = .003), and lower systolic blood pressure (P = .01) than in patients with normal RV systolic function. Logistic multivariate linear regression analysis with stepwise inclusion and exclusion revealed that gender, RV S', and RV free wall strain were independent predictors of peak VO2.RV function, assessed as S' and free wall strain, was independently related to EC, measured using CPX, in patients with HF and severe LV systolic dysfunction.

Haemodynamic effects of etomidate, propofol and electrical shock in patients undergoing implantable cardioverter-defibrillator testing.

BACKGROUND: Anaesthetic drugs and internal electrical shock may alter the haemodynamic status of patients undergoing implantable cardioverter-defibrillator (ICD) testing. Comparative data on the mechanisms of etomidate and propofol-induced changes in haemodynamic parameters are inconsistent. Also the effects of ICD shock on haemodynamics have not been extensively studied. AIM: To compare the haemodynamic effects of etomidate and propofol as well as electrical shock during ICD testing in a prospective, randomised trial. METHODS: The study group consisted of 63 consecutive patients (mean age 66 ± 10 years, 51 males) who underwent ICD testing. Haemodynamic parameters were measured using impedance cardiography (Task Force Monitor Systems, CNSystems, Austria) before and after injection of etomidate (n = 30) or propofol (n = 33) as well as immediately after internal defibrillation of ventricular fibrillation (VF). Parameters measured included heart rate, systolic (sBP), diastolic (dBP) and mean (mBP) blood pressure, stroke volume (SV), cardiac output (CO) and total peripheral resistance (TPR). RESULTS: Propofol significantly decreased the values of all measured parameters (sBP: 123.4 ± 17.1 vs. 106.3 ± 18 mm Hg, p < 0.0001; dBP: 83.7 ± 12.2 vs. 74.1 ± 13.8 mm Hg, p < 0.0001; mBP: 93.9 ± 13.1 vs. 81.1 ± 16.1 mm Hg, p < 0.0001; SV: 61.1 ± 19.3 vs. 56.4 ± 15.7 mL, p < 0.003; CO: 4.51 ± 1.07 vs. 4.17 ± 0.73 L/min, p < 0.003; and TPR: 1,735.8 ± 532.6 vs. 1,573.9 ± 390.5 dyn×s/cm5), whereas the only significant change following etomidate infusion was a decrease in SV (60.6 ± 11 vs. 56.8 ± 10 mL, p < 0.022). The propofol-induced changes were similar in patients with reduced (< 40%) vs. preserved (≥ 40%) left ventricular ejection fraction (LVEF) and in patients in heart failure NYHA class 0-II vs. class III-IV. Induction of VF and internal electrical shock did not cause major haemodynamic changes apart from significant, albeit very modest, drops in dBP and mBP (77 ± 2 vs. 72.9 ± 18 mm Hg, p < 0.002, and 85.2 ± 17 vs. 81.8 ± 20 mm Hg, p < 0.017, respectively). There were no complications during ICD testing. CONCLUSIONS: Propofol significantly decreased BP probably by both reducing CO and causing vasodilatation, whereas etomidate only slightly decreased dBP and mBP without affecting other parameters. Propofol-induced changes were independent of LVEF or NYHA class. Induction of VF and internal defibrillation did not cause clinically significant changes apart from very modest drops in dBP and mBP values.

Serrated polyps detected during screening colonoscopies.

AIM OF THE STUDY: It is estimated that between 15% and 35% of sporadic colorectal cancers (CRC) developing from adenomas come from serrated polyps. Currently, the most effective method used to prevent CRC is the removal of adenomas, including serrated polyps, during colonoscopy. The aim of this paper is to analyze the changes characterized as serrated polyps and detected during screening colonoscopies performed as part of the Screening Program for Early Colorectal Cancer Detection (SPED). MATERIAL AND METHODS: In our center, as part of the nationwide SPED between 2000 and 2009, 1,442 screening colonoscopies were performed. RESULTS: Serrated polyps were found in 11.9% of all patients and in 45.8% of patients who had polyps removed by endoscopy. In screening colonoscopy of the large intestine, the following polyps were found most frequently: hyperplastic, < 1 cm, without a stalk, multiple, located in the distal part of the large intestine, in men and in patients with a first-degree relative with a history of abdominal cancer. Detecting and removing polyps was facilitated by the fact that the cecum was intubated and the bowel preparation had been performed either very well or well. The detection rate of serrated polyps was not influenced by patients' place of residence or their age. CONCLUSIONS: Serrated polyps constitute a frequent, and very frequent among removed polyps, abnormality detected during screening colonoscopy.

Implantation of additional defibrillation lead into the coronary sinus: an effective method of decreasing defibrillation threshold.

We report a case of successful implantation of an additional defibrillation lead into the coronary sinus due to high defibrillation threshold (DFT) in a seriously ill patient with a history of extensive myocardial infarction referred for implantable cardioverter- defibrillator implantation after an episode of unstable ventricular tachycardia. All previous attempts to reduce DFT, including subcutaneous electrode implantation, had been unsuccessful.

Treatment with double dose of omeprazole increases ß-endorphin plasma level in patients with coronary artery disease.

INTRODUCTION: The proton pump inhibitor empirical trial, besides the analysis of symptoms, is the main method in the diagnosis of gastro-oesophageal reflux disease-related chest pain. ß-Endorphin acts as an endogenous analgesia system. The aim of the study was verify whether ß-endorphin plasma level is affected by omeprazole administration and influences the severity of anginal symptoms and outcome of the "omeprazole test" in patients with coronary artery disease (CAD) and chest pain of suspected non-cardiac origin. MATERIAL AND METHODS: Omeprazole was administered to 48 patients with CAD in a randomized, placebo-controlled, crossover study design. At the beginning of the study, and again after the 14-day omeprazole and placebo treatment, the ß-endorphin plasma concentration was determined. RESULTS: The level of plasma ß-endorphin after the administration of omeprazole was significantly greater than at the start of the study and following the placebo. Responders to omeprazole had an average lower ß-endorphin plasma concentration than subjects who failed to respond to this therapy. Subjects with symptoms in class III (according to the Canadian Cardiovascular Society classification) after omeprazole administration had a greater ß-endorphin plasma level than subjects in class II for anginal symptom severity. CONCLUSIONS: Fourteen-day therapy with a double omeprazole dose significantly increases the ß-endorphin plasma concentration in patients with CAD. Circulating ß-endorphin does not seem to be involved in the mechanism for the "omeprazole test" outcome, although an individually different effect on pain threshold cannot be excluded.

The effect of double dose of omeprazole on the course of angina pectoris and treadmill stress test in patients with coronary artery disease--a randomised, double-blind, placebo controlled, crossover trial.

BACKGROUND: Gastroesophageal reflux (GER) and coronary artery disease (CAD) frequently overlap, making the proper diagnosis of chest pain more difficult. GER symptoms may mistake anginal chest pain, and oesophageal acidification may induce myocardial ischaemia both in the rest and in the effort. Increase of oesophageal pH should prevent these conditions. AIM: To estimate the effect of double omeprazole dose on the course of angina pectoris and treadmill stress test in patients with coronary artery disease (CAD), using double-blind, crossover randomised, placebo-controlled study design. METHODS: We studied 48 patients with angina pectoris symptoms and significant narrowing of coronary vessels in angiography. After baseline examination and treadmill stress test all subjects were randomised to treat either with omeprazole (20 mg b.i.d.) or placebo for 14 days, using a double-blind, crossover placebo controlled design. RESULTS: Seventeen (35%) subjects reported more than by half decrease in symptoms severity after omeprazole and 6 (12%) after placebo (p=0,01). Omeprazole significantly decreased the number of chest pain episodes and number of nitroglycerin doses taken in the second week of both study phases, as well as the percentage of subjects with significant decrease of ST interval during the stress test (64% vs. 73%, p<0,05). However majority of other stress test parameters (i.e. test duration, DUKE index) have improved both after omeprazole and placebo administration (by 9-38%). CONCLUSION: Double dose of omeprazole significantly decreased symptoms severity in 35% of patients with CAD, as well as frequency of some electrocardiographic signs of myocardial ischaemia during stress test.

[Heterogeneity of insulin resistance level in gestational diabetes mellitus. Therapeutic implications]. / Zróznicowanie nasilenia insulino- opornosci w cukrzycy ciezarnych. Implikacje terapeutyczne.

OBJECTIVE: The evaluation of insulin resistance (IR) level in population of women with gestational diabetes(GDM) and its relation to treatment of GDM. MATERIALS AND METHODS: 657 GDM women, aged 17-45, treated between the years 2003 and 2005, in Bydgoszcz were studied. Age, pregravid body mass index(BMI), weight gain during pregnancy at the GDM diagnosis, week of GDM diagnosis, week of the beginning of insulin therapy and daily doses of insulin were assessed in the whole population. Daily doses of insulin were evaluated as minimal doses needed at the initial phase of GDM therapy and as maximal doses during gestation. IR was evaluated at the GDM diagnosis, with the use of homeostasis model assessment (HOMA-IR), based on fasting glucose and insulin concentration. RESULTS: 47% women were classified as low HOMA-IR(<2) subpopulation, 50% as intermediate HOMA-IR(2-10) subpopulation, 3% as high HOMA-IR(10-46)subpopulation. Subpopulation with intermediate HOMA-IR had higher BMI, higher weight gain and blood glucose at 0 OGTT compared to subpopulation with low HOMA-IR but lower insulin concentration compared to high HOMA-IR subpopulation. Women in high HOMA-IR subpopulation and in intermediate HOMA-IR subpopulation were twice as often treated with insulin, compared to low HOMA-IR group, accordingly, 58%, 42%, 24%. Daily insulin doses, assessed both minimal and maximal doses, were increasing parallel to HOMA-IR in whole population, accordingly, minimal doses of insulin, 16.0 = -12.7 vs 18.4 vs 20.8 vs 30.8 +/- 30.3 and maximal doses of insulin, accordingly, 39.0 +/- 322.4 vs 50.9 +/- 42.4 vs 70.3 +/- 30.3. CONCLUSION: The studied population of women consisted mainly of subpopulation with low or intermediate HOMA-IR value, in rare cases, of high HOMA-IR value. Our results suggest that adipose tissue is particularly associated with insulin resistance level in subpopulation with intermediate HOMA-IR. Both, frequency of insulin therapy and daily insulin doses are associated with insulin resistance level at the GDM diagnosis.

[Factors affecting the concentration of plasma tumour necrosis factor alpha (TNF-alpha) and liver function tests values in alcohol dependent males after alcohol drinking cessation]. / Czynniki wplywajace na stezenie czynnika martwicy guza (TNF-alfa) i poziom prób watrobowych w surowicy u mezczyzn uzaleznionych od alkoholu po jego odstawieniu.

AIMS: In our work, the factors affecting the plasma level of cytokine, tumour necrosis factor (TNF-alpha) and liver function tests values in alcohol dependent males after alcohol abuse period were analysed. METHODS: We studied forty-seven alcoholics, without severe liver disease, who were abstinent no longer than 14 days before the study beginning. In all 24-h gastric pH-metry, endoscopy, serum liver function tests and TNF-alfa concentration were estimated. RESULTS: The amount of alcohol drunk within 90 days before the study start correlated with plasma activity of AST, ALT and GGT. The plasma presence of TNF-alpha in 26 subjects was found, but in 21 patients this cytokine level was lower than the method sensitivity (< 0.05 pg/ ml). Using the step-wise method of multiple regression we found, that TNF-alfa level at the study commencement was determined by history of delirium tremens, Michigan Alcoholism Screening Test score, length of alcohol dependence, ALT activity, % of total monitoring time with gastric pH >3, intensity of antral H. pylori colonisation and number of standard drinks drunk for 90 days before the study start (ns). Similar factors determined liver function tests values variance. CONCLUSION: Values of TNF-alpha and liver function tests two weeks after alcohol withdrawal were independently determined by gastric pH, H.pylori infection and smoking, which suggests their potential synergism with a hepatotoxic effect of alcohol drinking.

[Carbohydrate metabolism and aging-controversy of ethiopathogenesis and pathophysiology. Part II. Changes in beta-cell function]. / Gospodarka weglowodanowa a starzenie sie organizmu--kontrowersje etiopatogenezy i patofizjologii. Czesc II. Zmiany w czynnosci komórek beta trzustki.

Many studies suggest the decrease of beta-cell function in people older than 60 years. Age-associated defect of beta-cell function can be detected in loading tests, especially with prolonged intravenous infusion glucose infusion. Pathogenetic mechanisms consist abnormalities in insulin processing, insulin secretion, insulin release kinetics with parallel lower insulin secretion capacity and impossibility of increasing insulin release properly to age-increasing insulin resistance. These pathogenetic changes are related to increase of visceral fat deposits and other mechanisms such as defects in beta cell structure, decrease in glucose and incretins sensing and defective course of replication/neogenesis processes.

[Carbohydrate metabolism and aging--controversy of etiopathogenesis and pathophysiology. Part I. Changes of insulin sensitivity]. / Gospodarka weglowodanowa a starzenie sie organizmu--kontrowersje etiopatogenezy I patofizjologii. Czesc I. Zmiany wrazliwosci tkanek na insuline.

Insulin resistance is one of the reasons of increasing carbohydrate metabolism disturbances with aging. Mechanisms of these changes had been partially elucidated. Decreasing of physical activity with increasing of total and abdominal fat are especially important pathogenetic mechanisms. Changes in glucose transporter 4 (GLUT-4) level in skeletal muscles and serum level of insulin like growth factor 1 (IGF-1) could be mechanisms independent of fat tissue. Other mechanisms which could be associated with insulin resistance in aging are related to leptin and adiponectin serum level or changes in mitochondrial energy metabolism and level of advanced glucose end products in diet.

[Insulin resistance in pregnant type 1 diabetic female. Case report]. / Insulinoopornosc u ciezarnej z cukrzyca typu 1--opis przypadku.

Insulin resistance may coexist with diabetes type 1 and make treatment of diabetes difficult. Case of 24-year-old type 1 diabetic female with insulin resistance features prior to pregnancy is reported. Exacerbating of insulin resistance during pregnancy was manifested by difficulties to overcome excessive weight gain and necessity to initiate treatment with high doses of insulin. The treatment was based on diet with progressive caloric restriction to 800 kcal/day in 35 week of pregnancy. That diet was continued till the delivery in 37 week. The fast acting analog insulin (Humalog) and long acting insulin (Humulin U) were used in treatment of diabetes. Treatment with low calorie diet did not cause negative effects on diabetic female metabolism and on the neonate state.

Differences in esophageal corpus motility in patients with pathological and non-pathological gastroesophageal reflux.

BACKGROUND: First- and second-order esophageal contractions are important factors responsible for esophageal clearance of refluxed gastric content. The aim of this study was to estimate the influence of acid reflux on second-order esophageal peristalsis. MATERIAL/METHODS: Simultaneous 24-h esophageal pH-metry and 24-h motility monitoring was performed in 213 patients with non-cardiac chest pain. Pathological gastroesophageal acid reflux (pGER) was defined as pH <4 for more than 4.5% of the total monitoring time. RESULTS: The group of pGER patients (n=65, 31%) had a lower percentage of complete and effective peristalsis, a higher percentage of incomplete peristalsis, and a lower mean contraction amplitude than the group of patients with normal esophageal acid exposure (nGER). Analysis of motility parameters in three periods, i.e. during acid reflux and 2 min before and 10 min after episodes (second-order peristalsis), showed that the pGER group had a lower percentage of effective peristalsis (20.6 +/- 13.3 vs. 29.6 +/- 16.2%, p = 0.002) and a higher percentage of ineffective peristalsis both during and after acid reflux, a lower mean contraction amplitude (56.5 +/- 30.3 vs. 70.0 +/- 32.8 mmHg, p=0.025), and a lower contraction frequency during acid reflux (1.6 +/- 0.7 vs. 2.6 +/- 3.1/min, p=0.001) and 10 min after (1.9 +/- 1.9 vs. 20.6 +/- 30.2/min, p=0.002), which indicated a lack of esophageal peristalsis acceleration after acid reflux in the pGER group. CONCLUSIONS: (1) pGER patients had ineffective esophageal peristalsis more frequently than nGER patients. (2) Impaired second-order peristalsis in pGER patients may be an important factor determining prolonged exposure of the esophageal mucosa to gastric content in addition to lower esophageal sphincter function.

[Insulin secretion at the diagnosis of gestational diabetes is lower in multiparas than in primiparas]. / Sekrecja insuliny przy rozpoznaniu cukrzycy ciezarnych jest mniejsza u wieloródek niz u pierwiastek.

UNLABELLED: Gestational diabetes mellitus (GDM) has heterogeneous ethiopathogenesis, pathophysiology and clinical features. OBJECTIVES: The aim of the study was to evaluate some of anthropometric parameters, clinical features and indices of insulin resistance and beta cell function in GDM women in first pregnancy and in GDM women in third and following pregnancies. MATERIAL AND METHODS: 877 GDM women, aged 18-48 years were studied. Both groups were compared according to age, BMI before pregnancy, week of GDM diagnosis, weight gain during pregnancy, fasting blood glucose, fasting serum insulin level, HbA1c, insulin resistance and beta-cell function indices. All parameters except BMI were evaluated at GDM diagnosis. RESULTS: Multiparas were older, with higher BMI and lower beta-cell function indices. CONCLUSION: At the moment of GDM diagnosis, insulin secretion evaluated by HOMA indices are lower in multiparas in comparison to primaparas.

[Gastroesophageal reflux disease and coronary heart disease--coexistence or interrelationship?]. / Choroba refluksowa przelyku a choroba wiencowa-- wspólistnienie czy zaleznosc?

There is the normal coronary artery appearance in 20-30% of coronarographies, made in patients with chest pain and/or positive noninvasive cardiological tests. The simple explanation of this fact is the presence of diseases which may affect coronary perfusion via mechanism independent to the diameter of main coronary arteries. One of them is gastroesophageal reflux disease (GERD). The presence of GERD symptoms in general population concerns about 30-40% of individuals, while non-physiological reflux is stated in 50-65-85% of patients with coronary heart disease (CHD). That means, that GERD is twice more frequent in patients with CHD than in general population. One explanation of the increased frequency of gastroesophageal reflux appearance in patients with CHD is the adverse effect of drugs used in treatment of cardiological diseases. Morover, one of potential mechanisms explaining the influence of esophagal disturbance on the appearance of coronary hipoperfusion may be their common neurological control of the functions. There are three aspects of it: vagal reflexes (esophageal-cardiac reflex), the disturbances of autonomic nervous system balance and changes in visceral pain perception threshold. Visceral reflex can combine GERD and CHD with mechanism of vicious circle: acid gastroesophageal reflux via vagal reflex may cause coronary hipoperfusion, and the products of anaerobic metabolism of cardiomyocytes may cause relaxation of lower esophagus sphincter, facilitating reflux. Additional mechanism connecting GERD and CHD is inflammation caused by Helicobacter pylori infection. The relationship between digestive tract pathology and evolution, as well as progression and complications of atherosclerosis together with similarity of clinical presentation imply the necessity of precise diagnosis of chest pain causes and caution in interpretation of laboratory examination results.

[The relationship between oesophageal and gastric pH during 24-hours pH-metry in patients diagnosed with atypical chest pain]. / Zaleznosc pH przelykowego od pH zoladkowego w 24-godzinnej pH-metrii u pacjentów z atypowym bólem w klatce piersiowej.

UNLABELLED: Gastric secretion is the only source of hydrochloric acid influencing oesophageal and extraesophageal symptoms in patients with gastroesophageal reflux disease (GERD). The aim of this study was to determine the relationships between gastric and oesophageal pH estimated by 24-hours pH-metry. PATIENTS AND METHODS: We studied 93 men suffering from atypical chest pain. In all endoscopy with mucosa biopsy and simultaneous gastric and oesophageal 24-hours pH-metry using two-channel antimony probe with 15 cm distance of measurement ducts were performed. RESULTS: Among studied patients 24 (26%) had pathological gastroesophageal acid reflux in pH-metry (above 4.5% of monitoring time with oesophageal pH<4). This patients group had higher percentage of monitoring time with gastric pH<4. but only with borderline statistical significance. We did not not find significant differences in values of gastric and oesophageal pH-metry parameters between patients group divided in relation to presence of endoscopic and histologic features of oesophagitis. We found only some significant, but weak correlations between gastric and oesophageal pH. CONCLUSION: Only weak relationship occurring between gastric and oesophageal pH suggests more important role of some other factors in pathogenesis of gastroesophageal reflux and oesophageal mucosa injury.